Building gender equity through community health systems
Summary
In 2023, Last Mile Health and Integrate Health commit to working with African Ministries of Health to strengthen and sustain gender-responsive community health worker (CHW) programs across four countries and develop and disseminate lessons learned that can inform other countries on their journey. Last Mile Health and Integrate Health will identify and reduce barriers to increasing the number of paid, professionalized female CHWs employed by national programs, strengthen national policy, and tailor gender-responsive programming to enable the delivery of quality care for 5.8 million women and children through their network of 6,521 CHWs. Lessons learned and best practices will be packaged and disseminated globally to amplify the impact of this work.
Approach
Building from Last Mile Health (LMH) ‘s 2022 CGI Commitment to Action and Integrate Health (Integrate) ‘s track record as a women-led organization, LMH and Integrate will work with African Ministries of Health (MOH) to strengthen and sustain gender-responsive CHW programs across four countries and develop and disseminate lessons learned that can inform other countries on this journey.
First, LMH and Integrate will strengthen the delivery of primary care across four countries (Ethiopia, Guinea, Liberia, and Togo) by strengthening gender mainstreaming. The organizations will identify and reduce barriers to increasing the number of paid, professionalized female CHWs employed by national programs, strengthen national policy, and tailor gender-responsive programming to enable the delivery of quality care to women and children by 6,521 CHWs. Ultimately, this work will expand access to care for 5.8 million people, while also contributing to greater gender parity in CHW programs.
Second, LMH and Integrate will capture lessons learned and best practices, and package them for global dissemination. The organizations will collaborate on virtual learning workshops, facilitate focus groups with health workers and key informant interviews, and collaborate on the development of a framework that applies a gender lens to the six components required for a professionalized CHW program. The organizations will also design and launch a global dissemination strategy to amplify the findings, centering the voices of female health workers. By sharing findings within networks like the Community Health Impact Coalition, gender mainstreaming best practices will have potential to scale through 30 member organizations working across dozens of countries worldwide.
Ultimately, gender inequity is holding CHWs back from reaching their full potential – including contributing to the realization of UHC and withstanding the shocks of climate change and epidemics. Together, LMH and Integrate will contribute to gender-responsive national programs in four countries and package lessons learned to advance this work globally.
Action Plan
Year 1 Milestones:
October 2023 – Develop a project plan that includes: 1-2 virtual learning workshops; focus groups with health workers; and key informant interviews with representatives from teams, MOHs, and funders.
December 2023 – Disseminate Liberia’s new community health policy with a focus on gender components to County Health Teams (Liberia.) December 2023 – Complete Kouroussa district (Guinea) baseline assessment; analyze health data to support tailored gender approach to implementation.
January 2024 – Work with Liberia MOH to conduct workshop/training in gender for community health program.
March 2024 – For International Women’s Day, run a campaign featuring stories of female CHWs and calls to action.
July 2024 – Complete all project plan activities.
June 2024 – Evaluation of the gender breakdown of newly recruited and trained CHWs and supervisors to monitor progress towards reaching the goal of 30% of new recruits being female in 2 Counties (Liberia) .
August 2024 – Draft report including replicable application of gender-equitable health workforce guidelines to be used across additional countries.
Year 2 Milestones:
September 2024 – Evaluation of gender breakdown of government CHWs in Anie district (Togo) , towards 40% objective.
September 2024 – IH and LMH co-host event to launch the global framework, underscore why it matters for the future of the UHC and pandemic preparedness and begin dissemination strategy. This will include the voices of female CHWs and MOHs.
June 2024 – New curricula and SOPs completed to include gender mainstreaming principles (Liberia.) December 2024 – Evaluation of the gender breakdown of newly recruited and trained CHWs and supervisors, towards goal of 30% of new recruits being female in 2 Counties.
Over the course of the year – At least four speaking engagements for female CHWs in global convenings.
August 2025 – Compile a report detailing the successes and challenges of the dissemination strategy and outlining opportunities to continue this work.
Background
Nearly nine million people around the world die each year from preventable causes (Kruk et al., 2018) . But we can change that through investing in community health workers (CHWs) and the systems that enable their success.
