In 1985, the Community Health Sciences Department at the Aga Khan University in Karachi, initiated the Urban Health Programme (UHP) with the intention of introducing a Primary Health Care model in the various squatter settlements across Karachi. This was accomplished in collaboration with communities, District Health Organizations, Urban Health Organizations, and union councils. Rehri Goth is included as one of the field sites. Each site includes a Community Management Team (CMT), which consists of community leaders (men and women), volunteers, school teachers, religious scholars and local health care providers such as traditional birth attendants. Community participation is encouraged through priority setting exercises with the CMT to identify health and developmental needs of the community that require immediate intervention. This promotes ownership and empowerment of community members. Management and accounting training is also provided to CMTs so as to build their leadership skills and allow these teams to run the project as their own. Community mobilization is then further enhanced through the provision of training and capacity building. Women are selected from the communities to be trained as Community Health Workers (CHWs). These are volunteers who are trained to provide basic preventative, dispensary and referral services.

Health care facilities have been established in these squatter settlements, as identified by CMTs and local government representatives. These facilities provide basic preventative and curative services on a private, free-for-service basis so as to maintain sustainability of the program. Services provided include immunization, antenatal and postnatal care, and family planning as well as those directed towards malnutrition and anemia. A referral system has been established to secondary and tertiary (both non government and government) facilities nearby. As part of health promotion and disease prevention, health education is the hallmark of the Urban Health Programme. Sessions are conducted by UHP staff and trained community volunteers to the community both at the facility and on an outreach level on various health topics. As Primary Health Care also includes rehabilitative services, a rehabilitation center has been established for disabled children at the field sites. Additionally, physiotherapy services are also provided for those with muscular-skeletal disorders.

As community development is inter-related to health and a component of comprehensive Primary Health Care, various developmental programs have been established by the Urban Health Programme so as to improve the quality of life of people living in squatter settlements. For example, adult (especially women) and children literacy programs have been organized with the assistance of CMTs. Other initiatives include micro-credit loan schemes, income-generating activities, and development of an adequate sewage system. For these developmental activities, UHP has been networking with various government and non-government organizations.

This program has recently been a first prize recipient of the Talloires Network MacJannet Prize for Global Citizenship on June 6, 2009 at Talloires, France. "The MacJannet Prize for Global Citizenship recognizes exceptional student civic engagement initiatives based in the Talloires Network member universities around the world and contributes financially to their ongoing public service efforts."

After visiting the Rehri Goth site of the Urban Health Program, my colleagues and I came to the realization that this program has achieved noteworthy milestones, especially since it was initiated from scratch with our a previous foundation to work on. Additionally, the cultural and religious barriers that had to be encountered and solved, with the communities of course, was no easy task. Therefore, it is no wonder that further areas of improvement were identified. For example, the immunization program runs only once a week at the health care clinics and once a week on an outreach level. Additionally, only one worker conducts the immunizations but she too has to travel far distances in order to obtain vaccine supplies. A comprehensive model of Primary Health Care would dictate the implementation of a routine vaccination schedule every day of the week. Due to several material, money and manpower resource restrictions, this is difficult to achieve. Community members need to be mobilized and trained as vaccinators in order to increase the human resource power, especially since the catchment population of only one field site is 40,000. Emergency Obstetric and Neonatal Care (EmONC) is not provided and communities rely on the referral system to secondary and tertiary health facilities for emergency care. These facilities are usually far away and families cannot afford transportation. Therefore, it is imperative that we train traditional birth attendants residing in communities so that they can conduct safe delivers and recognize obstetric danger signs so women can seek health care efficiently and effectively.

The following is a report I had written for my Primary Health Care course after a field visit to Rehri Goth and the Urban Health Program (UHP) that has been set up there by AKU. I will first provide you with some background before talking about the UHP.



