Pakistan’s Tharparkar: Beneath the doom and gloom, lie stories of resilience

Tharparkar often stands out for its appalling human development outcomes, with its alarmingly high number of child deaths, surging maternal mortality rates and fertility rates close to 5. So, what are some of the deeper issues hampering human development in this district of over 1.6 million people? To find out, we decided to take a trip.

We started our journey from Karachi to Tharparkar, the largest district of the Sindh province. During our eight-hour long drive, we saw the landscape change from high-rise buildings and ring roads to settlements of slums and finally to the arid desert land of Tharparkar. As we neared our destination, we often saw women carrying weight on their heads, seemingly impossible burdens balanced on their thin necks. On the surface, one sees their brightly colored clothes and bangles worn from their wrists to their shoulders. Yet they lead some of the most difficult lives. Early marriage, teenage pregnancy and malnutrition are just some of the many challenges they experience during their lives. In the words of our local guide, “they get up at 4 am, do household chores, look after the children, prepare food, fetch water, and work in the fields. All this even while they are pregnant.”

Early marriage, teenage pregnancy, and malnutrition are just some of the many challenges women in Tharparkar experience during their lives.

Our first stop was a Government Dispensary in Dahili, which provides basic health services to surrounding population. Located 200 kilometers from the district’s capital Mithi, the dispensary serves a population of around 20,000 people. With the vast distances of this district, facilities like these are the first and often the only level of care available for people several kilometers in any direction. In a country where 42% of women report distance to facility as one of the major obstacles to accessing healthcare, it is no surprise that in the harsh terrain of Tharparkar, with no road network, this is a major deterrent.

Tharparkar's harsh terrain and lack of road network is a major obstacle for people of this district to access healthcare services.

Fighting the odds are the Community Mid-Wives (CMWs) of Tharparkar. These trained health professionals provide assistance to women during labor, delivery, and after the birth of their babies. Meena Kumari, a midwife based at the Jesse Jo Par Government Dispensary told me “I travel 9 hours once a month to see my children and husband in Mithi. It is very tiring, but I do it for my job”. Lack of proper accommodation, no availability of mobile networks and a limited supply of electricity are some of the many challenging circumstances women like Meena and other midwives brave daily. These midwives are working under these incredibly tough, almost unsurvivable conditions – yet they are the only hope for the many more deprived women of Tharparkar. In view of their essential role, the continuity of their presence, quality of their training and living conditions need to be given utmost priority.

Midwives provide an essential role in Tharparkar's health services. The continuity of their presence, quality of their training and living conditions need to be given utmost priority.

Next, we made a stop at a Health House, a designated room in a Lady Health Worker’s house. In Pakistan, Lady Health Workers are the frontline warriors, who are residents of the community in which they work and provide door-to-door service and connect local communities with facility-based services. In a place like Tharparkar, their job is to not only provide basic health and family planning services, but to also provide counselling to undo centuries-long, deep-rooted social norms and practices, especially those surrounding family planning. The difficulties around the latter task are significant, hence it was not surprising to learn that some of the LHWs themselves were mothers of 4, 5 or even 6 children.

In Pakistan, Lady Health Workers are the frontline warriors, who are residents of their community and provide door-to-door service and connect local communities to facility-based services.

So how do you get people in far-flung deserts with sweltering heat to access health services? You bring the services to them. In areas like Tharparkar, outreach plays a critical role in improving and extending the reach of health care. In Kenya, for example, ‘camel clinics’ amble their way across the Samburu County, providing much-needed health and family planning services in the remotest areas. Makes one wonder, in the difficult, unyielding terrain of Tharparkar, perhaps it is time to turn to camels?

We at the World Bank, Pakistan, are preparing the Sindh Integrated Health and Population Project. Our decision to focus, through this project, on Sindh’s remotest areas was an obvious one. A quick glance at the numbers shows enormous disparities, with rural, remote areas, such as Tharparkar, at a clear disadvantage. Through this project, we aim to strengthen basic reproductive, maternal, newborn and child health services, bringing them as close as possible to the people in the remotest areas of Sindh – and hope that the road to their prosperity is not as rocky as the land of Tharparkar.

The Sindh Integrated Health and Population Project aims to strengthen basic reproductive, maternal, newborn, and child health services, bringing them as close as possible to the people in the remotest areas of Sindh.