4.1 Availability of Health Services
These inequities in reproductive health care access relate not only to gaps in provision of types of services, but also to availability of facilities. Overall, of the UCs where health resource assessments were conducted (n=636), 26% (n=165) are without EPI Facilities, and 31% (n=197) are without any health facilities at all (whether public or private).
Fixed facilities are a requirement for most reproductive health services. Only 3% (n=232) of the slums and underserved areas out of a total of 4431 areas in ten cities are located within a 3 kilometre distance from the slum areas, and 29% (n=1285) of the slum and underserved areas do not receive health outreach services from fixed facilities. Limited transport also impedes accessibility. In Quetta City of Balochistan Province, the Urban Slum Profile reports that access by female caregivers to health facilities is limited by the fact that there are scattered residential areas which are devoid of gender friendly transport facilities.29 In Karachi, with a population of 7,645,375, only 9% of the public health facilities located in the slums have an ambulance service. Although trends in facility delivery are improving (66% in 2017-2018 compared to 13% in 1990-91), it remains the case that 1 in 3 births are still occurring at home. 30
4.2 Female Workforce Participation
In the context of gender and health, workforce participation can refer to participation by women in the general workforce generally or in the health workforce specifically. In collecting data on the household characteristics in the national coverage survey, information was sought on the current employment status of women and men in the households, with 14491 women mothers being interviewed in the slums and underserved areas of 10 cities.
Nationally, of the 14491 women surveyed in 4431 slum and underserved areas in 10 cities, only 6% (n=833) had employment outside the home. Workforce participation rates for mothers were as low as 3% in Rawalpindi (n= 26 of 824 respondents) and 2% in Faisalabad (n= 13 out of 712 respondents).
This low workforce participation rate may be partly because the mothers interviewed all had children between ages 12 months and 23 months (the age parameters for inclusion in the immunisation coverage survey). However, these findings are consistent with other findings on female workforce participation, which illustrate that, despite some growth in recent decades, female labour force participation in Pakistan is well below that of other countries with similar national incomes. An analysis of Province wide female workforce participation to population ratios in 2017-2018 found such rates were low in Balochistan (6.7%) and KPK (9.3%) provinces, compared to rates in Sindh of 9.3% and in Punjab Province of 22.7%. 31
These low rates are attributable in part to the persistence of gender norms, which identify males of the households as the major income earners and decision makers, resulting in the confining of women at home, or restricting female workforce participation to certain socially acceptable labour force roles. The persistence of these gender norms reduces workforce participation, which in turn reduces productivity and constrains household incomes.32
The association between low female workforce participation and socio-economic status are further reinforced by the findings of the immunization coverage survey in slums and underserved areas. Of the 14,467 households surveyed, 54% (n=7846) of households derive incomes from daily wages and 56% of households (n=8060) are either occasionally or are always in income deficit. Just 6% of households (n=888) experience income surplus (i.e. have household savings).
One opportunity presented in the Urban Slum Profiles for improvement in health and social conditions is increased participation of Lady Health Workers (LHWs) and Visitors (LHVs) in PHC programs. This is not only a method of increasing female workforce participation but is also a means of providing more “gender friendly” health care services for maternal and child health care. The National Urban Slum Profile indicates that lack of female health sector workforce participation is a “discouraging factor” for attendance of women and children at health facilities.23
The primary function of the Lady Health Visitor (LHV) is to provide maternal and child health care. The survey of EPI facilities in eight cities found that 39% (n=163) of EPI facilities do not have LHVs placed in them. Of the 636 Union Councils in eight cities, the urban slum profiles confirmed that 25% (n=157) were not covered by LHWs. The regular visits of LHWs in the slum communities are important because these health workers educate and promote healthy behaviour and provide basic curative healthcare services, but overall, across the eight cities in which the urban profiles were conducted, it was found that 58% of the slums and underserved areas are not covered
by LHWs.24 This lack of availability is confirmed by interviews with 14,491 mothers during the immunisation coverage survey in 10 cities, which found that only 56% (n=8166) know about the work of LHWs.
4.3 Gender Friendly Health Services
The term “gender friendly health services” is applied in the profiles in the context of facility design, including waiting room arrangements and water and sanitation infrastructure, and the degree to which these categories of infrastructure are gender disaggregated.
Overall, 58% (n=238) out of the 422 facilities surveyed in eight cities did not have gender segregated waiting areas. Additionally, 43% (n=180) of the 422 facilities did not have gender segregated toilet areas for patients and staff, and 26% (n=11) of facilities had no toilet facilities at all. Water supplies were available at only 65% (n=276) of the 422 surveyed facilities. Gender segregated waiting areas were available at 42% (n=172) of the 422 surveyed facilities. Seven out of eight cities report inadequate seating capacity at clinics in or near slums and underserved areas. The National Urban Slum Profile indicated that the fact that 31% percent of the toilet facilities were gender mixed presented a “cultural barrier for females for easy use”, especially in cities such as Peshawar and Quetta where female caregivers may be considerably discouraged to get their children vaccinated due to the lack of such facilities.22 Issues of privacy of examination rooms inside clinics were not examined in the profiles.
Availability of reproductive health services, female workforce participation and gender friendly health infrastructure could all legitimately be classified as constituting “gender friendly health services.” Presentation of findings will now extend beyond the health sector to include description and analysis of gender issues reflected in educational attainment, social connections and welfare service, as well as autonomy of decision making.
