Overcoming Structural Violence in KPK’s Rural Health System: A Secondary-Method Study 

Abstract 

This dissertation is a critical analysis of structural and symbolic violence to maintain women’s marginalisation in healthcare in Khyber Pakhtunkhwa (KPK) in Pakistan. The article is based on Johan Galtung’s (1969) theory of structural violence and Pierre Bourdieu’s (1990) concept of symbolic violence. It asserts that women addressing health disparities are not a product of underdevelopment but rather are the results of systematic oppression that exist in political, institutional, and cultural frameworks. 

Using a systematic secondary research design, the paper will integrate results obtained through various reliable sources, such as the Pakistan Demographic and Health Survey (2017-18), the Pakistan Bureau of Statistics (2021), the World Bank (2023), the World Health Organisation (2023), and current scholarly studies. Results suggest three overlapping exclusion mechanisms, including (1) institutional disregard and policy underinvestment, with Pakistan spending 2.8% of GDP on healthcare; (2) gendered workplace inequalities, with more than 70% of all women medical graduates out of practice; and (3) socio-cultural and symbolic, with patriarchal practices and religion discourses normalising female suffering and inhibiting medical autonomy. 

The paper concludes that the National Health vision for 2023-2025 in Pakistan is constrained by technocratic and biomedical biases that undermine efforts to address structural inequality. It suggests redistributive health spending, gender-responsible workforce policies, and culturally grounded reforms aligned with the Sustainable Development Goals (SDG 3: Health and Well-being) and (SDG 5: Gender Equality). Lastly, the study reaffirms healthcare inequity as violence, which is a failure of morality and politics that needs structural justice, and not a technical solution. 

Keywords: Structural Violence; Symbolic Violence; Women’s Health; Khyber Pakhtunkhwa; Gender Inequality; Health Policy; SDG 3; SDG 5 

Chapter 1: Introduction 

Introduction  

Healthcare is a fundamental indicator of social equity, but in most parts of the world, access to healthcare is still influenced by structural imbalances that unequally disadvantage vulnerable people. In Pakistan, especially in the province of Khyber Pakhtunkhwa (KPK), women are exposed to recurring obstacles to healthcare related to underinvestment and inadequate infrastructure, and deeply embedded socio-cultural beliefs. These obstacles go beyond logistical deficiencies and constitute what Galtung (1969) refers to as structural violence, namely, a form of harm embedded in institutions, policies, and cultural practices that systematically limit opportunities and well-being. The topic of women’s healthcare exclusion in KPK, however, cannot be comprehended only based on descriptive reports about inadequate facilities or a shortage of staff but must also critically question the societal, cultural, and institutional frameworks that serve to maintain inequity. The chapter provides background and context on Pakistan’s healthcare system, defines the core research problem, outlines the goals and research questions, demonstrates how the study is relevant to Sustainable Development Goals 3 and 5, and provides an overview of the thesis structure. 

1.1 Background and Context  

Health is a universal human right and a foundation of social justice, even though the chronically underfunded health system in Pakistan is 2.8% of GDP, or sixfold less than the recommended 6% in WHO guidelines, and it does not serve rural or marginalised groups (World Bank, 2023). National inequalities demonstrate this inequality: according to PDHS (2018), 86 per cent of urban women give birth in health facilities, whereas 58 per cent of rural women do so. In Khyber Pakhtunkhwa (KPK), where infrastructure is underdeveloped, and strong patriarchal standards limit access to healthcare, inequalities are even further (Ali et al., 2024). 

Such circumstances are examples of structural violence, according to Galtung (1969), which is defined as the violence or harm that comes about due to social structures that deny people the opportunity to access basic needs. Rural KPK women must deal with a combination of structural barriers, such as the lack of female health workers, poorly equipped facilities, and cultural limitations that compel women to have men accompany them to where they want to go. In Buner district, 63 per cent of women delay care-seeking due to mobility restrictions (Rasheed and Mariyah, 2024). The health infrastructure is still at a very low level; there are fewer than 0.5 hospital beds per 1,000 individuals (Pakistan Bureau of Statistics, 2021). 

These inequalities are further reinforced by patriarchy, which limits female choice and makes male dominance a typical attitude (Shah, 2023). Women are socialised to accept these norms through symbolic violence (Bourdieu, 1990), in which they delay or even fail to seek care. As a result, healthcare inequality in rural KPK has long-standing historical roots, is structurally reinforced, and is systemic violence against women. 

1.2 Problem Statement  

Even after the country has made national commitments under the Sustainable Development Goals (SDGs), Pakistan still lags in maternal mortality and gender equality. The maternal mortality rate is 154 deaths per 100,000 live births, which is much higher than the neighbouring countries, e.g., Sri Lanka (36 per 100,000) (UNFPA, 2022). These deaths can be largely prevented, yet they are perpetuated through systemic inequities. 

The issue is particularly critical in KPK. The lack of infrastructural facilities is only one of the factors that influence access to healthcare by women, though deeply rooted patriarchal ideals also play a role. Health care is frequently understaffed, and the number of female health workers is limited, who are crucial in conservative environments, as the system is discriminatory and retention is low (Raza et al., 2023). There is a mobility restriction where women need to have the company of males, and since services are provided, they are not equally available. Reproductive health is still stigmatised to silence the needs of women, which promotes preventable morbidity (Naz et al., 2025). 

It is not merely a question of isolated gaps, but is instead a structural violence within the healthcare system of Pakistan. The policy discourses today tend to represent inequities as a failure of logistics, neglecting their structural causes in the form of gender inequity and cultural suppression. This study fills that gap by examining healthcare exclusion in rural KPK in terms of structural violence. 

