By Rosie Steege, Sally Theobald, Kate Hawkins

The health system is a growing employer of women and can help to contribute towards gender equality. Yet gender biases and discrimination are sadly alive and well within this sector. The need to promote gender transformational processes and decent work for health workers of all cadres was discussed at the WHO Human Resources for Health (HRH) Forum held in Dublin earlier this month.

A gender lens is often missing from analysis of the Community Health Worker (CHW) cadre of health workers who operate within communities serving as a vital link between them and the health sector. Although it varies by context, CHWs are predominantly women, often of lower socio-economic status, who have limited career opportunities. The HRH Forum provided an opportunity to highlight some of the gendered aspects of this cadre and showcase experiences and inspiring stories of action for CHW programmes. A panel chaired by Sally Theobald covered India, Brazil, South Africa and Malawi. She opened the session by highlighting the importance of gender and equity in human resources for health and “decent work” agendas, stressing that this lens needs to extend to CHWs who both experience gender inequities and also negotiate the ways in which gender and power play out within the households and communities they serve.

Gender dimensions of the ASHA programme

The first panellist was Kerry Scott (on behalf of Rejani Ved and Asha George) presenting work on the ASHA programme from India. The all-female cadre of staff was developed order to meet the country’s maternal and child health goals. The programme is now made up of 850,000 ASHAs (one per village). In order to better meet the needs of ASHAs a number of policy changes have been made. ASHA’s training has become residential with a crèche facility to ensure the women can participate and also fulfil childcare duties. ASHAs are included as member secretaries of village health committees. This enables them to move beyond the all-female maternal health space and encourages their active leadership in traditionally male dominated realms. Although ASHAs are not formally employed by the government, there are increasing monthly economic incentives for ASHAs to help them meet their need for regular income and encourage the uptake of banking services. The creation of more government scholarships for higher education for ASHAs creates more opportunities for women to access a career pathway. Newly introduced social security measures help support ASHAs via life and accident insurance and pension opportunities. Finally, the creation of rest accommodation in health facilities helps to increase ASHA safety and comfort (as one of their main duties is to escort expectant mothers to facilities to deliver, often at night).

These policy changes demonstrate positive active steps towards securing the safety and wellbeing of the ASHA as a mobiliser, facilitator and as a care provider. However, there are still challenges. There have been shocking examples of ASHAs being sexually harassed and even raped by community members and other health service providers in the course of their work. The government response has been to ensure that all service providers undergo sensitisation training, but there is still work to be done to ensure ASHAs’ safety and rights are protected at the community level. Kerry concluded with the call for constant adaptation of policies to ensure appropriate response to the ASHAs gendered needs. She posed the question, how do we balance policy progress against social norms which are slower to change?

Power, gender relations and heteronormativity in Brazil

João Nunes presented on Brazil and highlighted that there is a need for a political economy in analysis of human resources for health and the ways in which international political economies intersect with gender. Since its inception in 1987, the Brazilian CHW programme has been shaped by gender norms. The programme developed against a backdrop of neo-liberalisation, privatisation and an increasing feminisation of labour, where women were seen as precarious workers to fulfil permanent job needs. The programme was initially conceptualised as a way to reduce infant mortality whilst at the same time provide employment opportunities for poor vulnerable women and a make-shift solution for the health of poor communities. Perceived as natural carers and providers for their communities, these women are often required to go beyond their job specification and working hours, providing informal work which is not remunerated such as support for single mothers, victims of domestic violence, and sexual health.

As is often seen CHW programmes that require CHWs to come from the communities they serve, CHWs work in systems that enable and reproduce gendered vulnerabilities. Informal care work is seen as a women’s domain – this work is downgraded and informalised within the socio-economic system. Similarly, primary health clinics are understood to be a feminine space and often men do not visit. This is compounded by the cultural understanding that men must play a bread-winning role, working during the hours that the primary health care clinic is open. An example of how CHWs internalise and reproduce the norms that they work within was given with regards to the family health strategy – which assumes a binary heteronormative family of man, women and child. In recent years there has been change to make this strategy more diverse and reflective of current households and communities but there has been conservative push back with many CHWs themselves sharing these views.

