Long, precarious working hours, 24-hour emergency calls, delayed salaries, low wages, understaffing and exhausting shifts are becoming a familiar part of working life for healthcare workers in Pakistan. Doctors are expected to remain available throughout the night. Nurses carry long shifts with too few colleagues. Lady Health Workers continue to work in communities while struggling for proper service structures and retirement benefits. Behind the language of professionalism and public service is a much harder reality, where healthcare workers sell their labour under conditions they often have little power to change.
This is not simply a problem of poor administration. Something larger is happening to healthcare itself.
The old idea of the doctor was built around professional autonomy. Doctors possessed specialised knowledge and, within limits, considerable control over how that knowledge was used. That autonomy was always uneven. It was much weaker for nurses, paramedics and lower-paid health workers. But the expansion of managerial control and market-oriented healthcare is changing relationships across the sector.
The health worker increasingly looks less like the independent professional of the traditional model and more like a technical worker employed within a large institution. There are still clear differences between a doctor, a nurse and a factory worker. Their qualifications, social position and wages are not the same. All are increasingly subject to schedules, targets, budgets, managerial decisions and the discipline of the workplace.
This is what makes privatisation and outsourcing important. The question is not only who owns a hospital, but how work is organised inside it.
The recent tragedy at PIMS brings the issue into sharper focus. When public hospitals are reorganised through outsourcing, public-private partnerships and tighter managerial structures, there is a danger that cost-cutting and administrative efficiency begin to take precedence over the conditions required for safe care. If staffing is stretched, maintenance neglected, and workers have little say in how their workplace is organised, institutional failures can become matters of life and death.
This does not mean that every outsourcing arrangement will inevitably produce a disaster, or that public ownership automatically guarantees safety. The issue is the system of control surrounding healthcare. When responsibility is pushed through layers of contractors and administrators, those making decisions can become increasingly distant from the people dealing with the consequences. Hospitals cannot be run safely as though healthcare were simply another balance-sheet exercise.
PIMS should therefore raise a basic question, which is, who decides how a public hospital is run? The answer cannot rest entirely with administrators, contractors or government officials. Those working in these institutions know where the system breaks down, while patients and their families experience those failures directly.
There is another contradiction in Sindh. The provincial government has earmarked more than Rs148 billion for hospitals, specialised institutions and emergency health services in the 2026-27 budget. SIUT has been allocated Rs26.25 billion, NICVD Rs12 billion, the Pir Syed Abdul Qadir Shah Jeelani Institute of Medical Sciences in Gambat Rs10 billion, the Shaheed Mohtarma Benazir Bhutto Institute of Trauma Rs5.7 billion and the Sindh Integrated Emergency and Health Services programme Rs5.218 billion. PPHI, a public-private healthcare initiative, has also been allocated Rs24.7 billion.
These figures show that the problem cannot simply be described as an absence of public money. The more difficult questions are where that money goes, who controls it and under what conditions healthcare workers are employed. Hospitals can receive new equipment while staff remain overworked. Programmes can receive billions while employees remain stuck in lower grades. Infrastructure can expand while decisions about employment and service delivery are increasingly handed to private or semi-private management.
Public expenditure and marketisation can therefore exist at the same time. The issue is not merely how much the state spends, but what kind of health system that expenditure produces.
The struggle of doctors in Pakhtunkhwa illustrates this contradiction.
Doctors recently announced a pen-down strike as the second phase of their province-wide protest over salaries. The Neutral Doctors Forum said around 6,000 doctors had been observing the protest and demanded a 30 per cent increase in salaries. Emergency services were to continue, while routine services were withdrawn.
The doctors say they have not received any substantial salary increase since 2017 and that inflation has made their existing incomes increasingly difficult to live on. They have also pointed to the growing attraction of jobs abroad as prospects in the province deteriorate.
There is a certain irony here. The same doctors protesting over their own conditions have continued treating emergency patients during floods, the Covid-19 pandemic and other crises. They even suspended their protest to treat those injured in the Kohat suicide bombing.
Their dispute is therefore not a rejection of public service, but a demand to make that service sustainable. Doctors can have professional status and still be workers. The two are not mutually exclusive.
The struggle of Lady Health Workers in Sindh makes this even clearer.
Last month, LHWs from across the province gathered at Teen Talwar in Karachi to demand that their programme remain under the health department and to seek a proper service structure, promotions, pensions and gratuity. Their union also opposed outsourcing the programme to PPHI or another private entity.
The workers say that although they were regularised in 2012, many have remained in lower grades despite years of service. They have also demanded the restoration of medicine budgets and operational resources.
These are not abstract demands. They concern the everyday realities of employment.
An LHW occupies a very different social position from a senior doctor. Yet both are confronting a system in which essential work is carried out by people who have limited influence over how that work is organised. This is where the boundaries of professional identity begin to shift.
It would be too simple to say that every doctor, nurse or health worker has suddenly become part of a unified working-class movement. Healthcare remains deeply divided by qualifications, income, status and occupation. A senior specialist and a community health worker do not experience the health system in the same way.
But capitalism has a way of creating common pressures among people who previously understood themselves as belonging to different worlds.
As doctors become increasingly dependent on salaries, their interests can come into conflict with hospital management. Nurses facing understaffing and intensified workloads confront problems that cannot be solved individually. LHWs facing outsourcing and stagnant grades are forced to confront questions of employment and control.
The hospital becomes a workplace in a much more direct sense. Questions that once appeared administrative become political for the people working there. Who decides staffing levels, who controls the budget, who determines working hours, who owns the service and who carries the consequences when it fails?
This is also where healthcare struggles can connect with the wider working class.
Wage disputes may begin among doctors. Service-structure disputes may emerge among LHWs. Nurses may organise around staffing and workload. And beneath these different demands lies a common problem, that is, those who keep an essential public service functioning have limited influence over the conditions in which they work.
The significance of the present moment lies in whether these disputes remain confined to individual professions or begin to recognise their connections.
The future of healthcare workers' struggles in Pakistan will not be determined only by whether one salary demand is accepted or one outsourcing proposal is withdrawn. It will also depend on whether doctors, nurses, LHWs and other health workers begin to understand their separate grievances as part of a broader transformation in the organisation of healthcare.
The professional is still there, but increasingly alongside the worker.
What begins with wages, working hours, promotions or pensions can therefore open a larger question, namely, who should control the institutions on which both workers and patients depend?