Pages

Friday, 2 August 2019

HIV in Pakistan: Who knows, who cares?

By Shehrzadae Moeed and Adil Sayeed

Photo credit: Torange.biz


In April 2019, a doctor in Larkana’s Ratodero sub-district was arrested for allegedly passing on Human Immunodeficiency Virus, or HIV, to his patients. In the aftermath, as the Government of Sindh moved into firefighting mode, more than 30,000 individuals were screened, of which 851 tested HIV positive. More than 64% of these were under the age of six. In Kot Imrana, Punjab, the number of people with HIV increased from 1.4% in June 2018 to 13.4% in January 2019. It has been reported that over 5000 quack doctors operate in the area and 869 people have been diagnosed with AIDS. A recent report by the UNAIDS puts Pakistan on a list of 11 countries with the highest global prevalence of HIV, at 13%.

Why has Pakistan experienced sharply increased rates of HIV? In this blog, we will look at the data to assess why HIV remains prevalent and use cross-country evidence to learn lessons on tackling what is a very manageable illness.

HIV and its causes
HIV is an infectious disease that is spread through the blood, such as through used syringes, or transmitted sexually. It can also be transmitted to children if the mother is pregnant. The infection damages the immune system, and its most advanced stage develops into AIDS (Acquired Immune Deficiency Syndrome), which is life-threatening. It is a serious illness with global efforts to tackle it. However, even though it is a lifelong condition, developments in medicine mean that, with proper and regular treatment, an infected person can live a full life.

Commonly, the causes of the growth of HIV prevalence in Pakistan, similar to many developing countries, are attributed to medical negligence, a broken healthcare system, unregistered blood banks, and unlicensed practitioners, including quacks. In addition to this, the common Pakistani “penchant for receiving injections and drips as quick fix in lieu of healthy nutritional lifestyles” contributes to the inclining HIV prevalence in Pakistan.

Further, migrant labour forces open to commercial sex, and increasing man-to-man sexual activity, also contribute to this. In any other country where same-gender sex isn’t a criminal offence, governments work hard to ensure the practice of safe sex. In Pakistan, however, taboos around sexual health make it difficult for sufferers to seek help or even find a support group. If no one can talk about sex, who’s ever going to talk about safe-sex?

What does the data tell us
While the proximate causes commonly discussed in the media may have to do with unsafe sex, reusing needles, blood transfusions, and similar unsafe practices arising from quackery, medical negligence or drug use, the data suggests that the underlying cause, however, is the lack of awareness of sexually transmitted illnesses (STIs).

In the Pakistan Demographic and Health Survey (PDHS) 2017-18, only 32% of women and 67% of men reported that they had heard of AIDS. In Sindh, this is even lower, with 26% of women and 49% of men reported being aware of AIDS. These figures are very low.

Furthermore, out of every 100 women, less than 4 are aware of the fact that there is a treatment for HIV and less than 3 know where to receive HIV treatment. Similarly, less than 33% of men are aware of the fact that there is a treatment for HIV, and less than a quarter have any knowledge of treatment centers. Comprehensive knowledge about HIV is abysmally low, with only 4% women and 10% men being familiar with the details of this illness.

A lack of awareness of this public health challenge is thus endemic – a flip side of the same coin, however, is the discrimination among those who are aware. In the same survey, more than 50% of the respondents said they would not buy fresh vegetables from a shopkeeper who has HIV. Similarly, 46% of women and 48% of men who are aware of AIDS said they would not want HIV positive children to go to a school with those unaffected by this illness.

Discrimination in a population acts as a disincentive for people to get tested and treated. It is the taboo associated with HIV and AIDS that also leads to less people being open about it, thereby reinforcing the lack of awareness.

Way forward
What is clear is that the Government of Pakistan’s National AIDS Control Programme (NACP), which was established in 1986-87 and has received significant donor financing, has been ineffective in tackling the social causes of HIV/AIDS prevalence. Perhaps there is a need to learn from other countries – after all, Pakistan is not the first country facing this issue.

