BMA report

Healthier procurement: Improvements to working conditions for surgical instrument manufacture in Pakistan

Our research looked to identify any improvements in working conditions and labour rights in surgical instrument manufacturing in Pakistan.

Location: UK
Audience: All doctors
Updated: Monday 7 September 2020
Topics: International work
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The BMA, in partnership with Swedish lobbying group Swedwatch, undertook research to ascertain any improvements in working conditions and labour rights in surgical instrument manufacturing in Pakistan, following the inclusion of social criteria in procurement contracts. 

This report outlines our findings on the conditions at the factories we visited (supplying Sweden and England) and our recommendations for key stakeholders.


What you'll get from this report

  • Findings from our research into working conditions in surgical instrument factories in Pakistan.
  • Challenges and potential solutions for driving change.
  • Recommendations for key stakeholders.


Key findings

Our report found that, overall, conditions at visited factories (supplying Sweden and England) have improved. Conditions for the sub-contractors working for exporting factories have also improved. Child labour is now strictly forbidden, wages are paid in accordance with the minimum wage, and employees are not forced to work overtime.

However, challenges remain in health and safety, with workers still operating machinery without personal protective equipment. Capacity building in unionisation and collective bargaining is also needed. Management and employees state that unions are redundant because of good working relationships, but such statements fail to recognise the value of a union in giving workers a collective voice and in levelling the playing field between management and employees.

Evaluation of workshops (general vendors) outside of Swedish and English supply chains, where no social requirements are mandated, reveals little change since 2007. Employees work in cramped, poorly lit workshops with no ventilation. They are paid a piece rate, have little safety equipment, and child labour is still common practice. Much remains to be done to improve working conditions in the industry as a whole.



We have used the evidence and analysis in this report to produce a set of recommendations for key stakeholders. These include NHS Supply Chain, the Pakistani surgical manufacturing industry and the UK Government.

NHS Supply Chain

NHS Supply Chain is the largest procurement hub for goods in England and has awarded contracts to several UK suppliers importing instruments from factories in Pakistan.

  • Evaluate a model where the decisive factor in awarding contracts is not only price but can include a suppliers’ sustainability performance.
  • Exploit the full range of tools presented in EU directives with regards to setting social criteria in public contracts.
  • Further develop the LSAS system to require all suppliers to continually report on progress and to allow audit of any approved supplier.
  • Encourage other procurement organisations to follow the LSAS model by sharing best practice.
  • Identify additional needs and resources to support suppliers in implementing contractual requirements with regards to labour rights.

Pakistani surgical manufacturing industry

  • Work towards continual improvement in working conditions for employees in the industry, especially in health and safety.
  • Facilitate the formation of a union that can represent all surgical instrument workers, including those in subcontracted units and general vendor units.
  • Consider an industry wide agreement on pricing and explore how this can be enforced.

UK Government

  • In the transposition of the EU directives, exploit the full range of tools presented in these directives with regards to setting social criteria in public contracts.
  • Provide explicit policy to support or mandate the protection of labour rights in those procuring on behalf of the NHS or other public bodies.
  • Provide appropriate resources to enable the adoption of such policies in practice.
  • Act at EU-level to increase cooperation between member states in developing standards for social criteria in public procurement.
  • Introduction and executive summary
  • Methodology
  • Background
  • Swedish and UK buyers
  • Suppliers to Sweden and the UK
  • Back to Pakistan - findings on the ground
  • New EU directives on public procurement
  • Conclusions
  • Recommendations