1.2.1 Defining Structural Violence 

Structural violence is the preventable harm that results when social, economic, and political systems deliberately limit individuals’ ability to fulfil their fundamental needs (Galtung, 1969). It is embedded in the structure and manifests as unequal power and, hence, unequal life chances (Galtung, 1969, p. 171). The same is applied by Farmer (2004) to health, where early mortality among people with low incomes due to avoidable diseases is not a coincidence but the anticipated consequence of systemic inequality. 

In healthcare, structural violence presents itself in the form of neglected policies, systemic lack of investment, gender-based discrimination in personnel hiring, and social inequalities that legitimise exclusion (Farmer, 2004; Sen and Östlin, 2008). Bourdieu’s (1990) concept of symbolic violence helps supplement this concept by explaining how dominated categories internalise social orders and accept unequal access as a natural state of affairs. Combined, these frameworks indicate that unequal health status is not only perpetuated by poor infrastructure but also by systems of power, ideology, and policy that are deeply rooted in perpetuating inequality. 

Therefore, structural violence is an explanatory framework for this investigation, as it puts the non-inclusion of women in healthcare in KPK in perspective as a structural harm and policy failure rather than an active underdevelopment. 

1.3 Research Objectives and Questions  

This study aims to critically examine the role of structural violence in determining access to healthcare services by women in rural KPK by considering the interaction between infrastructure and socio-cultural norms and gender inequities. 

Objectives: 

1. To explore how systemic healthcare inequities in Khyber Pakhtunkhwa restrict women’s access to essential health services. 

2. To examine the influence of socio-cultural norms and gendered practices in shaping women’s health-seeking behaviours in rural KPK. 

   
   

Research Questions: 

1. How do structural inequities in Khyber Pakhtunkhwa’s healthcare system limit women’s access to essential health services? 

2. In what ways do socio-cultural norms and gendered practices shape and reinforce barriers to women’s health-seeking behaviours in rural KPK? 

   
   

1.4 Significance of the Study  

The importance of this study is threefold and has been discussed in terms of theoretical, policy-related, and practical. Theoretically, it uses the Galtung (1969) model of structural violence to examine healthcare in rural Pakistan, where exclusion is understood as systemic violence rather than a consequence of underdevelopment. It also incorporates the concept of symbolic violence, as described by Bourdieu (1990), to show how gendered subordination is internalised, perpetuating inequities without the need for overt coercion. The study challenges dominant narratives that attribute healthcare inequities to service-delivery failures by foregrounding women’s lived experiences. 

Directly related to the research policy-wise are SDG 3 (Good Health and Well-being) and SDG 5 (Gender Equality). Although Pakistan is a country of policy promises, it ranks 142nd out of 146 countries on the Global Gender Gap Index, and health inequities contribute significantly to this issue (Shah, 2025). KPK rural situation shows that shortcomings in correcting structural determinants weaken work on both objectives. The results will thus provide policymakers, NGOs, and international donors with action-oriented guidance to ensure their interventions align with the SDG targets. 

In practice, the study gives voice to women and records ways in which structural violence is operationalised in their daily processes of seeking health. It will help inform context-sensitive, gender-responsive reforms by emphasising institutional inadequacies and cultural obstacles. 

1.5 Thesis Structure Overview

The thesis is divided into six chapters. Chapter 2 is a literature review that explains theories of structural violence and healthcare inequities across the global, regional, and Pakistani healthcare systems, and identifies gaps that justify the research. Chapter 3 presents the methodology, including the systematic secondary analysis of the data based on such sources as PDHS (20172018), PBS (2021), WHO (2023), and World Bank (2023), and justifying the chosen approach as ethical and sufficient to investigate the problem of women’s healthcare exclusion in Khyber Pakhtunkhwa. Chapter 4 provides thematic results of structural obstacles and socio-cultural standards. These findings are placed in the context of broader scholarship in Chapter 5, and conclusions of key contributions, policy recommendations, and future research directions are presented in Chapter 6. 

Chapter 2: Literature Review 

Introduction 

The chapter critically analyses the available literature to provide a theoretical and empirical background for the research. It locates marginalisation of women’s healthcare in Khyber Pakhtunkhwa (KPK) in the systemic inequities, using the concept of structural violence, as presented by Galtung. Its central thesis is that the exclusion of women from healthcare in KPK cannot be explained solely by poverty, poor infrastructure, or a lack of resources. Still, it reflects structural violence that characterises the social, cultural, and institutional aspects of Pakistan. According to Galtung (1969), structural violence is the form of violence that limits people’s access to basic needs systematically. Farmer (2004) also emphasises the role of political and economic hierarchies in the development of health disparities. Gendered power relations, patriarchal standards, and the invisibility of policies in Pakistan restrict the agency of women and also strengthen the cycle of exclusion (Rizvi, 2008; Mehmood, 2019). Studies in rural KPK have revealed that material deprivation, stigma, limited mobility and gendered hierarchies of care all render the suffering of women as usual (Khan and Ejaz, 2020). The chapter is divided into five sections: an introduction to structural violence theory; global and regional disparities; South Asian gendered health barriers; Pakistan and KPK’s socio-cultural and infrastructural limitations; and gaps that justify the study’s qualitative approach. 