In Brazil, for example, massive reduction in cases can be largely attributed to a massive awareness program (prevention) coupled with widespread distribution of free medication (treatment). Their ministry of health also utilized social media in a 2014 awareness campaign. This also assisted in reducing the population growth rate which currently stands at a relatively low 0.8% as compared to Pakistan’s 2% annual growth rate. The success of Brazil’s AIDS campaigns is evident today as 84% of the population with HIV is aware of their condition as compared to just 15% in Pakistan.

In sum, Pakistan needs to rethink its strategy to fight HIV and AIDS. HIV, if caught and treated, can yield a normal life for those infected with it. If not treated properly, however, HIV can quickly develop into AIDS, which is life-threatening and a miserable condition to be in for someone infected with it. The spreading of STI’s and the chances of HIV developing into its last stage of AIDS are particularly high because of the lack of awareness and stigma associated with them in Pakistan. The NACP needs to tackle these head on, perhaps by talking about these issues from an early age, including sexual education in school, as other countries, including Brazil, have done. As long as there is a lack of awareness regarding the issue, these epidemics will continue to prevail and the people will continue to suffer.


The authors were interns at the Collective in July 2019.

Saturday, 29 June 2019

Reproductive rights

by Ayesha Khan

Sindh High Court
Photo credit: Wikimedia Commons


We are one step closer to having maternal health recognised as an inalienable right in the Constitution. The Sindh High Court recently ordered the government to make good on its commitment to set up four fully functioning obstetric fistula repair centres in the province, in response to a petition pending since 2015.

Friday, 14 June 2019

Low Cost, Low Access? A Misplaced Focus on Drug Pricing in Pakistan

By Kabeer Dawani

Source: https://www.goodfreephotos.com

There has been uproar in the media on recent increases in medicine prices, some of which are viewed as exorbitant. Many opposition politicians have made public statements condemning the government for this and social media is rife with disapproval. Further, as part of the cabinet reshuffle on 18th April 2019, the Federal Health Minister was removed, with the media claiming that this is because of the increased medicine prices.

Given medicines are a necessity, and in an environment with high inflation, some of the uproar is understandable; but are the claims that there is overpricing correct, or were these price increases legitimate? And what does pricing mean for availability of essential medicines, which are vital for public health? For the past six months I have been engaged in a research project on strategies to address corruption in the pharmaceutical sector, in partnership with the SOAS Anti-Corruption Evidence research consortium. While the project is still ongoing, I will borrow from this work to provide historical context to this round of price increases, point out negative consequences of controlling prices, and make a case for decontrolling prices for non-essential medicines.

Medicine Pricing Over the Years
The pharmaceutical sector is unique in Pakistan in that the universe of products have controlled prices, which are by and large enforced. This control is inconsistent and prone to rent-seeking. There was a virtual freeze of prices from 2001 to 2013, despite rising costs of production. Then in October 2013 the Nawaz Sharif government initially increased, but very quickly revoked this increase. The manufacturers went to court and managed to get a stay on the original increase. Following that, a pricing policy was introduced for the first time in 2015.

Due to inconsistent applications of the policy and pricing disparities from the past, litigation on medicine prices in various courts piled up, including on the 2015 policy. Eventually, the Supreme Court took all the cases together through a suo motu notice. On the SC’s orders and with due consultation, another pricing policy was introduced in 2018.

Over the past few years, the costs of production – mainly for raw materials, 95% of which are imported – have increased drastically due to two factors. First, devaluation of the Rupee since 2017 has increased this cost. Second, China’s environmental policy has resulted in an increase of prices of chemicals, and since China is the biggest supplier for Pakistan, this means higher raw material costs.

It is in this context that medicine prices were increased recently. In December 2018, the Drug Regulatory Authority of Pakistan (DRAP), through three Statutory Regulatory Orders (SROs) , allowed an increase in 600-plus medicines because of ‘hardship cases’ (but also reduced prices for 395 medicines). Then, acting on a SC order, and in lieu of the currency devaluation, DRAP permitted another increase of 9% for essential medicines and 15% for non-essential medicines. While there is no doubt some manufacturers may have increased their prices beyond that permissible, in general the price increase was merited and, in fact, long overdue.

