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Pendle.Net -> Kashmir - 1999 Visit -> Health & Social Services Report

Visit to Azad Jammu Kashmir and Pakistan, 7th - 21st February 1999.

Report of the Health and Social Services Group



The Health and Social Services group of the visit was made up of Health and Social Services colleagues from Burnley and Pendle.

These were:

bulletMr. Tom Daniels: District Purchasing Manager, Lancashire Social Services, Burnley.
bulletMr. Alan Gray: Mental Health Nurse working within Social Services.
bulletSr. Meg Davey: Day Hospital, Pendle Community Hospital.
bulletSr. Barbara Dole: Ward Sister, Pendle Community Hospital.
bulletSr. Debbie Gray: Community Mental Health Nurse, Burnley Health Care.

This report details the objectives, feedback and recommendations of the Health and Social Services group, which visited Pakistan and Azad Jammu Kashmir in February, 1999. This visit was as the result of the work of the Kashmir Working Party and His Worship the Mayor of Pendle, with support from Pendle Borough Council.

The Delegation consisted of representatives from Education and Career Services, Local Government, Burnley Health Care Trust and Lancashire Social Services. The delegates objective was to observe compare and contrast various aspects of service provision, culture and lifestyle in the regions of origin of the Asian Heritage population of Pendle.

This report considers in detail the nine objectives formulated by the group, with realistic recommendations for service provision and staff training. On completion it is apparent that several of the objectives overlapped and concurrent themes emerge, such as the importance of the joint family network, the position of older people in Muslim society and the limitation of resources for Service Providers.

Health and Welfare in Pakistan: The background.

National Public Health and Social Welfare is a recent innovation in Pakistan. In pre-partition India the British provided health care for Government workers and established several major hospitals, but did little for the remaining population. Limited resources and difficulty co-ordinating national and provincial responsibility for health care have hampered improvements since this time.

National Health planning began in the 1960's and the Government embarked on a major health initiative with substantial donor assistance from the World Bank. This programme is targeting maternal health, control of epidemics, training of female paramedics and improving the management of Provincial Health Depts.

There was a marked increase in the numbers of private hospitals and clinics in the 1980's with a corresponding decline in service provided by the Nationalized services. For instance in 1992 there was one physician per 2,127 people, one hospital per 131,274 people and between 1985 and 1991, 12.9 million people had no access to health care. Mortality rates remain high, particularly for the under 5's. The leading causes of death remain Gastroenteritis, respiratory infection, congenital abnormalities, TB, Malaria, Typhoid, Diphtheria and malnutrition.

In addition to Public and Private medicine there are indigenous forms of treatment. These include herbal treatments to balance the body humours and religious healing based on the HADITH of the Prophet pertaining to hygiene, moral and physical health and prayer. The use of Amulets containing Islamic verse, are relied upon to direct healing forces to those distressed or to protect from malign influences.

Social Welfare plans were first introduced in the 1960's but have never achieved much success. In 1984 President Zia introduced a Welfare system known as ZAKAT and USHR ORDINANCE, to introduce a national system of assistance to those without family. This system combined traditional Islamic welfare institution with those of a modern public welfare system.

Zakat involves payment and distribution of an Alms tax to the poor and needy. These usual include orphans, widows, religious scholars and those who do good work. Eligibility is broad and flexible and presumes great trust in the local Zakat Committee.

Formal Social Services provision as understood by the group did not exist. Instead the term when used in Pakistan refers to the work of volunteers who give time and money to good causes.

1.  Expand and consolidate knowledge of customs, cultural and religious requirements and their application in Health and Social Care settings.


The Group felt that they learnt a great deal about the customs, cultural and religious values of the Pakistan/Kashmir community first hand. On discussion it is now easy to discern how many issues are attributed to religious values which are in fact customs of a societal network and do not have their origins in religious doctrine. There are a variety of religious practices and beliefs in the Pakistan/Kashmir region, which would reflect differing views etc and yet there are common custom based beliefs and behaviours across these religious groups. An interesting additional strain to this issue is to recognise the potential powerful impact of imperialist legacies may have upon social interactions and relationships with public agencies.

Moving on to more specific points one of the fundamental cultural tenets witnessed was the existence of the importance attached to the Joint Family network and the responsibility placed upon women to care for their own and their husband's family members in times of need. Our limited experience suggested that this was the case across economic groupings but would seem to be more predominant in the rural cultures.

Linked to the strong joint family network/support system is the position that in many of the rural communities in the regions emphasis is placed upon the role of the community leader in providing assistance and dealing with public bodies for the vulnerable/disabled people within an area.

