Summary of CHW policies in Sierra Leone, Liberia and DRC

In Sierra Leone, the CHW programme was rolled out nationwide and 15 000 people were trained to provide a basic package of services at the community level with a focus on gender.23 Services included—reproductive, maternal, newborn and child health, integrated community case management of sick children and infection prevention and control.

In Liberia, the policy focused on the development of Community Health Assistant cadre (CHAs—a type of CHW) trained to deliver a package of preventive, curative, promotive, rehabilitative and palliative services as well as health surveillance. CHAs are supervised by Community Health Services Supervisors—a cadre of health worker who have been formally trained, for example, a nurse, physician assistant or midwife. Previous cadres of community health volunteers (CHVs), for example, community drug distributors remain in operation and were supervised by CHAs.21

In the DRC, there is no overarching CHW programme, but CHWs are organised into three categories: site CHWs (providing a package of community activities, such as distribution of Ivermectin and contraceptives, case management of malaria, diarrhoea and respiratory infections), promotional CHWs (providing health education to communities) and disease-programme CHWs (providing specific services for the programme such as the Expanded Programme on Immunisation).30–32

We use the term CHW to include CHWs in Sierra Leone and DRC and CHAs in Liberia. None of these CHWs are salaried, but they receive allowances. In Sierra Leone, CHWs should receive 100 000 Leones plus 50 000—80 000 Leones for transport and other logistics per month (equivalent of US$20–US$24); the minimum wage is 500 000 leones per month (equivalent of US$67). In Liberia, each CHA should receive US$70 per month, which is based on provision of a package of healthcare at the household level through a minimum of 4 hours of work/day; the minimum wage is US$75. In DRC, CHWs receive some financial compensation if they work for specific programmes, go to training events or from sales of health products such as bed nets. Table 3 provides a summary of the key findings from the policy review.

Selection and recruitment of CHWs

CHW policies were launched post-Ebola in Sierra Leone and Liberia to prioritise the selection of women as CHWs or CHAs. In both settings, this is due to the scope of CHWs’ work, which largely focuses on women’s health, maternal, new-born and child health.

All things being equal preference should be given to women, especially those who have worked with pregnant and new mothers (National Community Health Worker Policy, Sierra Leone, p21)23.

In Liberia, this prioritisation was further described by some key informants as being linked to gender roles within communities.

Men are always on the move, but women are the ones who stay home to look after home and family (National decision-maker, man, Liberia).

In DRC, there are perceived equal opportunities for women and men in the CHW selection process. Human resource policy as set by the Economic and Social Council of DRC in 1995 states that at least 30% of health worker posts, including CHWs, should be occupied by women.33 However, the policy does not state how this can be achieved in practice.

Polices in Liberia and Sierra Leone support the selection of women, nevertheless, there are many more male CHWs than female CHWs in both settings. In contrast, there are more women taking on the CHW role in DRC (table 4).

Policy ideals in terms of selection, attraction and recruitment were mediated in practice by societal and gender norms. In Liberia, it was reported that community-based selection processes favoured men. Some informants described this as difficult to change as it was viewed as a community norm or preference to prioritise men over women.

What satisfies the community…and if the community bring a male and I tell them no, they won’t feel good because it’s the person they feel comfortable with (facility manager, woman, Liberia).

In Sierra Leone, some participants believed that this correlates with men’s greater capacities due to having more education, more physical stamina and greater availability to work because they are not expected to do domestic labour.

Men can work harder than some of the women, especially walking long distances (community manager, man, Sierra Leone)

In both countries, it was reported that male partners and husbands did not want their wives to be employed, or to engage in community work. This was said to be a reason for the low numbers of women CHWs. Women experience limits on their mobility, often due to fear of sexual or gender-based violence.

In DRC, there are more women CHWs, where there were women’s associations. These associations advocate for women and influence husbands’ and relatives’ attitudes towards granting women permission to join the CHW programme.

Here in our health district, where you find nearly half of CHWs are female, there are women associations, but where there are no women associations, you find that there are more male community health workers (district manager, man, DRC).