Costs of Over-Regulation
The conventional argument in favour of controlling prices of medicines is a populist one: governments put a ceiling on medicine prices so as to enable the low income population to have access to affordable medicine. This seems to be borne out by the current controversy over increased prices, and the recent announcement by the Pakistan Pharmaceutical Manufacturers Association (PPMA) to reduce prices by 10-15 percent of 464 medicines ‘voluntarily’. There is indeed public pressure to keep prices in check – but does this also have a cost to economic growth and public health?

Our research into this shows that there are significant negative consequences to the strict price controls practiced in Pakistan. These costs pertain to shortages of key medicines, often leading to black marketing and increased imports, higher drug resistance, and withdrawal of multinational firms.

Businesses, by definition, operate for profit, and pharmaceutical manufacturers are no different. With a freeze in prices and no consistent increases, even though initial prices may yield high margins for manufacturers, these margins are inevitably squeezed over time because of inflation. The result is that producing a medicine is not profitable any more, leading to shortages of many essential medicines. For example, in 2015 there were multiple reports of a shortage in medicines for tuberculosis. When there are shortages, some people hoard supplies and sell on the black market for up to 50 times the original price, or the same drug is imported for a higher cost. The consequence of either an absence of a key medicine or much higher monetary costs is thus borne by the consumer.

The shortage hurts the poorest segments of society, who can only afford to get medicines from public health facilities, the most. One study estimated that, of a basket of essential medicines, only 15% are available in the public sector. This is not only because of public procurement issues because in the private sector, availability, at 31%, was twice as better but still much below what it should be.

When a medicine is not profitable to produce anymore, many manufacturers register a new drug to produce. At registration, manufacturers can get a price with high margins so that even if there is no increase over the short-to-medium term, they can make a profit. Thus, many first-generation drugs have stopped being made and instead manufacturers have gone on to produce second and third-generation medicines, which are more expensive. These new drugs can have prices that are ten-times higher than the original first-generation medicine. Again, the burden of this falls on the consumer whose out-of-pocket expenditure rises.

In addition to the costs to the general population, there is also a negative consequence to the economy and to public health because many multinational companies (MNCs) have exited the Pakistani market. Since there is no research and development of drugs in Pakistan, all new products are brought into the health system through MNCs who develop new medicines elsewhere. MNCs also have higher standards than local firms and invest heavily in developing human capital through trainings. This has a positive spillover in the local industry as pharmacists who are trained in these firms then go on to improve the quality of medicines being produced locally. Thus, the exit of MNCs, in addition to the economic costs of disinvestment, also leads to negative consequences on public health through other means.

Policy Implications
There appears to be a surprisingly effective political consensus on keeping medicine prices suppressed, and to which citizens hold governments accountable. Even prices that were raised through the proper mechanism, as defined in the pricing policy, have been criticized. However, given the issues I have described above, this consensus is misplaced because it misses out on the more important goal of access to medicines. Focusing only on affordability has the negative, and hugely important, consequence of unavailability of key medicines and in turn affects public health.

There is an urgent need to decontrol prices for non-essential medicines. With more than 750 manufacturers, there is sufficient competition in the industry to ensure that no one increases prices astronomically. In fact, one manufacturer told me that before the devaluation hit them, they used to sell 70% of their medicines below the notified maximum retail price.

The state can, however, rationally control prices of essential drugs. This will ensure that medicines which are prioritized will not have prices spiraling out of control.

More importantly, I would argue there needs to be a shift in the current political consensus. Instead of keeping prices in check, access to affordable medicines should be made through the existing government (primary, secondary and tertiary) healthcare system. Provincial governments already do this at scale and this can be improved and expanded.

Finally, in the medium term there also needs to be a concerted effort by the state to incentivize the production of pharmaceutical raw materials within Pakistan. Not only will this help reduce the trade deficit, it will also reduce the exposure of prices to fluctuations in the currency market, create jobs, and spur economic growth.


Disclaimer: This blog is an output of a research programme (SOAS-ACE) funded by UK Aid from the UK government. The views presented in this blog are those of the author and do not necessarily represent the views of the UK Government’s official policies.