2.1 Theoretical Framework: Galtung’s Structural Violence Theory 

Galtung’s concept of structural violence is key to defining the invisible healthcare disparities. Galtung (1969) differentiates between direct and structural violence, the latter existing within political, economic and social structures that silently deprive people of fundamental rights. This kind of violence becomes institutionalised, culturally supported and thus hard to realise. Mental health is also subject to structural violence; chronic inequality creates stress, anxiety and psychosomatic disease and generates what Farmer (2004) describes as social suffering, where people take the systemic neglect as personal failure. Farmer also advances the point that unjust structures lead to preventable deaths, rather than accidents. In Pakistan, the intersectional layers of patriarchal rules, exclusion due to class, and institutional negligence determine care recipients (Qureshi and Shaikh, 2018; Khan and Ejaz, 2020). In rural KPK, restricted female mobility, male-controlled decisions, and shortages of women’s health professionals intensify inequity (Naeem et al., 2019). Although some caution against overextending the concept (Springs, 2015), in maternal health and reproductive care, the link between systemic neglect and harm is direct. Thus, Galtung’s framework reveals women’s healthcare exclusion as systemic violence produced by policy biases, patriarchal culture, and governance failures (Qureshi and Shaikh, 2018; Nishtar et al., 2013). 

2.2 Global Perspective: Structural Violence in Healthcare Systems  

Structural violence in global healthcare is evident in persistent disparities despite medical advances. WHO (2023) reports 287,000 annual maternal deaths, 95% occurring in LMICs from largely preventable causes. Such inequities stem from underfunding, weak systems, and socio-economic marginalisation, as shown in Haiti and Rwanda (Farmer, 2004) and across South Asia (Ravindran and Sivakami, 2025). Wealthy countries also face racialised inequalities; African American women are three times more likely to die in childbirth than white women (CDC, 2022). In Pakistan, minimal health spending (2.8% GDP) disproportionately harms rural KPK women, where poverty, gender norms, and poor infrastructure intersect (Ali et al., 2024). 

2.3 Regional Studies (South Asia): Gender Inequities & Healthcare Access  

South Asia is an example of gender inequity and structural violence in the context of healthcare. Despite improvements during the MDG period, the region is doing worse in gender parity, ranking 142/146 globally, and Pakistan is at the same level (Global Gender Gap Report, 2023; Shah, 2025). Studies in the region evidence systemic exclusion: in Bangladesh, women have no control over their reproductive health due to husbands and mothers-in-law (Banik et al., 2023); in India, access is limited by caste, class, and gender at the same time (Desai et al., 2022); in Nepal, there is even twice as many women dying during childbirth in rural areas compared to urban (UNFPA, 2022). Pakistan is not an exception, as 32% of married women need to seek permission to access healthcare, and 39% mention financial considerations (PDHS, 2018). Scholars link this to patriarchal norms, precarity, and son preference (Ataullahyan et al., 2022). Intersectionality (Crenshaw, 1989), feminist political economy (Sen and Östlin, 2008), and social determinants frameworks (Solar and Irwin, 2010) further show how gender, poverty, and governance failures compound exclusion, particularly in KPK (Naz et al., 2025; Saeed and Saleem, 2025). 

2.4 Pakistan and KPK Situation: Socio-Cultural Norms, Health Infrastructure, Stigma. 

Pakistan’s healthcare system reflects structural violence through chronic underinvestment and patriarchal norms. Spending less than 3% of GDP on health (World Bank, 2023) contributes to a maternal mortality rate of 154 per 100,000 (UNFPA, 2022). In Khyber Pakhtunkhwa (KPK), women in Buner (63 per cent) are denied or held back from care because of mobility constraints (Rasheed and Mar’iyah, 2024) and aggravated by poverty and patriarchal decision-making (Ali et al., 2024). There is also stigma on reproductive health that worsens care-seeking (Goffman, 1963; Naz et al., 2025; Saeed and Saleem, 2025). The interaction of all these intersecting inequalities results in a vicious cycle where poor infrastructure, gender norms, and stigma continue to exclude women. 

2.5 Knowledge Gaps & Justification for Study  

Although studies about structural violence and gender inequity in South Asia are increasingly rising, there are still numerous gaps, especially in Pakistan. To begin with, most of the evidence is at the national level, through surveys such as the PDHS, which are excellent sources of statistics but lack insights into the socio-cultural processes underlying exclusion. According to Saeed and Saleem (2025), generalised surveys obscure the lived experiences of women in rural settings, whose lives are defined by the cultural norms of their contexts. 

Second, the current literature tends to discuss healthcare inequities as developmental issues, instead of categorising them as structural violence. Qayyum (2025) compares the situation of violence against women in Pakistan and South Korea and does not explicitly discuss healthcare. In the same manner, Riaz (2022) discusses patriarchal semiotics but fails to relate them to healthcare exclusion. This loophole undermines the capacity to discuss healthcare disparities as crimes that require immediate remedy. 

Third, women have not been sufficiently represented. Most of the Research gives too much emphasis to institutional or policy-level approaches and leaves out the lived experiences of stigma, denial, and structural neglect. Naz et al. (2025) show that it is vital to capture psychological harm; however, few studies put women at the centre. The lack of such narratives keeps invisibility going, where structural violence can be maintained. 

This thesis will fill these gaps by applying a qualitative secondary research method to the province of Khyber Pakhtunkhwa (KPK). It builds a subtle insight into the functioning of structural violence in the healthcare of women in rural Pakistan by synthesising the available qualitative research, policy documents, and academic studies. By critically utilising Galtung’s (1969) conceptualisation, the paper reinterprets healthcare exclusion not as an expression of underdevelopment but as an institutionalised and systemic violence perpetuated through social hierarchies, lacunae, and cultural limitations. This study has empirical value, as it synthesised and interpreted scattered data on healthcare inequality in KPK, and theoretical value, as it revealed the applicability and flexibility of structural violence theory in examining gendered health inequality in rural conservative settings. 

Figure 1: Conceptual Framework – Structural Violence and Women’s Healthcare in KPK  

Source: Generated by researcher 

The conceptual framework of this research is represented in Figure 1. It demonstrates how macro-level factors (policy oversights, financial structure, and atrocities) interact with meso-level factors (healthcare framework, labour force structure, and financing priorities) and micro-level factors (patriarchy, stigma, and mobility constraints) to create healthcare exclusion at the system level. The interrelations between these spheres explain the reinforcing relations of structural and symbolic violence, the legitimisation of cultural subjugation by the institutions, and the normalisation of the institutions by the internalised norms. The framework, therefore, visually depicts the argument of the study that the exclusion of women in healthcare in KPK is an intercultural, institutional, and policy-level violence that cannot be ascribed to deficiencies.