Additionally it became transparent that the usage of familial terms, particularly brother/sister, do not necessarily relate to blood relationships but can be attributed to more distant relatives or community friendships.

It was constantly noticed during our visit that any request for assistance or question as to whether there would be any difficulties in a request was generally met with a " No problem" response. We eventually began to realise that " No problem" signified that there was a problem but custom dictated that this should not be voiced.


bulletIn awareness training programmes the essential need for clarity and guidance in distinguishing between religious belief and custom values.
bulletThe need to recognize the role of the extended and joint family network system.
bulletThe need for a public education programme that health and social care support systems would ideally like to offer assistance to maintain and, where appropriate, give respite and relief to the network and not to replace it.
bulletThe need to ensure that support and respite services is culturally sensitive with ethnic minority workers in place.
bulletThe need to develop an understanding within health and social care professionals to understand the importance of identifying and relating to key family/community members when undertaking assessment and provision of services.
bulletThe need for workers undertaking assessments to ensure clarity regarding familial details to differentiate between blood relationships and other ones.
bulletTo recognize the " No Problem " response may need a more measured and lengthier time frame to gain some level of acceptance and trust before a more realistic assessment can take place.

2.  Identify different sections within Pakistani Muslim Society and how these divisions affect communities in Pendle and their relationship with communities of origin in Azad Kashmir and Punjab/Pakistan.


From our limited excursion across the regions of Kashmir and Pakistan it became readily apparent that there are distinctive differences between the various communities that exist in the region. This relates to both urban and rural divides and also differing regional variations. It is difficult to explain the vast difference in environment and general ambience between two similar rural areas - Muzaffarabad and Jhelum. Both similar areas on terms of social and economic condition yet vastly different in terms of outlook and feelings from an outsider perspective. It is recognized that there are even greater differences between some areas than those that the delegation visited.


Awareness of the region of origin of ethnic minority service users may help health and social care professionals provide a culturally sensitive service, perhaps cultural awareness training could be developed to highlight and explain these differences.

3. To acquire an understanding of the wider economic, educational and political situation in Pakistan and how this affects people's expectations of services in Lancashire.


It would seem fair to comment that the Group had a limited understanding of the economic and political situation within the region of Pakistan and Kashmir. In terms of the wider economic situation the group was able to witness at first hand the deprivation that existed and the need to develop infrastructures to improve transport, sanitary conditions and general health care provision. The region faces the daunting challenges that many other poorer nations face. The provision of the public health data by the Health Department of Azad Kashmir provide detailed analysis of the problems faced and the attempts that are being made to address the problems through government strategic planning.

Comparisons could be made within the structure of services within Azad Kashmir / Pakistan and the Western models in that primary, secondary and tertiary services existed. Generally however poverty reducing measures though in place for in excess of 30 years still required much further development.

In Lahore, huge efforts were made for its population of 6 million though poor or non-existent sanitary provision had a devastational affect on health. Here priorities were in the provision of safe blood, water, food and medicines. Major issues within the health professions were staff absenteeism, poor management, lack of accountability and poor management.

Regarding the political situation the concern regarding the unresolved situation of Kashmir, the Group experienced the intense feelings that the Kashmir issue aroused. Visiting the Refugee camps added to the awareness and the Group was able to see the human results of the ongoing dispute in the Region.

Prior to the visit the Health and Social care professionals had not fully grasped the history behind the Kashmir issue and listening to viewpoints and experience first hand raised the awareness of the importance of the issue to the Ethnic Minority community.


bulletService providers should be aware of the background of deprivation in which health care is delivered and the absence of social care which may influence the expectations of service users locally

4. To observe treatment, nursing and social care of illness and disability, both physical and mental and explore relationship between traditional and research-based treatments and care.


The group visited hospitals and health centres, but opportunities to actually observe nursing care and medical treatment were limited.

At Lalamusa Health Centre the medical officer in charge informed us that often patients consider some routine investigations, e.g. blood tests and x-rays to be actual treatments and are therefore very keen to undertake such procedures.

We discussed medication compliance with doctors from Lalamusa Health Centre who experienced problems whereby patients discontinue medication on feeling relief from symptoms with obvious implications with diagnosis such as diabetes, Tuberculosis etc. Awareness of health provision and poor education was thought to be responsible for this response together with much faith in traditional and simple remedies.

Facilities in this particular Health Centre were very basic. We visited the pathology laboratory, x-ray department and delivery room. The group donated a nebuliser compressor to this health centre.

On a visit to a private hospital, Noor Memorial Hospital in Mirpur, a senior doctor there told us that they had very little technology to aid diagnosis. There was Echocardiograph, equipment that the doctor himself did operate, but he felt that he had insufficient knowledge and training to effectively interpret the results.