A version of this blog was originally published by Prism, Dawn.

Friday, 31 May 2019

The language of disability

By Ayesha Mysorewala and Saba Aslam


Source: Pakistan Population Census report (1998). Pakistan Bureau of Statistics


Globally, the dialogue on disability has made a lot of progress. The 2006 UN Convention on the Rights of Persons with Disabilities (UN CRPD) marked an important shift in the discourse on disability by moving away from taking a medical approach towards a social model of disability. The social model suggests that “the barriers individuals face are not a result of their impairments (that the problem is not the individual), but that the barriers are created by society, attitudes and the physical environment”.[1] If a person with a disability (PWD) is able to exercise rights through for example, inclusive education, accessible transport, and has equal opportunities to work at public or private institutions, this may imply a social model of disability or a rights-based approach.

We argue that language used for disabilities has a key role in shaping barriers and access to an inclusive society.

A recent report by the British Council that focused on mainstreaming young Pakistanis with disabilities finds that persons with disabilities (PWDs) are often overlooked in discussions about Pakistan’s future. This is despite the fact that Pakistan has ratified the UN CRPD in 2011.

One manifestation of our collective lack of focus on disabilities is a lack of vocabulary and understanding for disability in local languages, including Urdu.

While conducting qualitative fieldwork for an ongoing project “Mainstreaming Inclusive Resilience in South Asia”, we were investigating the experiences of vulnerable groups, including PWDs, in natural disasters in Sindh. We found that there are varying understandings in communities regarding who counts as disabled. In surveys, this makes it very difficult to effectively identify PWDs.

Our team tried to establish a common vocabulary to discuss how communities understand disabilities. The Urdu word mazoor was an obvious choice (which has also been used in the Urdu questionnaire of the previous census). In qualitative interviews, however, this induced an image of a person who has physical impairments. Probing into specific types of disabilities led us to find that many categories such as hearing and/or speech impairments are not perceived as disabilities unless they prevent a person from engaging in productive work.

The problem of researching intellectual disabilities is even more complex. Communities themselves offered terms to us during the qualitative interviews. Disempowering words such as charyo and pagal were mentioned by a number of respondents to identify and describe extreme forms of intellectual disabilities, which to some extent indicates a culture of stigma and pity. In Sindhi speaking areas, we settled on using the word Jaddo (impairments) to enquire about disabilities. This created room to discuss more subtle intellectual disabilities such as slow learning in schools. It was clear, however, that people did not identify the latter as disabilities or mazoori. This led us to conclude that disability is constructed in a social context.

There is the additional complexity of variations in meaning attached to local terms in different contexts. Many of the local terms (including the ones mentioned above) are deeply rooted in the specific historical context of different communities, which warrants an entirely separate blog. The implication, however, is a need to exercise nuance in the meanings we attach to the terms that are used.

The lack of local metaphor to describe the concept of disabilities have implications for research and policy. The most significant one is the underreporting of PWDs.

The Pakistan Demographic and Health Survey (PDHS) 2017-18 follows an International Classification of Functioning, Disability, and Health that covers six core domains – seeing, hearing, communication, cognition, walking and self-care and disaggregates impairments, which is useful as respondents are asked about their level of difficulty in each of the domains. However, the 1998 census[2] reports mental disabilities in two categories: insanity and mental retardation[3] which may reinforce stigma, and make it less likely for respondents to report disability.

Undercounting in turn reflects a weak emphasis on needs of disability in policy and its implementation. Most legislative changes that have occurred are subject to the 1981 Disabled Persons Employment and Rehabilitation Ordinance, which deals mostly with setting quotas for PWDs in jobs. Post-devolution amendments to the Ordinance, however, focus on creating accessible infrastructure, providing special identity cards and expanding cash assistance to PWDs. Even though there are few laws that address broader issues of social exclusion at the national level.[4], we find that Sindh Empowerment of Persons with Disabilities Act 2018 and Balochistan Persons with Disabilities Act 2017 follow a social model of disability. The Sindh 2018 Disability Act is particularly exceptional as it stresses on inclusion of PWDs in all institutions. It is not clear however, the extent to which these legislations are implemented.