Chapter 3: Methodology 

Introduction 

This chapter outlines a qualitative secondary analysis (QSA) methodology to examine how structural violence limits women’s healthcare access in rural KPK. Using existing studies, policy reports, and national datasets, QSA enables critical, ethically sensitive analysis of systemic and cultural exclusion without collecting primary data, aligning with the study’s theoretical framework. 

3.1 Research Design: Qualitative Secondary Analysis 

This paper will use the qualitative secondary analysis (QSA) approach, which involves the reinterpretation of available qualitative information to answer new questions within a new theoretical framework (Heaton, 2004; Irwin, 2013). It interprets thematic evidence from narratives, policy, and context to identify institutional and socio-cultural sources of structural violence, as outlined by Galtung (1969) and expounded by Farmer (2004). The triangulation of sources (PDHS, 2018; Pakistan Bureau of Statistics, 2021) enhances the credibility and richness of the context (Thomas and Harden, 2008). 

Table 1. Systematic Review Search Strategy 

Source: Researcher’s compilation (2025), adapted from PRISMA and systematic review guidelines (Moher et al., 2009). 

Table 1 summarises the databases, search terms, and criteria used to identify relevant literature and datasets on structural violence and women’s healthcare in Pakistan. It reveals that five primary sources were systematically searched, with explicit inclusion and exclusion criteria, yielding 47 studies and reports that constitute the core collateral of evidence used in this qualitative secondary analysis. Overall, 357 records were located and underwent a series of screening and eligibility steps. The general selection process is shown in the PRISMA 2020 flow diagram (Appendix E). 

3.2 Rationale for Secondary Qualitative Research 

Qualitative research aims to comprehend phenomena through participants’ meanings, experiences, and social situations rather than through numerical measurement (Creswell, 2014). It is flexible, interpretive, and complexity-oriented. 

Secondary research, in turn, concerns studying available information rather than creating new information to generate new insights, interpretations, or theoretical knowledge (Heaton, 2004). In qualitative secondary research, the researcher uses narrative, textual, or interview-based information from previous studies that can be analysed anew without contacting the participants directly (Irwin, 2013). 

3.2.1 Why QSA Fits This Study? 

There are three reasons why a qualitative secondary approach is justified: 

To start with, structural violence is not a single event but a structural and historically entrenched circumstance (Farmer, 2004). To explore these phenomena, a design that would have synthesised evidence across a variety of layers, such as policy, institutional, and cultural, should have been used, rather than one-time interactions within the field. Secondary qualitative research offers a multivocal approach, enabling the comparison and integration of results from multiple previous studies on healthcare inequity in Pakistan (Ali et al., 2024; Naz et al., 2025). 

Second, this methodology considers both the ethical and cultural sensibilities. Direct contact with women on reproductive health risks violates cultural taboos and the safety of participants in such conservative areas as rural KPK (Mumtaz et al., 2012). Secondary research, which relies on published qualitative descriptions and institutional reports, ensures respect for local norms and the quality of analysis (Hesse-Biber, 2013). 

Third, the approach allows for critical reinterpretation of existing data by applying the concept of structural violence. According to Smith and Noble (2014), reanalysis helps a researcher recontextualise established issues by drawing on untapped theoretical knowledge. Much of the current literature in the case of Pakistan relates gender inequities as shortcomings of development; this study redefines them as a result of structural injury and policymaking-induced exclusion, which is in line with the theory of Galtung (1969). 

Therefore, philosophically and practically, QSA is well-suited to the current objectives of the research: it combines theory and evidence, supports ethical inquiry, and situates local experiences within the framework of international discourses on structural violence. 

3.3 Data Sources and Selection Criteria 

Such data were used to conduct the present study, based on secondary qualitative and policy-based sources published between 2015 and 2025. The selection was performed with the help of a purposive sampling strategy (Yin, 2018), where the priority was the materials meeting the following criteria: 

1. Works that are directly relevant to women’s access to healthcare in Pakistan or KPK, or to gender inequity. 

2. Apparent involvement of social, cultural or policy aspects of healthcare. 

3. Employment of qualitative/mixed-method designs providing narrative/interpretive information. 

4. Posting in peer-reviewed journals, credible institutional repositories, or established international organisations (e.g., WHO, UNFPA, World Bank). 

   
   

The primary sources were the Pakistan Demographic and Health Survey (PDHS, 201718), Pakistan Bureau of Statistics (2021), World Health Organisation (2025), World Bank (2023), and the qualitative articles by Ali et al. (2024), Naz et al. (2025), and Wahab et al. (2023). The policy and NGO reports on UNFPA and the Ministry of Health were included to offer the institutional context. 

Triangulation of these types of data enhances analytical validity (Patton, 2015). It ensures that structural violence is investigated in both quantitative (through indicators of inequality) and qualitative (through accounts of lived experience) ways. 

Table 2. CASP & GRADE-CERQual Quality Appraisal Summary 

Source: Researcher’s synthesis (2025). 

The quality appraisal of the primary studies and reports is summarised in Table 2 using CASP and GRADE-CERQual. All the sources were evaluated based on their relevance, methodology rigour, transparency and coherence, resulting in a total confidence rating. The majority of essential studies and institutional reports had a high confidence level, indicating that the synthesised themes in the findings chapters are based on solid, reliable evidence. 

