A VILLAGE STUCK IN TIME
The sun was about to set and Raila’s pain was increasing with every tick of the clock. She grew tense as it was the eighth month of her second pregnancy. There was no hospital nearby. And even if there had been, the family could not afford to seek proper medical help.
Time passed, and the pain kept increasing. She watched her five-year-old daughter running around, helpless to do anything and powered through the pain. Then, her body started swelling up. Her phuppo (aunt) called the local dai. Dais are local midwives, mostly self-trained through trial and error. Some have received formal training in assisting childbirth, but most have learnt the skill through generations of practice.
“It was eight at night.” Raila’s phuppo recalls. “The dai took a look at her and immediately asked to call a doctor from a village located a little far away. The doctor came and started an IV, after which her pain subsided a little and she fell asleep.”
The doctor and dai both went away.
At around 2am that night Raila woke up with an excruciating pain in her abdomen. She went to urinate and there she delivered her baby girl. She was all alone in her tiny little bathroom. The baby was not breathing.
“We didn’t call the dai and cleaned the baby ourselves,” Raila’s phuppo says. “Her baby was dead.”
She is sitting in the verandah of a small house in Kher Muhammad Goth. A strong wind is blowing, and she struggles to keep her head covered with her scarf. This wasn’t the first life that was lost due to a lack of medical care. Just five months ago, Raila’s mother had also lost her life.
Video: Raila’s phuppo recounts events from the fateful night (in Sindhi)
The story is chillingly common in households living on or below the poverty line. Raila’s husband is jobless and her father is a day labourer.
The day Raila delivered her stillborn all alone in the dead of night, she was at her grandmother’s place.
“There was no one to take her to the hospital,” says Mehrunisa, a trained lady heath worker in the village. “The family couldn’t afford that. Her child was dead inside her for at least two days.”
An undetected death within the womb poses serious health risks for the mother. In Raila’s case, the swelling that suddenly appeared all over her body was a related medical symptom. The day after she delivered the baby at 2am, she was shifted to a hospital after sunset in emergency in a Suzuki pickup.
“For an entire day she remained in extreme pain,” says Mehrunisa. “The entire family was simply looking at each other and no one was ready to take her to the hospital.”
Raila lives in Kher Muhammad Goth in Gadap Town in District Malir, an hour-and-a-half’s drive from Karachi’s toll plaza. The goth or village has an estimated population of 5,000 with around 500 small houses.
There is no formal estimate available for the number of women of child-bearing age living in this area, but women here are largely served by four dais who live in and around the village.
The dais follow a very basic procedure for delivering babies.
“Blade uthaya kaat dya, kaam hogaya. (Pick up a blade, cut and it’s done),” says Mehrunisa, explaining how a dai helps deliver babies. “If there are any complications, dais are useless.”
Video: Lady health worker Mehrunisa shares the problems faced by women in Kher Muhammad Goth
There’s a private hospital in Memon Goth, which can be reached in 45 minutes from Kher Muhammad Goth if there is no traffic congestion. Most of the women of the nearby villages go to this hospital for their ultrasound and Caesarian section.
Like Raila, Sughra is 25 years old. She is pregnant for the fourth time and has just started her seventh month. The first three times she was pregnant, she lost the child for reasons still unknown and undiagnosed.
“Either my child dies in the womb or a few hours after the delivery,” Sughra says.
Her second child was born with the help of a dai as they had no time to reach the hospital. The baby died a few hours after he was delivered.
Video: Sughra, 25, speaks about her stillbirths and infant deaths (in Sindhi)
BASIC HEALTH CARE NON-EXISTENT
The 2017 provisional census data available with the Pakistan Bureau of Statistics shows that district Malir has a population of 2,008,901 people. It is the largest district in Sindh in terms of area.
The government of Sindh has provided for 13 basic health units (BHUs) for district Malir. According to data acquired through a Right to Information (RTI) request, a total of 28 doctors, 89 paramedical staff, and 12 midwives have been sanctioned for appointment and a budget of Rs. 22.5 million was allocated and released in 2016-17. Additionally medicines worth Rs. 1.42 million were allocated to the BHUs in Malir for 2016-17.
However, the number of appointed medical staff is much lower than the sanctioned posts. According to data, only fifteen doctors have been appointed in the 13 BHUs, and no paramedical staff or midwives have been appointed. And so the positions for 13 doctors, 89 paramedics, and 12 midwives lie vacant as women such as Raila and Sughra helplessly lose their children.
This lack of basic health care facilities from the government has created a space, which, for poor women in the scattered goths of Malir district, has been filled by the dais.
