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
Between October 2023 and November 2024, Last Mile Health and Integrate Health designed and published the global framework for action. The organizations launched a joint project team, recruited research consultants, conducted a literature review, and designed a global framework based on the CHW lifecycle. The global framework was launched in November at womenchws.org, and was then disseminated via a digital marketing campaign. To amplify the commitment, the organizations hosted three major events: a June 13, 2024 Deeper Dive with CGI; a Private Roundtable during the CGI Annual Meeting on September 24, 2024 featuring President Ellen Johnson Sirleaf and CHW advocate Margaret Odera; and an upcoming Marmalade session at the Skoll World Forum on April 2, 2025 in Oxford, UK, which featured speakers from Co-Impact and the Elders. The framework was also presented to key stakeholder audiences, including the Global Fund, Presidents Malaria Initiative/USAID, and CHAI. Simultaneously, the organizations continued to drive country-level progress. For LMH, this included supporting the integration of gender recommendations into Liberia’s national health policy, resulting in an increase in female CHW recruitment from 20 to 36 percent in Grand Bassa County. In Ethiopia, over 200 CHWs and supervisors were trained through a gender-mainstreamed curriculum and results were shared in a March 2024 national stakeholder event. In Togo, Integrate Health supported the Ministry of Health to pilot national CHW reform in Anié district and trained 13 women CHWs as ambassadors. Lessons from Togo were shared with Guinea to adapt gender-responsive strategies. A baseline assessment was completed in Guinea, and CHW recruitment began in Kouroussa.
Looking forward, the organizations are committed to continuing implementation, advocacy, and collaboration with partners to advance gender equity in CHW systems beyond the initial timeframe.
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