In the same hospital the intensive care had an ageing cardiac monitor and archaic dialysis machine only. There were no patients in this unit during our visit.

The Noor Memorial Hospital cares for all patients in individual rooms, all with an additional bed for a relative to remain present throughout the patient's stay. The presence of a relative is considered to be totally routine and their needs appear to be considered in the same way as those of the patient with arrangements being made for meals etc.

A patient recovering from appendectomy receiving intravenous therapy and an indwelling catheter in situ was being cared for in a very stark basic room with his father present. The catheter drainage bag was resting in a bucket, which also contained empty medication bottles and other rubbish. When discussing the incidence of post-operative infection, the doctors felt this not to be a particular problem. There are no special procedures for the disposal of clinical waste.

The paediatric wards visited at the combined military hospital in Muzaffarabad were very busy and all the beds fully occupied. As discussed in the reports, pertaining to other objectives, at least two mothers and children shared beds. It was apparent that some of the children were very ill but we were unable to observe any medical treatment or nursing care being carried out during our visit. The visit was very high profile and at times members of the group found it disconcerting to be receiving more attention than those of obvious greater need.

With regard to disability, in the inner cities of Rawlpindi, Islamabad and Lahore, people with often severe disabilities could be seen begging in the streets. Anecdotal evidence was such that some of these disabled people are exploited and have to give a proportion of their "earnings" to "minders".

In the rural areas the extended/joint family system was more in evidence supported also by the strong sense of community. In these areas it was often local benefactors who assisted with the provision of adapted forms of wheeled transport resulting in optimum independence. People with disabilities appeared to be equal members of the rural communities.

Visiting the ill and sick by relatives, neighbours and friends is a traditional practice. The visits constitute a social obligation to the point that illness often becomes a social gathering when social ties are renewed. When hospitalized, the obligation is deeper, visitors feel it is a good deed obtaining a nearness to Allah. This highlights the importance of social ties - failure to visit at times of illness damages social relationship and may result in severing of social ties - more important to visit in hospital than marriage and birth visits.

Death: Death and time of death is believed to be predetermined and nothing can change it. though a sense of hope is maintained. Some believe that to speak of death can bring it about. There is an argument that talk of death - terminal diagnosis- should be avoided. Western models may be wholly inappropriate to Muslim culture. Anxiety is seen to add to an existing problem. There are few resources to resolve. Death enhances solidarity of family and social relationships and visiting is a social obligation.


bulletTo acknowledge that it is customary for relatives to be present at the bedside throughout a family member's stay in hospital, particularly during an acute phase of illness or when a condition is seen to be deteriorating or terminal.
bulletTo consider the need for rooms that are large enough to take an additional bed in the event of relatives wishing to remain close to the patient, a relative room near to the ward may not be close enough.
bulletTo be aware that investigations may be considered to be actual treatments and ensure full explanations are given using an interpreter if necessary and sufficient time and opportunities are available for questions/queries.
bulletTo be aware of the possibility of non-compliance with particularly long term medications, e.g. insulin and TB treatments.
bulletEthnic awareness training should deal with the sensitivity of talking about death, given that there is a belief that such discussions can hasten death.

5. To study how the needs of various client groups (as identified by local Purchasers and Providers) are addressed in the communities of origin, including Elderly, Learning Disabled, Physical Disability and Sensory Impairment, Mental Illness and Child Care.

Older People in Pakistan - Azad Kashmir

The position of older people in Pakistan Muslim society remains one of honour and respect. The obligation of family members to care for older relatives is seen as a right with any deviation being socially unacceptable. Operating on a cycle of delayed reciprocity, the parent caring and enables their children in return for care in later life. "They look after me better than I looked after them".

The treatment of older people in western society is seen as both alien and abhorrent. Older people in Pakistan are far from disengaged from society and family life, but were pivotal to it. Taking an active role in community affairs, offering advice and taking decisions within the family. The wisdom and knowledge accrued over the decades appeared to be valued and respected. Elders with whom we had opportunity for extensive debate appeared alert, sharp witted and stimulated by their active role in community life.

Migration of family members to urban areas or abroad does not appear to have diminished the "combined/jointed" family available to care for elderly relatives. One professional couple had forgone their career opportunities in the city to return to rural Kashmir to care for an aging parent, their obligation to a parent stronger than their desire for personal professional development.

There was no official retirement age in Pakistan or Azad Kashmir, with work continuing as long as the individual was physically capable. There are no benefits for older people or pension schemes.

