On a typical work day, Misra Yusuf, a community health worker in eastern Ethiopia, performs a variety of tasks, including vaccinating children against polio, administering contraceptive injections to women, screening individuals for tuberculosis, distributing bed nets for malaria protection, and helping with the construction of pit latrines. In addition to these responsibilities, she has administered around 10,000 coronavirus vaccines in her community and successfully handled a measles outbreak.
Despite working well beyond the 40 hours mandated by her contract each week, Misra Yusuf only receives a monthly pay of $90 from the Ethiopian government. This payment is discouraging for her, but she persists in her work because she values its impact.
Misra Yusuf is one of the few fortunate community health workers who receive some form of payment for their services. In Africa, 86% of community health workers are unpaid. Inspired by the challenges faced during the Covid pandemic and aided by digital technologies that have expanded reach to remote areas, community health workers are now organizing to fight for fair compensation. This movement spans across developing countries and shares similarities with the labor movements of female garment workers in those same nations four decades ago.
Community health workers in countries such as Rwanda and Liberia provide significant contributions to healthcare, including treating a significant number of malaria cases and delivering comprehensive curative, preventive, and promotive care. Despite these accomplishments, the majority of community health workers worldwide receive no pay or support. This lack of compensation is not only a labor issue but also a gender and public health concern, as highlighted by Madeleine Ballard, the CEO of the Community Health Impact Coalition.
The efforts of community health workers to advocate for fair compensation are yielding results. In Kenya, for instance, the government has started providing stipends of $25 per month to 100,000 female community health workers who are now recognized as a formalized group of health promoters. This victory was achieved through a campaign organized via WhatsApp, where women shared pictures of themselves carrying out their duties and learned lobbying strategies through an app.
For over a billion people in low-income countries, community health workers are the primary or even sole providers of healthcare throughout their lives. Organizations such as the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and USAID rely on these workers to implement programs with multimillion-dollar budgets. However, little to no funds are allocated for the crucial last-mile delivery of these programs.
Former and current staff members of these organizations stated that executive meetings often praised programs that could be implemented by unpaid community health workers, as they were deemed cost-effective. However, this notion has become less acceptable in recent years. Theresa Hwang, the deputy director for gender equality at the Gates Foundation, acknowledged the underpayment and undervaluation of women’s labor in the global health workforce. The foundation is now critically considering how to support and strengthen health systems to ensure fair compensation for community health workers.
Many global health programs fail to factor in the costs associated with community health worker delivery. This oversight occurs because the labor of isolated and marginalized women is often an inexpensive addition to these programs. Dr. Samukeliso Dube, the executive director of FP2030, highlighted that family planning services in Ethiopia and other countries heavily rely on community health workers. Consequently, the lack of budgetary allocation for their remuneration perpetuates the undervaluing of their work.
Only 34 out of 193 United Nations member states have officially recognized and established training, accreditation, and minimum wage requirements for community health workers. The U.N. General Assembly is expected to adopt a declaration on universal health coverage that acknowledges the importance of paying these workers and emphasizes gender equity.
Community health workers, who often have limited formal education and reside in remote rural areas, face challenges in organizing themselves. However, the proliferation of smartphones and free messaging services like WhatsApp has helped overcome these barriers. After witnessing the successful fight for payment by “lady health workers” in Pakistan, their counterparts in Nepal began campaigning for salaries.
Recent victories achieved by community health workers in different countries inspire others to advocate for fair compensation. Dr. Ballard stated that when neighboring countries with similar circumstances implement a minimum wage for community health workers, it becomes harder for governments to claim they cannot afford to pay them. As a result, a rising tide of change is sweeping through the community health worker movement.
The Global Fund has taken an encouraging step by mandating that countries receiving grants budget for community health worker delivery and the necessary funding to remunerate them. This requirement exemplifies a shift away from solely relying on unpaid workers.
The concept of utilizing community-based workers with minimal formal training to deliver healthcare has existed for centuries. It aims to serve populations residing in remote areas where healthcare professionals are scarce. Many countries have drawn inspiration from China’s barefoot doctors during the Cultural Revolution in the 1960s.
Health ministries often cite financial constraints as a reason for not paying community health workers. Resistance to compensation also stems from religious and political leaders with traditional views about women’s roles, who dismiss their work as something expected of them rather than as a legitimate occupation.
Governments frequently encourage women to volunteer as community health workers, promising social status improvements or offering small perks like bicycles or mobile phones. These tactics, combined with the perception of volunteerism, have deterred unions from organizing community health workers in the past. However, recent progress has demonstrated the need for change.
While successes have been achieved, significant challenges persist. In India, more than a million community health workers, predominantly women, staged their first-ever strike to protest against low pay (around $35 per month) and a lack of personal protective equipment during the Covid pandemic. Although they received support from the powerful All India Trade Union Congress, their demand for a guaranteed minimum wage remains unmet.
Progress can sometimes exacerbate gender imbalances in the workforce. When conditions and wages improve, men often fill the newly paid positions. Liberia faced this issue after transitioning from an all-female network of volunteer health assistants to a paid workforce, resulting in over 80% of the new positions being occupied by men. The Liberian government is now working to restore gender balance by implementing quotas for hiring women and reconsidering formal education requirements to recognize women’s experience.
Overall, the fight for fair compensation for community health workers continues, with the movement gaining momentum and achieving notable victories. The recognition of their essential role in healthcare delivery and the growing awareness of gender equity issues are driving forces behind this effort. The success of community health workers in organizing and advocating for their rights serves as a testament to their determination and the potential for meaningful change.