Mobile Health Initiative Exposes Digital Gender Divide in Pakistan

Another recent study — conducted by Media Matters for Democracy, a Pakistan-based nonprofit working on digital democracy, on the digital gender divide amid COVID-19 — corroborated the report, finding that 54 percent of its 215 respondents believed that, in the family setting, women using the internet was either considered bad or that there were some concerns about their usage.

Mobile Health Initiative Exposes Digital Gender Divide in Pakistan

The day in November 2020 that Shaista Bhatti, a 45-year-old Lady Health Worker (LHW) in Pakistan, fell ill, she had visited her younger sister, Shazia, who insisted on taking her to see a doctor. “She and her colleagues have been under pressure unlike before,” said Ms. Shaista.

From there, Bhatti was referred to another doctor for a cardiac exam, after which she was recommended an abdomen ultrasound. Less than two weeks later, Bhatti passed away.

“The doctors were shocked to see the state of her pancreas and asked how she had ignored her health for so long,” Ms. Shazia said over the phone, her voice cracking. “She only cared about being sincere to her work. I would ask her what was troubling her at work, and she would say I wouldn’t understand.”

For years, Bhatti had been going house to house as part of the government’s women-led primary health program, advising on family planning and vaccinating children against diseases in her hometown in the Tando Muhammad Khan district of Pakistan’s Sindh province. LHWs are deployed to remote areas by foot to counsel, diagnose, treat, and refer patients to larger facilities. They typically maintain records on paper.

It was all routine work for Bhatti and her colleagues until 2019, when the government launched a pilot test for a mobile app called “TIBBI,” a telehealth solution meant to digitize their operations for better efficiency. In addition to scheduling visits and inventory supplies, the app was also a means to determine the efficiency of the health workers’ program on antenatal and post-natal care, immunizations against childhood disease, and general health education.

About 50 health workers were given smartphones and trained on the use of the app. As weeks went by, however, LHWs began facing resistance from their patients. “The community turned aggressively on us when we started using a smartphone inside their homes,” said Faiza*, a LHW of 10 years. “They said it wasn’t good for nice women like us to bring phones into their homes.”

The initial design of the app included direct questions about the sexual and reproductive cycles of couples, which was ill-received by their patients: workers reported being yelled at and thrown out of homes for being vulgar and recording information on their devices.

“They (the community) troubled Bhatti so much that she ended up losing her life,” said Bushra Arain, chairperson of the All Pakistan Lady Workers Welfare Association, a union for the workers,. “What is more to say about her?”

Tando Mohammad Khan is a rural, agrarian community without sufficient health infrastructure. In 2016, the district had only 17 dispensaries to serve a population of a little over half a million. LHWs are often the only link to healthcare for women and children in more remote and underserved communities in Pakistan—often to which they themselves belong. This helps them develop cordial relationships within their neighborhood, as they are sensitive to the culture and contexts of the localities.

In Pakistan, internet usage is least common among populations living in rural areas. Only 1.5 percent of the rural Sindh province’s women population between 15 and 49 years of age have ever used the internet in their lives, compared to 11 percent of men, a 2018 demographic and health survey revealed. A lack of digital penetration by the state, in addition to patriarchal social structures, restricts women’s use of internet.

When the mobile-based initiative came into being, the health workers felt a shift in their relationship with the locals.

“I was once turned away from the gate by the man of the house who begged me — with his hands pressed together — not to use the smartphone,” said Naeema*, a LHW of eight years. “He said it wasn’t good for me.” She said that women barely own smartphones in her locality and usually use their husband’s or any other male family member’s to speak to relatives.

“People have charged after my colleagues with sticks when they saw us recording information on the phone,” said Rukaiya*, another LHW of four years.

Bhatti, a chief representative of the polio vaccine administration team and a pilot member of the TIBBI team, had expressed to colleagues and family that the app-based work was giving her anxiety, irregular blood pressure, and vomiting. “Once, while she was visiting a family, the family threatened to break her phone if she brought it in again,” said Ms. Shazia.

Workers would share concerns among themselves about how the job had never been this difficult, but when they brought them up to their program managers, they were told to carry on.

