Community Health Workers: The Gender Agenda
A Summary from the Webinar on February 10, 2016; Sponsored by Health Systems Global and CHW Central
CHWs serve their own communities and help build a link to the formal health system. CHW gender influences their work, management and experience. The webinar opened by defining some of the characteristics of Close to the Community (CTC) Providers: 70% are females; some are volunteers and others remunerated, training varies in length and depth. A number of issues and challenges with regard to CTCs/CHWs and gender were raised. For example, we know generally that cultural context and institutional factors influence how gender affects CHW recruitment, retention, and acceptance, among other things. However, there is a significant gap in the evidence-base on CHWs and gender. We need to better understand how specifically gender roles and relations influence or impact equity, service delivery, provider safety and vulnerability, client acceptance and access to services, recruitment and retention, professional advancement as well as CHW experience. We need to better document the workforce and disaggregate data by sex to improve our understanding of the CHW workforce.
Asha George, Johns Hopkins School of Public Health
Sally Theobald, REACHOUT Consortium, Liverpool School of Tropical Medicine, UK
Amuda Baba, IPASC, Democrartic Republic of Congo
Hana Rabadi, World Vision, Jerusalem – West Bank – Gaza
Gender, CHW role, recruitment and equity: The current CHW workforce is estimated to be 70% female. In many contexts, gender influences women’s access to and acceptability in the eyes of clients, underscoring the importance of considering gender in aligning CHW roles and recruitment. However understanding the support needed by CHWs is also critical.
Gender and client access: Universal Health Care (UHC) is at the center of the international public health agenda. As barriers to women’s access to care remain a critical challenge to achieving UHC, CHWs play an important role in opening up access. In many cultures and contexts, gender influences provider acceptability and client access to services. For example, in DRC men would rather discuss their issues with men; similarly in Palestine women discuss sensitive topics with female CHWs.
Gender, CHW compensation and equity: Much of the CHW workforce works on a volunteer basis or for very little pay raising questions about gender, pay equity and how governments and societies value women in the workforce. No or low pay may also be a deterrent to men entering the workforce, which could influence the effectiveness of some programs in reaching some populations with critical health services.
CHW gender, safety and vulnerability: Securing the safety of CHWs is a key issue in many countries. CHWs, particularly females, are vulnerable as they often work alone and sometimes need to travel at night or at odd times to serve clients. The recent rape and death of an ASHA in India made this point clear. ASHAs fear walking in the dark to attend expectant mothers. In settings, such as Papua New Guinea, women may seek support of male colleagues or husbands to escort them to see their clients. In rural DRC, many CHWs are elderly women. In times of conflict, nurses may leave their posts for more secure locations leaving CHWs responsible for patients and clients.
Gender, power and empowerment in CHW work: The CHW role increases women’s self –respect and status. Many are recognized and valued community members and role models. This has rolled over into their personal lives; for example in Palestine there is more autonomy in marriage choice, some have become members of the village council and officially registered at the directorates of health. CHWs are returning to school, becoming members of community councils and increasing their leadership role in the community.
CHWs as agents of gender culture change: CHWs have contributed to community acceptance of working women. Initially CHWs in Palestine were not accepted by communities or the health system and barred from working outside their communities. Most importantly, women lacked trust in their abilities. Collaborating with village steering committees and village councils, communities became more accepting of women working outside the home and supporting their communities. Palestinian female CHWs are now starting to counsel men on child care and danger signs so they can support their wives, changing the gender dynamics in their communities.
Gender and CHW experience: Experience influences CHW status in society for men and women. Pressure from competing demands as a CHW, a mother, father and spouse need to be recognized along with the importance of mobility and accessibility. In Nigeria women still seek spousal approval to work in distant areas; but husbands are not supportive. In Afghanistan, women are restricted from travelling to other villages. Limited mobility and lower education levels have an impact on career progression. Experience from Palestine shows building relationships between CHWs and family members, neighbours and relatives has resulted in more support for household visits and increased utilization of health services.
What next? To better understand the effects of gender on CHWs, we need:
- Holistic gender analysis of CHW services
- Intersectional and reflexive analysis of ways gender and power shape CHWs to influence their wider environments
- Evidence-based work of CHWs
- Formalizing CHW role in Health Systems
- Discussion about women’s work, their voluntary status and need for remuneration
- Clarification of the importance of men as CHWs
There are many challenges still to be met; but the Gender Agenda can no longer be ignored.
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