Introduction
Community health workers’ gendered experiences
Box 1: Key definitions | |
Gender—Gender is defined as the ‘socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for men and women and people of other genders'. | |
Gender analysis—A critical examination of how differences in gender roles, activities, needs, opportunities and rights/entitlements affect women, men, girls and boys in certain situations or contexts. | |
Gender norms—Accepted attributes and characteristics of being a woman or a man (ideas of how men and women should be and act) at a particular point in time for a specific society or community. They are internalised early in life and are used as standards and expectations to which women and men should conform and result in gender stereotypes. | |
Gender roles—Refers to what males and females are expected to do (in the household, community and workplace) in a given society. | |
Gender relations—Refers to social relations between and amongst women and men that are based on gender norms and roles. Gender relations often create hierarchies between and amongst groups of men and women that can lead to unequal power relations, disadvantaging one group over another. | |
Gender transformative—Addresses the causes of gender-based health inequities by including ways to transform harmful gender norms, roles and relations. The objective is to promote gender equality and foster progressive changes in power relationships between women and men. | |
Adapted from the United Nations. Gender Statistics manual. Available at https://unstats.un.org/unsd/genderstatmanual/Glossary.ashx |
Mozambican context
Study aim
Methods
Recruitment and data collection
Analysis
Ethical considerations
Results
Participants | IDI | FGD | KII | ||
---|---|---|---|---|---|
Ministry of Health official | 1× male | ||||
District level | Moamba | Manhiça | Moamba | Moamba | |
APE | 3× males 4× females | 3× males 4× females | 1× mixed sexa (6 participants) | 1× male (8 participants) 1× female (8 participants) | |
APE supervisor | 1× male 2× females | 1× male 2× females | |||
District supervisorb | 1× male | 1× male | |||
Community leaders | 3× males 1× female | 3× males 1× female | |||
Total | N = 30 | N = 3 (22 total participants) | N = 1 |
Experiences of selection and recruitment
Recruitment motivations
I think in the early days, I think people wanted to be APEs to help even, to help others in those times, but in nowadays, in the present moment, I think they want to be APE, I think it's more to get something like money, to work. [Supervisor IDI Manhiça, female]
Selection process
…the [Southern] provinces of Gaza, Maputo and Inhambane have a greater number of women. This is because… there are many women with husbands working in South Africa and as a way to take care of the family, women have to find something to do. This is the difference that we have, looking at the Central zone and North the woman has to take care of the house, the woman has little time, she cannot do anything, she is dependent on the man, the man is the one who determines if she is going to work… [in the South] …they adhere because their husbands are not there, they are out of the country working in the mines… [KII MoH, male]
It’s just because women have more time. Looking at women’s side you will see that they are who have this ability to take care of us, and men have more activities to do and must not be more related to this work. [Supervisor IDI Manhiça, male]
I think women are the most helpful. There are a few helpful men, but the big problem is that some people take the job and, without giving any information, leave to South Africa, leaving the community to their fate. That's one of the reasons that made our choice fall on a woman. [Community Leader IDI Manhiça, male]
A: …I worked with the father of this young man, he was my servant [health position] and so when this request came I did not go far, I came to get him right here. [Community Leader IDI Manhiça, male]
…during the selection they have not noticed the [female] side of being more open, more welcoming. They have noticed the friendship side, family, it’s much more a chance I give my nephew… to be APE, since he does not work, being a man… [Supervisor IDI Moamba, female]
Training programme
If I have to leave here to be in another place, for four months, here at home what is going to be eaten? For example, because now where I am, I only have 10 kg [of rice], I am trying to at least increase again that 10 kg, or this woman [wife at home] is going to haunt you. How is it possible to work to increase that food with that little allowance they gave us? [APE FGD Manhiça, male]
In the family, when I leave, I’m the male there (laughter) so no one will be [disciplining] the children for four months. I do not know how I made it staying here because [home] was lacking food…when we were trained it was time of starvation…We also had problems of a lack of food here, if I had a [lunchbox] here sometimes I would carry it to a child at home, but here we had difficulties. But we faced them, we are here, we win. We are winners. [APE, Male FGD Moamba]