Life expectancy in Pakistan and Azad Kashmir is currently 60 years of age, having risen from 48 years in 1947. However, this remains well below that of western developed societies. Due to life expectancy there is a low incidence of dementia and no specialist geriatric services.


bulletPossibility of intergenerational conflict for elders in UK if traditional patterns of care and obligation diminish in the future.
bulletAs 'life expectancy continues to increase, so will the incidence of disease associated with later life, such as dementia. Current service provision fails at times to meet the assessment of care needs of this client group and must be addressed.
bulletA combination of increased life expectancy and associated disease incidence may conflict with traditional patterns of family care for older people. This will present a challenge to community health care providers and social services.

Mental Health Services

As in the UK, Pakistan and AJK have seen a shift in service provision from large institutional care to small gender segregated units within District General hospitals in the urban areas. The urban population appeared to have a greater degree of informed awareness of mental health and illness and was more likely to seek treatment than the rural populations.

The picture is quite different in these areas where there were no specialist psychiatric service provisions. Local health professionals are reluctant to give a diagnosis of mental illness due to the associated stigma for the individual and their family. There was evidence of strong traditional beliefs about the cause of mental illness, for instance the belief in DJINNS possession by evil spirits or ill wishes of others. Individuals also attributed ill health to physical or environmental factors such as heat, of cold traveling through the body, foods or lack of sunlight. Such health care beliefs are likely to influence individuals' decision not to seek professional medical, help thus delaying treatment. Spiritual / traditional healers continue to play a major role in the treatment of mental illness. Individuals with mental health problems often returned to the rural areas from the cities as it was seen that the life was less stressful and they could be absolved from responsibility.

During visits to the Refugee camps in AJK and the combined military hospital the group was told that there were high rates of post traumatic stress syndrome and depression amongst this population. Doctors in AJK also reported high rates of depression particularly amongst women, attributed to socio-economic pressures and multiple births. It was also noted that a number of young girls presented with vague somatic symptoms, which they suggested could be associated with the perceived lack of opportunity for the future and limited lifestyle, which contrasts with images portrayed by the media.

There is no Mental Health legislation in Pakistan or AJK, the Police have no power to remove an individual to a place of safety and the individuals rights are not protected by compulsory assessment, treatment orders. There are no forensic services and a person's mental health is not taken into consideration if they commit a crime.

Many of the resources we would associate with a comprehensive psychiatric service in the UK were limited or non-existent in Pakistan and AJK a Community mental health nurses, Occupational Therapy, Psychologist Day hospital. It was reported that there was poor follow-up treatment in the rural areas with depot medication being given in field stations.

Interestingly advanced pharmacological treatments such as atypical antipsychotic treatments were prescribed but only for those individuals with the ability to pay for the treatment, as opposed to cheaper treatment options. There was eagerness amongst the professionals we met to offer evidence based interventions, but limited opportunities to keep informed of advances in psychiatry, due to limited availability of journals and Internet access in rural areas.


bulletAwareness of the variety of health care beliefs and associated stigma could be highlighted in the cultural awareness training sessions.
bulletHealth care beliefs should be explored on assessment and incorporated into plan of care to enhance compliance with treatment.
bulletImplementation of Government recommendations for single sex wards may impact upon the take up of psychiatric inpatient treatment.
bulletLocal community groups, health shops in collaboration with BHCT could play a vital role in the education of local communities about mental health issues and access to services.

Other client groups

There was no apparent division of specific client groups within the Health and Social Care systems, with the voluntary organizations being a "catch all", filling any gaps in service provision. There were no specific services for individuals with learning disabilities or physical disability. It was found that care was expected to be provided within the family, with symptomatic treatment being offered by the appropriate medical specialty. If in the exceptional case that family could not offer the care required, the only residential placements available were in the long stay psychiatric hospitals regardless of diagnosis.

Aids for individuals with physical disability were limited and rudimentary. The EDHI foundation provided basic items such as zimmer frames and crutches. Appropriate technology was available but had to be personally funded. The group had opportunity to meet with individuals with physical disability whose mobility and quality of life had been greatly enhanced by law tech, but highly effective equipment paid for by local benefactors.

Aids for sensory impairment such as glasses and hearing aids were available from the urban hospitals. Individuals with sight impairment who could not afford state provision or who had limited access to urban hospitals, relied upon voluntary eye camps. These were mobile camps that relied on medical and nursing volunteers to give their time to provide corrective surgery for conditions such as cataracts. Volunteers gave not only their time, and expertise, but also financial contributions and even blood. These camps also provided disaster relief and distribution of food parcels to needy families during the EID period.

Rural Health Centres also offer dental facilities and a dentist would enhance the team there. Provision of dentures seemed to be the exception rather than the rule.

In the rural health centre at Lalamusa a Committee had been established in an effort to raise local awareness regarding services available and to give health education. Expectations the local community were low and generally understanding of medical procedures and health care provision confused by poor education and literacy with X-rays being seen as curative rather than investigative.