With the advent of industrialization and with the global population rising at an unexpected rate, the world has witnessed a rapid urban growth from rural areas. Cities across the globe are rapidly increasing in size and in numbers due to increased opportunities and incentives for its people. However, despite of its obvious benefits, urbanization has been accompanied by negative and devastating consequences, especially for the poor in the developing world. In the developing world, economic growth and development in urban areas are severely inadequate to meet the needs of the growing population. This has resulted in environmental degradation and poverty at an unprecedented rate. Due to poverty and lack of available land, individuals and their families are forced to settle in slums or ‘squatter settlements.’

A squatter settlement is a residential area in an urban locality inhabited by the very poor who have no access to land which they can claim as their own. With the population of Karachi (an urban hub) continuously on the rise, so are the numbers of squatter settlements in this city. One such example is Rehri Goth (remember I talked about this village in one of my earlier blogs), located in the outskirts of Karachi, Pakistan. Rehri Goth is a 400 year old village at the coastal margins of the Arabian Sea with a population of 40,000. As with any other squatter settlement, Rehri Goth has her own share of health and developmental problems. For example, living conditions are extremely crowded and there exists unsafe housing infrastructure. Income generated from the fishing industry is not enough to meet the needs of the people. As a result, poverty is getting worse and worse. To further complicate the matter, literacy levels are very low with only 10% men and 4% women having attended formal schooling. A system for proper waste disposal does not exist within the community and neither is there a functioning sewage system. Additionally, as clean water supply is severely limited, diarrhea and other water-borne illnesses are of major concern. This is further aggravated by limited health education and unhygienic living conditions, leading to severe health complications such as acute respiratory infections and skin infections. Malnutrition is also a major concern within the community, resulting in anemia and poor growth and development. Therefore, crude birth rates, maternal mortality and infant mortality are on the rise and need serious attention.

In order to address the health and developmental needs of squatter settlements, such as Rehri Goth, a Primary Health Care model is needed. Primary health care is a people-centered approach aimed at providing universal coverage for essential health care services based on the principles of equity, accessibility, and affordability. This can only be accomplished through the participation of various stakeholders, especially communities. Other key elements of achieving this goal, as outlined by WHO, includes the reduction of social and economic disparities, organizing health services as per the needs and expectations of the community, and integration of health into all government sectors through public policies and reforms.

A colleague and I were conversing about our future career/education plans while enjoying some delicious samosas and chai (tea). She excitedly mentioned that she plans to either pursue her MA or MPH. However, when the topic changed to our love lives her smile turned into a forced smile. Her fiancee is against her working as well as pursing a higher education. He has made it perfectly clear to her that after marriage she is to stay home. Guess how old she is? 23! Since she is to get married in two years, she hopes she can fulfill her dreams of going back to school within those two years.

With her permission, I inquired further as to why her soon-to-be husband is against her working and going back to school. He feels that it is his 'responsibility' to provide for his family. That she should not be working and to let him be the 'breadwinner' while she rests at home. However, he had also said that he does not want her to work because that would mean she may have to work with male colleagues and this makes him uncomfortable.This may have more to do with cultural differences than trust issues. Additionally, he feels that after completing 14 yrs of education, "there is no need to go further." Apparently to him, 14 years of education is more than enough....

Again, I claimed ignorance and asked her how she feels about all this. Where does her happiness lie? Even though she wants to continue working, she also feels that she needs to make her husband happy.

That is a big sacrifice to give up your goals and dreams for the one you are about to spend the rest of your life with. But why can't couples support each other to pursue their individual and collective dreams? Why does schooling and working have to be only about making money? Why can it not be about passion, desire and happiness? I have seen this in Canada as well. Individuals obtain higher education at the best universities only to land the best job so that they can make the most amount of money. Why can we not do all of the above but do so out of interest and not solely to acquire material gain? Have we become greedy? Unmotivated? or have we surrendered ourselves to societal and cultural norms and expectations?

I am frustrated and stressed. This is why....