The beaming crevice that splits the wizened features of sixty-year-old dai Noorunnisa makes her glow against the backdrop of the desolate landscape of Kher Muhammad Goth. Donning a bright orange dupatta, a nose pin, and bangles on her wrists, she has a pleasant smile.
Noorunnisa doesn’t even remember how many babies she has delivered.
“After the delivery I tap the babies on their backs,” she says. “Hold them from one leg and bow their heads.”
Video: Noorunnisa, the village dai, speaks about her trade (in Sindhi)
Noorunnisa makes sure that her hands are clean.
“I cut the cord myself,” she says.
Blade uthaya, kat diya, kaam ho gaya. Mehrunnisa’s earlier description of the dai’s modus operandi echoes in Noorunnisa’s attempts to explain her trade with pride.
THE RICKSHAW THAT WAS ALSO AN AMBULANCE
There’s a lone rickshaw in the village, which is used to rush pregnant women to the hospital in case of any emergency. According to the data provided by Sindh’s health department, not a single ambulance has been sanctioned for BHUs in the entire Malir district.
And so, the rickshaw serves as the sole means of transport for heavily pregnant women and those in need of emergency medical care.
“Imagine the bumpy ride of a rickshaw on uneven village roads and the Link Road for a pregnant woman,” Mehrunisa says.
A lot of times, she says, women deliver their babies inside the rickshaw.
From the 13 BHUs established in district Malir, one is situated in this village. The village BHU closes after 1pm and remains closed over the weekends.
There’s a private midwife, Noor Khatoon, who has a small clinic just a 10-minute drive from the Kher Muhammad Goth. In terms of formal education, she just holds a Bachelor of Arts (BA) degree, achieved privately. But experience-wise she boasts of a decade-long career in midwifery. Noor Khatoon caters to at least six villages in the vicinity.
“Every influential lady of the village has got her number,” Mehrunisa says.
If there’s a complicated case or the pregnant women are anemic, Khatoon refers them to any hospital in the city. She charges Rs. 3,000-5,000 for a normal delivery case and Rs. 100 for a regular checkup.
Her clinic is a strange site in the otherwise underdeveloped area. There is a solar panel installed outside her clinic.
TECHNOLOGY STEPS IN TO HELP
To provide some relief to pregnant women in these remote villages, a local non- profit, the Poverty Eradication Initiative (PEI), has been attempting to develop a technology-based solution. PEI is working on the development of mobile application that will help community midwives (CMWs) determine the complication of a pregnancy in remote areas of Sindh. CMWs are specially trained nurses whose job is to help women who are delivering babies.
Speaking to Media Matters for Democracy at his office in Karachi’s Clifton area, PEI Executive Director Shahid Masood Yousaf says PEI has been working on a new concept, ‘Clinical Decision Support System’, with the help of artificial intelligence and software.
“This support system will help the CMWs determine whether a pregnancy will turn out to be complicated or normal,” Yousaf says.
As many as 300 new birthing setups will be established in six districts of Sindh, Larkana, Khairpur, Thatta, Mirpukhas, Hyderabad, and Dadu, and they will upscale around 150 of the current birthing setups.
Once the initiative is operational, “normal pregnancies can be entertained at the villages 24/7,” Yousaf says.
Yousaf says it has taken them three years to develop the Clinical Decision Support System and its related mobile application, which will be used by trained CMWs to enter the blood and urine analysis and family history of the patient.
“Once the data is entered, a specially developed artificial intelligence algorithm will analyse risk factors,” Yousaf says, adding that there will be 100 different data points and 10 different risk factors of pregnancy. “Every data point has a link with a risk factor.”
Before deployment, PEI will train CMWs in using the mobile application.
The application has been colour-coded for ease of use. A patient with a simple and normal pregnancy will remain green while yellow will be displayed with the patient’s name in case some complications are expected. If the colour turns red, Yousaf says, the patient should be rushed to a hospital.
PEI is also working with local ambulance services to ensure women reach local health facilities more easily.
MAP: SINDH’S MISSING MIDWIVES
IN SINDH, BHU NUMBERS TELL A SORRY TALE
In a place where stories like Raila’s and Sughra’s are largely considered commonplace, the complete failure of government’s health services is apparent. The data provided by the Sindh Health Department shows that collectively the posts of 343 doctors, 1,149 paramedics, and 196 midwives are lying vacant.
With only 33 of the 105 sanctioned doctors appointed and 72 posts lying vacant, the BHUs in District Karachi Central are at the top of an unfortunate ‘top 10’ list of districts where the majority of sanctioned posts for doctor at BHUs are vacant.
There are 58 vacant doctor posts in Thatta and Sujawal altogether, with only 27 out of 85 sanctioned doctors positioned at 51 BHUs in the two districts.
