The comparative agility of the community health worker cadre in fragile & conflict-affected contexts
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In this presentation Joanna Raven explores the comparative agility of the community health worker cadres in four fragile & conflict-affected contexts - Lebanon, Myanmar, Nepal and Sierra Leone.
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The comparative agility of the community health worker cadre in fragile & conflict-affected contexts
- 1. The comparative agility of the community health worker cadre in fragile & conflict-affected contexts Joanna Raven on behalf of Kyu Kyu Than, Hnin Kalayar Kyaw, Rouham Yamout, Fouad Fouad, Maya Abou Saad, Haja Wurie, Lansana Hassim, Emma Gbaoh, Abriti Arjyal, Obindra Chand, Ayuska Parajuli, Sally Theobald, Wesam Mansour, Kate Hawkins & Karen Miller
- 2. The gendered experience of CHWs in fragile and shock-prone settings: implications for policy and practice during and post COVID-19 CTC providers FASP settings Gender COVID 19 Aim: to explore the roles of CHWs and their gendered experiences during the COVID-19 pandemic in fragile and shock-prone (FASP) settings
- 3. Methods Sierra Leone: Kenema and Bonthe Nepal: Chandragiri and Gulariya Lebanon: 2 sites in Beqaa Valley Myanmar: South Dagon, Yangon
- 4. Methods Methods Document review Interviews and FGDs with CTC providers = 61 Key informant interviews with local stakeholders =25
- 5. Adapting role of CHWs during Covid-19 Community trust – familiar, from community Existing relationships enables good access Willingness to serve community; sense of duty Health system / employers want to use existing staff, low cost Able to innovate using local resources First people to respond to C19 in community (Myanmar) Well connected with social organisations / support groups COVID-19 roles Awareness raising about COVID Distribution of hygiene kits (PPE, etc) Tracking, screening, registering, following-up, referral of people with COVID Psychosocial support Home quarantine Support other people working in COVID Gender differences in roles Men: greater responsibilities Women: health education role Regular roles Clinical services (Lebanon) Antenatal care and delivery and postnatal care Awareness / health education Drew upon Ebola experience
- 6. Challenges that CHWs face in adapting their role during COVID: individual perspective “Need to adjust to have equilibrium between work and family. More sacrifice for women than men as men do not have much responsibility like women. CHW, woman, Myanmar “Family comes first: When the children are not going to schools, it exerts pressure on me. I am working outside, and when my children study online, I had to stay with them for hours. My husband is at home due to corona. This also exerts pressure.” CHW, woman, Lebanon Juggling multiple tasks Increased workload, particularly challenging when unplanned work “The workload was much… we have to visit quarantine homes twice a day and talk to them and check their temperature… And in some households, there are many people.” CHW, woman, Sierra Leone Travel and safety Fear of COVID Halted or limited income generating activities “There is a challenge for girls, and it sometimes needs for the family to accompany the girls (volunteers) on their way home from work. Sometimes, we have meetings at night. For me, my husband come and pick me up. For girls, we may need to arrange for their return trip. For example, township committee arrange a car for girls. For Boys, there is no problem as they can manage their own.” Supervisor, woman, Myanmar
- 8. Challenges that CHWs face in adapting their role during COVID: family Some have limited support for their role Some have limited support for household work “The family member scold asking, “Why do you need to do that work?” My own husband scolds me asking, “How much do they pay you? Why do you go there?” I have been used to this type of scolding. I let him continue scolding. I’ll carry on with my work.” CHW, woman, Nepal Adopt coping mechanisms e.g wake up early to do household chores, ignore
- 10. Challenges that CHWs face in adapting their role during COVID: community Stigma and discrimination from community members Reluctance to listen to women CHWs “Initially during the first wave some people in the community are frightened to talk to me which eventually reduced in the second wave.” CHW, woman, Myanmar “Neighbours and people around me used to tell me: Stay away from us. Don’t come closer. You work with Corona. Maybe you could infect us.” CHW, woman, Lebanon “Some of them lock their door. They have dog. The dog attacked us. When we ringed bell, they used to look at us and go inside fearing whether we might have brought corona. When we told them, “We need to discuss something with you,” only then they came out to their balcony.” CHW, woman, Nepal “Communities do not tend to often listen to women in certain situations due to cultural beliefs…they are not given the audience they need…so in some cases we provide them with a male back up if there should be pressing issues to be addressed.” Key Informant, man, Sierra Leone
