This document discusses how gender impacts the working lives of community health workers (CHWs). It identifies several gender-related challenges faced by CHWs, including communities not accepting health advice from female CHWs, difficulties for female CHWs in traveling long distances or being away from home for training, and pressures from husbands for female CHWs to prioritize family responsibilities over work. The document recommends that CHW programs and policies acknowledge these gender issues and promote more gender-transformative approaches to support CHWs and strengthen health systems in a sustainable and equitable manner.

1. How does gender
impact the working
lives of Community
Health Workers?
Rosie Steege
23rd October 2017
Matatcha CHW
Moamba, Mozambique

2. Contents
• Why is gender important?
• Gender challenges for CHWs
• Recommendations for sustainable CHW
programmes & policies

3. • “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)

4. Arminda, APE with mothers from her
community Manhiça, Mozambique

5. Contents
• Why is gender important?
• Gender challenges for CHWs
• Recommendations for sustainable CHW
programmes & policies

6. Steege et al. (Manuscript submitted for publication)

7. Training (HS level)
“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, KII

8. Palmina APE with her daughter
in Manhica Mozambique

9. Mobility
(Community level)
“the supervisors go out into the community and this is really difficult
terrain, sometimes you are going through jungle and going on hikes 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, KII

10. Marriage
(Individual level)
“Agriculture development agents are getting transfer, education. The one
who has a certificate level education is becoming diploma level and the
diplomas are becoming degree holder. We also have the right to get
married. We have to be with our husband as like other sectors doing.
There is a provision of government which says ‘the wife and the husband
should not separate due to work place’”
HEW, Ethiopia

11. Contents
• Why is gender important?
• Gender challenges in context of policies and
guidelines
• Recommendations for sustainable CHW
programmes & policies

12. Steege et al. (Manuscript submitted for publication)

13. Challenges to change
• Funding / sustainability
• Education levels by gender
– (especially in conflict affected
settings)
Gender bias in the health sector &
women’s leadership
– Larger systems issue  How can we
support CHWs to bring their voice,
perspective and leadership into
health systems
– Supportive supervision and space
for reflection
Dhatt R, Theobald S, Buzuzi S, Ros B, Vong S, Muraya K, et al. The role of women's leadership and
gender equity in leadership and health system strengthening. Global Health, Epidemiology and
Genomics. 2017;2.
Standing H. Gender – a Missing Dimension in Human Resource Policy And Planning for Health Reforms
2000.

14. Introduction
• IMAGE OF CHW
Meskerem and Tezeru –
Health Extension Workers,
Sidama Zone, Ethiopia

15. 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, KII

16. Opportunities for change
• 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
Perez LM, Martinez J. Community health workers: social justice and policy advocates
for community health and well-being. Am J Public Health. 2008;98(1):11-4.

17. Conclusion
• Gender impacts CHWs in a multitude of ways
• Current CHW programmes & policies do not acknowledge
the complexity gender plays ‘supply side’
– missed opportunity to promote gender transformative approaches at all
levels of the health system
– Recognition of gender influence can help in scale up and sustainability of
programmes
– Bottom up approach needed
• Implementation approaches on the ground are often
governed by gender but not policy
– Responsive policy inclusive of gender governing the implementation at
community level

18. Acknowledgements
• CHWs and key informants from
all genders that participated in
the research
• PhD supervisors - Sally
Theobald (LSTM) and Miriam
Taegtmeyer (LSTM)
• Kate Hawkins and the wider
REACHOUT consortium team
for valuable insights on gender

19. Contact us
• Website: http://www.reachoutconsortium.org/
• Twitter: @REACHOUT_Tweet
• Join the Health Systems Global TWG ‘Supporting
and strengthening the role of community health
workers in health system development’ email:
faye.moody@lstmed.ac.uk

20. Interested in Gender? Contact RinGs
• Website: http://resyst.lshtm.ac.uk/rings
• E-mail: RinGs.RPC@gmail.com
• Twitter: @RinGsRPC
• Google+: RinGs
• Linked In:
https://www.linkedin.com/groups/Gender-Health-Health-Systems-Group-
8293050/about
Photo Credit: bug_g_membracid

21. Thank you
rosalind.steege@lstmed.ac.uk
@rjsteege
Joel, community leader
Manhica Mozambique

22. 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)
• 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.
• Perez LM, Martinez J. Community health workers: social justice and policy advocates for community health and well-being. Am J Public
Health. 2008;98(1):11-4.
• Dhatt R, Theobald S, Buzuzi S, Ros B, Vong S, Muraya K, et al. The role of women's leadership and gender equity in leadership and
health system strengthening. Global Health, Epidemiology and Genomics. 2017;2.
• Standing H. Gender – a Missing Dimension in Human Resource Policy And Planning for Health Reforms 2000.
• Steege et al. How does gender impact the working lives of close to community providers? Empirical research, a review and conceptual
framework. Manuscript submitted for publication.