Citation: Closser S, Jooma R (2013) Why We Must Provide Better Support for Pakistan's Female Frontline Health Workers. PLoS Med 10(10): e1001528. https://doi.org/10.1371/journal.pmed.1001528
Published: October 8, 2013
Copyright: © 2013 Closser, Jooma. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The interviews quoted in this essay were conducted as part of research funded and facilitated by UNICEF in 2011. UNICEF had no role in the preparation of this manuscript and did not prompt the writing of this essay. The authors were salaried by their institutions during the period of writing; this salary support was not connected to the writing of this essay.
Competing interests: SC received travel funding from the Independent Monitoring Board for Polio Eradication to attend their meeting in 2011, a consultancy with UNICEF in 2011, and a contract from the Bill & Melinda Gates Foundation for research on polio eradication and health systems in 2011–2012. RJ declares no competing interests.
Abbreviations: GPEI, Global Polio Eradication Initiative; LHW, Lady Health Worker
Provenance: Not commissioned; externally peer reviewed.
Polio is a crippling and deadly viral disease. Through an impressive effort involving millions of people and billions of doses of oral polio vaccine, the Global Polio Eradication Initiative (GPEI) has interrupted polio transmission in all but three countries: Pakistan, Afghanistan, and Nigeria .
In Pakistan, weak health systems are a key reason that polio elimination is so difficult –. Rates of routine immunization, which would provide a population-wide firewall against polio, remain low .
Critical to the eradication effort in Pakistan are the country's 106,000 Lady Health Workers (LHWs), government health staff who work on vaccination teams in special door-to-door immunization campaigns. But militant groups have begun to target these workers, breaking down the front line of defense against polio.
Why Are Lady Health Workers Being Killed?
In December 2012, militants murdered 9 polio campaign workers in Pakistan, and the killing has continued into 2013 with the death toll now nearing 20. Workers going door-to-door delivering polio vaccine have been shot, and Lady Health Workers have been the targets of bombings at health centers –.
Aid programs generally, and vaccination programs specifically, have become associated with CIA and Western interests in Pakistan. The CIA's tactic of employing a fake vaccination campaign to search for Osama Bin Laden damaged health workers' credibility . The Taliban have targeted LHWs in the Swat Valley, ostensibly for promoting contraceptives and representing Western interests .
In this context, polio eradication's high political profile contributed to making the program a militant target. In the past few years, the leadership of the GPEI made a strategic decision to intensely and publicly engage national leaders in the hope of leveraging their perceived authority and oversight for the polio program –. The resulting greater political involvement has increased commitment and accountability ,,. Many observers see this development as wholly positive. However, we believe that the much-publicized importance of polio eradication to national leaders and international organizations helped to make polio eradication workers, including Lady Health Workers, targets of anti-government and anti-state elements ,.
Deep-seated ideological opposition to polio eradication by militants is unlikely: the Taliban, for example, actively support polio vaccination campaigns when it is politically advantageous ,. Militants might be killing polio workers for political reasons: attacking polio eradication is a way to attack national and international interests.
Here, we argue that achieving polio eradication and strengthening Pakistan's health system depend on a shift in the center of gravity of international engagement, away from high-profile engagement with federal leaders and towards supportive partnerships with Lady Health Workers and other ground-level staff.
Lady Health Workers Are Needed to Improve Pakistan's Health System
Each Lady Health Worker acts as the interface between around 150 urban slum or rural households and the health system. In addition to polio campaigns, she visits families monthly to promote family planning; advise on nutrition and hygiene; and create demand for antenatal care, childhood immunization, and use of skilled birth attendants. While the program is not perfect, independent evaluations have consistently shown improved health outcomes on a range of primary healthcare measures in populations with LHW coverage. The households served by LHWs are 15 percentage points more likely to have children under 3 years old fully immunized. Over 90% of communities served by LHWs report that they benefit from her services ,.
Lady Health Workers Are Needed for Polio Eradication
Pakistan's current polio eradication Emergency Action Plan  mandates that each of the approximately 80,000 mobile teams deployed in polio campaigns include a female. As there are few other women in the government health system, Lady Health Workers (LHWs) are an essential part of the polio workforce—more than 85% of the total number of LHWs are engaged in each campaign. They contribute to polio eradication through health education and door-to-door delivery of polio vaccine. Most importantly, because most are locally known women, their presence increases access to conservative households and decreases refusals.
Pakistan has decided not to suspend polio campaigns even in the face of danger to LHWs and other workers. This decision has received international approval because halting campaigns would probably mean a resurgence of polio, including possible reinfection of countries like India and China . Decades of painstaking progress might slide away.