3.4 Analytical Framework and Procedures 

Thematic synthesis was used to analyse the data, a method that aims to combine the qualitative results of several studies (Thomas and Harden, 2008). It was both deductive, guided by Galtung's (1969) theoretical model, and inductive, drawing on emergent themes from the literature reviewed (Braun and Clarke, 2006). 

It was a process that had six steps: 

1. Familiarisation: Reading and marking all of the chosen materials conceptually. 

2. Primary coding- finding categories that are connected to health inequities, gender standards, and bureaucratic neglect. 

3. Deductive categorisation is the arrangement of codes based on theoretical phenomena (e.g., policy neglect, symbolic exclusion, gendered access). 

4. Development of themes inductively - the incorporation of new and unexpected themes (e.g., female workforce attrition, cultural silencing of reproductive health). 

5. Interpretive synthesis - relation between patterns in studies to demonstrate how social and institutional systems reproduce harm. 

6. Validation: Comparing thematic interpretations to quantitative trends (e.g., maternal mortality, health expenditure). 

   
   

This combined method guaranteed depth and theoretical consistency, keeping thematic patterns aligned with the theory of structural violence while remaining open to new conceptual knowledge (Nowell et al., 2017). To better illustrate the qualitative secondary analysis and thematic synthesis followed in this study, Appendix D provides a step-by-step graphical guide to the process. 

3.5 Methodological Suitability and Critical Reflection 

This approach fits perfectly with the study’s objectives for several reasons. 

First, it can be epistemologically correlated with critical social theory, which aims to reveal power relations and structural inequalities inherent in social systems (Kincheloe and McLaren, 2011). Such a critique is made possible through secondary qualitative synthesis, which draws on a variety of empirical sources to uncover systemic trends of exclusion in healthcare at KPK. 

Second, qualitative synthesis is not limited to single-context analysis; it builds a meta-narrative that places local inequalities in a national and regional context (Thorne, 2008). This is necessary in the study of structural violence, which straddles fields such as policy, culture, and economics. 

Third, QSA increases transparency and reflexivity. The approach allows an interpretable method and supports critical interactions with existing knowledge by using publicly available studies and datasets (Irwin, 2013). In contrast to a fieldwork that favours the role of the researcher, this design prioritises epistemic humility, acknowledging that women’s experiences have already been reported but remain under-theorised (Hesse-Biber, 2013). 

In this way, this approach not only reflects the study’s objectives but also its ethical and feminist focus: reconsidering the silence, distortions, and omissions of current research to determine how healthcare exclusion can be viewed as a form of systemic violence. 

3.5.1 Defence of Methodological Choice 

When justifying this methodological decision, it is essential to show that Qualitative Secondary Analysis (QSA) is as rigorous and profound as, and in some ways better than, primary qualitative fieldwork in respect of this subject. 

1. Epistemological Fit: QSA is an addition to the theoretical approach to structural violence. Structural violence is beyond the powers of isolated individual interviews or localised ethnography, because this is a feature of systemic forces. The synthesis of several studies offers a more structural insight (Farmer, 2004; Heaton, 2004). 

   
   

2. Analytical Strength: The triangulation of peer-reviewed studies and policy sources of QSA makes it more reliable. The mixture of evidence types yields a meta-level insight into healthcare exclusion that primary studies do not always possess due to contextual constraints (Patton, 2015). 

   
   

3. Ethical Legitimacy: The primary Research on reproductive health of women in rural areas of KPK would be ethically and culturally constrained. QSA offers a methodologically reasonable and ethically justifiable alternative that will be harmless, respect privacy, and uphold good feminist ethics (Hesse-Biber, 2013). 

   
   

4. Academic Recognition: QSA has become a recognised and accepted research design in the social sciences (Irwin, 2013; Thorne, 2008). QSA studies are regularly published in major journals in public health and gender studies because they can generate new theory by building on existing evidence. 

   
   

5. Addressing Critiques: The most frequent criticism of QSA is that the researcher is not closely linked to the original data context (Heaton, 2004). This weakness is addressed here by (a) the selection of only high-quality peer-reviewed studies, (b) comprehensively recording source selection, and (c) sustaining interpretative transparency by use of theoretical coding. 

   
   

To conclude, this paper justifies QSA as a methodologically sound, conceptually consistent, ethically accountable, and practically requisite way of studying healthcare inequalities in conservative rural Pakistan. 

3.6 Limitations of the Method 

Secondary qualitative research has its limitations, even though it has its strengths. 

First, the use of available materials in the study implies less control over data quality and context (Heaton, 2004). The initial research varied across domains, sampling methods, and theoretical orientations. 

Second, provincial data are likely to mask intra-provincial differences between urban and non-urban districts in KPK (Sarwar, 2021). Third, there are time constraints; data such as the PDHS (2017-18) might not capture post-pandemic changes in health accessibility. 

Nevertheless, the constrained nature of them was reduced by using methodological triangulation (Patton, 2015) and critical reflexivity, so that interpretive findings were supported by more than one corroborating source. 

3.7 Ethical Considerations 

Although there was no direct contact with human beings in this study, ethical principles were applied at every step. All data sources were openly sourced and appropriately referenced to ensure academic integrity. Reflexive awareness was used to prevent misrepresentation of the authors’ findings or participants’ experiences in earlier studies (Hammersley and Traianou, 2012). 

In line with feminist research ethics, the analysis was intended to give voice to marginalised parties without replicating epistemic harm (Hesse-Biber, 2013). Ethical approval was obtained from the university’s non-empirical research section, ensuring compliance with the university’s guidelines on the responsible use of data. 

