Do women make the most effective community health workers?

Researchers have identified Bangladesh and Ethiopia community health worker (CHW) programs as particularly effective in transforming health outcomes at scale. Both programs rely overwhelmingly on women CHWs who are trained, equipped, and paid to respond to their community’s most pressing needs. Given this research and the WHO’s recommendation that countries implement affirmative action policies to preferentially select women during CHWs hiring processes, should decision-makers conclude that women make the most effective CHWs?

We spoke with leading global health experts to address this question and they said the evidence is nuanced. “Like a lot of things, it all depends,” said Stephen Hodgins Associate Professor, School of Public Health, University of Alberta. "Factors to consider include culture, social norms around women’s status and mobility, and economics, just to name a few.”

And of course, it matters what health services are being provided, as well as women's empowerment and poverty alleviation goals often considered outside the purview of health programs.

“There is evidence showing female CHWs can be more effective in some contexts, for some tasks including women’s health, family planning, and pre and post-natal care,” said Dr. Madeleine Ballard, Executive Director, Community Health Impact Coalition, Assistant Professor, Icahn School of Medicine at Mount Sinai. “As a blanket statement, however, it just isn’t true that women are more effective CHWs.”

In fact, researchers have found that, in some contexts, male CHWs are particularly effective at addressing men’s health concerns. Researchers in Uganda found that “men were more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labor in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells.”

Another task in which male CHWs may outperform women CHWs is community mobilization activities, said Hodgins. “Research indicates that organizing the community to build latrines, drain mosquito breeding areas, and vaccination campaigns may be activities better suited for men in many traditional, rural areas,” he said.

At the same time, health decision-makers need to recognize that hiring and training women as paid CHWs has a few important impacts that ripple beyond the health sphere: hiring women CHWs can elevate the status of the women serving as CHWs; can broadly improve the status of women within a community as a whole, loosening social norms around work and travel for women; can increase access to health information and health care for women who, because of low mobility and low education in many communities, otherwise have poor access to both health information and health care; and, lastly, women CHWs liaising with their women patients can help shift health care decision making towards women.

What’s more, points out Henry Perry, Senior Scientist at the Department of International Health at Johns Hopkins Bloomberg School of Public Health, in low- and middle-income countries, “the most pressing health issues in many rural areas are maternal and child health and family planning. These domains naturally lend themselves to women health care providers, include CHWs.”

Research also indicates that women CHWs provide another – unexpected - benefit: reduced turnover. “Attrition is a key issue for CHW programs. Attrition tends to reduce CHW effectiveness and increase costs,” said Hodgins. “A common scenario is that ambitious young men in rural areas take the CHW jobs as a first job and then leave it when they find another opportunity. Women in rural settings often have different life expectations. So, they stay in those positions longer.”

What’s more, when women CHWs receive a salary, “research shows that they are more likely to spend the money to provide support for their children than are men,” explained Perry. “So, the greater benefits for socioeconomic development that come from providing women CHWs with a salary are particularly important.”

For these reasons, hiring women to serve as CHWs can magnify the impact of health, anti-poverty, and women’s empowerment programs.

As one NGO leader in Bangladesh told Exemplars researchers, “We can’t speak about community health without speaking about how the community views women, and that’s why we started to think about this work as integrated and more about poverty reduction than just health, and this requires female empowerment and shifting how society views these women.”

But if the research indicates both male and female CHWs have benefits and are needed, why is there so much talk of giving women preferential treatment in hiring CHWs?

One key reason is that there are significant challenges for women interested in obtaining CHW positions. These include: many women do not have the educational requirements required of CHWs, in some communities it is considered inappropriate for women to travel to other villages on their own, men are more likely to apply for such positions (particularly if the positions are paid), and men are more likely to be able to attend remote training sessions required of CHWs.

That’s why governments need to implement recruitment, training, and employment policies and practices that accommodate and encourage women CHWs.

Consider the case of Liberia, where women make up only 20 percent of the rural CHW cohorts, called Community Health Associates (CHA). Marion Subah, Liberia Country Director for Last Mile Health recently wrote that Liberia’s lack of female CHWs has created “gaps in quality of care. Women have been reported as less comfortable to discuss details of family planning, pregnancy, or delivery with male CHAs and are more likely to mention side effects and danger signs to female providers.”

While some of the largest CHW programs in the world today utilize exclusively or primarily women CHWs, including Pakistan’s Lady Health Worker Program, India’s Accredited Social Health Activist (AHSA) Workers and Anganwadi Workers, and Indonesia’s Kaders, many others struggle to hire enough women.

It is worth noting that the choice is not binary. Rwanda, for example, uses Binomes – a pair of CHWs (one male and one female) who work together; Afghanistan uses pairs, husband and wife teams that are recruited together.

Whichever model is pursued, Dr. Ballard recommended that health leaders seeking to develop effective CHW programming focus on four key issues: “CHWs should be paid, consistently supervised, continuously trained and equipped." She also added that "perhaps the biggest headline related to gender and CHWs is that the vast majority of CHWs (>70%) are women and the vast majority go unpaid. It is inherently exploitative to ask individuals to volunteer as a condition to access health care for themselves, their family, and their community - yet we seem happy to ask women to do it. Interestingly enough, the qualitative literature suggests that where CHWs are poorly paid, it's understood as a "woman's job," but where they're actually supported like professionals, [with] pay, training, benefits, the ranks suddenly fill with men.”