Underpaid and under threat, dedicated female workers strive to improve the health of impoverished women and children.

Karachi, Pakistan – For Pakistan’s Lady Health Workers, it is a life of verbal threats, physical abuse, and unpaid salaries.

The South Asian nation of more than 207 million people is one of three countries in the world, along with Afghanistan and Nigeria, where the transmission of the potentially deadly polio virus is ongoing.

In 2017, five polio cases were reported in five districts in Pakistan, down from 306 cases across 43 districts in 2014.

But for the women largely responsible for bringing the figure dramatically down, their work is anything but safe or lucrative.

Two Lady Health Workers were shot dead while on polio-vaccination duty in the southwestern city of Quetta in an attack earlier this year.

The Lady Health Worker Programme was introduced in Pakistan in 1993 in order to make primary healthcare accessible to women who are confined to their homes, and to effectively administer immunisation campaigns among children. Currently, 125,000 women are employed as part of the health programme.

The women work in some of the harshest conditions imaginable. In conservative neighbourhoods, they are often vilified for carrying out tasks deemed un-Islamic by local leaders.

Their families, particularly husbands and fathers, often oppose their work, which takes them inside the households of strangers.

An average day

Rukhsana, who didn’t want her surname used for security reasons, is a middle-aged Lady Health Worker from Akhtar Colony, a congested lower-middle-class neighbourhood in the southern city of Karachi.

A typical workday in Karachi, Pakistan’s most populous city, starts with millions of people making their way towards the city centre or industrial areas on public and private transport. It for most finishes after sunset.

Rukhsana arrives at her designated neighbourhood on a bus and walks door-to-door to offer birth-control counselling for women, vaccinations for children, and primary healthcare advice on disease prevention.

Every month, she visits nearly 150 households, or about 1,400-1,500 people, she told Al Jazeera while walking through the cramped locality.

Research by Public Services International into the problems faced by workers such as Rukhsana reveals issues such as irregularly paid wages, sexual harassment, and threats to personal security.

Inadequate protection while on polio duty has been highlighted as they often meet life-threatening resistance across the country.

The Lady Health Worker Programme was introduced in Pakistan in 1993 in order to make primary healthcare accessible to women [Shameen Khan/Al Jazeera]

“Almost 90 percent of the women working as Lady Health Workers have no control over their own salaries,” Mir Zulfikar Ali, of the Workers’ Research Organisation that conducted the research, told Al Jazeera.

Rukhsana is a qualified medical lab technician and worked as one until she had her son. “I gave it up for my son and as soon as he turned four, I started working as a Lady Health Worker so I could pay his school fees and work flexible hours,” she said.

Her ex-husband was never able to hold a job so her irregularly paid salary of about $125 a month was the only household income.

As she walks through the dusty lanes with open sewers, Rukhsana points at a small metal gate labelled “health house”, where she lives for $45 a month so she is accessible to the community.

“I have to be present in the neighbourhood in case a woman wants to come see me or ask for contraceptives, birth-control pills or first-aid help,” she explained.

Although the work hours for her full-time job are flexible, Rukhsana finishes her daily house calls and report writing before sunset.

She then does a four-hour part-time shift as a technician at a local medical laboratory. At 10pm, as her workday comes to an end.

Dangerous work

Physical violence and sexual harassment are the most pressing issues for Lady Health Workers.

They are often targeted during countrywide polio campaigns, or for protesting against unpaid wages. In 2011, a worker died during a demonstration and clashes with police in Lahore.

“These women don’t discuss their problems openly as officials in important government positions, most of whom are men, threaten them with consequences such as sexual abuse or dismissal of their jobs,” said Ali.

In 2012, thousands of Lady Health Workers staged multiple protests across the country demanding their salaries.



Physical violence and sexual harassment are the most pressing issues for Lady Health Workers [Shameen Khan/Al Jazeera]



“The government responded by attacking them with baton charges and water cannons,” Ali said.

The incident led to more demonstrations and eventually, Pakistan’s chief justice called for the workers to be made permanent government employees with their salaries paid regularly.

Despite the justice’s order, it’s still rare that they receive their money on time.

“Usually, we get paid after three, four or even six months, which becomes an issue for those of us who run the monthly household expenditure,” said Rehana, who also pays for her daughter’s college education.

Her surname, like other women in this story, was not published to protect her identity.

Meeting the community

At a home in Akhtar Colony, Rukhsana attends a health session led by her neighbourhood’s supervisor, Nasra.

A confident middle-aged woman, Nasra spent seven years working as a Lady Health Worker before being promoted. Among other duties, she holds weekly sessions with each worker to discuss community issues, as well as problems they encounter.

Women begin to file into the brightly coloured living room of the house. Greetings, handshakes and jokes go around before they settle down.

Nasra gives a talk on women’s health, basic hygiene for women and children, and community cleanliness before opening the floor for questions.

According to Nasra and Rukhsana, the most commonly reported problems are related to women’s health, viral illnesses among children, and lack of cleanliness on the streets.

Sidra, 19, a mother of two, said she struggles to control her weight and admits she had no concept of sexual health when she got married at 16.

“We can’t tell them about birth-control pills or contraceptives until they have had their first baby,” Nasra said.

“We can’t tell their parents not to marry them before the age of 18 either, as these things are not appreciated or accepted in our culture. If we say something, they turn against us and accuse us of corrupting their daughters.”

Accusations, slurs and disapproval from the communities they serve are not new for Lady Health Workers.

Cultural animosity

In 2012, a year after Osama bin Laden was killed in a US-led military operation in Abbottabad, a local doctor was found guilty of treason because he collected DNA samples from bin Laden’s family under the guise of a hepatitis vaccination campaign.

According to Ali, this led to an increase in violence against polio workers and resistance to healthcare efforts.

“Anti-polio speeches were propagated through mosques by religious leaders who greatly influence public thinking in our country. Killings were carried out in the name of religion as polio drops were labelled ‘haram’,” he said.

Centuries-old traditions also make it difficult for them to do their jobs.

“Some people don’t even open their doors for us and call us ‘American agents’ for administering vaccinations and promoting birth-control pills,” said Nasra.

She recalled an incident when one of her team had a gun pointed at her head for insisting on providing polio vaccines at one home.

Some men, Nasra added, invite Lady Health Workers inside their houses on the pretext of vaccinating children, and then sexually harass them.

“When we are sent to other areas where we are strangers to the locals, they treat us with suspicion and harass us,” Rehana said.

The problems Lady Health Workers face are largely attributed to Pakistan’s male-dominated society, Rukhsana said. “It’s a man’s world. No one cares about women.”