For me it was difficult because I am a mother, I am a father, I have a son who is seven years old… I even asked my sister to go stay with my son, sometimes the night at [8 pm] she sent me a [message] then I seek airtime to call, she just wanted to tell me that at home has no oil, no sugar, has nothing, I was not well trained because it was not always easy. [APE Female FGD, Moamba]
Q: Do their husbands agree to let their wives go to the training for four months?R: That, indeed, happened. The APEs that were in the training with our APE, there were three ladies whose husbands did not like and so the [husbands] suspended them from the training. However, when we distributed the cattle offered by PATHFINDER to the other APEs, their husbands complained.Q: What are the motives for men who have suspended their wives from APE training, other than what they have already mentioned related to lack of salary?R: The main reason was related to home activities. They did not see the reason for leaving their homes for an activity that has no benefits. [Community Leader IDI Manhiça, male]
Experiences shaping retention of APEs
Remuneration
Q: In your experience, why do people usually leave?R: Money problems.Q: Is it money for both men and women?R: …It is money because other women sometimes have a husband and the husband lets her go to work and at the end of the month there is nothing, before we were eight months without receiving the subsidy and the husband becomes demoralised, it is preferable to leave because… they do not give you anything [APE IDI Moamba, female]
Q: You said men usually give up, what are the reasons men quit?R: Because men are the head of the family and all responsibilities rely on them, such as providing money for children to go to school, food and many other things. So, the reasons for many to quit taking in account the amount we receive as subsidy while we have much work to do as APE. [APE IDI Moamba, male]
I have worked with many projects but never ceased to be an APE and I will not leave, so far, I want to continue, even without money… A person’s life is not bought. [APE IDI Manhiça, female]
More and more NGOs coming with more work but no money for that. The first organisation that came in said will give 1200 [meticais to] APEs, and these new organisations that are coming in now are exploiting us, but we will not stop working… We are going to work because we are in our country, in the community, what we are doing is not only helping the community alone, we are helping the whole country… but the country is not giving us priority, it does not value our work… This NGO asks the State, we want APE, they should say ‘we have APE, these APEs are receiving the value of another NGO if you also want to work with APE you also have to give something!’ Does not mean anything working for five NGOs while I'm only receiving salary from one NGO. [APE IDI Manhiça, female]
And if the ministry cannot pay us because our level is so low it should train us more us more, increase our training, because we have the capacity to learn more… We are still available to receive more studies, to continue helping the population, but we have to see the subsidy because they are already exploiting us, we are slaves of the ministry, because even servants receive more than we do, but we are doing a lot of work… [APE FGD Manhiça, female]
Career progression
We hope they will help us, maybe they may give us scholarship so we can increase our level. Don’t you one day want an APE like me, to graduate from university? Wouldn’t you guys like that? Hearing that an APE, a lady was an APE, now she has done a degree. [APE FGD Manhiça, female]
…the APE accepted to help the community but did not accept to be exploited, now the APE is being exploited. They are violating the rights of the APEs… they made a doctrine, it says the APE has no right to receive much subsidy because we have the right to go to the farm, do other jobs… but when the supervisor calls to say ‘I am coming to your house, I come to do supervision’, that day even if you have another [job] you cannot leave the house, have to wait for the supervisor to come to do supervision then that day that you were not in that work that sustains you is missing… We are working and we are happy with our work, but our concern is only subsidy… [APE IDI Manhiça, female]
Subsidy demoralises us a lot, other APEs eventually get another job, so the boss who employs me, will not accept the rest of the time to work as an APE. For example, you can say that you enter here [at] 6:00, I will leave 18:00 hours, so already for the work of APE I will not do anything because I will leave at 18:00, I cannot do home visits at night, because they will say you are no longer working in health, you want our women (laughs) …We are not well with will, but we are working. [APE FGD Moamba]