The concept of having visiting specialists to the health centre appeared astonishing to the doctors there. ENT and other specialists were available in nearby large towns for both children and adults but funding would have to be found privately. Ear syringing was available at basic health units.

Community members requiring nursing care would generally have these needs met in the home. In the civil/military hospital in Muzaffarabad it was accepted that some families could not cope with the care of the terminally ill and 2-3 beds are available at the hospital for such care. In the community families generally expect themselves to cope and would gain advice from other family community members who had former experience. The female health workers had also experience of giving advice and occasionally assisting with care in the home.

We saw many inappropriate aids to mobility in use that affected gait so much as to cause secondary problems. Simple aids and adaptations, i.e. shoe raise, provision of elbow crutches, were not evident in the community. A young disabled man of around 20 years with gross deformities and muscular wastage of the legs moved himself on a wheeled platform, which appeared like a large skateboard with no padding. This man risked his safety begging for money close to moving vehicles on the busy streets of Rawalpindi.

6. To examine statutory and voluntary childcare systems specifically to issues regarding child care provision and child protection.


There was no formal childcare provision or child protection legislation in Pakistan or Azad Kashmir. The group witnessed large numbers of Afghan street children begging in the major cities apparently without access to adequate food and shelter.

The Edhi Centres founded by Edhi Sahib in 1951 now form a network of around 240 welfare centres throughout Pakistan. They are funded by donations, not only from the people of Pakistan, but also worldwide, and would appear to carry out work comparable to the Social Services Department in the UK. The Edhi foundation sought to reunite separated families, negotiated with family members in case of suspected child abuse and took in abandoned children who were placed in residential care or adopted. We asked about the possibility of a child needing an advocate, it was thought that the need for this had not arisen though some form of monitoring through volunteers existed for repatriated children and families.

As a voluntary service, the Edhi foundation would educate about and seek to prevent infanticide by offering confidential, practical support. A cot would be found outside each Edhi centre to accept unwanted children that were born out of wedlock. The child would be taken to the hospital and examined. Woman volunteers would feed the child then arrangements would be made to transfer the child to Islamabad and then to Karachi . The child's name would be changed to avoid stigma, and arrangements would be made for the child to be adopted or to remain at the Edhi Centre. Adoptions outside the country were very rare due to very complicated immigration and administration involved.

Wherever possible lost children were reunited with their parents, the Edhi foundation used available media to aid this. Whilst at the Edhi centre at Mirpur we met with a seven year old child who was lost and was thought to have lived in Rawalpindi. The Edhi Centre's latest project was the setting up of a school for 11 deaf and dumb children.

7. To examine the concept of rehabilitation following illness hospitalization in Pakistan, including any links between hospital and community.  Examine the roles of those comparable to members of the Health Care Multi-Disciplinary Team e.g. Occupational Therapist, Physiotherapist, Speech and Language therapist, Dietician and Social Worker.

The nursing representatives, having a special interest in rehabilitation, hoped to study this specific concept, but having visited hospitals and health centres and met with doctors and representatives of the regional health Ministries of Punjab/Azad Kashmir, it became apparent that modification of these objectives was necessary. However the group found that the terminology we use has a somewhat different interpretation in AJK.

Lack of funding and therefore lack of resources means those public health issues, e.g. inadequate sanitation, obviously have to take priority and what could be considered to be basic health care only is available. The doctors with whom we met in hospitals and health centres, particularly those with experience of working in Europe, N America and Australia, fully understood the concept of rehabilitation and the roles of the multi-disciplinary team and expressed some feelings of frustration due to being unable to offer these services. Following orthopaedic surgery, basic physiotherapy is available on the hospital wards but there is no follow-up in the community post discharge. This appears to lead to the emphasis being placed on the caring role of the family rather than independence being encouraged.

Having visited several hospitals and health centres, the only place we saw mobility aids, i.e. crutches and walking frames, was in the Edhi Centre at Mirpur.

The Edhi Foundation appears to have a wide remit taking in people in need of shelter, e.g. drug abusers, those with learning difficulties, administering an adoption system and even ensuring a dignified funeral/burial to people found washed up in the rivers following floods whilst also tracing their relatives.


bulletTo be aware of the possibility that, particularly elderly people, may not fully understand the concept of rehabilitation.
bulletTo ensure that the role of services of each appropriate member of the multi-disciplinary team is effectively communicable both verbally and written. Check the availability of leaflets, etc, in the appropriate language. Provide interpreters if necessary during discussions and case conferences. Encourage feedback to ascertain perception and understanding.