Ghotki and Umer Kot both have 26 vacant doctors’ positions. Only six doctors are working in 34 BHUs in district Ghotki and 13 doctors are serving at 32 BHUs in Umer Kot.
The number of positions of doctors lying vacant at Basic Health Units in Sindh districts.
The trends remain similar when it comes to missing paramedics and midwives.
Without either doctors or paramedics, the dire situation of primary health care for citizens dependent on government health care services becomes immediately apparent.
MISSING NURSES AND PARAMEDICS
Sindh districts with the highest number of vacant nurses and paramedic positions at BHUs.
For women like Raila and Sughra, the numbers across Sindh do not offer much hope.
Malir, the home district of the two women, appears to be the 7th most affected district in terms of vacant positions for midwives.
The data shows that not a single midwife has been appointed to fill the 12 midwife positions sanctioned at 13 BHUs across the district.
Sindh districts with the highest number of vacant midwives’ positions at BHUs.
In addition to district Malir, the districts of Thatta and Sujawal, Karachi South, Karachi East, Karachi Central, Kambar and Shahdad Kot and Tharparkar do not have a single midwife working at the district BHUs.
Even though there isn’t much clarity of budgets of most districts, one has to praise the Sindh Health Department for being as forthcoming as they were. In Khyber Pakhtunkhwa, getting access to even this basic data proved to be impossible.
MORE OF THE SAME IN KHYBER PAKHTUNKHWA
The plight of pregnant women living on or below the poverty line appears to be the same in Khyber Pakhtunkhwa (KP).
Official documents obtained through RTI requests have revealed that even in provincial capital Peshawar, only 8 midwives are appointed at 47 BHUs. However, trusting the data that was provided is as difficult as trusting the tall claims that are made by the Pakistan Tehreek-e Insaf (PTI) provincial government, which has boasted of revolutionary improvements in the health care system.
In district Peshawar’s case, for instance, the number of BHUs listed in one official response is 47, while in another it is 48.
Many BHUs of the province are operating without any medical officer at all. For example, in Abbottabad only 41 doctors have been appointed against 56 sanctioned posts at 54 BHUs.
In Upper Dir’s Jabar area, the local BHU has not had a medical officer for the past six months. Dispenser Siraj Ahmad is heading the BHU in the absence of a medical officer.
Siraj says the Jabar BHU was established in 2005. In the last 13 years, seven doctors were appointed from time to time but none of them spent much time at the BHU and had left soon after appointment, he says.
The lack of doctors is not the only thing that haunts this BHU.
There is no electricity in this health facility. For women from the area, the BHU does not even offer a labour room. Pregnant women are being cared for by a local lady health worker. Even the lady health worker, however, cannot take proper care during childbirth and delivery due to the lack of gynecological and obstetric facilities.
Samina Koser, a lady health worker with BHU Charpariza in Peshawar, currently works as the female technician at the BHU.
Koser says the Charpariza BHU does not have labour room facility due to which many mothers and children have been died during complicated childbirths there. These women cannot be provided antenatal care either; there are no doctors and no electricity or equipment to provide ultrasound facilities.
Video: Samina Koser speaks about the problems at BHU Charpariza
The situation is precarious in many districts of KP. According to the 2017-18 Annual Development Programme, Rs. 135 million are allocated for the 767 BHUs in the province, which means there is an allocation of only Rs. 17,601 per BHU for the entire year. The official data acquired for this story shows that 60% of the BHUs are operating without a doctor in different KP districts.
Dr. Mohamad Riaz Khan, the Medical Officer at the Charpariza BHU, says his BHU is catering to a population of 30,000 people. According to the United Nations Millennium Development Goals (MDGs), Dr. Khan says, there should be one BHU for every 5,000 people.
Overall, in Khyber Pakhtunkhwa, there are only 767 BHUs for a 33.53-million population or one BHU per 43,715 citizens on average. In the provincial capital Peshawar, there are 47 BHUs for 1.97 million residents or one BHU per 41,914 people. These numbers are eight times higher than the MDG target.
The Charpariza BHU is visited by 40 to 50 patients on a daily basis, according to Dr. Khan. People most frequently visit the BHU to get their children vaccinated, he says. The BHU is often unable to provide even the vaccination services.
“Most of the time, our BHU staff is called for polio vaccination drives,” Dr. Khan says. “The BHU functions cease for a week during the polio campaign because the medical officers have to go for the campaign.”
In case there is an evaluation process associated with the polio drive, Dr. Khan says, the BHU ends up staying closed for more than a week.
Matters get worse because the Charpariza BHU does not have solar-powered refrigerators to keep the vaccines. Instead, they use ice cubes to keep the vaccines cold.