In many parts of Pakistan, UN staff who work on polio campaigns have been pulled from the field for their safety. At the same time, LHWs continue to put their lives at risk ,.
Without UN staff in the field, polio eradication needs LHWs more than ever. If eradication is to succeed, particularly in conflict-torn areas, LHWs' full support is essential.
Lady Health Workers Risk Their Lives, But Do Not Receive a Living Wage
While media accounts of the killings commonly depict female vaccinators as “aid workers” heroically working for the health of others, the reality is more complicated ,–. LHWs are often in desperate financial straits and work for pay of under US$5 per day because there are few other jobs available to women (Box 1). Financial insecurity is a serious problem for LHWs. It is also a major issue for other women who are hired temporarily a few days a month for polio vaccination campaigns. Married women often become LHWs because their husbands are absent, drug addicts, disabled, or underemployed; unmarried women often take on the work because their father is dead or unemployed and any brothers are unable to financially support the family –.
In 2011, SC conducted semi-structured interviews with more than 60 frontline polio workers and supervisors, a sample drawn from all provinces of Pakistan. Detailed information on this study was presented in a report for UNICEF . In these interviews, the vast majority of LHWs and other frontline polio workers said their income was insufficient for basic needs: food, transport, and housing. Most were in families with a rate of income around—or well below—US$2 a day per person. Female polio workers said that low pay dampened their motivation. “When after working so hard you get so little money, your heart breaks,” one woman explained. “And you don't want to do that work. It's the truth” .
As many female health workers in Pakistan are the sole or primary source of income for their families, a living wage to ensure food security and availability of school fees for their children is a necessary first step towards engaging them as strong partners. The GPEI, which has an annual budget of over US$1 billion, should prioritize funding for this purpose . At a minimum, workers should receive Rs. 1000 (a little under US$10) per day for the three days a month they work on polio campaigns, and both regular and polio pay should be delivered on time.
A living wage can be the linchpin of a stronger policymaker–LHW partnership, and can have positive effects beyond polio eradication. One analysis of routine immunization coverage in Pakistan recommended changing incentives for health workers and better engaging LHWs .
Box 1. Financial Need and Health Work: A Lady Health Worker's Story
I became an LHW because of problems at home. I have no choice. I get paid for my blood and my sweat, but there's relief in the work too… Everything is so expensive now, so expensive—but I can scrape by. Thank God.
When I became an LHW, I was responsible for my son. I was living with my parents. My husband had left. He came back after three years, after I'd figured out how to take care of myself, how to take care of my son. And I'm very satisfied that I didn't have to beg from anyone. Sure, my salary was very small, but it was my own money. With that money I took care of myself, I took care of my son, I'm sending him to school. I'm very satisfied with that. My son is seven, mashallah, and he's in second grade…
It doesn't matter what your family background is, standing on your own two feet is the most important thing… It's just the first step that someone has to take by themselves. When someone tries, Allah surely will give them rewards for their work, and Allah builds courage in that person.
[Interview conducted by SC in June 2011.]
Building Stronger Partnerships with LHWs Will Lead to True Health System Strengthening and Help Eradicate Polio
Contribute to Security by Lessening the Visible Involvement of Political Leaders
The induction of a new government in Islamabad after the recent elections presents an opportunity for partners in polio eradication to shift their focus from a “leader-centric” model to one that focuses on gaining the true support and advocacy of grassroots health workers. To contribute to secure conditions for these workers, national engagement must visibly shift away from the federal level. The international stakeholders of the GPEI should, in the near term, restrict high-profile involvement with government functionaries and focus on a new strategy that values, supports, and engages its critical frontline workers.
Such a program could be at once far-reaching and low-profile, building on the existing system for training polio workers to communicate their crucial role in this historic project. This strategy should complement a program of empowerment and career development for these workers.
Build Capacity by Providing More Opportunities for LHWs
Limited opportunity for career advancement is a real problem for LHWs ,–. Many LHWs and other polio campaign workers desire more education and the opportunity to advance within the health system, but feel that opportunities to do so are not available (Box 2).
Pakistan's Expanded Program on Immunization has recently started training LHWs to administer injectable vaccines in an effort to bolster lagging national immunization rates and augment the efforts of facility-based vaccinators. This promising start could be deepened and expanded by making the LHW responsible for routine vaccinations in her area and making her home, the “Health House” of the community, the vaccination center for her neighborhood . Studies in a variety of settings show that such community-centered vaccination is effective in strengthening routine immunization –. The health establishment of Pakistan should be assisted in gradually increasing the number of LHWs to cover the 40% of rural and urban slum populations presently outside the ambit of the program. Such steps could improve Pakistan's weak routine immunization rates, which would also further the eradication of polio .
