On Thursday, the Lady Health Workers’ (LHWs) protest turned violent. One of the staffers of the programme set himself on fire – a man jumped in with fire extinguisher to put it out – and police launched into an intense scuffle with the remaining protestors to keep them from lighting their oil-drenched clothes on fire.

“We have been protesting for months with no success, now we are desperate and we will burn ourselves to get noticed!” screamed the lady health workers from Sindh outside the National Press Club in the federal capital as officials from the Ministry of Human Rights tried to placate them.

At the core of the ongoing LHWs’ protest is the simple problem that their jobs are unsafe and their salaries have not been paid for months.

As health has been devolved to the provinces, national health programmes have suffered uncertainty as their fate remains undecided even months after the 18th amendment. In the case of the Lady Health Workers programme, this has put the pays of the over 100,000 staff of the program in jeopardy – and forced them to come out on the streets to save their bread and butter.

The Lady Health Workers Programme

The LHWs programme was launched in 1994 as the National Programme of Family Planning and Primary Health Care. The programme trained women to serve as community health providers in rural areas across the country.

“Today the number of lady health workers has reached 100,000, which is an indicator of its effectiveness and now LHWs have become the backbone of all national health programmes because different national health programmes are being implemented at the grass root level through them,” explained Dr Farah Sabih, a health expert at World Health Organisation (WHO).

The programme has received positive responses from all quarters. The forth comprehensive review of the programme found that households in communities served by the LHWs were 11 per cent more likely to use modern family planning methods, 13 per cent more likely to have a tetanus vaccination, 15 per cent more likely to get a medical checkup within 24 hours of a birth, and 15 per cent more likely to immunise children below three years of age.

One LHW is responsible for approximately 1,000 to 1,250 people, or 150 homes, and visits 5 to 7 houses daily. The scope of work and responsibility of LHW includes over 20 tasks, ranging from Health Education in terms of antenatal care and referral, immunisation services and support to community mobilisation, provision of family planning and basic curative care.

In fact, this expansion of LHWs role has become reason for critique of the programme. At a launch of new research findings by the National Commission on the Status of Women, one of the researchers concluded about the programme that it is effective and attains its objectives, but the additional responsibilities of administering polio drops and the like have diluted the LHWs effectiveness in their original field of family planning. However, the research also emphasised that the programme should not be closed because it has an integral role to play in national health.

The issue

When the LHW programme came into existence, it assigned a nominal stipend of Rs 3,200 and allowed flexible working hours.

This was supposed to be the state of affairs till July 2011, but after devolution, when provinces refused to adopt the programme because of financial constrains, the federal government extended the PC-1 and committed to keep providing financial support for the programme till 2015.

According to an expert who has seen the LHW programme evolve over time, as the LHWs were given more responsibility and their stipend not increased, this created discontentment among their ranks.

The result was the protests that had been ongoing for the last four years. The LHWs have been demanding a salary raise and a proper service structure through regularisation. “We are demanding for our rights peacefully. When we are assigned extra work, we should be paid on time and should be provided job security through regularisation,” said one lady health worker who works in Bhara Kahu.

The demands of the LHW are not without weight. In response to their protests, in 2010, the Chief Justice of Pakistan Iftikhar Mohammad Chaudhry took suo moto notice of their issue and directed the government to frame service rules for them and fixed their minimum wage at Rs7, 000.

Who owns the LHW programme?

“Devolution proved to be another setback for the programme because it fell through the cracks as the centre abandoned it but the provinces were not ready to bear the expenses of these national programmes,” said a health official not willing to be named.

After negotiations between the federal and provincial governments, it was decided that federal government would provide the financial assistance to these programmes but all the managerial issues would be dealt with by the provincial governments.

Dr Ghulam Asghar Abbasi, Chief Health, Planning Commission of Pakistan contradicted that the issue was financial in nature and told Dawn: “This state of affairs is not a result of any financial crisis. It is simply a management issue on the provincial end. We have already released Rs8 billion this year for vertical health programmes including the LHWs programme.”

“I don’t understand why these LHWs are protesting in Islamabad since devolution has given the responsibility of their programme to the provinces. It is now a provincial decision if the programme should be regularised or not. We are only responsible for the financial assistance,” he said. But the protestors in Islamabad argued that the centre was responsible for their pays and therefore should take responsibility. One LHW explained that meeting basic needs had become impossible for her family since they were not being paid their salaries and this was affecting the performance of many like her. “Many of my colleagues don’t go to far-flung areas and only administer polio drops to the children living close to their residence. They justify it by saying that we are not given salaries and transport facilities so why should we perform our duties honestly,” she stated.

Meanwhile, meetings are taking place on both provincial and federal level to resolve the issue. The prime minister has passed orders to pay their salaries while according to reports the Sindh Assembly on March 30, 2011 has also passed a bill to regularise the LHW programme. But the continuing protests show that these have been hollow moves without concrete action to resolve the issue.