SOMET HING is terribly wrong with the status of women and girls in Pakistan today. A host of embarrassing results in gender equality studies illustrates this starkly. The one most often quoted: Pakistan sits in the second to last position on the 2017 Global Gender Gap index below countries like Rwanda, Egypt, Bangladesh and even Saudi Arabia. The nation performs poorly on all the major indicators: women`s economic participation and opportunity, educational attainment, health and survival, and political empowerment; only Syria does worse than Pakistan in these areas. And only Yemen did worse than Pakistan in 2016, when we were also in the second to last place.

A report from the UN on gender equality published recently indicates that the poorest Nigerian women still f are better in nutrition than women at a similar poverty level in Sindh. Malnutrition, food insecurity, school completion, access to drinking water Pakistan fared worse than the other three countries included in the study: Colombia, Nigeria, and the United States.

Recently, another disturbing report was published in The Lancet examining poor maternal, child and adolescent health indicators. Pakistan, like other Muslim-majority countries, had lower rates of contraceptive use, f amily planning, antenatal care, skilled birth attendants, measles vaccinations, DTP3 vaccinations, and worse access to improved water and sanitation facilities than non-Muslim countries.

This situation is usually blamed on poverty: women simply don`t have equal access to basic healthcare, nutrition or education, which are already in short supply in Pakistan. But the Lancet study directly linked poor maternal health to a lack of pro-women legislation in Muslim countries: domestic violence, marital rape, emotional violence and physical violence are not suf ficiently prosecuted or punished in countries like Pakistan. How Pakistani women are treated under Pakistani law negatively affects their health.

In short, women and children are more likely to get sick and die in Pakistan simply because of the burden of being female. This is called a `disproportionate burden of disease` according to Ariba Moin,Huda Fatima and Tooba Fatima Qadir, Pakistani doctors who participated in a Women Leaders in Global Health Conference of 2017, which highlighted the importance of women leadership in health worldwide.

Pakistan`s patriarchal society that blocks prowomen laws f rom being implemented is also responsible for a lack of female leadership in its health sector. As Dr Moin et al wrote in a letter to the Lancet, in Pakistan, women make up more than 70 per cent of the academic medicine population, but only 3pc of legislators and senior health of ficials in the country. While Dr Sania Nishtar was health minister in 2013, Pakistan`s ranking in the health and survival index improved greatly, but Pakistan needs dozens, if not hundreds more women in positions to make decisions about women`s health if there is any hope for widespread change in women`s health. Yet with 70pc of Pakistan`s female medical school graduates not even entering the profession after qualifying, this seems like a long way of f from achievability.

On the opposite end of the spectrum, there`s another link to poor performance in women`s health indicators: women`s contribution to Pakistan`s economy remains undervalued and undercounted, particularly in the backbone of Pakistan`s economy. Not the f actories, the banks, or the of fices, but the agricultural sector, which provides a livelihood for over 40pc of the nation`s workforce and where women perform a myriad of tasks harvesting and planting, caring for livestock. The women themselves don`t even recognise this as `work`, instead calling it `chores`in addition to their responsibilities of childcare and homemaking.

Haris Gazdar is a social scientist who studies women`s labour in Pakistan`s agricultural sector. In 2017, his LANSA study of Pakistan`s agricultural labour force and its effect on women`s health and nutrition in rural Sindh found that not only was women`s work unrecognised and unpaid; but worse, all the work that they did in the fields, often while pregnant or nursing without adequate food, caused them and their children to suf fer from malnutrition and stunting.

While women`s empowerment is thought to lead to higher income and better health and this ismore likely true in cities, as well as among the rich and more educated the agricultural work that Pakistani women have always done in large numbers in the rural areas is directly causing poorer health for them and their children. According to Gazdar, women must be recognised as workers by the state, employers, communities and by the women themselves. Formulating a law to this effect is a vital first step towards protecting their rights and promoting their well-being.

At the same time, as Dr Moin and her colleagues observed, we need women in health leadership positions who can institute gender-sensitive health awareness programmes for women and men, health education for communities so that the burden of care is lif ted of f the shoulders of women, and immediate action to improve the health and nutrition of women labourers. It is imperative that such an ef fort is not politicise d, and that high-up appointments are made only on candidates` ability as leaders to improve the lives of Pakistan`s women and children.

A positive development, among all the gloom: according to Haris Gazdar, the Sindh Assembly recently passed a law that brings agricultural workers and other informal workers into the ambit of the existing labour law. `This creates a mandate for policy reform and an opportunity for activism on specific measures,` he says, calling it a considerable step in moving forward the discussion on the rights and well-being of women agricultural workers.

But we need much more, and fast. Improving women`s health requires a top-down, bottom-up strategy that includes strong policy, prescriptive measures, and firm political positions on gender equality that focuses on what`s solid, replicable and scalable in this diverse and populous nation. And as always, pro-women legislation must be strongly enforced as of now, to reduce the cost of genderbased violence on women`s mental, emotional and physical health. Only then will women and their children have a chance of not just surviving but thriving on all counts in our country. • The writer is an author Twitter: @binashah