Time for transformation: supporting community health workers on the path to gender equity

Community Health Workers (CHWs) are increasingly relied upon to supplement human resources for health shortages in low-and middle-income countries. CHWs occupy a unique interface position between communities and the health system and are able to reach the most marginalised communities. Unlike other cadres, they do not operate out of an institutional space, but instead operate within the gendered boundaries of their communities. The literature review conducted as part of this thesis demonstrates the multiple ways gender norms and relations interact with broader contextual factors and other axes of inequity to impact the working lives of CHWs. Yet these ‘software’ considerations are not reflected in policies which establish and guide CHW programming. This thesis aims to answer the following research question: How do gender norms and relations shape both CHWs’ working lives, and how do CHW policies and guidelines play out across differing contexts? A new framework is presented which demonstrates how gender roles and relations impact CHWs’ working lives across various levels from the individual, to community and health systems. The thesis then uses mixed qualitative interview techniques to understand the processes of CHW policy making at a national and international level (via key informant interviews, n=11) and to what degree gender is considered within the development process. Finally, the thesis explores how different policies play out within two distinct country settings – Mozambique and Ethiopia. In Mozambique qualitative techniques (IDIs, n=31and FGDs, n=3) are employed with CHWs, their supervisors, community leaders and key informants to explore the gendered implications of policies relating to the recruitment and retention of CHWs. Further, it investigates how gender roles and relations affect livelihood negotiations for male and female CHWs. In Ethiopia qualitative techniques (IDIs, n=19 and FGDs, n=8) are employed with CHWs, their supervisors and community leaders to unearth the gendered impact of new guidelines surrounding the use of mobile phone technology (mHealth). The findings are analysed against a gender framework to discuss how gender equitable the mHealth intervention is for the all-female cadre of CHWs. This thesis finds that although gender roles and relations impact the working lives of CHWs - gender is not considered comprehensively in CHW human resource policies. This may be in part because context-relevant evidence, tools and guidance on how to encourage gender equitable CHW programming and policies are lacking. This is compounded by a lack of national sex-disaggregated data on CHWs, high levels of fragmentation of policy actors and limited input from gender experts and departments. The policy making process is not a simple one and is inherently shaped by power relations. This complexity is mirrored in how CHW policies play out on the ground – existing gendered power dynamics limit female CHW’s choices over their livelihoods in Mozambique, and in Ethiopia, new gendered power dynamics were created among HEWs with access to mHealth. The findings demonstrate that CHW policies and guidelines do not exist in a vacuum but are mediated and shaped by gender relations and other contextual factors that operate across individual, household, community and institutional levels. The findings also provide a base for concrete suggestions for gender equitable CHW policy making, which are presented in the discussion. People working within the health system should reflect on its role as a gendered institution, aiming to transform gender inequities from within. This is critical at the community health system level, which is increasingly relied upon to reach marginalised communities. The time is ripe to enact policy change to ensure CHW programming is more gender equitable and responds effectively to the differing needs of the men and women who serve as CHWs – the sector’s critical link for the provision of health promotion and disease prevention services. This in turn, will encourage gender transformation on a broader scale and help CHWs feel supported and valued in order to best serve the needs of their communities