There are no comprehensive records of PWDs at local administrative levels such as districts and Union Councils. There is also a lack of sensitization around disability amongst local government officials and the district and Union Council levels. In our discussions with communities, we found that this leads to great deal of exclusion of PWDs and their needs in evacuation and relief measures, and adds greater burdens on already distressed households in disaster-prone areas. It also leads to inappropriately designed interventions by organizations funded by donors who pressurize an emphasis on disability without it being internalized by those implementing the programmes.

There is a need to foster open debate on disability and establish a more contextualized understanding and empowering language for various kinds of disabilities at all levels. Comprehensive legislation in all provinces (and its tracking) would be an excellent step. However, there is still a long way to go in moving from a culture of neglect and stigma around disability to one that focuses on empowerment and rights. Perhaps the first step can be thinking about how we talk about PWDs in our everyday conversations.



[1] The Economist Intelligence Unit. (2014). Moving from the Margins: Mainstreaming Persons with Disabilities in Pakistan.

[2] Full reports on disability from 2017 census are not yet publicly available

[3] The Mental Health Ordinance of 2001 provides a relatively comprehensive set definitions of intellectual impairments. Gilani et al (2015) argue that this law outdated archaic and imprecise terms such as lunatic, insane and asylum

[4] Special Citizens Act (2008), for example, states that PWDs shall be provided access at all public places such as reserved seats in public places and in transport

Monday, 6 May 2019

Women activists and their turn to the courts

By Ayesha Khan

Hina Jilani, a renowned lawyer and leading activist in Pakistan's women's movement speaking at World Conference of Women's Shelters, 2015
Photo Courtesy: Hina Jilani


Women’s activists in Pakistan have a strong tradition of turning to the courts to advance their rights, and in the process edifying the courts, government, public and media along the way. Along with my colleagues Sara Malkani (an advocate of the High Court and representative of the Center for Reproductive Rights) and Zonia Yousuf at the Collective, we have spent many months collecting documentation and conducting interviews with activists (mainly members of Women’s Action Forum (WAF)) to understand how and why they have turned to the courts even during very dark periods in our nation’s history.

Naysayers (and there is no shortage of them here) would argue, why bother with a corrupt judiciary and an even more corrupt political establishment? No one really believes in the rule of law! True, even Prime Minister Imran Khan recently promised to preserve the jirga system in erstwhile FATA even after the Supreme Court explicitly declared tribal jirgas unconstitutional in January this year. This final judgment from Saqib Nisar ended a story that began with activists petitioning against jirga in Sindh, which declared them unconstitutional in 2004, and followed with petitions to the Supreme Court filed by the National Commission on the Status of Women (2012) and the KP government (2018), all invoking our fundamental rights (including Article 10A, right to a fair trial) and demanding women’s protection from customary practices, honour killings, and other crimes sanctioned by this retrogressive remnant of our so-called culture.

But if you were a woman in Pakistan, and found yourself accused of zina during the 1980s, you surely would have wanted Asma Jahangir or Hina Jilani to fight for you and invoke, as they often did, Article 25 (equality of citizens) and Article 4 (right of individual to be dealt with in accordance with law) of your fundamental rights in your defence. You would surely be relieved to know they won almost all of their thousands of cases before it became virtually impossible to file charges of zina when the law was finally amended in 2006.

And if you were Rukkaiya Iqbal, filing the first ever case under the new 2013 domestic violence law in Sindh, surely it would be a profound relief to see your abusive husband jailed and sentenced for his years of violence towards you, and you would be grateful that Karachi advocate Sara Malkani believed in the courts enough to argue your case even though it would be the first time the judge had ever heard of the new law.

We all know that rape trials almost never end in conviction, but since activists fought so hard, despite protestations from the Council of Islamic Ideology, to have the law changed, politicians finally passed the 2016 Anti-Rape Law to make DNA testing mandatory in cases of rape. This, too, was on the back of a constitutional petition on the use of DNA testing, filed by Salman Akram Raja and activist Tahira Abdullah in 2012, to mandate improvement in investigation and trial procedures. Now it is hard to believe there was ever any argument about the admissibility of DNA as evidence.

