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Gender & policy in
Community Health
Worker programmes
Rosie Steege
12th June 2017
Matatcha CHW
Moamba, Mozambique
Contents
• Why is gender important?
• Gender challenges in context of policies and
guidelines
• Future of CHW programme policies
Introduction
• IMAGE OF CHW
Meskerem and Tezeru –
Health Extension Workers,
Sidama Zone, Ethiopia
• “My challenge is the communities couldn’t
accept what I told about health facility
delivery. The pregnant woman wanted to
deliver at home because her husband didn’t
permit her to deliver in the health facility.”
CHW, Indonesia (REACHOUT context analysis)
Arminda, APE with mothers from her
community Manhiça, Mozambique
Palmina APE with her daughter
in Manhica Mozambique
Contents
• Why is gender important?
• Gender challenges in context of policies and
guidelines
• Future of CHW programme policies
Key informant interviews
Training
“where women were nominated they were sent to this training institution
they are away from their family for you know, up to a year and it was very
difficult because we have a couple instances where some women arrived,
didn't know that they were pregnant, found out that they were pregnant
and had to drop out which was hard for them because they were so excited
and wanted to do this and then another issue was men, if you will, just
asking them to come back, they didn't feel comfortable with their wife
being you know in a far off place, with a bunch of people that they didn't
know. ” Zambia
Mobility
“the supervisors go out into the community and this is really difficult
terrain, sometimes you are going through jungle and going on hikes and
these sorts of things, and we use motorbikes to get there and what we
found is that a lot of the women, who are the supervisors going out are
petite, and actually getting them on a bike and having them actually be
able to ride the bike through all this muddy terrain and navigate all of this
sometimes its just impossible… So [we send] out another person with them
and usually its a man but again, this is all stuff that at the national level it
hasn't really been thought through how we are going to navigate some of
these points but they are real life implementation challenges, that have a
funny gender dynamic.” Liberia
Contents
• Why is gender important?
• Gender challenges in context of policies and
guidelines
• Future of CHW programme policies
Current challenges
• Funding / sustainability
• Education levels by gender
– (especially in conflict affected
settings)
Gender bias in the health sector
– Larger systems issue  How can we
support CHWs to bring their voice,
perspective and leadership into
health systems
– Supportive supervision and space
for reflection
Current opportunities
• Natural researchers
(Perez & Martinez, 2008)
– CHWs have untapped
insights around gender,
equity and power 
should be harnessed to
build more responsive
health systems
• Representation from
Gender dept. and
women’s groups needed
• HMIS data for CHWs
disaggregated by gender
should be used to support
decision making
Mehret Lamiso, Becha
Kabele, Ethiopia
Case study –
ASHA programme
– National policy adapted by each state
– Female nodal officers bringing gender issues to table
• Safe spaces, harrassment
– Modular training
• Residential
• Childcare on site
• Female only facilitators
Safety
“So you have to have a programme that sensitizes
every service provider male and female above the
ASHA to gender - that hasn't happened and that’s
terrible because the ASHA can be as aware of gender
issues as you care to make her and then she goes into
this person's house and gets raped.” India
Conclusion
• Gender impacts CHWs in a
multitude of ways
• Current CHW policies do not
acknowledge the complexity gender
plays ‘supply side’
– missed opportunity to promote
gender transformative approaches at
all levels of the health system
– Bottom up approach needed
• Implementation approaches on the
ground are often governed by
gender but not by policy
– Responsive policy inclusive of gender
governing the implementation at
community level
Leopoldina, APE
Moamba Mozambique
Acknowledgements
• CHWs and key informants from all genders that
participated in the research
• REACHOUT consortium family
• PhD supervisors - Sally Theobald (LSTM) and Miriam
Taegtmeyer (LSTM)
Thank you
Email: rosalind.steege@lstmed.ac.uk
Twitter: @rjsteege
Joel, community leader with his
community in Manhica Mozambique
References
• Theobald, S. MacPherson, E. McCollum, R. Tolhurst, R. (2015) Close to community health providers post 2015: Realising their role in
responsive health systems and addressing gendered social determinants of health REACHOUT BMC Proceedings. 9(Suppl 10):S8 (18
December 2015)
• Gomez, W. (2015) A literature review exploring how the gender of a community health worker impacts provision of healthcare services
in low and middle income countries. LSTM, unpublished, cited with permission.
