Supporting close-to-community health workers in fragile settings requires a gendered approach

1 November 2021

Experts at the recent ‘Close-to-community providers in fragile settings and vulnerable communities during crisis: Gender and COVID-19’ webinar discussed evidence from Brazil, Lebanon and Nepal. Participants also got an overview of the global situation for these vital workers. Lynda Keeru of Pamoja Communications [opens in new tab] reports back. You can watch a recording of the session here.

Close-to-community health workers play a vital role in supporting their local health systems in providing care and support to their communities. They often reach the most marginalized of people. Their roles can be particularly critical in fragile and shock-prone settings and during times of crisis, such as the current COVID-19 pandemic.

Health systems are not gender neutral and gender shapes every part of our world. Rosemary Morgan explained that women health care workers really are the drivers of health as they make up 70% of the 200 million workers who contribute to the health and social sector. They also deliver care to about 5 billion people worldwide and contribute $3 trillion annually, half in the form of unpaid work.

Who are close-to-community providers?

Health workers play different roles and have different designations in the communities they serve, with community health workers (CHW) constituting a large group. Close-to-community providers often have a lower socioeconomic status, educational level and are often women. They occupy the bottom of the health system hierarchy and are subject to the structural power relations which shape the health sector and their societies.

They are usually the first point of contact with the health system for community members and provide promotional, preventive and/or curative health services. The direct contact with communities enables them to expand access to services and hence contribute to improved health outcomes. They play a central role in times like the COVID-19 pandemic, where health systems are overwhelmed and there are shortages in health workers and health supplies.


Brunah Schall pointed out that Brazil is one of the epicenters of the pandemic. In her presentation, Brunah indicated that the president of Brazil is openly against gender-related discourse, and it is no wonder that 80% of all pregnant women who have died from COVID-19 around the world are from Brazil. The community health workers model in Brazil goes way back to the 1970s. Brazil’s community health workers face many challenges. Owing to the fact that CHWs in Brazil are not considered to be health professionals, access to personal protective equipment is a struggle. There were no COVID-19 standards rolled out to guide community health workers in their jobs and they have frequently faced threats and aggression in some territories during the pandemic. CHWs in Brazil are most essential to the Quilombolas who are the remaining communities created by slave descendants. These communities face a host of challenges that have an impact on the CHWs that serve them. These include: transport problems, domestic violence issues, lack of training, and water shortages that made the virus spread a lot faster.


Abriti Arjyal explained that Nepal is in its early years of federalization. Owing to this, power has devolved to local governments, who are responsible for providing basic health services and other public health programmes. The close-to-community providers in Nepal are Female Community Health Volunteers (FCHVs), and there are about 52,000 of them at a ratio of 1 per 120 households. They bridge the gap between communities and government health services, consequently reaching the previously unreached. They engage in community-based preventive and educational activities which are very useful in the progress of many key health indicators. To this end, FCHVS form a critical linkage for prevention and control of COVID-19. Some of their roles include: raising awareness about the virus, distribution of hygiene kits, tracking, screening, registering, doing follow-ups and referrals for people with COVID-19 among others. The experiences of this cadre of health workers during COVID-19 has been highly influenced by norms and values. These include fear and discrimination from the community because of concerns about infection, planning and decision-making processes that are not gender sensitive, and inadequate supportive behavior, particularly from men. They also often had to deal with lack of support from both family members and their health systems.


As ably presented by Rouham Yamout – Lebanon, which was once a high middle-income county – has been in a multi-crisis since October 2019 and could be termed a failed state. This has had dreadful implications for the health system: there has been a tremendous decrease in income of health workers, a massive exodus of health workers and too much service demand on surviving facilities. The practice of outreach and employment of volunteer close-to-community providers in Lebanon developed with the influx of Syrian refugees starting from 2012. The refugees live in settlements far from population centers and transportation, with a lot of restrictions imposed on their movements because of the illegality associated with their status. Many can’t afford the co-payment for health services subsidized by UNHCR and so they do not go to healthcare facilities. Close-to-community providers in Lebanon comprise auxiliary nurses employed in local civil sector health facilities, social workers, UN and NGO outreach workers, ambulances drivers, mental health workers and midwives. Many of these are women with the multi-crisis conditions pushing female refugees to enter the jobs market as voluntary close-to-community providers. These close-to-community providers took charge of most COVID-19 related tasks, and were in some regions the sole healthcare providers to Syrian refugees. They provided continuation of health services while the entire health sector was going through financial turmoil. Due to the desperate need for paid work, many close-to-community providers, particularly women, accepted deplorable working conditions.

Silke Staab in the closing remarks gave very insightful reflections, like reiterating the fact that women, particularly those who are already disempowered, are paying a very high price during the pandemic. She highlighted that most of what was discussed centered around healthcare, but she added that the fragility of care arrangements extends far beyond that. The fragility was there even before the pandemic and are systemic, even in countries considered relatively stable. As is the case with many other things, COVID-19 was just the big revealer. To this end, she spoke about the UN Women’s Feminist Plan for Sustainability and Social Justice [opens a new tab] that takes a broader systemic perspective on the care crisis to provide a roadmap for a gendered response of recovery and transformation. Her presentation focused on the care economy pillar and the need for a paradigm shift.

The COVID-19 pandemic besides magnifying and exacerbating existing inequalities, is a catastrophe in fragile and vulnerable settings. This translates to dreadful working conditions for the CHWs who sit at the bottom of the health system. Ergo, it is important that the negative impacts of COVID-19 are addressed for the wellbeing and sustainability of the health workforce.