- 12. Challenges that CHWs face in adapting their role during COVID: health system Limited training and supervision Limited equipment and supplies including PPE Not prioritised for vaccine Limited financial support for additional roles despite policy “There was no proper training - our main source of information was Facebook” CHW, woman, Myanmar “The money that they gave us was too small… during a lockdown, we have to buy things in the house to eat. The family burden is too much on us we have our children to look after and other family members.” CHW, woman, Sierra Leone “We can hardly secure the PPE for the employees.” Key informant, man, Lebanon “I feel very sad when they send us for work but don’t provide us necessary equipment. We tell them [health workers] that we are in need of safety items while visiting community. But HWs say even they don’t receive adequate supply at health post.” CHW, woman, Nepal
- 13. Families: help in doing their work, arrange transport, accompany to and from work Community: strengthen links with community leaders and organisations Health system: training, incentives, protection from infection Mental health support and development of coping mechanisms: “Providing us with the support we need will makes our work easy…Without support, the work cannot be done as required.” CHW, man, Sierra Leone Innovation: digital technology for supervision and training Recognition: “It would be really good if the health department recognizes the community health volunteers and tries to connect and collaborate with them more” CHW, woman, Myanmar CHWs need support
- 14. www.rebuildconsortium.com @ReBUILDRPC joanna.raven@lstmed.ac.uk Thank you This project is funded with UK aid from the British people
Editor's Notes
- Second, future-proofing health systems will benefit from the flexibility of roles of CHWs in changing contexts. So in this presentation I want to focus on a study that we are just finishing that has looked at how CHWs have adapted their roles during the COVID 19 pandemic.
- Most countries in the global South, and particularly FASP contexts, have a shortage of formal health workers and are increasingly looking to a range of CTC providers (eg. Community Health Workers and traditional birth attendants) to fill the gap and reach the most marginalised2. The COVID-19 pandemic has demonstrated the value of CTC providers and their importance in the response. In this study we have particularly focused on the gendered experience of CTC providers - gender roles and relations are context embedded and dynamic, shaping the social determinants of health as well as the experiences of CTC providers3 and need understanding and addressing to appropriately support CTC providers as they navigate new and existing challenges.
- We have conducted the study in settings in 4 fragile countries – Lebanon, Nepal, Myanmar and Sierra Leone.
- We used three methods: 1. Reviewing documents and policies about chws in COVID19 2. Interviews and FGDs with CHWs: There are ranges of CHWs in each context. We selected for each context Myanmar: female auxiliary midwives who work on maternal and reproductive health and male community health workers who work on environmental health and disease control. Nepal: Female Community Health Volunteers (FCHVs) support health promotion and prevention activities at community level. National guidelines call for FCHVs to be part of the COVID-19 response, in coordination with local governments. Sierra Leone: CHWS as part of the national CHW programme who deliver a package of services at the community level Lebanon: The study included only Syrian HW employed informally: Syrian refugees with health background employed regularly in non-authorized informal healthcare venues established by the Syrian community and Syrian refugees of different background employed informally by authorized NGOs as volunteers. 3. Key informant interviews with managers, supervisors, leaders of CHWs from facilities, and communities. (SL: CHW peer supervisor, Mammy Queen, DHMT; Myanmar: facilities; Nepal: supervisors, mayors, ward chair person, municipality managers. Lebanon: NGO facility and outreach supervisors, managers ) Drawing on the findings from these 4 settings I want to present about the adapting roles of CHWs during COVID19; the challenges that they face in taking on these roles; and the support that they need.