8. Consider the role of carer and support available.


The Quran states that 'taking care of one's family is as important as other religious duties'. The group found that the extended and joint family shares the caring role often diluting tasks and stress involved. Female family members who develop considerable expertise predominantly gave care.

Elderly family members with whom we had opportunity to talk to were happy to be cared for and accepted that some care, though unnecessary, was freely given and received. It was evident that age commands much respect and authority and that it was seen as disrespectful to let elderly family members live alone. This strong sense of duty was said to be reinforced by both religion beliefs and culture.

Respite facilities were generally unavailable though family members appeared to offer each other mental and physical support. The Edhi welfare Centre at Mirpur was in the process of carrying out a census of the local area to ascertain the need for respite in the form of a Day Centre locally.

The caring role appeared unchanged when the family member became hospitalized. In the hospitals we visited, each in-patient had a close family member present to assist in basic care. In Noor Memorial Hospital in Mirpur, carers were supplied with a bed within private rooms, but in contrast, we witnessed the Paediatric Ward in Muzaffarabad, which accommodated 3 mothers each with a child on each bed within an eight-bedded ward.

Little or no assistance is visibly available to aid the plight of the physically disabled adults and children in inner towns and cities who beg for their income. Aids to disability were found in these areas to be absent or hand made basic items. In rural areas there appeared to be evidence of support from local benefactors community leaders to provide aids for some members of the community.


bulletBe aware of the strong "duty of care" within the community.
bulletConsider methods of involving family members in care and hospitality requirements to do this, i.e. put you up bed in same room as patient.
bulletThe need for cultural understanding in providing congruent nursing and medical practice cannot be overstated.
bulletThe 'no problem' response may require further tentative investigation.
bulletBe aware of potential effects of westernisation in the role of the cover in carrying out responsibilities with fewer family members to assist and support. Provide and promote sensitive cover support assessment and flexible services to maintain care in the community.
bulletBe aware of possible ambiguity between desired goals of patients and corer and unnecessary assistance given by carer within a treatment period. Promote benefits to all of independence and rehabilitation concept care and treatment goals should be explained and negotiated between client, carer and staff members.
bulletEmbrace carer presence on ward, hospital, day care or clinic environment as appropriate, using presence to assist in continuity of care.

9. Investigate status of women in Pakistani Muslim culture and within Health and Social Care professions.


The status of women within Health and Social Care Services has been detailed elsewhere in this report.

The role and position of women in Pakistan/Muslim society is obviously a very complex combination of religion and culture and society's expectations.

In the cities, women were more in evidence in the shopping areas and restaurants.

In the rural areas women appeared to remain more secluded in the home. On occasions, the female members of the group were invited to meet the female family members. There was an obvious strong kinship between the women within the extended/joint family and the women appeared comfortable and relaxed and happy to discuss the position of women in Pakistan/Muslim households.

We established through meeting the Health Secretary for the Punjab that the gender gap is one of the main issues. It was understood that 70% of service users were women and children and that the majority of service providers should be female. Therefore at government level equality of women appeared to be promoted. The benefits of education and promotion of women were acknowledged however, our experience in most areas be it in health, education or in government itself saw little evidence of this principle.

Throughout the visit, contact with women was limited. One group member took the opportunity to raise this issue during a public meeting. Her speech wasn't generally well received with applause from the fellow members of the group only.

Educationalists stated that 61% females and 40% males left education before secondary levels.

The same educationalist (Punjab Health Minister) said that lots of women who work 12-15 hours a day in the home welcome the birth of a girl to share their labour with and therefore may have only limited amount of time in education.


Health and social care employees should be encouraged to be aware of and explore their own ethnocentric values particularly in relation to the role of women in Muslim society.

10. Examine nurse education (pre and post registration), the type and extent of evidence based practice taught in nursing and medicine and other influences on practice.  Study nurse recruitment and the profile of nurses.


The group visited two different regions i.e. Azad Kashmir and Punjab and found varying criteria in operation with regard to both nurse training and the structure of nursing.

Azad Kashmir

We met with the acting Health Minister for Azad Kashmir Dr Jabir Ahmed Khawja in Muzaffarrabad. He spoke mainly of the role of Lady Health Workers. These women are usually aged between 20-50 years old and are preferably married. Village leaders are responsible for the selection process. They are selected from the area in which they will hopefully work in once trained and 1800 out of 2000 available posts are filled. It would appear that training is usually on the job with other experienced lady health workers taking responsibility for this. The training lasts for 2 years.

The area of Azad Kashmir covers 13,000 sq. km and has a population of 3,000,000. Life expectancy is around 60 years. 15% of the population is under three years of age. Infant mortality is 90/1000 births and maternal mortality is 67/1000.

