Research on gender and close-to-community providers of health care – providing policy guidance in a pandemic
COVID-19 hit the world in late 2019 with a devastating impact. The virus quickly spread and was granted the status of pandemic by the World Health Organization. With no available vaccine or treatment countries took emergency action, implementing non-pharmacological interventions such as lockdowns, restrictions on movement and quarantines of the sick. As many people became grievously ill and required medical assistance, governments acted to protect their health systems and economies, deploying health workers to identify the sick, provide health advice and – as scientific breakthroughs were made – to ensure access to vaccination.
All countries were impacted by the COVID-19 pandemic, but some were more prepared and resourced to deal with its impacts than others. Health systems in many low- and middle-income countries are beset by chronic shortages of human resources for health. The strength and resilience of their health systems are detrimentally influenced by low numbers of staff and cadres within the health workforce.
What problem is being addressed?
Many countries, particularly those in fragile contexts, have a shortage of formal health workers and are increasingly looking to close-to-community (CTC) providers to fill the gap. CTC providers (often known as Community Health Workers) are health workers who carry out promotional, preventive and/or curative health services and are the first point of contact at community level. A CTC provider can be based in the community or in a primary healthcare facility as either a volunteer or a lower-paid member of health staff and are often from the communities they serve. CTC providers are often called upon in times of crisis, such as during disease outbreaks, and were deployed as workers in the COVID-19 response.
There are a great many benefits to the CTC cadre – for example, their proximity to the people they serve, the levels of trust they can build with their communities, their ability to understand and act on the social determinants of health. However, there are chronic weaknesses in the management of this cadre and the support they receive from the health system, their communities and wider society. Some of these weaknesses are gendered.
As the lowest end of the health system, CTC providers, who are often women, can be paid less and exploited more. In some countries, such as Nepal, all CTC providers are women. Female CTC providers are often valued because of their ability to visit households and to talk about sexual and reproductive health issues in ways that are not socially acceptable for men. However, as women they also carry the burden of restrictive gender norms. They often struggle to juggle the responsibilities of work and the caring and domestic duties that they are expected to lead or perform alone at home and within their communities. At work they may find their voices are less prominent in decision making and that they fail to reach management and better paid positions which are considered the preserve of men. In a crisis these gendered challenges can be magnified and exacerbated leading to gendered discrimination and the sub-optimal function of the health system.
A range of CTC providers were part of the COVID-19 response. In Lebanon, there is inadequate access to health services for both Lebanese citizens and Syrian refugees. As a result, many refugees rely on outreach services and informal health facilities, which employ health workers from the Syrian community who are forbidden from practicing in Lebanon. In Myanmar, there are 50,000 CTC providers, including female auxiliary midwives and male community health workers delivering maternal and child health and disease control services. As part of the COVID-19 response, all CTC providers and community volunteers worked in quarantine facilities, distributed food, and conducted hygiene activities. In Nepal, national guidelines called for Female Community Health Volunteers (FCHVs) to be part of the COVID-19 response and around 50,000 FCHVs worked as CTC providers, supporting health promotion and prevention activities at community level. In Sierra Leone, there are 8,700 CTC providers across the country who provide a basic package of services, mainly centred around maternal and child health. They took on additional health education and preventive care roles during the COVID-19 pandemic.
Understanding and avoiding gendered distortions of the system was particularly important in the tumult and confusion of the COVID-19 pandemic.
What did we do?
To respond to the evidence and knowledge vacuum of how to support CTC providers during the COVID-19 pandemic, ReBUILD rapidly began research projects in Lebanon, Nepal, Myanmar and Sierra Leone (there’s more on this work here). We used document reviews, in-depth interviews or focus group discussions with CTC providers, and key informant interviews with local stakeholders to generate in-depth and contextual information.
The evidence generated by ReBUILD, along with the communications and research uptake work in all settings, led to a range of changes.
The research has been presented at meetings at the local health systems level, with elected officials, administrators, deputy mayors and facility staff present. It has also been presented to CHW coordinating units within Ministries of Health. It has been used to improve understanding of the challenges being faced by CTC providers, such as stigma, the lack of health insurance and risk of infection. In Sierra Leone, our work has contributed to bringing visibility to the CHW programme and has further reinforced the need to advance gender equity in the programme (as detailed in personal correspondence).
At the local level the research project and its findings have enabled discussion of gender equity, an often sensitive and taboo topic, with a view to introducing mechanisms to support CTC providers. For example, in Lebanon local health institutions had no other choice other than to rely on informal health workers from the refugee community in the response to the COVID-19 pandemic. The exodus of regular health staff due to the overwhelming economic crisis in the country, coupled with others avoiding work in fear of catching the virus and in protest at deteriorating salaries due to the devaluation of the local currency, meant that there was a shortage of health workers. The majority of those recruited to handle the COVID-19 response among Syrian refugees were women. However, this act of survival could not take place if women could not overcome social and family restrictions on women’s work.
These discussions of the challenges of gendered work are being acted upon in the ongoing participatory action research in Lebanon, where women are coming together to create collective childcare spaces to help overcome the double burden of work both inside and outside the home (more on that study here). This process is acting as a quasi-rights education programme as women reflect on the ways in which gender norms and other inequities (such as those related to their refugee status) shape and constrain their opportunities.
To increase family support and reduce the discriminatory behaviours at community level, CTC providers in Nepal developed a short video capturing the work they do, showing their level of engagement and importance. The video (which you can watch here) has been showcased to stakeholders, community people and family members, enhancing their understanding of the CTC providers and their work within their community (more on how the video was produced here).
We were able to bring issues of gender to prominence in the discussions of international research bodies such as Health Systems Global – the main membership group for researchers in our field. In 2022 we presented our research at a webinar of their Thematic Working Group on Fragile and Conflict-Affected Settings (watch that video here). Our work has made the important position of CTC providers, and their gendered experiences, more prominent in global research discussions about both resilient health systems and pandemic responses, with the Working Group and also with bodies such as the WHO Gender Equity Hub and at an event at the 2023 World Health Assembly.
At the webinar we spoke alongside Silke Staab from UN Women who presented their feminist plan for sustainability and social justice post COVID-19. The formal and informal caring responsibilities of CTC providers is being increasingly recognised and lauded, and is also placed within global feminist frameworks, pointing to the need to reorganise our systems of care so that they no longer over-burden and inhibit the opportunities of women. This is a new way of viewing issues that have, up until this time, had little traction outside gender scholars in health.
This research has influenced CHW policies, guidelines and practices at the national and sub-national levels, assisting CTC healthcare providers in responding effectively to shocks, overcome gendered barriers, and function optimally as health workers. It has raised awareness about gender among female CHWs themselves, enabling them to take steps towards realising their rights, such as through the provision of childcare to help address their double burden. It has also contributed to global framing and discourse related to women’s labour in response to disease outbreaks.
Image: Female Community Health Volunteers in Nepal engaged in producing a film which documents their lived experiences