- starting work Firstly, when the pandemic started, in some settings CHWs did not start COVID 19 work immediately. Myanmar: routine work stopped for first few months; did most of their work via phone; then started work – visiting homes, doing health education. Nepal: Some FCHVs were working from the very beginning of COVID- 19 /lock down, whereas some started work after a few months of lockdown. Although, FCHVs regular roles and responsibilities, which primarily requires home visits and personal interaction, were interrupted during the initial few months of lockdown due to fear of transmission, some FCHVs contacted women and elderly people via telephone through the personal networks to get and provide update on any relevant issues. Lebanon: health centres closed at start, then gradually reopened – and workload increased SL: CHWs had COVID specific roles in the first three months of the COVID-19 response Layering of roles What we saw was a kind of layering of roles – so CHWS has their regular roles of general health education, maternal and child health care, clinical work; and on top of this they had the COVID19 roles such as awareness raising about hygiene and physical distancing, contact tracing, screening, following up, referral of people with COVID, attending to people who were in home quarantine, providing psycho social support We also saw a gender difference in roles in some settings: Lebanon: men hold posts with greater responsibilities – require more overtime and shifts; women as health educators. Men are trusted with assignments with more responsibility, requiring longer schedules Women refuse overtime to rush home, losing both extra money and professional opportunities Myanmar: Administrative roles were more likely be taken by men, whilst women were more likely to take on health educators/informers of information role, preventive activities and collecting lists of people with COVID-19 and their family members so that they can access quarantine services Reasons they were able to take on these roles Community trust – CHWs were familiar to the community – level of trust already there, most were from these communities. these existing relationships enabled them to access families They were willing to take on these roles – saw it as their duty in a time of emergency Could draw upon their links with community leaders and organisations to do their work Able to innovate to use local resources e.g. In Sierra leone, they encouraged communities to use jerry cans as hand washing stations The health system, employers wanted to use them - allow cost available resource In Myanmar – the CHWs were the first to respond to covid in the community – they wer the first to give advice etc In Sierra Leone, CHWs drew upon their experience of working during EVD – how to talk with people and reduce fear, how to do contact tracing
- There are several challenges that CHWs faced in adapting their role and these are from the individual perspective: 1. Juggling multiple tasks: Community gender norms in all the settings, meant that women CHWs faced having to juggle multiple tasks of CHW work – regular, and COVD, housework, looking after families and home schooling during lock down 2. Increased workload: There was increased workload – again this layering of tasks, roles. For example in Sierra Leone, CHS were expected to provide twice daily reports on families / individuals in quarantine. It was particularly challenging when additional work came up unplanned – women CHWs found this particularly difficult as they were trying to manage their homes and families too. 3. Travel and safety: Challenges in traveling to and from work safely were raised. In Myanmar: women have restriction especially late nights and need to be accompanied by their families. Men are freer to move without any restriction. In Lebanon: public transport is unsafe for women CHWs – risk of assault especially in Taxis. It is unaccepted socially to be unaccompanied especially when dark: “Their thinking is like: you are a girl and you are attending camps by yourself. People ask: You have nobody else? And even when we quit the camp and look for a car, we are not viewed positively, Outreach CHW, Lebanon 4. Fear of COVID: Getting COVID -19 infection was a common fear. This caused anxiety and stress amongst the CHWs: highly contagion, less safety measures, inadequate information; and there were no support mechanisms for anxiety and mental stress 5. Halted or limited income generating activities: This was specifically raised in Sierra Leone, there was disruption in small businesses and other sources of income generation due to lock down and travel restrictions; halt in other income generating activities to focus on COVID-19. There was also an increase in prices of staple foods. This led to increased stress. It was particularly challenging for women CHWs who were widows or single parents “It was not easy… especially for us with kids… we were just working in the community and we had nothing… so the little we had is the only thing we were using.” (Bonthe, CHW, Female)