And it bears mentioning that an adult woman’s right to marry out of her own free choice was fiercely contested in the 1990s, when the cases of Saima Waheed, Humaira Butt, and two hundred others were heard by the Lahore High Court, while the media and public alike were transfixed by the spectacles of these young women turned on by their fathers for refusing to be married off against their will? Patriarchal authority was on trial during those years, and it didn’t fare too well as lawyers Jahangir and Jilani used Articles 25 (right to equality) and Article 35 (protection of family) to defend women’s right to choose. Ultimately they won their cases, and the Supreme Court gave a final ruling in 2004 upholding this right. But, are we really still talking about this in the 21st century?

Believe it or not, activists were swimming against a turbulent tide of public and media indignation over the daughters who defied their parents, but thankfully we seemed to have moved on to other issues. Among them is the right of a woman giving birth not to die or be injured for life in the process. In 2015 Malkani filed a petition on behalf of activist Sheema Kermani’s theatre group Tehrik-e-Niswan, Dr Shershah Syed and Kiran Sohail in the Sindh High Court (SHC). She argued that women who suffer from debilitating obstetric fistula (a rupture caused by prolonged labour due to inadequate emergency health care services) have their rights to life and dignity violated and the Sindh government must properly implement its maternal and neonatal and child health programme to end this entirely avoidable and debilitating injury.

In February this year, the SHC recently ordered fistula repair centres to be established in four district hospitals in Sindh, and all reports suggest the government is responding promptly. Certainly justice delayed is somewhat better than denied altogether.

This is just part of the story about women’s strategic use of the courts. WAF member and lawyer Shahla Zia filed the most important environmental public litigation case in our history in 1992, against WAPDA for inflicting damage upon life and citizens, and won it in the Supreme Court two years later. Her achievement was to have the right to a clean environment recognized as part of our inviolable right to life, leading to the first Pakistan Environmental Protection Act in 1997.

The tone of our recent 2018 elections was altogether different from any previous one, for many reasons. One was because new laws had ruled out the possibility of banning women in communities from voting, a practice favored by the religious right and their friends in some parts of the country. This was the result of petitions filed as far back as 2001, when activists protested against the conduct of elections in district Swabi, and later again in 2015 against bans in Lower Dir. While the latter petition is still pending in the Supreme Court, the Election Commission of Pakistan got the point and helped politicians to ensure the 2017 electoral reforms contained a provision requiring at least ten percent of women in each constituency to caste their vote for the polling to be valid.

And the story doesn’t even end here, as I have yet to refer to the cases about other petitions regarding missing persons, arbitrary detentions, bonded labourers, non-Muslims’ right to divorce, and more. Until next time.


This blog is based on research conducted as part of our work with Action for Empowerment and Accountability, a programme supported by UK Aid and conducted in collaboration with the Institute of Development Studies at the University of Sussex.

Friday, 29 March 2019

BISP, Citizenship and Rights Claims in Pakistan

By Rehan Rafay Jamil

A focus group discussion with BISP beneficiaries in Chatto Chand, Thatta.
Photo credits: CSSR's field research team


Taking Stock of Ten Years of the Benazir Income Support Programme (BISP)

Over ten years since its establishment, the Benazir Income Support Progamme (BISP) has become Pakistan’s largest social safety net, providing coverage to over 5.6 million women and their households across the country. The expansion of BISP over the past decade marks an important shift in social policy in Pakistan. BISP has now been overseen by three elected governments and has resulted in a significant increase in federal fiscal allocations for social protection. Despite vocal reservations about its name expressed by some political parties, the program remains Pakistan’s largest flagship poverty alleviation program with international recognition.[1]

Third party impact evaluations of BISP have largely focused on its poverty alleviation, nutritional and gender empowerment impacts.[2] [3] These evaluations point to important reductions in poverty and improved nutritional levels for beneficiaries and their households. Oxford Policy Management’s 2016 evaluation finds reductions in BISP households’ reliance on casual labor and an increase in household savings and asset accumulation.[3]

BISP is one of the largest cash transfer programs targeted exclusively at women in the Global South, making the gender impacts of BISP important to understand. In their evaluation, Ambler and De Brauw (2017) find some changes in gender norms and attitudes amongst beneficiaries and their families. Their study finds that female beneficiaries are more likely to have greater mobility to visit friends without their spouse’s permission, are less likely to tolerate domestic violence and male members are more likely to contribute to household work.