CHWs need to be skilled, supervised, salaried, and supplied by a well-functioning primary health system operating at national scale and integrated into broader public systems via data and financing (Last Mile Health calls these the Six Ss) . Under these circumstances, CHWs can improve the accessibility and availability of primary healthcare (WHO, 2018) , and maintain healthcare delivery among significant disruption (Ballard et al., 2022) . They are also highly cost-effective, with up to a 10:1 return on investment (Masis et al., 2021) .
The opportunity now is to scale this proven intervention to reach more patients across Africa. To do this, we must confront an injustice: community health services are primarily delivered by an unpaid, predominantly female workforce.
It is estimated that women contribute $3 trillion to global health annually—half in the form of unpaid work (WHO, 2018) — and that at least 6 million women work unpaid or underpaid in community health (Community Health Impact Coalition 2023) . In Africa, more than 85% of CHWs, the majority of whom are women, are not paid for their work (The Global Fund, 2022) . This is not only a labor rights issue, but also reduces the impact of community health programs. Though CHWs primarily treat mothers and their children, country case studies underscore that programs not designed through a gender lens often fail to deliver on the potential of the program. As one example from Last Mile Health in Liberia, female patients reported a strong preference for female providers when receiving maternal and reproductive services.
To ensure community health programs can respond to the urgent crises our world faces today – including pandemics and climate change – we must dismantle gendered barriers that prevent women from becoming paid, professionalized CHWs and deny them from receiving the healthcare they deserve.
Progress Update
Global -Launched project team with members from LMH and IH meeting every 4-6 weeks to define success for and advance commitment.
-Established framework for a CHW career path, encompassing stages from pre-recruitment to retention.
-Recruited gender consultant to provide evidence on gender-responsive health systems, leading to the drafting of an opinion paper.
-Hired graphic design consultant to develop a visually professional representation of the CHW career path framework.
-Conducted joint virtual campaign run to celebrate International Women’s Day.
Togo: -Analyzed gender-responsive programmatic activities across the organization and identified gaps for continued improvement.
-Trained 13 CHW ambassadors, focusing on public speaking, gender and climate-related health issues, and Community Health Impact Coalition’s CHW advocacy course, so that they can join the CHW bureau as speakers and advocate for their needs.
-Added the reporting system.
Guinea: -Baseline assessment completed in Kouroussa. -Efforts to increase the number of female CHWs are underway; workshop held between Guinea and Togo teams to apply gender – responsive programming lessons learned from Togo to Guinea. Liberia: -Marion Subah, Last Mile Health’s Liberia Country Director, and Yasmin Madan, of Co-Impact published an op-ed highlighting Last Mile Health’s joint efforts with the Liberia Ministry of Health and partners to identify the systemic barriers preventing women from professionalizing and moving into paid roles in the community health workforce.
-In most recent recruitment in 2023 in Grand Bassa County, the number of new female community health workers increased from 20 to 36 percent.
Ethiopia: -Facilitated blended learning training for nearly 200 community health workers and supervisors on non-communicable diseases and major communicable diseases, designed using gender-mainstreaming principles for the entirely female health workforce.
-Results from training outlined above shared with stakeholders at dissemination event in Addis Ababa in March 2024 in partnership with the Ministry of Health, and will be scaled nationally.
Partnership Opportunities
Last Mile Health and Integrate Health seek the following resources for this commitment:
Financial resources to fully fund community health delivery, knowledge gathering and management, advocacy, and dissemination activities.
Partnership with organizations with expertise in gender-transformative programming; advocacy; data-driven analysis; etc.
Access to advocacy platforms to share real time learnings and insights from commitment activities.
Media contacts (platforms, journalists, conferences, etc.) to amplify the voices of women health workers and their call to actions., Last Mile Health and Integrate Health offer the following to other partners:
Best practice information and framework from four African countries, to be disseminated globally.
Platform to amplify voices of women health workers – through consultation activities, and global convenings and advocacy days
Advocacy talking points/media toolkit – through gathering learnings and advocacy messages from women health workers themselves, formulating them into a toolkit other orgs can promote