- Family support was really important for CHWS to be able to do fulfil their work during COVID-19. For example, in Nepal, family members assisted by completing household chores (cooking food, taking care of children). In Myanmar, families helped with organising transport and accompanying them when doing their work. However, this support was not provided for all CHWs and in all settings. Some CHWS did not receive this kind of support because: Voluntary nature of work without any form of benefits and monetary incentives Concern around safety of CHWs themselves and their family members considering their engagement and exposure to COVID 19 Not getting the dinner on the table, or not doing their household chores - scolded by their husbands and elder family members CHWS developed coping mechanisms to accomplish both social and professional responsibilities: Waking up early to complete household chores before staring their CHW work Ignoring the scolding Despite supervisors knowing these challenges, no support from health system Lebanon : In Lebanon, women workers do not contest especially their primary caring role. Some do not trust their household responsibilty to husbands even when those are willing to help
- Stigma and discrimination from community members towards the CHWS themselves but also their families. Community members were reluctant to listen to their advice and health message and receive care; they were also isolated from any social activities. They were viewed as carriers of the virus. In Sierra Leone, some CHWS were accused of prolonging COVID so that they could receive more money – assumption that they would be receiving good payment. The stigma and discrimination appeared to reduce as the pandemic continued for example in Myanmar stigma was observed in the early phase of the COVID 19 as community fear about contracting the disease. But as they practice wearing mask and hand washing less stigma is seen in the second wave. CHWs were able to reduce this stigma and discrimination through talking with community members, drawing on the trust they had gained with them before the pandemic. Reluctance to listen to women CHWs: this was seen in Sierra Leone and Myanmar and Nepal – where women CHWs struggled to convey messages and advice to some men in the communities. In Sierra Leone, some supervisors paired women with men CHWs to overcome this issue.
- 1. Limited training and supervision In Myanmar and Nepal reliance on informal sources of information and support, such as radio, TV, Facebook; quick updates via phone In Lebanon and Sierra Leone, training was provided which helped them to understand about COVID 19, use of face mask, physical distancing. In Lebanon, training was reinforced through online reminders Nepal supervision: Mostly quick update and reporting was done either through regular phone calls from health post in-charge, or through monthly meeting with FCHVs at health post 2. Limited equipment and supplies PPE, masks, hand sanitisers ran out; non fitting PPE; CHWs often bought their own; often resused them 3. Not prioritised for vaccine This came up in Myanmar 4. Limited financial support for additional roles despite policy In Lebanon: Officially men and women paid according to duties and posts however men are privileged as men are more likely to take overtime and extra pay; and men are usually at higher positions (even with equal education) because of community demand of men in leading positions In Sierra Leone: were meant to receive $20 per week for COVID 19 resposne activities, but this was not seen as enough compared with workload, not being able to take on their usual income generating activities and increase in prices of food. some did not receive, and others it was late, or not full amount. In Myanmar – get some financial support from NGO programmes but nothing extra for their COVID-19 prevention activities. pay out of own pocket for transport for household visits. Nepal: Most CHWs did not receive any kind of incentives/remuneration according to the policy (C-19 specific); unaware about policy and what they should receive; key informants reported that allocation of limited budget at the local level was major constraint to provide incentives to CHWs
- finally: CHWS need support to be able to take on these important roles during a shock like COVID 19: Families: need their help in doing their work – household chores, transport, understanding. This could be done through more communication with families, greater recognition from the health system and community for their work. Community: need to strengthen the links between community leaders and organisation to enable women and men CHWs to do their work and be supported in this. Not completely rely upon the CHW relationships with community – give them some back up Health system: strengthen the training and access to information – e-health, m health could help here; incentives policy is transparent and followed so that this does not damage CHW relationship with the community as seen in Sierra Leone. providing adequate equipment and supplies to protect from infection mental health support and support to develop coping mechanisms and recognition of this is important.