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