Literacy was a requirement for CHWs in DRC and Liberia. In general, men were more literate, highlighting how the education of boys is prioritised due to entrenched patriarchal preference. County and district-level informants in Liberia described how:

In the interior…boys’ education is prioritised over girls’, with girls remaining in the kitchen (community manager, woman, Liberia).

Literacy challenges are compounded in FCAS, where education has historically been disrupted due to conflict. This places women at an even greater disadvantage. To overcome these challenges, and to try and continue to prioritise women in CHW selection, informants in Liberia and Sierra Leone described working with women (and some youth) to try and increase their literacy levels.

Where women and youth have been unable to read and write they have been encouraged to join the elders’ educational programme so that they can be incorporated into the programme (national decision-maker, man, Liberia).

This has helped to some degree with, ‘some women who as a result of literacy support linked to the CHA programme have completed school and are in midwifery school’ (community manager, woman, Liberia). Informants believed that embedding literacy programmes within CHW training would support the participation of women and other people with literacy challenges.

Retention and remuneration

Key informants from all three settings and CHWs in Sierra Leone reported that retention of CHWs is shaped by gendered norms within households and communities.

As reflected in CHW selection processes, women’s ability to work can be constrained by patriarchal hierarchies within the family. In many settings, women have domestic responsibilities, including housework and care for children and relatives. They juggle these roles with their CHW work, limiting the time they can spend at work and affecting their performance and retention.

As for female CHWs, especially married women, due to their family responsibilities, in most of the cases they arrive late, as they need to make sure they have covered home need. If they have a child who is unwell, that also affects their presence as they need to care for the child. To overcome it, we just make sure that we understand them, as when they are there, they are really productive (district manager, man, DRC).

In many settings, men have the final say in how women allocate their time to household work and CHW work, and ultimately whether women stay in the role of CHW.

Sometimes, their husbands are not happy as we engage their wives for volunteer work for a long time (facility manager, woman, DRC).

Male CHWs are more likely to find a paid job and leave their role as CHW. They are expected to be the breadwinners of the family (and sometimes multiple families), and, therefore, seek paid work. This is more frequent, where there are more employment opportunities such as in the gold mining areas of Sierra Leone. On the other hand, woman CHWs were seen as being more stable, as ‘they don’t go away’ (facility manager, man, Sierra Leone).

Demonstrating how gender intersects with marital status to determine the need for income-generating opportunities, women in female-headed households sought additional work, as they were, ‘without a man to support’ (CHW, woman, Sierra Leone).

Some felt that women, especially those who have worked as traditional birth attendants, were willing to provide care with no or ad hoc financial incentives.

If a woman chooses to become a CHW, she can do it genuinely. They don’t disobey. Some had [worked] as TBAs (Traditional Birth Attendants) and have not been receiving anything (money) in the past, but they were still happy to do the job (facility manager, man, Sierra Leone).

To overcome the issue of attrition among men, respondents reported trying to replace them with new recruits. One facility manager (a woman) in DRC reported taking a different approach and providing income to male CHWs in the hope of assigning some value to the work that they do, ‘I just have sometimes to use my own money to give them [male CHWs] so that they realise the expected work’. This approach, while innovative and pragmatic, reinforces the gender norms that exist within the community, suggesting that men’s labour is worthier of payment than women’s.

In many cases, women have limited opportunities for career progression due to literacy and mobility issues and gendered roles, which can be demotivating and result in attrition. As one respondent from the DRC noted:

Something surprising is that females are the majority, but men seem to be more active, and are more available to serve, and there are males who occupy responsibility positions (facility manager, woman, DRC).

This was also seen in Sierra Leone, where most peer supervisors (CHWs with additional training, allowances and responsibilities) are men, and women rarely perform this role because of lower literacy, lower education levels and gendered expectations and norms around leadership.

Safety, security and travel

Gender dynamics influence how CHWs travel around their communities and access households. In all settings, key informants and CHWs reported that women found it difficult to travel long distances for their work. This was due to social expectations of women and, ‘a reluctance of husbands to let their wives walk outside the community’ (national decision-maker, man, Liberia).

These gendered expectations and restrictions lead women to different roles during campaign activities. One supervisor in Liberia described the ability of men to travel these longer distances unescorted and completing more work.