• Jackson, R. Kilsby, D. (2015) We are dying while giving life: Gender and the role of Health Extension Workers in rural Ethiopia .84p.
Accessed 5 Feb 2016. Available from: http://www.eldis.org/vfile/upload/1/Document/1601/Gender%20and%20HEWs%20report.pdf
• Saprii, L., Richards, E., Kokho, P. and Theobald, S. (2015) 'Community health workers in rural India: analysing the opportunities and
challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles', Human Resources for Health, 13(1), pp. 1-13.
• Najafizada, S. A., Labonte, R. and Bourgeault, I. L. (2014) 'Community health workers of Afghanistan: a qualitative study of a national
program', Confl Health, 8, pp. 26.
• Mumtaz, Z. (2012) 'Gender and social geography: Impact on Lady Health Workers Mobility in Pakistan', BMC Health Services Research,
12, pp. 360-360.
• Uzondu, C. A., Doctor, H. V., Findley, S. E., Afenyadu, G. Y. and Ager, A. (2015) 'Female health workers at the doorstep: a pilot of
community-based maternal, newborn, and child health service delivery in northern Nigeria', Glob Health Sci Pract, 3(1), pp. 97-108.
• Razee, H., Whittaker, M., Jayasuriya, R., Yap, L. and Brentnall, L. (2012) 'Listening to the rural health workers in Papua New Guinea - the
social factors that influence their motivation to work', Social Science & Medicine (1982), 75(5), pp. 828-835.
• Fotso, J. C., Higgins-Steele, A. and Mohanty, S. (2015) 'Male engagement as a strategy to improve utilization and community-based
delivery of maternal, newborn and child health services: evidence from an intervention in Odisha, India', BMC Health Serv Res, 15 Suppl
1, pp. S5.

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The importance of gender transformative policies for CHW programmes

  • 1. Gender & policy in Community Health Worker programmes Rosie Steege 12th June 2017 Matatcha CHW Moamba, Mozambique
  • 2. Contents • Why is gender important? • Gender challenges in context of policies and guidelines • Future of CHW programme policies
  • 3. Introduction • IMAGE OF CHW Meskerem and Tezeru – Health Extension Workers, Sidama Zone, Ethiopia
  • 4. • “My challenge is the communities couldn’t accept what I told about health facility delivery. The pregnant woman wanted to deliver at home because her husband didn’t permit her to deliver in the health facility.” CHW, Indonesia (REACHOUT context analysis)
  • 5. Arminda, APE with mothers from her community Manhiça, Mozambique
  • 6.
  • 7. Palmina APE with her daughter in Manhica Mozambique
  • 8. Contents • Why is gender important? • Gender challenges in context of policies and guidelines • Future of CHW programme policies
  • 10. Training “where women were nominated they were sent to this training institution they are away from their family for you know, up to a year and it was very difficult because we have a couple instances where some women arrived, didn't know that they were pregnant, found out that they were pregnant and had to drop out which was hard for them because they were so excited and wanted to do this and then another issue was men, if you will, just asking them to come back, they didn't feel comfortable with their wife being you know in a far off place, with a bunch of people that they didn't know. ” Zambia
  • 11. Mobility “the supervisors go out into the community and this is really difficult terrain, sometimes you are going through jungle and going on hikes and these sorts of things, and we use motorbikes to get there and what we found is that a lot of the women, who are the supervisors going out are petite, and actually getting them on a bike and having them actually be able to ride the bike through all this muddy terrain and navigate all of this sometimes its just impossible… So [we send] out another person with them and usually its a man but again, this is all stuff that at the national level it hasn't really been thought through how we are going to navigate some of these points but they are real life implementation challenges, that have a funny gender dynamic.” Liberia
  • 12. Contents • Why is gender important? • Gender challenges in context of policies and guidelines • Future of CHW programme policies
  • 13.
