“We are dying while giving life”: Gender and the role of Health Extension Workers in rural Ethiopia

“We are dying while giving life”: Gender and the role of Health Extension Workers in rural Ethiopia

The health sector is a key priority sector for addressing women’s needs and priorities in Ethiopia. Under the Health Sector Development Program (HSDP), the Health Extension Program (HEP) aims to improve equitable access to essential health services through neighborhood (kebele) based services with a strong focus on sustained preventive health actions and increased health awareness. The HEP includes 16 health intervention packages that are delivered by two government-salaried Health Extension Workers (HEWs) who are assigned to each rural kebele of around 5,000 people. HEWs spend much of their time on community outreach programs to households, especially to mothers and children. Women are selected for the HEW role because of their key role in improving the health of mothers and newborns at the community level.

Within this document, the authors wanted to understand gender dimensions of the HEWs’ role and experiences of serving in that role in the HEP; issues of HEWs’ performance and satisfaction; and to identify possible gaps and come up with recommendations for improvement. They specifically wanted to give voice to the HEWs; to critique some of the assumptions underlying the gender aspects of the HEP; and, to make recommendations for considering gender issues/mainstreaming gender and HEWs empowerment in the HEP. Job opportunity and desire to help the community were the main reasons for HEWs joining the HEP.

The things that make them HEWs happy are helping mothers and children, ensuring they are vaccinated and that women attend Antenatal Care (ANC) and are referred to health centers for skilled attendance during delivery—things that coincide with the goals of the HEP. However, a recurring theme among HEWs’ responses is that they struggle with excessive workload including unpaid overtime in fulfilling their responsibilities. This is exacerbated by their gendered household duties, which have not diminished with their taking up of paid work in the HEW role. Other constraints in their duties include trying to manage day-to-day with a shortage of medical and other equipment and lack of transport.

Many HEWs spoke of feeling unhappy with the lack of career path or opportunities to move into positions with more or different responsibilities and better conditions. While there are some limited opportunities to upgrade training, few HEWs believe there is much opportunity for them to better themselves or move beyond the HEW role. For some, the lack of opportunity for advancement impacts on their enjoyment of being a HEW. The lack of opportunity to transfer was raised repeatedly by HEWs and appears to have been a source of considerable dissatisfaction and practical inconvenience, or worse, for many HEWs. Under HEP policy, HEWs have been unable to transfer from one location to another because they have been recruited from their own kebeles on the understanding that they will return to them after training and serve in their own community. The no-transfer policy means that some HEWs who have worked for many years in one place and have married and had children are unable to live with their husband and children. The authors examined the findings in the data through a ‘gender lens,’ using a number of established gender analysis conceptual frameworks. A key conclusion is that the health system, and the HEP specifically, are in some ways gender blind in that they fail to look at the gender of the health workers who are responsible for delivering the health services to women.

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