Lady Health Workers in Pakistan: On the Front Line and Under Fire

Emerging Voices features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is by Maxine Builder, a research associate for global health at the Council on Foreign Relations.  

On November 26, four vaccinators were gunned down by militants in the Balochistan province of Pakistan. Three of these slain vaccinators were women, targeted because of their work on a campaign to vaccinate over 238,000 children against polio.

Pakistan is rapidly losing the fight against polio, and lady health workers (LHWs), such as the ones murdered in Balochistan, may prove to be the critical component to the overall success—or failure—of worldwide polio eradication.

Pakistan has become the primary battleground in the war to end polio, in no small part because rates of polio have increased more quickly there than in any other country over the last year. Over four times as many polio cases have been reported in Pakistan in 2014 than in 2013 (260 and 64 cases, respectively), and the year is not yet over. Fourteen new polio cases were reported during the week of November 26, and three of those occurred in Balochistan province, where the four polio workers were killed.

LHWs are on the frontlines of healthcare in Pakistan and are often tasked with running anti-polio campaigns. The Pakistani government created the LHW Program in 1994 with the goal of providing essential, primary health services at the community level, especially in rural settings. These women go door to door, interacting with families in their communities and providing health education and some basic health services. There are now over one hundred thousand LHWs, of whom 85 percent are engaged with the anti-polio campaign. The program is effective in providing critical primary healthcare: households visited by LHWs are 15 percent more likely to have children under the age of three fully immunized.

LHWs—and Pakistan’s entire campaign to eradicate polio—are under threat from extremists; since December 2012, militants have regularly attacked women working on vaccination campaigns. The attacks are fueled by conspiracy theories claiming the polio vaccine was created by Westerners to sterilize Pakistan’s children, a fear bolstered by the revelation that the CIA used a fake hepatitis B vaccination drive to track down Osama bin Laden. Last week’s incident is just one more in a long string of violent acts that have delayed progress in eradicating polio globally. In May 2014, the World Health Organization (WHO) declared the current spread of polio a public health emergency of international concern, in part because of this violent trend.

Vaccination drives are delayed not only by the violence itself, but also by the strikes organized in response to attacks. LHWs quickly responded to last week’s violence in Balochistan, refusing to participate in the anti-polio campaign that had been attacked, calling for protection, and promising not to return to their jobs until government officials could ensure their safety. “We want protection,” they chanted, criticizing law enforcement for ignoring their concerns.

But violence isn’t the only concern for these women. Although LHWs have been salaried government employees since January 2013, they are still fighting for fair wages. Becoming a LHW is one of the few jobs a Pakistani woman can have in government, and LHWs have reported wages that are lower than those of male manual laborers, as well as late payment of salaries.

Across Pakistan, LHWs have demanded a “regularization of services”—referring to a standardization of training, expectations, and wages—primarily by boycotting and postponing polio vaccination campaigns. For example, LHWs in Charsadda organized boycotts of anti-polio drives in July and September of this year, resulting in over 900 LHWs refusing to participate and delaying the vaccination of over 200,000 children.

According to the WHO, the “over-riding priority for all polio-infected States must be to interrupt wild poliovirus” in order to achieve global eradication. Strikes by LHWs only impede this progress, especially when these women have repeatedly demonstrated their effectiveness in the fight to eradicate polio. Pakistan should support these women to achieve their common goal. The demands of LHWs—security while doing their jobs and timely, fair wages for a job well done—are beyond reasonable, especially when compared to the consequence of delayed anti-polio drives: the failure of the global polio eradication campaign. These women’s participation is necessary to ensure every child is vaccinated and the spread of polio is stopped for good.