  • 14. Current challenges • Funding / sustainability • Education levels by gender – (especially in conflict affected settings) Gender bias in the health sector – Larger systems issue  How can we support CHWs to bring their voice, perspective and leadership into health systems – Supportive supervision and space for reflection
  • 15. Current opportunities • Natural researchers (Perez & Martinez, 2008) – CHWs have untapped insights around gender, equity and power  should be harnessed to build more responsive health systems • Representation from Gender dept. and women’s groups needed • HMIS data for CHWs disaggregated by gender should be used to support decision making Mehret Lamiso, Becha Kabele, Ethiopia
  • 16. Case study – ASHA programme – National policy adapted by each state – Female nodal officers bringing gender issues to table • Safe spaces, harrassment – Modular training • Residential • Childcare on site • Female only facilitators
  • 17. Safety “So you have to have a programme that sensitizes every service provider male and female above the ASHA to gender - that hasn't happened and that’s terrible because the ASHA can be as aware of gender issues as you care to make her and then she goes into this person's house and gets raped.” India
  • 18. Conclusion • Gender impacts CHWs in a multitude of ways • Current CHW policies do not acknowledge the complexity gender plays ‘supply side’ – missed opportunity to promote gender transformative approaches at all levels of the health system – Bottom up approach needed • Implementation approaches on the ground are often governed by gender but not by policy – Responsive policy inclusive of gender governing the implementation at community level Leopoldina, APE Moamba Mozambique
  • 19. Acknowledgements • CHWs and key informants from all genders that participated in the research • REACHOUT consortium family • PhD supervisors - Sally Theobald (LSTM) and Miriam Taegtmeyer (LSTM)
  • 20. Thank you Email: rosalind.steege@lstmed.ac.uk Twitter: @rjsteege Joel, community leader with his community in Manhica Mozambique
  • 21. References • Theobald, S. MacPherson, E. McCollum, R. Tolhurst, R. (2015) Close to community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health REACHOUT BMC Proceedings. 9(Suppl 10):S8 (18 December 2015) • Gomez, W. (2015) A literature review exploring how the gender of a community health worker impacts provision of healthcare services in low and middle income countries. LSTM, unpublished, cited with permission. • Jackson, R. Kilsby, D. (2015) We are dying while giving life: Gender and the role of Health Extension Workers in rural Ethiopia .84p. Accessed 5 Feb 2016. Available from: http://www.eldis.org/vfile/upload/1/Document/1601/Gender%20and%20HEWs%20report.pdf • Saprii, L., Richards, E., Kokho, P. and Theobald, S. (2015) 'Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles', Human Resources for Health, 13(1), pp. 1-13. • Najafizada, S. A., Labonte, R. and Bourgeault, I. L. (2014) 'Community health workers of Afghanistan: a qualitative study of a national program', Confl Health, 8, pp. 26. • Mumtaz, Z. (2012) 'Gender and social geography: Impact on Lady Health Workers Mobility in Pakistan', BMC Health Services Research, 12, pp. 360-360. • Uzondu, C. A., Doctor, H. V., Findley, S. E., Afenyadu, G. Y. and Ager, A. (2015) 'Female health workers at the doorstep: a pilot of community-based maternal, newborn, and child health service delivery in northern Nigeria', Glob Health Sci Pract, 3(1), pp. 97-108. • Razee, H., Whittaker, M., Jayasuriya, R., Yap, L. and Brentnall, L. (2012) 'Listening to the rural health workers in Papua New Guinea - the social factors that influence their motivation to work', Social Science & Medicine (1982), 75(5), pp. 828-835. • Fotso, J. C., Higgins-Steele, A. and Mohanty, S. (2015) 'Male engagement as a strategy to improve utilization and community-based delivery of maternal, newborn and child health services: evidence from an intervention in Odisha, India', BMC Health Serv Res, 15 Suppl 1, pp. S5.