1) I made the stupid mistake of not booking a 2-way flight when booking for Karachi from Vancouver. Because of this mistake, I am having a hard time booking a one-way flight to Vancouver. Apparently, people in Pakistan book flights two weeks before their expected departure. Booking in advance, say a month or two, is to be laughed at. That is the reason why I am having a hard time booking my flight back. On top of that, the 4-5 travel agents I am in contact with are each giving me different information and making me run around in circles. I am not used to this. I am used to booking two months in advance via Internet. No travel agents, no middle men, no fuss! Lets not forget the corruption that is involved here either. One travel agent gives me a higher rate for the same flight as compared to another travel agent all to get extra commission. When confronted with this, the other travel agent is accused of being a liar and a fraud. I then looked at flights for the same airline online and lo behold! The rates were 5 times higher than what the travel agents had proposed. Lets also not forget that as soon as they see I have a Canadian passport, they automatically assume that I have money coming out of my rear-end. It is common in Pakistan, as I'm sure in other countries, for foreigners to get ripped off.

2) I keep getting random phone calls on my cell phone and on my land line from random people (men) at odd times of the night (2 am, 4 am, 5 am etc...). This has been happening for months and I am losing my patience...Initially when these men would call I would genuinely think that they called the wrong number by accident and I would try to help them out. I then found out that some men call random numbers, hope that a girl would pick and try to be "friends" with them. I now have 3 numbers stored on my cell phone as, 'Creepy Balouch' (he thinks I am a Balouch and wants to marry me), 'idiot', and 'stalker.' I seriously think these three numbers belong to the same guy...Also, a friend of mine has called one of these numbers and literally yelled at him. He said, "If you do not stop bugging my sister then you will regret it" That sure didn't help....

Anyways, because of these random men, I have found myself becoming rude. When I recieve these random calls now by men asking to be "friends" with me I say "I do not want to be your friend and do not call me ever again!" I am getting annoyed at my recent change in behaviour. But I cannot help but get annoyed by these men! So now I sleep with my phone receiver off the hook and cell phone on silent. I cannot deal with this anymore....

I was talking to a colleague the other day when I realized that he was the only one not eating lunch (we had ordered biryani). Curious me asked him why he wasn't joining the rest of us. His simple and most touching answer: "I am saving my lunch for my kids when I get home. They will love it."

Parents, including mine, sacrifice for their children day in and day out. They spend every single living moment concerning over their children, providing for them, nurturing them, and protecting them from the "world's evils." Knowing this and being the recipient of it, I could not help but feel emotional and sad after hearing my colleagues statement because this is not the first time I have heard this type of statement. In fact, I have witnessed it. Individuals here and in other developing countries are so poor that they are unable to fill their stomachs. I am sure you are familiar with this situation. But my heart goes out to those who sacrifice their health and well-being so that their children can survive, even though the food they receive may not be the healthiest. Imagine wondering every hour of every day as to how you will feed your family. Imagine wondering whether your child will survive or grow up to be a healthy adult. Imagine watching your child waste away before your very eyes. Imagine going to sleep hungry yet content that your child isn't. Most of us cannot imagine this because we have not lived through it and may never need to.

This reminds me of a story about my parents when we were living in Karachi. My mom and dad had cooked a meal with whatever little they had. We were not well off at all. However, they never got to enjoy that meal because my baby brother had well....urinated over the food. I mean he was just a little baby and he didn't know any better. I am sure I might have done something like that as a baby as well. The outcome? Brother was fed but my parents went to sleep hungry that night and who knows how many more nights they went to sleep hungry.

During my Primary Health Care course, I had the opportunity to visit a non-government organization called HANDS (Health and Nutrition Development Society) in Malir (a town in Karachi). Since 1979, HANDs has been promoting health, education and the alleviation of poverty in marginalized communities in Pakistan. This includes, 9.0 million people living in nearly 7000 villages in 15 districts of Sindh and one district of Balochistan. HANDS is certified by USAID.

We visited this particular organization because our course objective was to gain practical and theoretical knowledge about primary health care set up in an area serving marginalized populations. This experience also gave us an idea how both private and non-private organizations can work together in partnership as well as how communities can be mobilized and empowered to take care of their own health and well-being.