Finally, João described how there are many obstacles to the discussion about women’s sexuality which has an impact on what CHWs can do in their formal conversations and advice. Women are seen as mothers and daughters and activities to support women’s sexual health is perceived to be limited to vulnerable groups such as sex workers or trans women. Due to religious and cultural norms discussion about sexuality can be very difficult. For example, the use of condoms is not acceptable for married couples. In the same way that heteronormative gender norms limit women’s capacity to provide sexual and reproductive care, they also constrain men in becoming CHWs. Due to sexual politics men are unable to enter homes which prevents them from providing adequate care. This suspicion of men and reluctance for them to enter the household space, is not unique to Brazil and similar dynamics have been seen in Kenya and many other countries.

Gender roles and CHWs in Malawi

Kingsley Chikaphupha from REACH Trust (and co-chair of the Thematic Working Group) gave us examples from Malawi, where there are both male and female Health Surveillance Assistants (HSAs). He highlighted how recruitment of CHWs, is not considered from a gender perspective and because of this there is a large imbalance between the numbers of men and women performing the role. Across all districts there are 30% male HSAs to 70% female HSAs. However, when you look specifically at hard to reach areas within these districts, the numbers are flipped, with 70% male, 30% female.

In hard to reach areas the 30% that are female also appears to be diminishing – this may be due to pressure from husbands to leave the role, or often it is reported that female HSAs leave if they are married to men in who are posted to work in urban settings due to their jobs. In some cases, male HSAs had wives who were posted to urban settings however, they chose to remain in rural areas due to cultural norms that make it shameful for men to be seen to follow their wives.

We heard how this imbalance affects the health of the community as, although both male and female HSAs have the same responsibilities on paper, in reality the division of labour is quite gendered.  In most settings male CHWs are more privileged than women with greater access to supervisory roles and equipment such as motorcycles.

King called for: 1) More gender disaggregated data on CHWs; 2) Greater support for skills development; 3) Gender transformative approaches in CHW policy; 4) Work with broader coalitions to prompt societal transformation, a review of current gender strategies, and the creation of a gender frameworks for CHWs.

Working with CHWs to engage fathers in health, wellbeing, and care

Andre Lewaks of Sonke Gender Justice South Africa, talked us through the MenCare Project,  gender transformative training by CHWs to promote father’s involvement in Early Child Development (ECD).

In South Africa 64% of children don’t live with their biological fathers following patterns that reflect strong cultural and patriarchal norms that promote women as the natural caregiver for children. For every hour of unpaid care given by a man, a woman gives eight. The MenCare Project trained child and youth care workers (CYCWs), provided home visitation programmes and complimented this with onsite mentorship and support of CYCWs.

A mixed methods evaluation of 544 fathers who took part in the project found a positive transformative change in attitudes towards heteronormative care roles and women’s labour. For example, when asked whether they agree with the statement “a women’s most important role is to take care of her home and cook for her family” before the intervention 79% of men and 60% of women agreed. After the intervention, this dropped to 31% of men and 33% of women. Participants also realised father’s roles went beyond provision of financial support and some women also reported that they realised their own role in the entrenched patriarchal mind set of the community.

The project reported that CYCWs had an improved capacity to understand and engage men. Men had an improved ability to express themselves which in turn improved communication between partners and lead to improved sharing of household responsibilities. Importantly, in a context of a high prevalence of intimate partner violence, there was a reduction in men’s abusive behaviour.

Instilling a gender transformative approach to National CHW programmes

Sarah Crass (on behalf of Polly Walker) discussed the gender transformative approaches that World Vision International (WVI) are undertaking through their CHW programmes in Lesotho, Ghana, Sudan and Mauritania. This includes the Timed and Targeted Counselling (TTC) model.

Fathers’ have a huge impact on children’s cognitive outcomes and even the relationships that they will go on to have in later life. Negative father figures can result in early sexual debut and increased childhood pregnancies. WVI’s evaluations found that a key limitation of CHW programmes, is lack of male partner engagement. Through their TTC model men are included by default and indicators for their involvement are included. It uses positive role modelling and healthy family models to engage men in family activities including time to play with their children and take part in other household activities traditionally viewed as women’s work. The model also makes use of male and female CHW pairs in household visits which is beneficial to circumvent norms that may inhibit cross gender discussions.

