As world leaders gather virtually for the Generation Equality Forum in Paris this week, how to build back better for women will be at the top of the agenda.
Women have been disproportionately impacted by the economic and social fallout of the pandemic. An estimated 47 million more women and girls have been pushed into poverty. And, gender parity has been pushed back by another generation, with the World Economic Forum estimating that it will now take 135.6 years to close the gender gap globally.
If the impact of the COVID-19 pandemic has not been gender-neutral, then our response must not be gender-neutral.
This is especially vital for health systems, as women make up almost 70% of the health and care services workforce globally but subsidize the global economy by an estimated $1.5 trillion annually in the form of unpaid work. Building gender-transformative health systems — with women serving as paid, professionalized community health workers — is necessary to prevent the next pandemic, advance universal health coverage, and achieve greater gender equality.
By giving women at the center of primary health systems opportunities to excel, we can ensure these systems have gender-transformative benefits.
—Supporting women at the center of strong health systems
As the world works to recover from the COVID-19 pandemic and build back better, it should look to a key lesson from the past 16 months: The best emergency system is a strong primary health system.
Community health workers, who serve the daily health needs of their neighbors, are the backbone of strong primary health systems. Cited as a vital component of the responses led by high-performing countries by the Independent Panel for Pandemic Preparedness and Response, they have been essential first responders during the pandemic.
When paid, trained, supplied, and supervised, community health workers have successfully maintained primary health services during the pandemic.
Investing in national community health worker programs is a smart investment, both during crisis and calm. However, too many paid, professionalized community health worker programs are leaving women behind. To build back better, we need to understand the barriers women continue to face in serving as paid members of our health workforce.
Gender parity in Liberia’s National Community Health Assistant Program
Liberia is an example of a primary health system that could be strengthened by greater gender parity.
Following the 2014-2015 Ebola epidemic, the Government of Liberia committed to making primary health care universal for people living in rural and remote communities. Its National Community Health Assistant Program has since recruited, trained, and employed nearly 4,000 community and front-line health workers, who now treat 45% of all reported malaria cases for children under 5.
By paying a professionalized community health workforce, the program also created new jobs in rural areas and had a clear commitment to hiring women. The problem? According to data gathered by Last Mile Health and the Liberia Ministry of Health, only an estimated 18% of Liberia’s community health workers are female.
The program, intended to encourage hiring women as community health workers, was not effective in overcoming gendered barriers, including societal gender norms and expectations, literacy disparities, and more.
Lack of gender parity in the community health workforce is an obstacle to maximizing the impact and sustainability of the program. Liberia’s disease burden continues to disproportionately affect women — maternal mortality is a leading cause of death and there is low coverage of modern family planning methods nationwide.
In addition, evidence from the Liberia Ministry of Health and partners indicates that “[harmful gender] norms can be internalised and reproduced within the health system leading to inefficiencies and inequities in the way that services function.”
This can contribute to gaps in access to care, with community members concerned that female patients would not be comfortable interacting with a male community health worker about pregnancy or reproductive health. This was underscored by a recent Sayana Press study from Last Mile Health, which found that most women preferred interacting with female community health workers to get access to family planning.
The Government of Liberia has the opportunity now to listen to women, better understand their barriers to entry, and enable greater gender parity in the national program.
The care economy costs women. It’s time to pay up, advocates say at CSW
COVID-19 has shown the economy depends on women’s unpaid work. Short-term responses should be rolled into systemic change, according to experts at the 65th session of the Commission on the Status of Women.
The Liberia Ministry of Health and Last Mile Health have made a commitment as part of the Gender Equal Healthcare Workforce Initiative — convened by the World Health Organization, the Government of France, and Women in Global Health — to conduct a comprehensive gender assessment of the national program to better select, train, and retain women as paid community health workers.
Interventions may include prioritizing women to replace male community health workers who leave the program, establishing or strengthening programs in rural areas to improve literacy and additional incentives for female community health workers.
There may be a challenging road ahead to achieve gender parity in the program, but it is vital to the strength of the primary health system as a whole.
Build back better and more equal
As we look to rebuild our health systems, institutions designing, implementing, and funding primary health systems must overcome gendered barriers holding women back from serving as paid community health workers by being very deliberate.
By giving women at the center of primary health systems opportunities to excel, we can ensure these systems have gender-transformative benefits, such as improving the social and economic status of women and providing sustainable employment, while expanding access to essential health services and building resilience for the next pandemic.
It’s time to build back better and more equal. And it starts with investing in women.
Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildingBackBetter.
About the authors
Siobhan Kelley
Siobhan Kelley is the director of communications at Last Mile Health, where she is responsible for overseeing the organization's brand, thought leadership, and storytelling. She has nearly 10 years of experience supporting organizations working to advance universal health coverage.
Marion Subah
Marion Subah is the Liberia country director at Last Mile Health, where she manages the organization’s partnership with the Liberia Ministry of Health to scale and sustain the National Community Health Assistant Program. A trained nurse-midwife, she has 40 years of experience working in Liberia's health system.
