Healthcare workforce inequities in Pakistan - an intersectionality-informed mixed methods enquiry

This thesis explores how layered social and structural inequities shape healthcare workers (HCWs) experiences in Pakistan and is associated with their job satisfaction, with potential implications for workforce retention. Human Resources for Health (HRH) are the keystone of health system and required a more nuanced understanding for their optimal planning. However, globally and in Pakistan, the existing understanding and planning, both remain narrowly supply-driven, overlooking systemic inequities and power hierarchies within which HRH operates. Guided by a dialectical pluralist philosophy and integrating critical realism with social constructionism, the study applies an intersectionality-informed mixed-methods design comprising three complementary strands: (1) a systematic scoping review of global evidence on HRH inequities, which revealed critical gaps, particularly the neglect of intersectional approaches and lacunae in regional evidence; (2) a cross-sectional survey of 843 HCWs across Pakistan, analysed through OLS, path analysis, MAIHDA modelling, and multigroup SEM, which identified workplace experiences mediated through recognition, professional growth, discrimination and aggression at workplace; and 3) 21 in-depth interviews with HCWs that contextualised statistical patterns, illuminating how cadre hierarchies, gender inequities, ethnic affiliations, and geo-spatial marginalities intersect to create adverse work environments. Findings highlight that workplace inequities in the health sector in Pakistan are systemic and intersect to shape unique journeys. Inequities like professional hierarchies and structural neglect have institutionalised doctors’ dominance while undermining the legitimacy, voice and career pathways of nurses and AHWs. Satisfying and retaining this workforce hinges on Motivation factors, which in turn are determined by a workplace that supports, values and empowers the workforce. Conceptually, the thesis extends global HRH scholarship by “flipping” the HRH cube and embedding an intersectional equity lens within the Health Labour Market framework, advancing understanding of how systemic inequities drive workforce outcomes. Practically, it calls for equity-oriented policies targetting disadvantaged HCW groups, vulnerable groups, ensuring sustainable and dignified health workforce experiences in Pakistan.