But maybe when it comes to distances, maybe there is a gender issue, because the female we are not strong to walk longer distances. So, when there is a campaign there are some distance and some hard-to-reach areas we will assign a male there because the female won't go. That’s a gender issue. I think is reasonable because … females are much lesser in strength than males. Males can cover a longer distance and feel normal, but female don’t cover that distance and remain normal (facility manager, man, Liberia).

Long distances may require CHWs to stay in communities overnight. One manager in Liberia described that sometimes when she reached supervision locations, she had to stay overnight as it was dark and not safe for her to return.

We go in the field, we sleep in the field. I have to walk on seven hours distance to go for supervision, and then I have to supervise the CHAs on two hours. Before I come back, darkness will catch me and I will sleep there. No compensation. I spend more time in the field, so they should see about compensating me for accommodation and feeding. These are things that can really affect performance (community manager, woman, Liberia).

CHWs attend women during childbirth and sick children and adults during the night. This raises security concerns; in Sierra Leone and Liberia, male CHWs or relatives tended to escort the woman CHWs to households at night.

Transport costs incurred during CHW work may inadvertently favour men who have more income-generating opportunities. As one facility manager, a man, in DRC explained:

You know, sometimes they have to use their own means of transport even their money to organise activities, you know, this a bit challenging, and that might affect their performance.

Community norms and preferences

Key informants from all contexts, and CHWs from Sierra Leone, reported that gender norms shape both CHW and service acceptability. In all contexts, concerns were expressed about women’s/communities’ readiness to accept men working on sexual, reproductive and maternal health. In Liberia, many key informants reported that men CHAs find some health areas difficult to discuss with women, for example, pregnancy, sexual health or feminine hygiene and that community members would hide these issues.

For a man to go into detail about pregnancy with a woman, they will find it difficult. When [a man] comes she will just say I am not feeling well. But if she has any danger sign, maybe she has sore between her leg, she will [show the] female, but she will not be able to show it to the male (facility manager, man, Liberia).

In the DRC, key informants reported that women were perceived to be more able to counsel both men and women about health matters than men.

Well, female community health workers, we have them, yes because as I said before they have very good communication skills as far as dealing with women is concerned, they can better understand themselves. They are also able to communicate to men without any problem (Facility manager, man, DRC).

Key informants in Sierra Leone felt that some community members were suspicious of men CHWs and their motives for caring for women in the community. They were often accused of ulterior, sexual motives if talking to women in communities. This led to men and women CHWs being deployed in pairs.

Complaints from men that male CHWs are talking with pregnant women - thought they were wanting to have sexual relationship with her. If female CHWs do this there is no problem. [It’s a] common problem. There was a time we held a meeting and decided that the men should not go alone but should be accompanied by a female so that all of us can do the work together; and go in the day and not at night (community manager, man, Sierra Leone).

Can CHWs address gender norms in the community?

Gender norms within the community shape communities’ views of CHWs and service acceptability. We found emerging evidence of CHWs strategising and working together to address harmful gender norms that restrict health and well-being. They had not been formally trained to take on this role. Only in Sierra Leone did training include a limited focus on how gender shapes community norms and how gender should be considered during community entry and relationship building. In Sierra Leone, a district health manager reprimanded a man CHW for beating his wife as this contradicted the ethos of the programme.

In all contexts, it was believed that CHWs were well positioned to relay community concerns and health conditions to the health system, and that this could address negative gender norms. Key informants in DRC explained how CHWs were able to act as intermediaries to give women’s voices a platform and to encourage women to express their concerns.

CHWs’ willingness and ability to interact with and challenge harmful gender norms emerged most clearly through the photovoice methodology, which was used in Sierra Leone. Via their photos and facilitated group discussions, CHWs demonstrated agency in negotiating and challenging gender norms within their work. They supported each other in generating solutions to address gendered challenges. For example, CHWs discussed how to speak with community leaders and families about bed nets, so that they were not just used for men or for fishing but also for women and children. They explored approaches that encourage women to generate income for their family such as rearing poultry. They considered ways to support women who had been abandoned by partners and families, or grandmothers who were looking after Ebola orphans.