By: Rebecca Furth, Initiatives Inc.
The session Towards a Community Health Worker Gender Action Framework: Implications for Decent Work, Rights and Responsibilities, at the 4th global forum on Human Resources for Health brought together five panelists[i] to share evidence and experience on how gender shapes CHW work and how CHWs can be agents for gender transformation. Through its explicit exploration of gender and CHW work, the panel made the case for a gender action framework in CHW program design and evaluation. 
The panel began with examples from India (Kerry Scott) and Brazil (João Nunes) that illustrated how the creation of CHW programs is often inherently gendered and how this gendering can make CHWs simultaneously powerful and vulnerable. India and Brazil each created CHW cadres explicitly made up of poor women who were trained to support the needs of their female community members with a specific focus, at least initially, on addressing reproductive, maternal and child health. In India, expansion of the accredited social health activist (ASHA) program to promote ASHAs as secretaries of village health committees has increased their social and political influence and acceptance. The program is also working to increase opportunities for ASHAs to earn incentives to enhance their income earning potential; provide avenues for career progression; and enroll in life insurance, accident insurance and pension schemes to improve their future well-being. These measures respond, at least in part, to ASHA’s needs as women health care workers and, by empowering them, increase their authority, economic opportunity and voice in their communities.
While these programs have had the positive and important intention of meeting women’s unmet need for services and expanding women’s income-earning potential, as Nunes points out, they also frequently reproduce patriarchal cultures that relegate women’s employment to a precarious and informal realm of the economy. In these contexts, women’s low-paid labor exposes them to additional risks and frequently requires them to perform outside of their designated roles, further “informalizing” their work. Importantly, both presenters noted that this focus on women CHWs and on women’s health has, wittingly or not, epitomized CHW work as women’s work, thereby creating a perceptual obstacle to men taking up CHW work and failing to address men’s unmet need for services.
Examples from Malawi presented by Kingsley Chikaphupha showed how gender biases influence CHW recruitment and shape the nature of their work. While the establishment of Health Surveillance Assistants (HSAs) created an important opportunity for the health sector to contribute to gender equality, recruitment of HSAs has not been adequately examined from a gender perspective and imbalances persist in the workforce. Overall, 30 percent of HSAs are male and 70 percent are female, but in rural areas, the statistics reverse with 70 percent male and 30 percent female. Reasons for the imbalance are linked to urban and rural economies – men have more employment opportunities in urban areas than in rural areas – and to gendered notions of work and family that discourage women from earning more money than their husbands. Across the urban and rural divide, male CHWs are generally more privileged with a higher percentage promoted to supervisory roles and accessing resources such as motorcycles. The presentation further emphasized that these employment disparities directly affect service provision. For, although CHW roles and responsibilities may be uniform and “gender-blind” on paper, in reality, male CHWs will focus more on certain services and clients and female CHWs on others. Thus, in the provision of critical health services, gender considerations in recruitment and deployment of CHWs matter significantly.
And what of the potential for CHWs to serve men’s health and social needs and challenge societal gender norms? Presentations from Andre Lewaks and Sarah Crass, underscored the importance of CHW’s in addressing men’s needs for services and fostering positive change in families and communities. In south Africa, where 64 percent of children do not live with their biological fathers and where more than five million single mothers support their children, CHWs are being enlisted to help transform men’s roles as caregivers and supportive partners. Trained to council men on child care and their important roles as fathers and as husbands, CHWs have contributed to changing men’s and women’s perspectives of their domestic roles and have helped increase sharing of household tasks, reduce domestic violence and improve the ability of men to express themselves in their relationships. Similarly, World Vision International has implemented a timed and targeted counseling approach, provided by CHWs, across thirty-three countries to improve child wellbeing by strengthening parental engagement and support – explicitly included men in this initiative to enhance the positive involvement of fathers in their children’s lives. World Vision is still evaluating its work, but, as in the South Africa example, has witnessed increased sharing of household chores by men, more attention to women’s diet and wellbeing during pregnancy and decreases in child abuse and gender-based violence.
Moderator Sally Theobald summed up the session by emphasizing the critical importance of explicitly considering gender in CHW program design, implementation and evaluation. She stressed, “If we see CHWs as embedded in and part of the communities they represent then transformative training can change the experience of CHWs themselves and the work they do in negotiating gender dynamics in the communities they serve.” To achieve this, we need to put gender onto the agenda and consider the establishment and implementation of CHW programs through a gendered lens.
Want more detail on this important and thought-provoking session? Click here to read a detailed report by Rosie Steege, Sally Theobald and Kate Hawkins.
[i] Moderated by Sally Theobald, Professor in Social Science and International Health, Department of International Public Health, Liverpool School of Tropical Medicine, UK. Presenters: Kerry Scott (on behalf of Asha George), University of the Western Cape, South Africa; João Nunes, Department of Politics, University of York, UK; Kingsley Chikaphupha, REACH Trust, Malawi; Andre Lewaks, MenCare, Sonke Gender Justice, South Africa; and Sarah Crass (on behalf of Polly Walker), World Vision UK.
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