Family, marriage and household dynamics
Q: Do you think that one of the reasons men tell women to quit is because they do not want them to have their own money, their financial independence?R: No, that's not correct. For example, I am a girl, I am an APE, I am dating a boy from Gaza province, he wants to marry me, well, I can say I have reasons to accept him and quit APE work, but this decision is not about money, it’s because I love him, I want to have my own home and family, as well as conditions to get food and educate my child. [APE FGD Moamba, female]
…Women give up because the husband has a decision at home, to this day there is this, there is a husband who has a decision at home. ‘You should stay here, instead of going to the farm, leave these people, or even leave work, leave these activities here, I say stay here at home.’ Others drink, smoke, these husbands are stubborn, for example, if I come home, I drank, I smoked and I find you, my wife, and there is someone having a test there, I can make you stop [treating them] there and prepare a meal for me at the table…as I am the one who decides here at home… she will quit (the APE) because she wants the save her marriage. He even announces this, ‘you know nothing, your income adds nothing here at home.’ She ends up giving up because no woman will like to always receive beating, punches, slaps and know that I am not gaining anything. [APE FGD Moamba, male]
For example, this young man here [an example APE man] receives 1200 [meticais], will he build real home with 1200? His girlfriend wants artificial hair, but this 1200 is not enough, so, if this APE gets a good job he will definitely leave APEs work. If someone tells him that there’s a job opportunity in Inhambane province where he’ll get paid five or seven thousand he will definitely leave APEs work. On the other hand, for an old man it’s different because there are few opportunities due to the age, so old men are likely to remain in their APE work. It is difficult for any old man to quit. He can remain in his community. [APE FGD Moamba, male]
Well in my group there was a colleague after training worked a few months but ended up giving up, travelled to South Africa but she was not married, even was a young woman in her 20s, so I do not know what was her influence, eventually she abandoned and on her return she wanted to get involved again but she had already been replaced by another colleague. [APE IDI Manhiça, male]
Discussion
Health system goals | Policy changes and rationale |
---|---|
Recruitment factors | |
Training | Modular, flexible training options support both men and women who balance APE work with other paid employment opportunities and domestic obligations. This can also help to reduce issues around the length of training APEs face in being away from family obligations. Residential training can create a sense of solidarity but can be limiting for women with childcare responsibilities, and men who feel a duty to provide for their families. On-site childcare should be offered to support this. |
Household dynamics | Community sensitisation programmes to encourage women to have autonomy in decision-making over livelihoods and challenge patriarchal norms. |
Selection | Training with community leaders on gender and power relations as well APE roles, programme aims and importance of accountability to ensure women have equal opportunities for selection. |
Retention factors | |
Remuneration and social security | Remuneration for APEs commensurate with working hours and skills (in hand with strict selection criteria to ensure equal selection of women). This will help reduce attrition and improve motivation. Social security in the form of employment-based health insurance, a component of universal health coverage, should be provided. Contracts should ideally be issued to formalise labour rights for CHWs, such as maternity and paternity leave and holiday and sick pay. This provides security to APEs and does not discriminate against women for their reproductive roles. |
Career progression | Sufficient educational opportunities to improve literacy for female CHWs who want to go on to further education would contribute positively to the development of communities. Sufficient sponsored courses for eligible female and male APEs to undertake further training to enter into the health system. Opportunities for a career structure, e.g. promotion to supervisor or senior APE. This should be considered alongside barriers women may face to get there and be accompanied by mentorship, supportive supervision and preferential selection of qualified female candidates until gender parity is achieved. |
Working conditions | Provision of formal, stocked health posts for APEs to support the safety and legitimacy of the cadre. Sensitisation on gender-based violence with community members. |