To make such changes empowering and not exploitative they must be built on improved wages and enhanced support for LHWs from supervisors and district health officers. Problems in the pharmaceutical supply chain and payment provision must be addressed ,,. The recent “regularization” of LHWs, which extends to them the same job security and benefits that other government employees enjoy, along with an increase in regular salary to Rs. 9,000 (about $90) a month, is a major step in the right direction . A program truly engaging LHWs as partners would build on this promising start to craft a program of collaborative engagement that listens to LHWs and takes their needs seriously.
A critical part of supporting LHWs is providing effective security. Some LHWs are refusing the police escorts provided to them, apparently because they make LHWs more visible . This suggests that current security strategies are suboptimal, and that the government machinery alone cannot provide secure conditions for vaccination outreach. Complicating the issue is the fact that the threat to health workers is multidirectional and includes local players in many troubled districts. The GPEI currently employs experts in epidemiology, virology, and communications. Now it is critical that, in addition, the program engage security experts to develop district-wise strategies for providing world-class security to LHWs. These local solutions should be incorporated into the polio campaign plan.
To provide broader support for LHWs, formal opportunities for job advancement should be provided. Pakistan has an acute shortage of nurses –. Opportunities for midwifery, nursing, and other advanced training for Pakistan's most experienced and conscientious LHWs would open doors for hardworking women and add cadres of skilled health staff to Pakistan's health system. Studies have identified opportunities for career advancement and professional development as two important contributors to vibrant community health worker programs –. Tying such opportunities to clearly communicated performance targets would give talented women struggling to support their families fresh reason for commitment.
Pakistan's LHWs have the potential to achieve universal immunization and polio eradication in the country. In fact, both of these goals are probably impossible without their full support. Achieving them depends on a shift from treating frontline female health staff as disposable labor to truly engaging them as well-supported, active partners in achieving a healthier Pakistan.
Box 2. Job Advancement: The Experience of One Lady Health Worker
I became an LHW when I was very young… I had such desire to become a doctor! There was a dentist here, and I used to go to her office and follow her around and work for her, just out of interest, I wanted to know more about how I could become a doctor… I've been thinking of further study, because really, I want to move up. But I look, and there really aren't any ways for me to advance. There's no chance, absolutely no way. All of my dreams, I've left them all behind. What I wanted to do.
[Interview conducted by SC in June 2011.]
Anat Rosenthal, Erin Finley, and Matthew Luck provided useful feedback on the manuscript. Sohail Anjum provided valuable assistance with the interviews excerpted here. Siri Steiner, a medical writer, edited this manuscript for structure but not content, and was unpaid. SC and RJ take full responsibility for the essay.
Wrote the first draft of the manuscript: SC. Contributed to the writing of the manuscript: SC RJ. ICMJE criteria for authorship read and met: SC RJ. Agree with manuscript results and conclusions: SC RJ.
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- As the Global Polio Eradication Initiative deploys its endgame strategy, the commitment and effectiveness of field health workers in polio-endemic countries is critical.
- Ongoing attacks on Lady Health Workers and other frontline health staff in Pakistan appear to be an unintended consequence of the high political profile of polio eradication.
- Achieving polio eradication and strengthening Pakistan's health system now depends on a shift in the center of gravity of international engagement, away from high-profile engagement with federal leaders and towards supportive partnerships with Lady Health Workers and other ground-level staff.
- Nearly all women who work on the health frontline in Pakistan do so because poverty and a lack of other opportunities force them to accept a job with pay of under US$5 per day.
- Steps to support Lady Health Workers and to engage them as strong partners should include paying a living wage, developing world-class security strategies, and providing opportunities for career development and advancement.
Labourers are the backbone of our society, and without any doubt I can say that our nation’s progress cannot be achieved until we enlighten and reform our working class. PHOTO: REUTERS
This year again, the first of May marked the lives of the working class with great zeal and zest, as it symbolises their hard work and hope for better socio-economic outcome.
In Pakistan, the situation is quite distressing. Soaring inflation, excessive loadshedding of electricity and gas, unemployment, rising poverty and poor law and order, all contribute to making lives of people worse.