3.8 Summary 

Overall, this chapter has provided a qualitative secondary research methodology grounded in the theoretical framework of structural violence. This approach is vehemently defended as the best that can be used to examine the systemic, policy-driven, and cultural factors that determine the exclusion of women in healthcare in KPK. The research synthesises existing Research and policy evidence thematically, thereby contributing to theoretical and practical insights into how institutional structures perpetuate health inequities. The subsequent chapter presents the analysis results, structured around the major themes that depict the forms of structural violence in rural KPK’s healthcare systems. 

Chapter 4: Findings and Analysis 

Introduction 

The chapter critically reviews secondary sources, policy reports, and national data to understand how structural violence, a driver of women, is being marginalised in healthcare in Khyber Pakhtunkhwa (KPK). The presentation is divided into three interrelated themes: institutional neglect and policy underinvestment, gender and access inequalities in the workforce, and socio-cultural and symbolic barriers. These elements combine to show that structural marginalisation of women in healthcare is reproduced through the political, institutional, and cultural systems. 

4.1 Institutional Neglect and Policy Underinvestment 

The structural exclusion background of Pakistan is its chronic underinvestment in public health. The country lacks sufficient infrastructure, especially in rural provinces such as KPK, as health expenditure is only 2.8% of GDP, well below the WHO-recommended 6% (World Bank, 2023). KPK also lacks more than 0.5 hospital beds per 1,000 people, whereas the national average is 1.1 and the global average is 5 (Pakistan Bureau of Statistics, 2021). These inequalities are not due to chance, but rather to urban-centric policy priorities. According to Sarwar (2021), 65 per cent of national health expenditure is allocated to secondary and tertiary hospitals in megacities, whereas primary care in rural areas is in abject neglect. 

For rural women in KPK, such neglect means they must travel long distances for basic maternal care, and sometimes they lack transportation or a male companion (Rasheed and Mar’iyah, 2024). Its results can be seen in the maternal health outcomes: maternal mortality ratio (MMR) in Pakistan is 154/100,000 live births, which is fourfold higher than in Sri Lanka and almost twice that of Nepal (UNFPA, 2022). Maternal mortality is also especially elevated in mountainous regions of KPK, where facility births are uncommon (PDHS, 2018). These kinds of inequalities are the material manifestation of structural violence as Galtung (1969) refers to it, the harm caused by institutional negligence and disequilibrium of resource allocation. 

4.2 Gendered Workforce and Access Inequalities 

One of the structural elements of women’s exclusion is the gender aspect of the health workforce. Although women are more than 70 per cent of the medical graduates in Pakistan, less than 35 per cent of them enter or continue working because of the perception of harassment, structural discrimination, and poor maternity policies (Raza et al., 2023; Moazzam et al., 2025). Access is highly limited in conservative areas such as KPK, where women are not traditionally encouraged to visit male doctors. 

The primary care programme in rural areas is the Lady Health Worker (LHW), which is chronically underfunded and poorly managed. In KPK, 18 per cent of LHW positions were vacant, and, according to a 2024 audit, many employees had not received pay for several months (Government of Pakistan, 2024). These lapses undermine maternal outreach, vaccination, and community trust. Also, rural women spend an average of 3.2 hours to access a health facility, compared to 40 minutes for urban women (PDHS, 2018). These institutional barriers, together with the norms that demand male accompaniment, reinforce gender-based inequalities in access (Naz et al., 2025). 

4.3 Socio-Cultural and Symbolic Violence 

Exclusion is even strengthened by cultural and symbolic forces that naturalise the suffering of women. With reference to Bourdieu (1990), symbolic violence is the way internalised norms render inequality as natural. In KPK, women are expected to be obedient and modest, which prevents them from seeking timely care (Shah, 2025). Rasheed and Mar’iyah (2024) also discovered that 63 per cent of women in Buner district delayed or shunned care because of the lack of a male guardian. Religious accounts also relate issues of reproductive health to testing by God instead of the ramifications of structural neglect (Wahab et al., 2023). 

Poor reproductive health education adds to stigma related to menstruation, infertility, and obstetric complications, which prevents seeking any help, particularly male help (Naz et al., 2025). This symbolic violence helps bring social suffering, which Farmer (2004) refers to, because women absorb systemic failures into personal failure. 

4.4 Interlocking Structures of Violence 

Violence, in terms of structures, institutions, and culture, is reinforcing. Policy omission leads to structural paucity of infrastructure, cultural practices justify the exclusion of women, and organisational practices perpetuate gender inequality. According to Ali et al. (2024), it is a closed loop of deprivation that makes the suffering of women invisible and normalised. Appendix B is a diagrammatic representation of the intersection of macro-, meso-, and micro-level forces that limit women’s access to care. 

4.5 Summary 

The chapter concludes that healthcare exclusion in KPK is not the result of specific deficiencies but rather an expected consequence of interactions among political, cultural, and institutional structures. These results support the overall argument of the study that structural violence against women, manifested as a lack of health in KPK, is rooted in both Pakistan’s healthcare and government systems. 

Chapter 5: Discussion 

The chapter posits that the exclusion of women in healthcare in Khyber Pakhtunkhwa (KPK) is systemic violence that is created by overlapping structural, institutional, and symbolic practices. Based on the ideas of structural violence formulated by Galtung (1969) and Bourdieu (1990), and on the concept of symbolic violence, it analyses the empirical results of Chapter 4 and demonstrates that state neglect, gendered subordination, and cultural reproduction contribute to unequal access to healthcare. Those dynamics help explain Pakistan’s inability to achieve Sustainable Development Goals (SDGs) 3 and 5 and reveal the vulnerabilities of the 2023 national health policy system. 