BISP and the transition from Cash Transfer Beneficiaries to Citizens

The evaluation reports provide some evidence that BISP has also had a wider set of intended and unintended consequences in influencing beneficiaries’ access to public institutions and spaces. Perhaps the most frequently cited impact of BISP has been a marked increase in rural women’s access to computerized national identity cards (CNICs), a prerequisite for obtaining the program. CNICs can be seen as the first step to citizenship and rights claims in Pakistan. The most significant impact of the rapid increase in CNIC registration amongst BISP beneficiaries has been with regards to voting. Ambler and De Brauw (2017) find evidence that BISP beneficiaries are more likely to vote in national elections. But whether BISP beneficiaries are empowered by the cash transfer to make a wider set of rights claims and access local state services, is less clear.

In order to understand some of the changes brought about by BISP in the lives of rural women, I conducted qualitative field work, including in-depth interviews and focus group discussions with beneficiaries and their spouses, in the district of Thatta in Lower Sindh. Thatta has a high proportion of BISP beneficiaries (47 percent), being a high poverty district. The aim of the fieldwork was to develop an understanding of how beneficiaries and their families perceive of BISP and whether the program has brought about any changes in their engagement with local state services.

Beneficiaries’ Perceptions of BISP and the State

One of the most striking findings of the fieldwork was the gendered differences in the perceptions of BISP between beneficiaries and their male household members. The beneficiaries we interviewed were engaged in limited agricultural or domestic labor. They invariably associated the program most closely with Benazir Bhutto, at times even reporting the funds being directly from her and the Pakistan People’s Party (PPP). Responses amongst adult male household members were more varied, with some attributing the program to the Benazir Bhutto or the PPP, while others answered it was a federal government program. A handful of male respondents interviewed believed the program was funded by donor agencies.

Voting preferences and Clientelism

Despite the fact that many respondents in Thatta identified BISP closely with Benazir Bhutto or the PPP, my research found little overt evidence of the program being used for clientelistic purposes. Beneficiaries and their families reported very low levels of interference of politicians in beneficiary selection. Although a substantial number of households reported grievances about other poor households not obtaining the cash transfer, when asked in follow up questions if political connections could help people enroll in the program, the vast majority of beneficiaries said no. Voting preferences of BISP beneficiaries, over time also reflected deeper affiliations to political parties or specific candidates. For example, BISP beneficiaries’ party preferences in Thatta tended to be split between the PPP and the influential Shirazi family, who sometimes contested elections independently or forged alliances with other larger political parties.

The Politics of Recognition and Access to Public Spaces

The most striking impact of BISP reported by beneficiaries and their households was changes in women’s mobility and access to public spaces. Women in rural settings in Pakistan typically have very circumscribed access to public spaces. While few beneficiaries interviewed reported going to state institutions such as Union Councils, police stations or district courts, the vast majority reported obtaining the BISP transfer directly and keeping a share of the transfer for themselves before sharing it with their spouses and families.

Beneficiaries and the male household members described long ques of hundreds of beneficiaries waiting at authorized branchless banking agents and commercial banks when the transfers are disbursed. Although the vast majority of female beneficiaries interviewed were either illiterate or had only a few years of formal schooling, their responses indicated a growing awareness about the disbursement timings, amounts and arbitrary cuts that local middle men would invariably extract for ‘assisting’ them in obtaining the transfer.

The vast majority of beneficiaries and their spouses reported feelings of dignity and pride in obtaining a BISP cash transfer and being recognized by the state as rights bearing citizens. These preliminary findings suggest a gradual shift in both beneficiaries’ perceptions and access to public spaces and services, even if their wider engagement with the local state remains limited.