Through this intervention WVI found that TTC counselling is more productive and results in a greater number of concrete decisions being made if male partner is present. They also found that at the policy level male involvement is inadequately addressed and there is dearth of evidence here. They report that policy makers are aware of this gap and are keen to explore new methods for male involvement in community health as the non-participation of men inhibits early childhood development. Through a qualitative evaluation of the TTC model, they were able to report that male involvement leads to improved sharing of household chores with male partners. Male partners were also reported as more likely to take an interest in mothers’ nutrition during pregnancy and accompany mothers to give birth.

This panel helped to illuminate some of the issues facing CHWs and the communities they serve around gender. It was part of a larger call for greater gender analysis of challenges facing human resources for health which was heard throughout the conference.  For more information on gender and CHWs see our previous webinar on this topic and the REACHOUT blog. If you are interested in community health workers – join our thematic working group by emailing Faye.moody@lstmed.ac.uk.

Read the article

By Kate Hawkins, Sally Theobald, Rosie Steege, Maryse Kok, Mohsin Sidat, Kingsley Chikaphupha, Ralalicia Limato, Hermen Ormel, Daniel Gemechu Datiko, Robinson Karuga

To celebrate International Women’s Day the REACHOUT Consortium held a symposium in Nairobi on “women in the changing world of work”. This symposium grew out of a recognition that the sex of the Community Health Worker (CHW) influences their interaction with the health system.

Gender norms also shape CHWs’ different experiences in the course of their work both with households and the health sector. We have argued that CHWs play a critical interface role – connecting the health sector with the community – and although an analysis of the ways that gender influences this was not explicitly built into our research design from the outset, it emerged as an important issue in our REACHOUT context analysis. To investigate further, a Liverpool based Masters student, Woedem Gomez, undertook a literature review on gender and close-to-community (CTC) providers.  REACHOUT PhD student, Rosie Steege is exploring this topic in international policy discourse, as well as conducting empirical case studies in Ethiopia and Mozambique investigating how the health system can best support both male and female CHWs, recognising their differing needs.  We also worked with the Health Systems Global Thematic Working Group on CHWs to hold a webinar to share learning on gender and CHWs in different settings, including Democratic Republic of Congo and Palestine; which triggered further debate and questions.

Based on this learning and the premise that we still have time in the last months of our research programme to further educate ourselves on this area (and at least encourage others to consider from our lessons learned, positive and negative) we decided to spark off the process with a dialogue that enabled our team to engage with other stakeholders in Kenya.

Gender norms and related attitudes and behaviours are not fixed

We heard that gender norms are contextually specific and subject to flux and change through time. Mohsin Sidat (Mozambique) pointed out that many years ago women were not allowed to learn and practice medicine and about 100 years ago female physicians were still exceptional in the medical world. Today the scenario is different and, for example, in Faculty of Medicine of University Eduardo Mondlane where he is Dean they have about 60% female students. This clearly indicates gender roles in medical study and practice have changed.  Nevertheless, for centuries, the role of midwifery has been reserved for women and it continues to be so in recruitment and training of midwives. The midwifery role attributed to women is acceptable in most countries and few men take it up (in Sub-Saharan Africa). However, men and women are trained as Gyneco-Obstetricians and both perform deliveries and the role of men at this level is not questioned. These gender ascribed roles within health sector are certainly historical and perhaps also consolidated by social and cultural norms.

Miriam Taegtmeyer (UK) made a strong case that it is the responsibility of health systems researchers to challenge gender inequities – it is an ethical issue – and one that enables us to contribute to tackling the social determinants of health, as well as harmful practices such as gender-based violence and female genital mutilation.

CHWs are leaders

There is increasing focus on women and leadership in the global community, although this often focuses on leadership within the UN, WHO, donors, national parliaments and universities and is not extended to the community level. Sally Theobald (UK) led us through the global literature in which it has been argued that women may make up 70% of the CHW cadre.

They are arguably leaders at the community level. Unfortunately, although training and salary differ across contexts, female CHWs are more likely to be unpaid than their male counterparts – which is a unacceptable example of gender inequity, with higher level positions often reserved for men. Drawing on research on leadership in the Kenyan system more generally Kui Muraya (Kemri, Kenya) explained that there are social and cultural factors which are a hindrance to women’s leadership. Women’s domestic responsibilities often mean that they do not have the same amount of time for this work which means that these barriers need to be tackled if quotas are to be met.

