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The importance of gender transformative policies for CHW programmes
1. Gender & policy in
Community Health
Worker programmes
Rosie Steege
12th June 2017
Matatcha CHW
Moamba, Mozambique
2. Contents
• Why is gender important?
• Gender challenges in context of policies and
guidelines
• Future of CHW programme policies
3. Introduction
• IMAGE OF CHW
Meskerem and Tezeru –
Health Extension Workers,
Sidama Zone, Ethiopia
4. • “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)
10. Training
“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
11. Mobility
“the supervisors go out into the community and this is really difficult
terrain, sometimes you are going through jungle and going on hikes and
these sorts of things, 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
12. Contents
• Why is gender important?
• Gender challenges in context of policies and
guidelines
• Future of CHW programme policies
13.
14. Current challenges
• Funding / sustainability
• Education levels by gender
– (especially in conflict affected
settings)
Gender bias in the health sector
– Larger systems issue How can we
support CHWs to bring their voice,
perspective and leadership into
health systems
– Supportive supervision and space
for reflection
15. Current opportunities
• 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
16. Case study –
ASHA programme
– National policy adapted by each state
– Female nodal officers bringing gender issues to table
• Safe spaces, harrassment
– Modular training
• Residential
• Childcare on site
• Female only facilitators
17. 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
18. Conclusion
• Gender impacts CHWs in a
multitude of ways
• Current CHW policies do not
acknowledge the complexity gender
plays ‘supply side’
– missed opportunity to promote
gender transformative approaches at
all levels of the health system
– Bottom up approach needed
• Implementation approaches on the
ground are often governed by
gender but not by policy
– Responsive policy inclusive of gender
governing the implementation at
community level
Leopoldina, APE
Moamba Mozambique
19. Acknowledgements
• CHWs and key informants from all genders that
participated in the research
• REACHOUT consortium family
• PhD supervisors - Sally Theobald (LSTM) and Miriam
Taegtmeyer (LSTM)
21. 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)
• Gomez, W. (2015) A literature review exploring how the gender of a community health worker impacts provision of healthcare services
in low and middle income countries. LSTM, unpublished, cited with permission.
• Jackson, R. Kilsby, D. (2015) We are dying while giving life: Gender and the role of Health Extension Workers in rural Ethiopia .84p.
Accessed 5 Feb 2016. Available from: http://www.eldis.org/vfile/upload/1/Document/1601/Gender%20and%20HEWs%20report.pdf
• Saprii, L., Richards, E., Kokho, P. and Theobald, S. (2015) 'Community health workers in rural India: analysing the opportunities and
challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles', Human Resources for Health, 13(1), pp. 1-13.
• 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.
Notes de l'éditeur
Gender in policy and how it influences CHW programmes
Start with why its important to have gender in policy
And close with a case study of where gender is reflected nicely
CHW programmes are widely varied
BUT the key commonality of CHWs is that they come from the community they serve
These types of gender biases are well documented within the context of community health and CHW programmes
Gender biases are present so when we are thinking about community interventios
Largely missing is that because CHWs come from communities they are subject to the same gender norms but that is not largely reflected in policy
In truth – gender interactions are complex, varied by context and my PHD has been seeking to map some these complextities
So this is the conceptual framework that we have developed and really it serves to highlight the complexites of the ways in which gender plays out across the different contexts and within the National context – factors on the RHS – and is mediated by other axes of inequity on the LHS
Moving out from HS to COMm to CHW
And I will talk through some of these examples in the presentation as we go on… (not enough time now but if want to talk after)
in our REACHOUT context analysis -– in Mozambique there are Low female recruitment rates due to 4 month training away from home – issues that I explored as part of my research and indeed this emerged as a theme – where husbands were generally not supportive of their wives undertaking the APE training or indeed APE work – as they did not want them to be away from home…care for children and household etc.
As part of my research I have been conducting a policy analysis to understand the current level of acknowledgment in policies – and spoke with KI in the countries with stars -
Gender is rarely mentioned in the context of CHWs
Some national HRH policies/guidelines recognise the importance of gender responsiveness at the higher levels of the health system
But as we see from conceptual framework gender permeates across all aspects and from the KII there are examples of how programmes are responding to gender influences on the ground/community level but this is not yet reflected in national policies
Echoing our findings from Mozambique in REACHOUT
The KII also highlighted issues with training elsewhere – in Zambia for example – long time away from home and have reported instances of husbands not wanting to let their wives attend, or women finding out they are pregnant and then having to leave
SOLUTIONS _ ALL FEMALE TRAINERS LIKE ASHA PROGRAMME< SHORT MODULAR COURSES < BUDGET FOR ON SITE CHILD CARE
Mozambique - “Some women know how to write and read; however, some husbands refuse to allow their wife to become an APE, arguing that she will have a relationship with other men during the training and that she will not have time to take care of the household and the children.” Mozambique
This issue of transport came out in several contexts eg Afghanistan, Bangladesh – where it prevents upward movement of CHWs (supervisory role)
But this example from Liberia illustrates how ad hoc solutions are being implemented on the ground & overcoming challenges
How can we address these norms as well as practical issues
Safety concerns
So to come back to this its good to have it at a national level, when we think about challenges in health systems (funding, education etc) then we need to consider gender while develop all national policies (with regard to how it feeds in to the health system) – because we we can see the interplay gender has across these.
So coming back to example of training in Mozambique – we need policies that don’t just accept this and work around it, but we need policies to transform these norms and sensitise the community to be accepting of this
Even if policies were reflective of these issues – its not that simple – current challenges from a health system perspective need to be thought about while we develop policy for example…
So policy needs to be intersectoral – considering the contextual realtities whilst still having the gender lens.
- Input from CHWs is common – via consultative FDGs, surveys or committees
Not usually bottom up – more of a checking process not enough engagement from CHWs
ASHSA programme in India is an exception with strong feedback mechanisms from nodal officers
More of a bottom up approach needed – opportunities for CHWs to input
Natural researchers (Perez & Martinez, 2008)
CTC providers have untapped insights around gender, equity and power should be harnessed to build more responsive health systems
need to include this vital interface cadre in debates and efforts to support women’s leadership in health
- CHW Policy development often cited as inter-sectoral
but not often representation from women’s groups or specific gender departments
- HMIS data for CHWs may be disaggregated by gender
often not used to support decision making with regard to CHWs
National policies – that can also be adapted locally… For example
ASHA _ nodal officers in India being women – opportunity to bring gender issues to the table
Each state adapts things
SAFE spaces for ASHAs during delivery
Modular training
Childcare
Female only facilitators
Safety was reported to be an issue in several contexts – some ad hoc suggestions where
Safe spaces in delivery rooms?
Male accompaniments are sent along? In Liberia male accompaniments are sent along
Male Female CHW pairs?
But Issues remain around gender sensitisation of the whole community
Gender impacts not only communities abilty to seek health care, but also CHWs ability to supply health care as CHWS operate within the same gender dyamics as the community.
To date minimal attention has been paid to the influence of gender on CHW programmes from a health systems policy perspective.
This is a missed opportunity to promote gender transformative approaches at different levels of the health system.
There is recent impetnus to change this and many countries implementation approaches on the ground are goverened by gender dynamics – stronger links should be made