Using knowledge translation to advance gender equity through the community health worker program in Sierra Leone

Sierra Leone has faced several challenges which have had a significant impact on the country’s health system and its ability to respond effectively to crises and deliver high-quality care to the population. The Ebola outbreak in 2014-15 highlighted these challenges and resulted in the development of strategies to strengthen health system resilience. While there have been improvements in the health system since the outbreak, significant challenges remain, and ongoing efforts are needed to ensure that the health system is better prepared to respond to future health emergencies.

The Community Health Worker (CHW) programme is one of the strategies implemented to address the weaknesses in the health system – strengthening primary healthcare services and improving community engagement in health promotion and disease prevention. It plays a crucial role in the national effort to achieve Universal Health Coverage. Accordingly, a CHW policy was launched in 2016, that recognized the gendered dimensions of the programme and was designed to be “gender transformative”.

At the national level, the programme is coordinated by the CHW Hub, which sits within the Ministry of Health and Sanitation. ReBUILD has engaged with the CHW Hub for many years and has supported the use of evidence-based decision-making to optimize the performance and track the progress of the programme. This case study explores the role of knowledge translation in advancing gender transformative policies and programming through the CHW programme in Sierra Leone through support from the ReBUILD project.

What problem is being addressed?

Recognising the important role of CHWs during the 2014 Ebola Virus Disease outbreak, a Presidential declaration was made to absorb the cadre into the health workforce, guided by the 2016-20 CHW policy and designed to be “gender transformative”. However, there was a need for evidence on how to effectively integrate CHWs into the health workforce and support their ongoing training and development in a holistic manner, ensuring that gender considerations were core as intended.

In response to this need, in 2018 ReBUILD designed a study to explore the integration of CHWs into the health workforce and the policies and practices needed to support their effectiveness. Ascertaining evidential gaps is crucial for the success of any new initiative, and ReBUILD provided invaluable support in this regard. To complement these endeavours, it is crucial to establish strategies that guarantee the translation of evidence into policy and practice.

What did we do?

ReBUILD committed to ensuring the relevance and usefulness of its study by engaging with the CHW Hub throughout the research process, creating a two-way knowledge sharing platform, promoting national ownership and leadership, and establishing a strong partnership between researchers and practitioners. The research team provided evidence to the Hub on a rolling basis, supporting the real-time implementation and validation of planned activities. This included recommendations for the health system, including promoting CHW integration into communities, establishing effective supervision processes, providing frequent training and capacity building, ensuring timely payment of incentives, and offering non-financial incentives. Community recommendations emphasised the importance of regular engagement to address communication gaps. The subsequent report influenced the adaptation of the 2021 National CHW Policy, leading to the completion of new CHW recruitment and training. Policy decisions included expanding CHW coverage areas, integrating different CHW programs, adopting an integrated supervision approach, implementing digital data collection, advocating for regular training, and introducing performance-based payment. Financial incentives were increased to motivate CHWs, matching current exchange rates and doubling their previous amount. These efforts aim to strengthen the CHW Program and improve healthcare delivery in Sierra Leone.

Also, the CHW Hub actively participated in dissemination events and the development of policy briefs, effectively raising the profile of the research.

To supplement these efforts, ReBUILD, through its Responsive Fund, initiated a study in 2021 on the gendered experiences of CHWs during the COVID-19 pandemic. ReBUILD’s research highlighted that the development of the 2016 gender transformative CHW policy missed an opportunity to effectively engage with the community to ensure consideration of the influence of gender norms at the community, household, and programme levels.

Context-specific gender norms and relations can impact the role of CHWs, potentially contributing to health inequities. Gender norms can affect how men and women view their roles in the community, while gender relations can influence the way that men and women interact with each other in the context of health care.

Impact

The ReBUILD study is significant in Sierra Leone, as it is the sole/lead research initiative that delves into the gendered implications of the CHW program in the country. This lack of attention to gender implications has long persisted in CHW programs across several regions, leading to potential inefficiencies and inequities in program delivery.

However, at the 2023 CHW symposium held in Liberia, a CHW peer supervisor from Sierra Leone presented on, “How gender impacts and influences the role of CHWs in Sierra Leone”, highlighting how CHW programs can unintentionally reinforce gender inequity and the importance of addressing gender norms in program development. The presentation acknowledged the potential for CHWs to understand and challenge gender norms, in line with our work, promoting their positionality and agency in the process and emphasized the need to address the impact of gender norms on CHWs to enhance the effectiveness and equity of these programs. This suggests progress towards adopting gender transformative policies that promote top-down strategies in their development and implementation.

The post-symposium report from the Sierra Leone team also captured a key learning from the conference: practical approaches to making CHW policies more gender equitable. With the ReBUILD study’s findings and recommendations, there is potential for a shift in the narrative towards a more gender-transformative and equitable CHW program in Sierra Leone.

The ReBUILD research program’s engagement with the CHW Hub also contributed in bringing visibility to the programme and promoted engagement with development partners:

• World Bank – requested ReBUILD evidence to inform the review of the CHW policy in 2020
• Last Mile Health – a member of the ReBUILD research team was asked in June 2022 to serve as a member of the Technical Advisory Group for its “exemplar in global health” research project. This created an additional platform for engagement with the CHW Hub and other researchers from the region and to advance gender equity in the CHW programme. For example, during a meeting, evidence from the ReBUILD study about the experiences of female CHWs in the training component of the program was shared, highlighting its relevance for consideration and potential integration into the design of the training component of the exemplar in global health project.
• Village Reach – consulted with ReBUILD in February 2023 for insights on the CHW programme to consider how they could support it.

Thus, collaboration and knowledge translation approaches between researchers, policymakers, and practitioners demonstrate the potential for cross-sectoral development initiatives to support evidence-based policies and practices that improve healthcare outcomes in post-conflict settings like Sierra Leone. This also demonstrates the potential for the research program to have a wider impact beyond the immediate stakeholders.

In conclusion, this case study highlights the importance of designing research programs that are responsive to the needs of stakeholders and promote long-term knowledge exchange. The partnership between ReBUILD and the CHW Hub demonstrates the potential for a knowledge exchange platform to support evidence translation into policy and practice. However, it also highlights the need to consider gender implications when revising policies. Finally, the impact of the research program extends beyond the immediate stakeholders and has the potential to contribute to wider policy and practice improvements.

Further information

There are other ReBUILD for Resilience case studies here 

Image: CHWs meet during the study into the gendered experience of close-to-community providers in Sierra Leone