[1] Gazdar, H. (2011). Social Protection in Pakistan: In the Midst of a Paradigm Shift? Special Article. Volume 46 No. 28. Economic and Political Weekly.
[2] Ambler, K., De Brauw, A. (2017). The impacts of cash transfers on women’s empowerment: learning from Pakistan’s BISP program. Social protection and labor discussion paper; no. 1702. Washington, D.C.: World Bank Group.
[3] Cheema, I., Hunt, S., Javeed, S., Lone, T., & O’Leary, S. (2016). Benazir Income Support Programme – Final impact evaluation report: Oxford Policy Management.




Monday, 18 March 2019

The Plight of Domestic Workers in Pakistan

By Kabeer Dawani

Photo credit: Facebook.com/Maid2Shop

One aspect of the Aurat March 2019 which, amidst the backlash from the patriarchy, did not receive much attention was female domestic workers coming out in significant numbers to ask (among other things) for their right to fair compensation. As seen above, they asked, “Do you pay your domestic workers the minimum wage?”

This is not an unreasonable question, but the fact of the matter is that, as a society, we don’t treat our labour well. This is true for labour across sectors (agricultural, industrial, and the service sector). Labour laws are routinely circumvented, and state enforcement of those laws is lax at best. (For example, see this recent report by Human Rights Watch documenting egregious violations in the garments industry.)

Domestic work, however, is perhaps one of the most exploitative forms of labour. Globally, the ILO estimated that domestic work is the number one form of forced labour in 2017. There is little research on Pakistan specifically. In one of the only studies on domestic work in Pakistan, Haris Gazdar and Ayesha Khan find that some domestic labour arrangements “come very close to outright slavery” due to the bondage that is created by employees borrowing in advance of their salaries.

This is just one form of exploitation however. As the Tayabba torture case demonstrated, other issues abound: child labour is rampant; there is widespread verbal, sexual and physical abuse, including inhumane work hours; and wages for domestic workers are far below minimum wage. In short, they do not have human dignity.

In particular on the minimum wage, the Labour Force Survey (LFS) can be used to provide an illustration of what is a startling picture. In 2017-18, more than half of those employed earned a monthly wage that was below the minimum wage of Rs.15,000. Specifically for the category ‘household employees’, the average wage is Rs.9,272. Most remarkable perhaps is the gender wage gap: female domestic workers earn Rs.6,098, almost two-thirds below the legal minimum wage and more than half of what men earn. It is thus clearly also a gendered issue.

Further, on such low income, it is no surprise that these workers have to take on insurmountable amounts of debt, are not able to send their children to school, and suffer from poor nutrition and health outcomes.

Are Domestic Workers Entitled to a Minimum Wage?

When you ask someone if they pay their domestic workers minimum wage, their response is usually a self-serving justification that domestic workers don’t fall under minimum wage laws. This is, unfortunately, largely true (but no less morally reprehensible).

Until a few months ago, no legislation existed across Pakistan for the protection of domestic workers. Although the Senate passed a bill a few years ago, this has not yet been enacted by the National Assembly. It was only at the end of January 2019 that legislation formalizing domestic workers was passed in Punjab. This Act criminalizes work below the age of 15, stipulates that domestic workers must be paid minimum wage as set by the Minimum Wage Board, and includes several benefits, such as sick and maternity leave and pensions. The legislation is progressive and unprecedented in Pakistan. Indeed, no other province has formalized domestic work yet.

While legislation will not change things overnight, and there are serious issues of implementation, it sets an important direction for a more equitable Pakistan. In a setting where market power determines wages – and employers have all the power – legislating for a minimum wage (and ideally a living wage) for domestic workers also creates the baseline for changing social norms. One hopes the other provinces can follow Punjab’s example sooner rather than later.

Nevertheless, taking care of those who literally take care of you, your children, and your home should be the humane thing to do, even if it isn’t the legal thing to do. I would like to end by quoting from a superb recent essay in the New York Times by Princeton Sociologist, Mathew Desmond, in which he powerfully illustrates the human impact of higher minimum wages:

“A $15 minimum wage is an antidepressant. It is a sleep aid. A diet. A stress reliever. It is a contraceptive, preventing teenage pregnancy. It prevents premature death. It shields children from neglect.”