“We know this is a dangerous practice, but we do not have any alternative,” says Dr. Khan. “We don’t have an ambulance and in case of emergencies we have to call one from Rural Health Centres.”
Video: Dr. Mohamad Riaz Khan speaks about BHU issues
Dr. Khan accuses the KP government of corruption of billions in medicine, jobs, and logistics in the health sector. He also claims funds for medicines in the district were never fully utilised. (His claims could not be verified.)
“We had Rs. 7 million as budget for medicines in district Peshawar,” he says. “But medicines worth only Rs. 3 million were purchased.”
Attempts to acquire data from the KP health department about budget allocations, releases, and expenses proved to be futile. Despite using sources and constantly following-up on the status of requested information, the health department was not forthcoming about any budgetary details.
A DOWNWARD SPIRAL
A woman from the Badaber village in Peshawar district says until two years ago a lady doctor used to visit their local BHU in an ambulance. The doctor used to bring an ultrasound machine and she would examine pregnant women.
But the doctor does not visit anymore, the woman says.
Now, the women of Badaber village practise childbirth at home with the help of dais – the local midwives.
“If a dai is not available, we look for women who have experience of childbirth in the village or in case of emergency, we go to the hospitals in Peshawar,” the woman says.
Zeenat from Dasu in KP’s remote Kohistan district says there are two ambulances available at her local BHU, but both are out of order.
The Dasu BHU does not have facilities to treat accident victims and only a single lady health worker to treat women’s health issues. Zeenat says that even the lone lady health worker is not available most of the times. In effect then, the women of Dasu are also left without any medical facilities for mother and child.
The people in the area claim the BHU’s staff is always appointed on political basis. It appears these appointments do not always translate into service delivery as the medical staff is often present only on paper and payroll but not available for duty.
According to Population Council data analysed by the Daily Times, Pakistan loses 14,000 women in childbirth every year. This translates into one death every 37 minutes. Given the condition of heath services demonstrated by the public data, one does not need to wonder why.
About the Data
MMfD submitted two information requests each to the health departments of Punjab, Sindh, Khyber Pakhtunkhwa, and Islamabad to seek public records about primary health care facilities, commonly known as Basic Health Units (BHUs).
In one of these two requests, information was demanded about: the district-wise annual budget allocation for the BHUs, a detailed breakdown of annual budget, the funds actually released to the BHUs, the details of medicines allocated to the BHUs during the most recent fiscal year, and the number of emergency vehicles available at the BHUs.
The second information request sought the total number of BHUs in each district, the numbers of posts sanctioned for doctors, nurses, and midwives at the BHUs, and the numbers of working doctors, nurses, and midwives at the BHUs.
The requests were relatively straightforward. Data about the financial and human resources allocated to the BHUs had been requested. Administrative units, such as the provincial health departments, do not have any excuse to be missing these records. After all, the medical staff is on the government payroll. Their salaries go out each month, and the public health care systems cannot simply forego their annual budget planning and reporting duties.
However, the health departments proved extremely inefficient in supplying these records.
The Punjab health department stalled the process for months, and eventually returned a list of names of all BHUs in the province along with a list of the number of patients treated at each district BHU for various diseases. These were not the details that were requested. The queried data was never provided.
The Khyber Pakhtunkhwa (KP) health department returned the total number of BHUs in each district and the number of working paramedics and specialist doctors, but it never supplied the sanctioned posts for each category of medical staff. In the absence of the sanctioned posts, a determination of the vacant posts at BHUs in each district could not be made. Only two out of 25 KP districts – Mardan and Dera Ismail Khan – returned annual allocated and released budget amounts for their BHUs along with the funds allocated for BHU medicines. Even these two districts, however, did not provide a detailed breakdown of the budget amounts.
For the BHU budget data, the response of the federal health ministry and the Sindh health department was similar to the KP health department. Only annual aggregate figures were supplied. However, Sindh and the federal health bodies provided data on human resources as requested, albeit partially in Sindh’s case. The Sindh health department only provided data for 19 of its 29 districts. Notable omissions were the districts of Hyderabad, Larkana, and Sanghar, all of which have populations of more than 1.5 million residents. The partial data meant services could not be compared across all districts.
The available medical human resource data also had some reliability issues that could not be reconciled. For example, for Sindh’s Shaheed Benazirabad district, the data showed no sanctioned posts for doctors and midwives at BHUs but claimed 38 doctors and 45 midwives had been appointed to the BHUs.
Production, editing, and reporting team:
Farzana Ali (Story and reporting from Khyber Pakhtunkhwa)
Oonib Azam (Story and reporting from Sindh)