The average household has 7 persons and only 57% of children under 3 years presently receive routine immunizations.

The role of the lady health worker appears to consist of mainly health education with women and children being the main targets, promoting primarily birth control ad immunization. The lady health workers are expected to visit either 100 houses or 1000 women and children per week, but their role is seriously challenged by reduced resources - financial input has decreased 50% in the past year and the mountainous landscape with the inhabited areas very scattered causes problems with access.

The lady health workers theoretically have no involvement in direct nursing care, but 2 LHW we met with in a village health centre (one was a supervisor) told us that they did sometimes assist families with the basic nursing care required by their relatives. We talked about such nursing problems as incontinence and pressure area care. They were very aware of these problems and did support families with both advice and occasionally practical assistance, but there are no aids available.

With regard to qualified nurses, in Azad Kashmir, we visited a combined military hospital in Muzzafarrabad. Army nurse training is of 4 years duration and this hospital has training facilities, although we didn't visit any training areas. It was said that training outside military hospitals lasted three years, was to diploma level and was affiliated to universities.

This hospital has a total of 260 beds but at busy times may have up to 400 patients. Spare mattresses are available and patients may be nursed on available floor space or even outside on verandas. The figures quoted for staffing of the hospital were:

Doctors - 18

Nursing Officers - 17

Nurses (trained) - 27

Paramedical staff - 225

Nurses at this hospital work 8 hours shifts, 7 days per week with the nurse/ patient ratio being 1:8. On visiting the paediatric ward we saw 45 children accompanied by a relative usually mother, sharing beds, i.e. 2 or 3 children/mothers to each bed with 2 nurses working on the ward. We spoke with one nurse briefly but she appeared overwhelmed and the interaction was poor. The ward was very stark and some of the children were obviously very ill.

We heard here that when the need for treatment, e.g. surgery, is identified it is carried out usually within days and the waiting list principle doesn't seem to apply. The figures given for surgery were 3,970 operations carried out in 1997.


A meeting with the Health Minister and his team in Lahore illustrated that both health and education are seen as priority areas and both have huge political support. The major issues being addressed in this region are the large school drops out rates, particularly girls leaving school early in the rural areas.

The general government principle appears to be that as 70% of clients in the health service are female; this ratio should be replicated in the health service provision. In the Punjab, as in Azad Kashmir, family planning and immunization are seen to be major problems and lady health workers are employed here as in Azad Kashmir.

Another problem that the Punjab Health Ministry has been confronting is that of counterfeit medication leading to non-compliance, it has been common place in Pakistan for unlicensed pharmaceutical companies to manufacture poor quality, ineffective and sometimes-dangerous medications. A massive inspection programme of manufacturing plants and pharmacies has been undertaken and is 75% completed, but there is obviously a long way to go before public confidence is boosted and maintained.

With regard to nursing in the Punjab we visited a large general hospital, Jinnah Hospital in Lahore. Here a nursing officer spoke of the Pakistan Nursing Council, the governing body that recommends a nurse/bed ratio of 1:10 and shifts of 6 hours, 6 days per week. This directive is adhered to at Jinnah Hospital, but as previously stated in the combined military hospital in Muzaffarrabad the nurse/bed ratio was 1: 8 with 8 hour shifts worked 7 days per week.

The nursing officer informed us that Jinnah Hospital has its own training school and is at present over-subscribed. The length of training here is 3 years.

It is usual for post registration nurses to be further developed abroad, usually Australia, to learn new concepts and techniques and cascade the training to colleagues on return. This seemed to be a practice in large inner city hospitals.

The Health Ministry official who accompanied us to Jinnah Hospital felt that interest in nurse training has been boosted by the narrowing of differentials between doctors' pay and nurses' pay, but felt that there is still progress to be made.

We visited an emergency admission ward at Jinnah Hospital where there appeared to be only a few in-patients and disorganization probably caused by our visit! As we had found in our previous hospital visit in Muzaffarrabad, discussion with the nurses, despite interpretation, was limited, but it would appear that the 2-3 nurses on duty that day were trained nurses. We did not visit the school of nursing and it was unclear what proportions of training were classroom and clinically based.

Recommendations - please refer to Objective 11.

11. To gain an understanding of the barriers to recruitment to nursing and social care professions for people of Pakistani origin and report on these to respective agencies.


The group had opportunity to discuss the issues regarding recruitment of nurses with Health Ministers from Azad Kashmir and the Punjab and how these issues were being addressed. In the Punjab, the group were informed that it was recognized that a high standard of nurse training was necessary to help raise standards of health care in hospitals.