After Bhatti’s death — and frustrated by their unaddressed concerns of harassment — the workers protested, demanding action against the constant harassment and violence. According to the workers, government representatives fired a few of their colleagues for leading the protests. Many workers we approached either refused to disclose details or only agreed to speak to us anonymously, out of fear of termination.

“There were complaints initially when the program started, but now, they have almost subsided,” said Dr. Daulat Khan, a government health officer for the Tando Muhammad Khan district. “I believe as far as the idea of ascertaining the regularity, punctuality and compliance of the workers goes, the app has been very successful.”

The workers, however, report their jobs are far from better because of it.

Oversimplified perceptions about smartphones — and technology more broadly — as either good or bad for women are common in Pakistani society.

A recent report found that the gender gap in mobile ownership is most pronounced in South Asia — and is at its widest in Pakistan, at 38 percent. While women’s access to mobile internet has improved overall in low-and middle-income countries in 2020, the gender gap is still considerable and further exposed by the COVID-19 pandemic.

In Pakistan, 27 percent of women mobile users do not use the internet because of family disapproval, the report found — the highest among surveyed countries in Africa, Asia and Latin America.

Another recent study — conducted by Media Matters for Democracy, a Pakistan-based nonprofit working on digital democracy, on the digital gender divide amid COVID-19 — corroborated the report, finding that 54 percent of its 215 respondents believed that, in the family setting, women using the internet was either considered bad or that there were some concerns about their usage.

“In the case of women health workers, the fear or disapproval of technology has more to do with whom the data is going to — maybe a man?” said Hija Kamran, one of the study’s authors. For example, Kamran explained, should a woman’s private, personal details be made known to men, it could endanger the household or bring shame to it. The fear, however unfounded, stems from not knowing what may happen with that information, since the community doesn’t have enough knowledge of the technology itself being used to gather the information. “It is very much about the lack of control.”

Researcher Zainab Durrani — a project manager for the Digital Rights Foundation, a nonprofit advocating for human rights in digital spaces — said that online spaces are very much an extension of offline spaces; in the case of Pakistan, it’s dominated by men and deemed unsafe for women.

“Internet usage is very much a manifestation of independence,” she said. Consequently, “we see the digital gender divide as more pronounced in small cities and rural areas.”

The TIBBI app isn’t Pakistan’s first foray into testing an mHealth intervention using community-based women health workers as the primary technology users. Between 2008 and 2010, a two-year pilot project was implemented to develop a reliable and efficient monitoring system for antenatal care in remote villages. Like with the TIBBI app, the LHWs were trained and given mobile phones to record patient data.

Back then, too, patients were hesitant; some patients’ husbands weren’t comfortable letting health workers use devices while attending to their wives, believing that it was an inappropriate collection of private information. And in one case, a LHW indicated that she wanted to work in another community because her father did not approve of her carrying a smartphone with internet access and a camera.

It is a challenge to introduce technology-based innovations into a rural community, said Shafaq Baloch, one of the app’s creators who worked closely with the government in its implementation in the district. “There was a lot of resistance from health workers too because who would want their daily activities to be constantly monitored through real-time data?” he said. “So, conspiracies about harassment and violence were spread by the LHWs to discourage use in the community.”

Baloch, for his part, dismissed the harassment and mistreatment of his app’s users as hyperbolic, but concerning their protection, he nonetheless emphasized that community buy-in was essential to avoiding resistance and fear of the smartphone. “There was no plan to involve or introduce the concept to the community,” he admitted. “Unless you make that groundwork, the locals won’t tolerate such an idea.”

Nine months after Bhatti died, her family is still struggling to get the backlog of her salary cleared from the administration. In fact, the government is thinking of expanding the pilot into nine other districts, according to Arain and Dr. Khan, while there is little to no discussion to scale it or make it sustainable in the long run.

“We will meet with the provincial government and urge them to change the strategy that led to all that Shaista Bhatti had to endure,” said Arain. “The government needs to meet the community leaders and tell them why this is being done and why it is better. This treatment with our workers by their own communities is unacceptable.”

Originally published at Womens media center