The lower income working class is a direct sufferer of the uncontrollable sky-rocketing price hike which is driving them into a poverty trap and starvation. The prices of food items and daily commodities are increasing exorbitantly; basic things like flour, rice, vegetables, and pulses are out of the poor man’s reach.
I can’t help but wonder about the impact of Labour Day on labourers living in Pakistan. Labourers are the backbone of our society, and without any doubt I can say that our nation’s progress cannot be achieved until we enlighten and reform our working class.
I met different people from the working class. They had diverse backgrounds and earned as little as Rs400 per day individually. With me, they shared the miseries and harsh realities of their life as I inquired about their views on May Day.
“My meagre income is insufficient to meet the family’s basic needs. We always run out of money by the end of month and have to ask different links for cash to help.” said Nawaz, a carpenter and head of five-member family, living in a downtown area of Karachi. “The government should formulate an easy loan facility for people like me who want to start their own small businesses.” he suggested. The situation has forced his wife and daughter (a primary school drop-out) to work as maids.
Nawaz, a carpenter
Undeniably, Nawaz’s suggestion is a reasonable one. Lengthy documentations and time-consuming procedures required for a loan application are a big obstacle.
It is an open reality; Pakistan’s weak economy can’t take the entire burden on its shoulders, and so, each and every person has to contribute on his own to facilitate the life of the poor working class living in bad shape. The private sector can share the burden of government in this regard by building free of cost cabins, free tools and light machinery.
Free schooling, skill development or technical education for children of lower class is the need of the hour.
Ashfaq, a daily wage worker, feels guilty for being unable to provide education to his children.
“I want to see my sons as government officers and my daughters as teachers, but unfortunately it’s just a dream that I will never be able to fulfill.” he said with teary eyes.
Ashfaq, a labourer
Apart from the government, NGOs are already working to support free education/training programmes, there is still a wide gap and that can only be overcome by widening the scale of work in every town, and village.
Improving the condition of ghost schools in far-fledged villages is essential to make the education structure for people living in villages better.
Our working class/labourers do not have the same rights as their counterparts are enjoying in developed countries, although they are the engines of our socio-economic growth.
“Since the Baldia Town fire incident, I am always worrying for the safety of my daughter, but I can’t stop her from working as we don’t have adequate income to fight high inflation.” said Bashir; a mechanic whose daughter works in a garment factory.
Bashir, a Pakistani mechanic
Long working hours, lack of health facilities, safety measures, and social protection are the vital issues of the working class, but the common practice of our industrial sector is to deny the basic rights of its labourers. Until the government formulates a strict inspection policy along with a check and balance system before issuing licenses, horrifying incidents like Baldia Town fire cannot be avoided.
In recent years, the crippling law and order situation has directly influenced the lives of labourers all over the Pakistan. One such example is Akbar, a gardener, who was happily working in his hometown in Khyber-Pakhtunkhwa (K-P) but as the security situation deteriorated there, he migrated to Karachi leaving behind his family in hopes of a safe working environment. Unfortunately he is facing the same volatile situation here. The miseries of people from Karachi to Khyber cannot be addressed until government keenly resolves the law and order issue.
Akbar, a gardener
Pakistan’s women, too, play a vital role in boosting our economy, but they are also facing many hardships.
“Low wages for women as compared to their male counterparts are the main problem. Poor transportation is also a hurdle. We compromise because we have to run our household. ” said Shabana, who works in a textile unit.
Tussle for equal pay is the most highlighted issue faced by both urban and rural woman. Only stern implementation of laws can eradicate this discrimination.
Moreover, employers mostly deny or reluctantly give women maternity or sick leave and hardly ever promote. Harassment is another major problem that working women face. How can they use their skills to their fullest when their work environment is not safe for them? The existing social security laws scantily safeguard women workers especially home based workers.
What I have felt after talking to these people is that they are disheartened and have lost their confidence in government machinery. When I tried to ask them about Labour Day, they all said one thing:
“No holiday on May 1 for us.”
To my dismay, none of them was even aware of labours rights or labour laws.
They expect nothing new from the upcoming elections either, as most of them believe that politicians only came to them when they needed votes. Soon after the elections, the labourers are forgotten.
Upon asking about medical support, paid holidays, limited work hours, safety measures, improved infrastructure, and proper accommodation, they individually showed their anger, frustration and hopelessness in the system.
Great determination is required to resolve the current scenario. Laws should be implemented strictly to facilitate the labourers and gain what little is left of their confidence in the country and its system.
If the government cannot do this, the least we can do is tip our labourers lavishly as this is the only luxury they can ever hope for,
PHOTOS: TANVEER KHADIM
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