"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
Occupational segregation by sex is one of the most important and enduring aspects of the labour market globally. This segregation is particularly apparent in health care where women make up over 70% of the health and social care workforce. Yet they remain vertically segregated to the lower tiers of the health system. This is evidenced by the vast numbers of women who make up Community Health Worker cadres worldwide. Tackling these gendered distortions in the health labour workforce is becoming a global priority, with a recent Global Health Workforce Network call for evidence in this area.
Community Health Workers are increasingly relied upon in settings with a shortage of formal health workers to provide services to communities, serving as a bridge between the health system and the community. They come from the communities they serve so are well placed to understand, and work within, cultural and gender norms and power dynamics. Many programmes aim to leverage their understanding of gender norms to improve access to services for women in communities. One common norm is the notion of acceptability or preference of healthcare provider by gender. How do you best reach women to, for example, improve maternal and child health outcomes? You use women.
When it comes to gender transformative Community Health Worker programming, gender norms and their impact on service uptake and access is a widespread consideration. But what about the gender norms that impact the Community Health Workers’ daily working conditions? As part of work under the REACHOUT consortium we conducted a literature review together with analysis of findings from our own empirical research to understand how gender norms, roles and responsibilities impact this cadre.
Here are three focus areas that Community Health Worker programme managers and people who write policy should bear in mind:
1) Safety and security – Women and men face physical risks when carrying out their role as Community Health Workers. Instances of rape and sexual harassment of women were reported in our own research in Kenya and also in the international literature across multiple contexts. This is a particular concern for Community Health Workers who are attending to pregnant mothers late at night, which makes them more vulnerable. They can also be placed in precarity and put at risk of community backlash if they are called upon to address and transform harmful practices within communities such as female genital mutilation and gender-based violence. Protecting them from these risks needs to be built into programme design and existing laws on violence against women should be enforced to assist victims in attaining justice without fear of retaliation.
Male Community Health Workers who have to visit women unaccompanied in their homes are also sometimes thought to be breaking norms and can be in danger of harassment and discomfort. Security is especially important in fragile and conflict-affected settings but is important in all programmes and should be considered a part of workplace health and safety.
2) Mobility – Women’s mobility is sometimes more limited than men’s due to fears over safety, culture, and practicalities such as lack of appropriate equipment for transporting supplies across difficult terrains. For example, in Northern Nigeria female Community Health Workers were prevented from using motorbikes, unlike their male colleagues, because it exposed their legs. Programme design should consider and address these practicalities. In some settings, such as Pakistan, women related that being a Community Health Worker was empowering as it enabled them to move around in their communities in ways that were previously unacceptable.
However, breaking norms around mobility could also marginalise and disadvantage Community Health Workers because they are perceived as acting in ways that are inappropriate for women. Lack of mobility can also limit women’s opportunities for career progression as having to move around freely to visit different health posts is common in supervisory roles. Community Health Worker programmes should include these practical and logistical issues in their initial planning and should create mechanisms to alert managers to new threats and vulnerabilities that arise.
3) Remuneration, incentives and career progression opportunities – Community Health Workers are important to the health system in many settings. However, too often the position remains unpaid or voluntary and it is assumed that it is something women can fit in around their other domestic responsibilities and work.
When positions are advertised as paid or become formalised, they may be taken up more by men. When communities are asked to nominate workers for paid positions they may favour men who they perceive to be the ‘breadwinners’ within households. Health systems are shaped by, and can shape, gender norms. Programme managers should be mindful of how their programmes could replicate and reinforce harmful or inequitable norms that may lead to the exploitation of women. Paid Community Health Worker positions for women, such as Health Extension Workers in Ethiopia, have been praised as providing economic independence for their employees and a path to female empowerment. However, while they receive a salary, female Health Extension Workers experience a high burden of work, no paid holiday time and little opportunity to further their career. The Ethiopian programme also still relies upon women’s unpaid labour through the volunteers who make up the Health Development Army which supports the paid Health Extension Workers.
Programmes should be built with gender equity in mind and gendered considerations should be taken into account as programmes evolve. Community Health Workers are arguably leaders in their communities, yet opportunities to progress through the ranks are limited. Furthermore, as one of the lowest cadres within the health system they have few chances to influence policy making and priority setting, and we lose many opportunities to draw on their unique and community embedded knowledge. Community Health Worker programmes can be empowering and provide much needed employment in many contexts. As attitudes and gender norms change, programmes need to be able to keep up and re-evaluate whether they are doing no ‘gender-harm’ and providing continuous opportunities for progression, skills development and economic and physical security to men and women on an equal basis.
aRosie Steege is a final year PhD candidate at Liverpool School of Tropical Medicine, Department of International Public Health. Her PhD, in conjunction with the REACHOUT consortium, looks at gender relations and how they impact on CHWs experiences - her fieldwork took place in Mozambique & Ethiopia.
bKate Hawkins is the Director of Pamoja Communications Ltd and the communications lead for the USAID SQALE project and the REACHOUT Consortium.