4.4 Schools and Health Literacy
The urban slum profiles confirm that there are strong connections between a mother’s educational status and the coverage of vaccination in their children. These findings are attributable to several factors, including knowledge of mothers about the benefits of vaccination. In the national sample of 14,491 mothers of children aged 12-23 months, just 67% (n=9659) could state that vaccination protects from diseases, with the remaining 33% (n=4832)either not knowing or stating other reasons for vaccination being given.
A second reason is lack of access to school education. Overall, 27% of slums and underserved areas are without schools. Of the 1,978 mothers in the national coverage survey who had children with zero doses of vaccines, 1,505 (76%) had zero years of schooling, in contrast with the mothers of children of fully immunised children, of whom 47% (n=3598) had zero years of schooling. The links between schooling and development is summed up in this extract from the qualitative discussions:
“I still remember the day when I was married to him (my husband). I was 14 years old and in the 8th grade. I had ambitions of pursuing higher education and making something out of myself so that I could have a better life than my parents had and could choose a better life for my children-to-be. It seems it was not in the cards, after all.”33
There are two further criteria which can be applied relating to access to information about vaccination and modern health care. These include social connections and autonomy of decision making, both of which will be taken up in the following sections.
4.5 Social Connections
The Urban Slum profiles report widely on the availability of community based and civil organisations in communities in eight of the ten cities, as well as on the number of formal and informal groups available in the slums and underserved communities, as outlined in Table 1.
Table 1
Prevalence of Community Organisations and Social Welfare Schemes in Slums and Underserved Areas in 8 Cities (n= 3114)
Types of Groups and Schemes in 3114 Urban Slum or Underserved Areas in Eight Cities
|
No.
|
%
|
Informal Groups
|
Masjid/Church, Zakat, School or Health Committees, Unregistered Community Based Organisations, Jirga/Punchaiyat
|
1082
|
35%
|
Civil Society
|
Education, Health, Loans, Water, Human Rights
|
72
|
2.3%
|
Social Welfare
|
Loan and Stipend Schemes, Social Benefit Cards, Vocational Skill program.
|
1512
|
49%
|
The information demonstrates extremely low levels of formation of community level organisation and social connections with regards to health and education. These observations, coupled with the fact that only 6% of women surveyed work outside the home, suggest that lack of knowledge and demand and supply of services is not being compensated for through community organisation and social networks. It reinforces earlier findings of limited knowledge of households of the benefits of vaccination. It also raises questions about access of women to sufficient channels of communication enabling them to make autonomous and informed decisions about use of modern health and education services.
4.6 Autonomy of Decision Making
The immunization coverage survey in slums and underserved areas found that, of 14,441 mothers, 1985 of their children (14%) did not receive any vaccine. As illustrated in in figure 3, the most common response for why children did not receive vaccines was that family permission was not given (33%, n=647)., with particularly high response rates for non-permission in the slums of Karachi (48%), and Quetta and Peshawar (both 43%). As figure 3 illustrates, there are also other reasons include ‘fear of side effects’, ‘no time for vaccination’ and unaware of vaccination timings etc.
This lack of autonomy over decision making and limited social connections and availability of schools, coupled with low availability of a female health workforce participation, all interact to create a powerful social and institutional web of influence excluding women from informed decision making about health care. The following extracts from the Karachi urban slum profile highlight the challenges and complex dynamics of the urban poor women in seeking out health care:
”It is very difficult to find time to go out of home. My husband takes care of responsibilities outside home…my husband does not allow me to travel alone and he does not have time available to take kids for vaccination by himself as it results in forgoing a day’s wage.’ ”28
‘Bareera aged 12 months and 2 days, lives in a small, dilapidated slum …Residing here for the past 07 years, their house is composed of 02 rooms in which a total of 11 people live. ………. Aged 24, Bareera’s mother is illiterate and has not ever received any formal education. She is completely unaware of childhood vaccination and its significance. She says: “Bareera has not received any vaccination due to her grandfather’s disapproval. He becomes infuriated by such a proposition and is highly sceptical of the presence of men in vaccination centers….”’34
From a perspective of inequities, autonomy of decision making not only relates to the issue of equal access of girls and women to vaccination services. It also remains the case that, even though there are significantly more boys fully immunised than girls, that fact that a significant minority of boys are still not fully vaccinated demonstrates that a mother’s lack of autonomy in decision making affects access of both boys and girls to primary health care services. A plausible explanation for a significant proportions of boys not being fully vaccinated is related to the fear of side effects as illustrated in figure 3.
4.7 Inequities in Health and Social Outcomes
Given the reported low availability of a female health workforce, health facilities and reproductive health services in the slums as reported in sections 4.1-4.3 of this paper, it would be reasonable to conclude that reproductive health and child mortality outcomes are likely to be comparable to PDHS findings in 2018. Although there are narrow gender gaps between fully immunised boys (54%) and fully immunised girls (53%) in the immunization coverage survey in slums and underserved areas, from a gender and public health impact perspective, the critical intervention for consideration is the role of women as primary health care givers supporting improved access of both girls and boys to immunization and other health services. Vaccination coverage rates are significantly lower in urban poor settings, with the Pakistan Demographic and Health Survey (PDHS) in 2018 demonstrating a coverage rate of 66% for fully immunised child rate compared to 54% (fully immunised child) in the urban health coverage survey.35