Editor's Notes

  1. Gender in policy and how it influences CHW programmes Start with why its important to have gender in policy And close with a case study of where gender is reflected nicely
  2. CHW programmes are widely varied BUT the key commonality of CHWs is that they come from the community they serve
  3. These types of gender biases are well documented within the context of community health and CHW programmes Gender biases are present so when we are thinking about community interventios
  4. Largely missing is that because CHWs come from communities they are subject to the same gender norms but that is not largely reflected in policy In truth – gender interactions are complex, varied by context and my PHD has been seeking to map some these complextities
  5. So this is the conceptual framework that we have developed and really it serves to highlight the complexites of the ways in which gender plays out across the different contexts and within the National context – factors on the RHS – and is mediated by other axes of inequity on the LHS Moving out from HS to COMm to CHW And I will talk through some of these examples in the presentation as we go on… (not enough time now but if want to talk after)
  6. in our REACHOUT context analysis -– in Mozambique there are Low female recruitment rates due to 4 month training away from home – issues that I explored as part of my research and indeed this emerged as a theme – where husbands were generally not supportive of their wives undertaking the APE training or indeed APE work – as they did not want them to be away from home…care for children and household etc.
  7. As part of my research I have been conducting a policy analysis to understand the current level of acknowledgment in policies – and spoke with KI in the countries with stars - Gender is rarely mentioned in the context of CHWs Some national HRH policies/guidelines recognise the importance of gender responsiveness at the higher levels of the health system But as we see from conceptual framework gender permeates across all aspects and from the KII there are examples of how programmes are responding to gender influences on the ground/community level but this is not yet reflected in national policies
  8. Echoing our findings from Mozambique in REACHOUT The KII also highlighted issues with training elsewhere – in Zambia for example – long time away from home and have reported instances of husbands not wanting to let their wives attend, or women finding out they are pregnant and then having to leave SOLUTIONS _ ALL FEMALE TRAINERS LIKE ASHA PROGRAMME< SHORT MODULAR COURSES < BUDGET FOR ON SITE CHILD CARE Mozambique - “Some women know how to write and read; however, some husbands refuse to allow their wife to become an APE, arguing that she will have a relationship with other men during the training and that she will not have time to take care of the household and the children.” Mozambique
  9. This issue of transport came out in several contexts eg Afghanistan, Bangladesh – where it prevents upward movement of CHWs (supervisory role) But this example from Liberia illustrates how ad hoc solutions are being implemented on the ground & overcoming challenges How can we address these norms as well as practical issues Safety concerns
  10. So to come back to this  its good to have it at a national level, when we think about challenges in health systems (funding, education etc) then we need to consider gender while develop all national policies (with regard to how it feeds in to the health system) – because we we can see the interplay gender has across these. So coming back to example of training in Mozambique – we need policies that don’t just accept this and work around it, but we need policies to transform these norms and sensitise the community to be accepting of this
  11. Even if policies were reflective of these issues – its not that simple – current challenges from a health system perspective need to be thought about while we develop policy for example… So policy needs to be intersectoral – considering the contextual realtities whilst still having the gender lens.
  12. - Input from CHWs is common – via consultative FDGs, surveys or committees Not usually bottom up – more of a checking process  not enough engagement from CHWs ASHSA programme in India is an exception with strong feedback mechanisms from nodal officers More of a bottom up approach needed – opportunities for CHWs to input Natural researchers (Perez & Martinez, 2008) CTC providers have untapped insights around gender, equity and power  should be harnessed to build more responsive health systems need to include this vital interface cadre in debates and efforts to support women’s leadership in health - CHW Policy development often cited as inter-sectoral but not often representation from women’s groups or specific gender departments - HMIS data for CHWs may be disaggregated by gender  often not used to support decision making with regard to CHWs National policies – that can also be adapted locally… For example
  13. ASHA _ nodal officers in India being women – opportunity to bring gender issues to the table Each state adapts things SAFE spaces for ASHAs during delivery Modular training Childcare Female only facilitators
  14. Safety was reported to be an issue in several contexts – some ad hoc suggestions where Safe spaces in delivery rooms? Male accompaniments are sent along? In Liberia male accompaniments are sent along Male Female CHW pairs? But Issues remain around gender sensitisation of the whole community
  15. Gender impacts not only communities abilty to seek health care, but also CHWs ability to supply health care as CHWS operate within the same gender dyamics as the community. To date minimal attention has been paid to the influence of gender on CHW programmes from a health systems policy perspective. This is a missed opportunity to promote gender transformative approaches at different levels of the health system. There is recent impetnus to change this and many countries implementation approaches on the ground are goverened by gender dynamics – stronger links should be made