5.1 Structural Violence and Institutional Exclusion 

According to Galtung (1969), structural violence refers to any harm that is not necessary, such that when social systems deny people access to the most essential needs, then they are said to have become structural violence. This violence is manifested in KPK through the chronic underinvestment in health care and the lack of gender-responsive policy. Pakistan allocates 2.8 per cent of its GDP to health, which is among the lowest in South Asia and well below the WHO-recommended 6 per cent (World Bank, 2023; WHO, 2023). It is not a dispassionate deficiency of the resource but an arrangement option. According to Sarwar (2021), 65 per cent of national health expenditure is spent on urban secondary and tertiary hospitals, while little is spent on rural primary care. This creates a structural imbalance that favours urban and wealthy men over rural women. 

Such disparities are reflected in primary health outcomes. According to the PDHS (NIPS, 2018), 58% of rural women deliver in medical institutions, as compared to 86% of urban women. The countryside women also lack access to female doctors, transport, and affordable maternal care (Farmer, 2004). The consequences are intergenerational: children born to women with a lack of maternal care are at a higher risk of malnutrition and stunting, which creates structural inequality on a long-term basis (UNFPA, 2022). In this way, the health system, as a unit, becomes a generator of vulnerability, a structural violence, but not intentional. 

5.2 Symbolic Violence and Cultural Normalisation 

Although structural violence creates material deprivation, the idea of symbolic violence by Bourdieu (1990) elucidates how the cultural norms legitimise and normalise such deprivation. Women’s seeking behaviour in KPK is influenced by patriarchal beliefs on modesty, obedience, and gender roles. According to a study by Rasheed and Mar’iyah (2024), nearly two-thirds of women in Buner district were denied access to healthcare facilities without a male escort, even in emergencies. Naz et al. (2506) found that most women internalised their limited mobility as the will of Allah, and they suffer because it is their destiny to endure and not an institutional or structural neglect. This internalisation is indicative of Bourdieu’s argument that domination is best achieved when it is perceived as natural. 

Symbolic violence is also reproduced by state discourse. Wahab et al. (2023) demonstrate that health campaigns launched by the government in rural KPK often support patriarchal discourses by portraying the health of women as mainly an aspect of motherhood. This kind of messaging diminishes women to reproductive bodies, to influence policy priorities and the expectations of the population. Symbolic violence thus operates in tandem with structural violence. It transforms deprivation into a norm that is nevertheless culturally acceptable and creates what Farmer (2004) refers to as the pathologies of power. 

5.3 Intersections of Structure, Gender, and Culture 

KPK has structural and symbolic violence, but these two work together and not separately. Symbolic violence justifies structural deficiencies by culturally instilled ideas on modesty and gender pecking order; structural neglect leads to service, staff, and infrastructure deficiencies (Ali et al., 2024). The obvious example is the constant lack of female medical staff. Women do not pursue medical careers due to gender norms, yet female employees are vital in gender-segregated spaces (Raza et al., 2023). This paradox shows how institutions and culture conflict. 

This dynamic is also depicted in the Lady Health Worker (LHW) Programme. Though this programme is meant to enhance the access of rural women, it is marked by low wages, unstable working environments, and low recognition (Government of Pakistan, 2024). The feminised structure is a reflection of symbolic hierarchies, which devalue the labour of women, as policies meant to deal with inequity are reproducing the inequalities that they are intended to solve. 

5.4 Policy Implications and SDG Gaps 

The National Health Vision 2023-2025 recognises gender inequality but lacks mechanisms for structural change (Government of Pakistan, 2023). Although Pakistan commits to SDG 3 and SDG 5, it ranks among the lowest countries globally, 161st of 193 countries (UNDP, 2023), and has made little progress in maternal health and gender equality. Current policy is still clinically-based, with the emphasis on increasing services rather than on the systemic and cultural forces that restrict women’s access to them. According to Saeed and Saleem (2025), health policy in Pakistan is focused on symptoms rather than structural causes, discounting the fact that women have limited mobility, male guardianship, and feminisation of underpaid health labour. 

To achieve any significant improvement, the sources should be shifted to the rural population, staffing should be more evenly balanced by gender, and gender analysis should be incorporated into every stage of policy development. Symbolic reform, education, media, and communal activities are also vital to break the cultural norms that legitimise the exclusion of women (Shah, 2025). 

5.5 Conclusion 

Structural and symbolic violence combine in such a way that women are excluded from healthcare in KPK in a systematic and morally significant way. Galtung’s framework exposes institutional neglect, while Bourdieu’s theory shows how patriarchal norms sustain this neglect through misrecognition and consent. To meet SDG 3 and SDG 5, Pakistan must redefine health policy as a mechanism of social justice capable of dismantling both structural and ideological barriers. Only through such transformation can healthcare shift from a site of systemic harm to one of empowerment for women. 

Chapter 6: Conclusion and Recommendations 

This final chapter summarises the dissertation’s key results and presents theoretical and policy recommendations. The paper has explored the interaction of structural and symbolic violence to maintain the exclusion of women in healthcare in Khyber Pakhtunkhwa (KPK), Pakistan. Based on Galtung’s (1969) theory of structural violence and Bourdieu’s (1990) concept of symbolic violence, it was proposed that healthcare inequity was not accidental but structural, embedded within political, institutional, and cultural organisations that reinforce inequality. 

Based on a secondary review of the available literature, national databases, and policy reports, the study revealed that the healthcare system in Pakistan is a location where gender, class, and geography intersect to create long-term trends of marginalisation. This chapter concludes with evidence-based recommendations and outlines avenues for further research to broaden the theoretical and empirical scope of this study. 

6.1 Summary of Findings 

This paper furthered three main lines of argument: 

1. Institutional Neglect as Structural Violence: 

Institutionalised harm is the chronic underfunding and bias of the policies towards urban centres. The rural regions of Pakistan, such as KPK, are systematically under-resourced, with the country spending 2.8 per cent of GDP on health, which is less than half the WHO-recommended 6 per cent (World Bank, 2023; WHO, 2023). Higher rates of maternal mortality (154 deaths per 100,000 live births) and extreme service disparities between rural and urban areas are the outcomes of this policy negligence (UNFPA, 2022). 