Many changes had been made in an effort to raise the profile of nursing including a salary increase on completion of training up to that of 4/5 of a doctor's salary, pre and post education was developed with opportunities of studying overseas. In Jinnah Hospital in Lahore, all nurse training was over subscribed and in Azad Kashmir all training places for lady health workers were filled, ladies being channeled into this particular field by community leaders from their rural areas. Since recent autonomy within state hospitals in the Punjab it was now possible for health trained professionals to be involved in the selection process, discipline and the termination of staff where appropriate. It was recognised that where accountability lay more action was needed.

It was found that policy makers at the highest level felt that barriers to nurse recruitment were being tackled and hoped that by 2002 all recruitment issues would be addressed! There was, however, evidence that at grass root repugnance existed in a woman health worker giving total care to male patients and that the basis for this was on religious grounds. In times of conflict when need was greater, this role was seen to be more acceptable. This was found to be the greatest barrier firmly rooted. The status of nursing and social care professions were slowly being raised all the same in city and town areas and where higher standards of training and care were evident, younger medical practitioners had more insight to changes than older members of the medical profession did. It was felt the new generation of nurses was more professional and problems were resolving.

The voluntary role within medical and caring roles seem to hold much status and was prominent. Regarding alms given the Quran stipulates that one should share with the less fortunate the blessings of wealth that God has given one.


bulletVolunteering plays a major part in the Asian culture. Investigate ways of further linking voluntary service with a wider and focused work experience placement in an effort to gain awareness regarding health and social care professions, with thorough evaluation and follow up.
bulletConsider present trust involvement at schools, colleges. Seek to highlight barriers by discussion, debate, and questionnaires targeting schools, colleges and youth groups. Once highlighted, look at methods of accommodating cultural differences within nursing practice and training and family friendly policies.
bulletAudit attendance from Asian community on health related college courses and university of CL and monitor uptake within professions.
bulletMaintain links with work experience students and gain feedback from placement.
bulletDevelop further contacts within Asian community including nurses from within that community group. Ensure information is user friendly and up to date.
bulletWhen planning open days, serious consideration should be given to hospitality and welcome. Contact names/cards will assist in developing links.
bulletSeek contact within the Asian community leaders to liaise with a view to promotion of Health Service careers.

12. To establish (and maintain on return) links with fellow Health and Social Care professionals in Pakistan in order to exchange knowledge and experience of practice and continue developing cross-cultural awareness.


Many of the Health Care providers in the rural areas of Pakistan and Azad Kashmir reported difficulty accessing relevant journal publications and recent research. Access to the Internet was not possible due to telecommunication systems that could not provide direct phone lines. However, in the major cities such as Islamabad there were newspaper advertisements for Cyber cafes and access to computers in the major teaching hospitals.

Contact addresses were exchanged with the majority of Health and Voluntary care providers with an agreement to exchange relevant journal articles, research papers. A mailing list can be compiled of professionals working in the communities from which the Pendle Pakistan population originates for the purpose of maintaining contact and developing a network of cultural and professional exchange.

On a personal level, members of the Health and Social Services group hope to continue to support the health and social care voluntary organisations, i.e. eye camps and EDHI foundation whose valuable work contributed greatly to all sectors of Pakistan society.

One private hospital in Mirpur has specifically requested an exchange visit to the UK to enhance their skills to operate cardiology equipment and in intensive care. However, the equipment available in the hospital would now be obsolete in western hospitals i.e. ECG machine read out display was an oscilloscope and hot pen readout, rather than print out.


The two weeks spent in Pakistan/Kashmir were crammed with non-stop visits, receptions, meetings and seminars. The map illustrates the distances traveled and often the delegation were "on duty" for 14 - 15 hours a day resulting sometimes in fatigue but always in a sense of achievement and satisfaction.

The contrast of the breathtaking scenery and the narrow, terrifyingly winding roads of Kashmir with the busy, noisy grid locked cities of Lahore and Rawlpindi is difficult to describe as is the genuine warmth and hospitality of all the people we met.

The members of the Health / Social care group feel proud to have been members of this delegation. As the report illustrates, the experiences, observations and information acquired has resulted in the formulation of recommendations which will hopefully provide a sound basis for the consolidation and improvement of service provision to those of Asian heritage background.


We would like to convey our thanks to all the organizers, Pendle Borough Council, members of the Kashmir Working Party and all those who were involved in arrangements made and for tendering such warm hospitality throughout the stay. We are grateful to Elaine Swarbrick, Pendle Community Hospital Manager for her vision and support throughout, Derek Weston, Sam McCumisky, Chair of Social Services Ms. D Pollitt, and to Linda Davidson for her assistance with typing. Final thanks to those who stayed behind and maintained family life.



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