In the heart of Quetta, a silent battle rages on against a backdrop of patriarchal dominance and systemic neglect. Amidst the rugged terrain and ancient traditions, Lady Health Workers (LHWs) navigate a labyrinth of challenges as they endeavour to deliver crucial healthcare services to their communities at the cost of their self-respect and honour, sometimes even at great risk to their lives.
While LHWs go door-to-door by foot to ensure no one gets left behind in receiving critical medical attention — especially vaccination, it is they who have been left behind by the government, which refuses to create a structure which is free of embedded structural violence against them.
LHWs are a cadre of Community Health Workers (CHWs) who provide health services in remote areas and disadvantaged urban portions of the country. Their prime responsibilities include immunisation campaigns, family planning, modern health methods, basic nutritional awareness, and maternal and neonatal services. To carry out these responsibilities, they have to take part in door-to-door campaigns, particularly the polio vaccination drive. However, the mobility of LHWs is difficult due to gender barriers of segregation in a patriarchal context.
Patriarchy, in general, means male dominance in a family, particularly, and in a society, generally. It means men uphold institutions and have direct control over the decision-making process.
LHWs are also tasked to bridge the gap between community and health centres. Consequently, LHWs are tasked with regular home visits as well, which generates a lot of issues for them. In a conservative tribal culture, women cannot move freely and initiate regular visits.
Thankless job
Khalida Bibi* is one of the more than 100,000 LHWs who face harassment and abuse while serving the community with restricted mobility. She details her experience of working as an LHW in and around Quetta:
"It is gruesome to conduct vaccine campaigns in extreme temperatures with meagre wages. Whether it is raining or freezing, it is pertinent for us to visit the remote areas. Equally unfortunate is the behaviour of the local populace, who ask unnecessary questions. Some even shut doors while knowing who we are, while others don't bother to entertain our team when we knock on every door of the union/Tehsil."
Unfortunately, from professional socialisation to integration in the local healthcare system, Lady Health Workers (LHWs) face structural violence at the hands of a patriarchal system in Pakistan, particularly Balochistan. In this context, Johan Galtung, a Norwegian scientist and Peace Studies Scholar, propagated the theory of Structural Violence. He maintained that within a social structure, there may not be a person who directly becomes violent against another person. Instead, violence is part of the system or propagated by the system, resulting in unequal opportunities and suppression of rights and opportunities.
If an LHW faces challenges in coping with mobility during a vaccination drive, it is termed as violence that they are facing. However, if LHWs complain about violence embedded in patriarchal values, either in the form of verbal abuse or physical attacks with (100% prevalence rate)[https://pubmed.ncbi.nlm.nih.gov/37938187/], it is deemed as structural violence.
As far as violence is concerned, the World Health Organisation (WHO) defines it in the following words:
"The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation."
Problems with professional socialisation of LHWs
Muhammad Chaudhry, in his research work titled Lady Health Workers in Pakistan: Tracing Personal and Professional Trajectories Within a Patriarchal Context, 2019, explains that patriarchal social structures do not mean that women are completely deprived of power or rights or access of institutions. The study also indicates that patriarchy comprises six social structures that empower men over women socially and culturally. These structures include housework, paid work, sexuality culture, violence and the state.
Meanwhile, Khalid Bibi* recalls how difficult it was for her to serve the community's maternal and neonatal health issues.
"As an LHW and a housewife, it is difficult to bear the inappropriate behaviour of the community towards me, especially during the immunisation campaigns. It becomes worse when people spit at us or hurl abusive and insulting comments at us. We don't take part in these campaigns out of enjoyment. We have a family to earn for."
When it comes to polio vaccination campaign, the violence becomes rampant when health workers face abuse, taunts, tease, harassment, name calling, character shaming and even spitting on the face.
Overall, the door-to-door campaign is considered inappropriate due to cultural reasons in a society where women are expected to live behind the four walls of the home.
In this context, Khalida Bibi* laments the behaviour of her family in these words;
"My family members taunt me for carrying a bag and going door to door to offer health services. After all these years, I am the only married LHW in my union council, and this has put more cultural and less professional burden on me. I guess earning a livelihood in a conservative society like ours is no less than a sin."
Additionally, Khalida* mentions that the campaigns have become difficult because many people think knocking on their doors and waiting outside is against their cultural code of conduct and even poses an insult to their honour. This issue has also been highlighted in a study Issues Faced by Lady Health Visitors (LHVs) Working for Polio Immunization Campaigns in District Quetta, 2018, where it is highlighted that 70% of LHVs are unable to collect data because people either don't open doors or slam doors on their faces.
The study also mentioned LHWs face such behaviour due to a lack of trust, whereas it can also be described as gender discrimination. This lack of trust can be ascribed to how they are perceived to roam neighbourhoods 'aimlessly', or therefore, LHWs are called "Loafers" (vagabond and time wasters) by locals. These objections are highly gendered because people look down upon their work and consider it a form of insult in many areas.
On the other hand, many scholars believe that cross-national studies can better grasp structural violence. Consequently, a research article titled Structural Violence on Women: An Impediment to Women Empowerment, 2017, envisages that violence happens due to varied structures embedded in the society. This approach explains how women's treatment relates to society's prevailing conditions.
However, the Galtung concept opposes this theoretical underpinning because he thinks social structures themselves cause harm to women and other vulnerable segments of society.
Weak service structure of LHWs
The integration of LHWs into the health system is still devoid of a basic service structure.
Zareef Baloch, a freelance journalist from the coastal town of Pasni in Gwadar district of Balochistan, says even after years, the provincial government prefers to hire LHWs on daily wages despite the presence of vacant posts in the health department. He further laments that the provincial government not only ignores the need for LHWs to have a service structure and increase their pay but also avoids taking notice of the precarious conditions of their security where they are targetted and even killed.
The Lady Health Workers' Strategic Plan (2022-28), has also called for vacant posts to be advertised and filled as per the decided criterion. In addition, the plan envisages government pay scales along with a monthly honorarium while avoiding contractual appointments. However, 90% of LHWs complain about the delay in the provision of monthly salaries. During immunisation campaigns, they work for as little as Rs500 per day which is low and it takes more than a month to get paid.
"Initially, we were not considered a part of health centres. With the regularisation of the service structure, things are different now. However, there are still loopholes that are stopping the full-scale integration of LHWs in the healthcare system," said LHW supervisor, Ibra Faiz*.
Following that, the Lady Health Workers' Strategic Plan (2022-28) also highlighted the slow process of funding that causes delays in the release of salaries or monthly honorariums. Apart from the slow process, the diversion of the budget towards other government sectors has cut into the fiscal allocations for health. Besides, the plan also points out the lack of an appraisal mechanism for LHWs, which not only demotivates workers but also affects the programme's overall efficiency. Overall, the LHWP (Lady Health Worker Programme) service structure is impaired by different threats ranging from exploitation to low wages that have greatly reduced the productivity and growth of health workers.
Furthermore, a report titled Socio-economic impacts of delayed wages on Lady Health Workers and their families, highlighted the underpaid and unpaid salary structure of LHWs. The report revealed that the average LHW has to borrow from the local market to meet day-to-day necessities of life. In addition, a survey indicated that in 63% of the households' male members don't earn and rely on the salary of LHWs. Therefore, 87% of the LHWs reported mentioned that they have no control over their salary owing to the patriarchal suppressive attitude of our society.
The story of LHWs in Balochistan is a testament to their resilience and a call to action for the society to ensure that those who work so hard to ensure their good health are at least greeted upon our doors with respect and kindness and for the government to ensure that the systems that govern LHWs are fair and gender equal.
*Name changed to protect identity