Kingsley Chikaphupha (Malawi) reflected on how at the recent Kampala conference a community health volunteer (CHV) articulated these issues very clearly. Framing his thinking via the Sustainable Development Goals (SDGs) and in particular SDG 8 relating to decent work, he posed the question: Are we providing enough decent work for women?  He felt that if one were talking about gender and CHWs and all of the unpaid volunteers were women and most of the paid positions were filled by men, then this is a serious problem. If the health system provides decent work to women, there will be no excuse for excluding women from decision making. However, others argued that women having paid jobs doesn’t automatically mean they are heard when it comes to decision-making; in many organizational setting men’s voices are more often heard (they are in higher positions etc.).

Daniel Gemechu Datiko (Ethiopia) explained how (all-female) Health Extension Workers (HEWs) in his setting are paid and that this is a deliberate move to recognise the work of women as part of the health system and empower them by expanding the role that they were already doing for free in the community. Wages cover the opportunity cost of the time that they spend doing this work. HEWs leadership is positioned and explicitly recognised through their role as the secretary for the village committee/leadership, this positon allows them to call meetings, share health related information and to influence their peers. Some HEWs have moved up the career ladder and obtained their diploma and Bachelors degree, and in some cases they have been assigned to health centres and district health programmes. In three years’ time all of the HEWs will complete their training diploma as a matter of national policy. However, there are still very few female supervisors – so although we are paying this cadre of women, there is still a ceiling for them to become leaders among HEWs and until we address wider issues of female education/ gender and culture norms then this will remain a barrier.

In a story from Kenya, Penina Ochollo, explained how she had observed female CHWs taking leadership when it was not offered. A group of female CHWs who had been working for ten years got tired of retired men from the big city dominating in the community councils and pocketing expenses. Through their lobbying one of the local women got elected to the council anddespite being in the minority, it changed the dynamic. She argued that initiatives like this need support and that gender mainstreaming needs to come from county leaders in line with the Kenyan gender mainstreaming strategy which was written in 2006 but has sadly yet to be fully implemented at County or community level. In her reflections, Penina stated that women took up leadership in delivering community health services whilst delivering on pressing household and societal duties – with no financial incentives.

Being a CHW can be empowering but there are gender-related challenges

Penina shared many insights about the trajectory of CHW programmes in Kenya. She explained how the trainings that CHWs receive create changes in their personal and family life. Becoming a CHW enables them to participate in exchange visits around Kenya, to network and attend training seminars which inspire them. They are no longer ‘poor ladies’. Whilst some husbands agreed that there had been positive changes in the home due to this, they were suspicious about home visits, that their wives might be involved in mpangowakando (having extra-marital sexual relationships). This led, in some cases, to gender based violence. The likelihood of suspicion and violence increased proportionately to the CHWs popularity in the community and influence with local leaders. She explained that male CHWs have the potential to influence other men in the community however they were not always received favourably by husbands who were suspicious of their presence in the house – another trigger for gender based violence. Penina argued that there was a need to work with the male partners of female CHWs to ‘sensitise’ them to what the job involves and include them in things like workshops so that they better understand the CHW role and its impact. Other countries, such as Ghana, have chosen for an explicit combination of male and female CHWs at the village level, which also needs special attention on how to address gender and optimize programme outcomes.

Rifat Mafuza explained how in Bangladesh the concept of women’s empowerment is explicitly linked to economic empowerment within the CHW policy. For this reason, CHWs are linked to micro-credit schemes to expand their economic potential and that their interactions with women in the home also cover access to education, legal services etc.

Gender-sensitive policy making and implementation is a gap that needs to be filled

Penina reminded us about the 1978 Alma Ata Declaration and the policy trajectory of primary health care and community health care. As the community health strategy was developed in Kenya they called upon the assistance of women, “they were the rock to move this mountain!” Women were the first choice of CHWs as they were directly affected by issues like nutrition and family planning. Initially women volunteered; it was not a paying job and had no career path. Men were not interested. There was too little attention to gender in the implementation of the strategy and its development over the years. She explained that male involvement has become more and more critical – particularly in terms of support for maternal, newborn and child health. Greater numbers of men are becoming CHVs but the ratio today is still around an 80/20 female to male.

