CHAND Bibi lives in a small house located in the small alleys of the populous neighbourhood of Samnabad. She is a lady health worker (LHW), employed by the health department, and her job entails walking door-to-door, lugging her medical kit and miscellaneous equipment, in the neighbourhoods she is assigned to.

When you meet Chand Bibi, a middle-aged portly woman, she seems larger than life, with an aura of wisdom that comes with years of experience. It is thus hard to imagine that a person could have such a vulnerable existence as hers.

“We start the day knowing that anything can happen,” she says, a trace of a grim smile etched on her face. “It is not easy to go to every household, without knowing who or what we will encounter.” Her fears are not misplaced.

In January, Sakina and Rizwana — mother and daughter — were shot dead in Quetta by unidentified assailants. A few years ago, in 2015, a suicide bombing in Quetta, outside a vaccination centre ended up killing 15 health workers. The Taliban and another militant group, Jundullah, had claimed responsibility for the attack. In most cases of violence, LHWs are shot dead, usually in KP or Balochistan, but in Punjab, too, they face insecure working conditions.

“They sic their dogs on us, they beat us up…verbally abuse, sexually harass,” says Rukhsana Anwar, an outspoken LHW who is leading a recent protest for implementation of service structure for LHWs. “Our girls have to travel to remote areas with absolutely no security.”

With these threats looming over them, the LHWs, overworked and underpaid, say they are usually ‘cowed into submission’ by the health department. Sick and tired of the department’s apathy towards them, the LHWs held a sit-in in front of the Punjab Assembly a few weeks ago.

“Our services have been made permanent since 2012,” says Nazia. “But now six years have passed and we are still waiting for our service rules to be implemented. When the government wants us to work they threaten us with show cause notices and set targets for us to achieve. But no one cares about our working conditions.”

Their protest lasted five days, during which a lady health worker died, while several fainted in the oppressive heat. They even braved baton charge by the police. “But the government took its sweet time in agreeing to sit down to talks,” says Nazia.

Rukhsana says a government higher-up had called them in a meeting and ordered them to take back their protest in front of the media. “We will give notifications later he told us,” she says. “It was only because of the media watching everything that we had the guts to continue our protest. Lekin hukoomat ne hum ko zaleel kar diya hay.”

Even though the government finally agreed to implement the pending service rules and give the LHWs their arrears, there appears to be absolutely no confidence in the government’s promises. The LHWs complain that even now, there is no sign of payment of those arrears.

“We were promised our arrears by April 10,” says Rukhsana. “They continue to promise us that our payments are under process. But we really don’t trust them. They have always kept us under pressure, manipulating us, harassing us even threatening us with show cause notices.”

According to Rukhsana, there are 50,000 LHWs in Punjab. But the problems of reproductive health as well as vaccination are so widely spread, especially in rural areas, that the importance of lady health workers is increasing.

Despite lack of medical facilities and access to emergency services, LHWs continue to go door-to-door, spreading awareness about issues pertaining to reproductive health and diseases, and vaccinating children and babies. For many, especially pregnant women, they are a blessing.

Pregnant women are registered under an area’s Basic Health Unit and their cases are followed up till the day of delivery. Yet many believe that their work is ‘anti-Islamic’ and part of a ‘Western spy network’.

An LHW typically works in a population of 1,500 people — or approximately 245 to 300 houses — divided over a period of 26 days. They reject the notion that they are simply glorified midwives. “We have a programme which encompasses a lot of other things, including infant and maternal mortality rates, nutrition, and obstetric care,” she says, adding that unfortunately the programme is increasingly being reduced to achieving targets only.

Many LHWs have to support their families financially. With a disabled son and no husband, Chand Bibi works for over eight hours a day and feels that she deserves to make much more money than what she is paid. An LHW is paid Rs16,000 a month, slightly more than the minimum wage for unskilled labourers.

Take polio campaigns for instance. “One [polio] campaign lasting 10 days pays Rs1,900 for three days, while the rest of the week we work for free,” says Chand.

Published in Dawn, April 15th, 2018