2. Gendered Workforce Inequality: 

Although the proportion of medical graduates is more than 70 per cent women, fewer than 35 per cent of them remain in active service (Raza et al., 2023). Feminised health labour and devalued economically through structural discrimination, unsafe working conditions, and lack of provision of childcare services have negatively affected health labour (Government of Pakistan, 2024). 

3. Cultural and Symbolic Violence: 

Women have limited mobility and autonomy in healthcare services, which are patriarchal ideologies that are supported by religion and custom. Women tend to internalise suffering as the divine will, as in the case of Naz et al. (2025). As Bourdieu (1990) explains, suffering is part of the misrecognition or the normalisation of domination. This cultural submissiveness justifies state abandonment and weakens the struggle. 

These results, combined, affirm that women’s healthcare exclusion in KPK is a structural, symbolic, and intersectional violence, a pattern of governance failure, cultural hierarchies, and unequal power relations. 

6.2 Theoretical Contributions 

This paper adds to the literature that has been building that structural violence is a major contributor to gendered health inequities in the Global South. Combining both the Galtungian and Bourdieuian paradigms, it demonstrates that structural harm is not just material deprivation but also symbolic and cultural influences that justify inequality. 

Moreover, it puts healthcare policy at the centre of structural reproduction: the same institutions charged with promoting equity tend to reinforce exclusion through bureaucratic inertia and gendered hierarchies (Farmer, 2004). This synthesis expands the framework of Galtung because it shows that in patriarchal societies like Pakistan, structural violence manifests through symbolic violence. 

6.3 Policy Recommendations 

To fulfil SDG 3 (Good Health and Well-being) and SDG 5 (Gender Equality) in Pakistan’s health sector, reforms need to shift technical adaptation toward structural change. Based on the findings, the following recommendations are suggested: 

1. Reallocation of Health Expenditure 

• Increase healthcare spending to at least 4.5 per cent of GDP over the next three years, with primary and rural healthcare as a priority in KPK and other underserved provinces (World Bank, 2023). 

• Deviate tertiary care funds to the urban centres and invest in Basic Health Units (BHUs) and Maternal and Child Health centres at village levels. 

  
  

2. Gender-Responsive Workforce Policies 

• Introduce positive retention programmes for female doctors, such as flexible work arrangements, childcare, and a safe working environment (Raza et al., 2023). 

• Gender audits should be institutionalised in hospitals and in the public health departments to track discrimination and career advancement. 

  
  

3. Revitalisation of the Lady Health Worker (LHW) Programme 

• Pay LHWs on time, promote their career growth, and provide training. 

• Make LHWs part of health governance systems, elevating them to community health leaders rather than support staff (Government of Pakistan, 2024). 

  
  

4. Integrating Cultural Sensitivity into Health Policy 

• Conduct community-wide awareness initiatives with the help of religious authorities and local influencers to break male-centric discourses on female healthcare. 

• Provide gender and health education in schools, as this will challenge the internalisation of gender inequality at an early age (Shah, 2025). 

  
  

5. Accountability and Governance Reform 

• Form an Independent Provincial Health Equity Commission (KPK) with the role of auditing gender and regional inequality. 

• Make Gender Equity impact Assessments of all provincial health budgets and projects annually (UNDP, 2023). 

  
  

6.4 Future Research Directions 

In this paper, I have identified the following future research areas: 

1. Feminist Political Economy of Health: 

Research on how neoliberal policy changes and privatisation strengthen gendered exclusions in Pakistan’s healthcare sector should be considered in the future (Saeed and Saleem, 2025). By incorporating feminist political economy, scholars can examine how the world’s economic systems reinforce local structural violence. 

2. Intersectionality in Structural Violence Analysis: 

Intersectional frameworks that account for the intersection of class, ethnicity, and displacement with gender to determine healthcare access in KPK are required (Khan et al., 2024). Such methodologies would bring forth the stratified vulnerability of women, especially those of the Afghan refugees and those of the lower caste minorities. 

3. Comparative South Asian Studies: 

Comparisons across South Asia would help identify regional trends in structural and symbolic violence in healthcare and shed light on shared colonial histories and policy failures (Banik et al., 2023). 

4. Participatory Policy Research: 

Women should be co-producers of knowledge in future research, applying participatory action research to anticipate lived and community-based solutions to problems (Mumtaz et al., 2012). 

6.5 Conclusion 

This dissertation has shown that healthcare inequities in Khyber Pakhtunkhwa are not the issues of development, but rather the manifestations of structural and symbolic violence, which is the harm that was inherent to the political economy of Pakistan, its healthcare governance, and the culture of patriarchy. 

To shift to real reform, Pakistan needs to rethink healthcare as a social justice issue rather than a service-delivery issue. Unless the promises of SDG 3 and SDG 5 are to be fulfilled, structural transformation based on gender equity, cultural change, and redistributive policy is fundamental. 

Peace, as Galtung (1969) defines it, is not the absence of direct violence but the presence of justice. Health justice for women in KPK requires dismantling the visible and invisible systems that deny them the right to dignified, autonomous lives and care. 

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Appendix A 

Health System Inequities in Pakistan and Khyber Pakhtunkhwa 

Appendix B  

Interlocking Layers of Structural Violence in Rural KPK Healthcare 

Appendix C 

Gendered Health Workforce Pipeline and Attrition in Pakistan 

Appendix D 

Qualitative Secondary Analysis Process and Thematic Synthesis Steps 

Appendix E 

PRISMA 2020 Flow Diagram – Systematic Review Process 

Sources: Adapted from PRISMA 2020 guidelines (Page et al., 2021).