We heard from Sally that CHWs can support change in the community– in terms of the social determinants of health and harmful gender norms – but we don’t always give them the tools or support to do this. This requires the support of the health system through policies related to supervision and community oversight bodies who need to be sensitised to gender-related. Summarising discussions, Maryse Kok (the Netherlands) explained how in community health committees in Kenya there are more males than females but that this is sometimes at odds with the constitutional requirement that no more than two-thirds of elected or appointed public bodies consist of one sex. Even when policies like this exist, their implementation may be slow. Kingsley suggested that when it comes to the selection criteria for CHWs we take our own biases into the process. If we say that women have more caring qualities, we influence the way that clients see male workers which makes it difficult for them to be employed as CHWs and carry out the role.

Salim Hussein (Kenya) returned to this point arguing that we need to mainstream gender inclusivity throughout the community health programme and that CHWs need to be trained in how they can improve gender equity and given messages that they can disseminate to the community. For this to be successful we need to sensitise formal health workers and to motivate and incentivise the leaders so that they have the capacity to advocate for gender equity. Simultaneously we need to assist communities in holding leaders to account. There was a strong plea for more leadership at all levels: from international to national and communities. Carol Ngunu (Kenya) explained that in Nairobi County they are ensuring that traditional birth attendants (TBAs) become CHVs because their experience in these roles means that they understand the challenges and norms in the community – and are an accepted support system that men feel comfortable with. She also outlined that Nairobi county is the first Kenyan county to roll out the gender mainstreaming guidelines in health facilities and the importance of these reaching the community level, including community leaders. She also stressed that there is a need for gender specific targets in health programmes.

The international literature outlined by Sally shows how the CHW role can bring personal harm and risk of sexual and gender based violence. This concern about safety was echoed by Penina and other participants, particularly the risk of sexual and gender based violence as they do this work, which needs to be a priority area to be addressed by the health system.

The contribution of CHWs to sexual and reproductive health and rights

We heard many examples of frontline, cutting edge sexual and reproductive health work by CHWs in diverse settings. For example, Licia Limato (Indonesia) explained how kader (community health volunteers) play a role to support unmarried, pregnant, teenage girls who are highly stigmatised and shamed. Usually, because of social disapproval and laws that prohibit service provision to unmarried women, the family hides the daughter in the house for the full pregnancy, with no ANC checks. Then at the time of delivery they are more likely to use the services of a TBA than the formal system. Because they are ‘of the community and for the community’ kader are more aware of when a young woman is pregnant and isolated. They often counsel parents about the importance of health checks with persistence. Sometimes they take the girls to formal services, mostly to the village midwife for delivery under the cover of darkness.

Rifat (Bangladesh) spoke about the ways in which maternal mortality has been reduced through the provision of safe abortion, or menstrual regulation (MR), services. There is a government regularised system of MR with trained providers. CHWs play a key role in referral of clients to MR services and REACHOUT has been supporting quality improvement to these systems and the supervision of CHWs.

Christine Sammy (Kenya) spoke about the improvements that have been made to family planning, HIV and maternal health services through the involvement of CHWs in Kitui county. The CHVs have been trained in recognising the danger signs and other elements of maternal health. They are becoming referral champions and are monitoring expectant mothers through house visits. By encouraging male involvement more households are saving money for transport costs so that women can go to the health facilities for birth. She emphasized the importance of collaborating with non-state actors, such as LVCT Health, in building the capacity of CHVs in maternal health.

Continuing the conversations

At the recent Kampala Conference we heard from CHWs in India and Uganda that some of their concerns relate to gender. In REACHOUT we believe that as researchers we have a moral obligation to let the voices of CHWs be heard ‘up there’ in national governments and in organisations like WHO. Given the increasing policy attention being given to this cadre of health worker, the coming years bring opportunities to gather and disseminate more information.

We will consider how we can communicate with a larger body of CHWs, policy makers, researchers and practitioners to keep conversations alive. In particular, the SDGs have a focus on unpaid care and there is more that we can do to make the links between this and volunteer labour in the health sector. We also need to look at the working conditions of CHWs as it relates to the concept of ‘decent work’.

Link to the article

Photo: The image is of Mehret Lamiso at her health post in Becha Kabele, Ethiopia. It was taken by Rosie Steege.