Some of the services provided by HANDs include: education programs (for midwives, educators, nurses, community doctors, and volunters), Early Childhood Development, primary school education, micro-credit loans and other financial services, programs aimed at establishing clean and safe drinking water, vocational training, medical services (OBGYN, Lab, OR, EMONC, radiology, vaccination, family planning, etc..)

A distinctive feature about this organization is that it works hand-in-hand with the communities and the people it serves. The communities were consulted before the services and clinics were set up. The people were asked as to what problems and issues they are facing and what type of services they would like in their communities. This concept of community mobilization and participation is of the utmost importance to any health care system in any part of the world. In fact, community participation is one of the principles of the Primary Health Care. It's the community that decides (or should decide) what it needs and how to best solve their problems. Organization can provide technical support to communities but should not force their will. Only this creates sustainable and committed communities.

As part of HANDS, young women are given training in handicraft and sewing, free of charge. We were given the opportunity to see the textile workshop set up by HANDS. So many young women were working on various different designs on various different fabrics taught by their instructor. I talked with a couple of these wonderful ladies because I wanted to see what they thought about this program and what are they personally benefiting (if they were) from this program. One lady said that it is a 3 month training program for women living in marginalized communities across Sindh. This same lady also mentioned that when she is done with the program she will go back to her community and with the skills she has gained, she will open up her own shop and sell her designs. I had asked, "Why are you doing this? What motivates you to do this?" She said, "Because this is my passion. This is what I like to do." Every women in that women said the same thing. So I asked, "What about your family? Do they support this?" Another women answered, "My father encourages me. They want me to do this." I also found out that all the supplies (sewing machine, fabrics, scissors, etc) are all provided free of charge. How wonderful is it that women are empowered to pursue what they love instead of being forced to settle with something they have no interest or passion for. This is community participation.

Historically, women in Pakistan are not allowed to leave their homes without the company of a man. This is true for other patriarchal societies as well. Women's mobility into the public sphere is restricted so much so that they are confined to the four walls of their homes. Not only their mobility, but their behaviour and activities are also dictated only by the men in their lives. Hence, women are responsible for maintaining the family honor by being obedient to the demands placed on them by these men.

During my field visits to the Karachi slums (katchia badis) and rural areas, I continuously hear stories of women not being allowed to leave their homes without their husbands, brothers or fathers. This means that if a women needs to go to a health center for any sort of health care for herself or her child, she cannot unless she is accompanied.

Sadly, this remind me of a story. A women was pregnant with her 9th child. First of all, she did not want to be pregnant anymore and proposed to her husband that she would like to get her tubes tided. Her husband refused, saying that it was "unislamic" to do so as that would "go against Allah's will" since it is "Allah who allows us to have children." Let me just briefly add that there is no mention of this in the Holy Quran and furthermore, Islam is a faith of intellect. These two are inextricably linked, that one relies on the other.

So this women continued to work during her pregnancy as a house cleaner as the family income was not adequate to meet the needs of the entire family. Additionally, she was very weak and malnourished. During my experience, I have learned that short birth spacing is extremely harmful to the health and well-being of the mother as well as her children due to nutrient deficiencies as well as limited psycho-social interaction. Such was the case with this mother. While at work, she started to bleed and needed to go to the hospital immediately. Since her husband was not home, she was not allowed to leave the house. The local people knew this and hence, did not provide her with any assistance. However, a traditional birth attendant recognized the severity of this situation and travelled for 3 hours in order to get the village lady doctor to see this women. Unfortunately, the lady doctor had been relocated. When the birth attendant returned to this women's house, the women had bled to death....

This story bothered me a lot even though I know this is a regular occurrence. Why do we have such little respect for women? If God created us equally, then why are men given more rights then women? I refuse to buy in to the idea that "people are just not educated enough" or "there is a lack of awareness." First of all, what does it really mean to be "educated?" Second, I think this has more to do with behaviours that are deeply engrained and rooted in culture and tradition. Behaviours are hard to change, especially when that is all you have ever known.