#MeToo meets #HealthForAll: How achieving universal health coverage can (and should) drive gender equity
The #MeToo movement went international recently as a chorus of voices called attention to gender inequities in the fields of global health and development. Laurie Garrett took aim at the power imbalance in public health in her piece on foreign policy. A Twitter storm was unleashed after Duncan Green posted an all-male list of ten top thinkers on development on his blog. In response, lecturer Alice Evans guest-posted “The Perils of Male Bias” for the same site. Others have weighed in elsewhere.
As the Executive Director of Hope Through Health, a nonprofit working to strengthen community-led health systems in Togo, West Africa, having these debates focused on the “very male-dominated” development field is an important moment. There lies, at the intersection of the #MeToo and #HealthForAll movements, a tremendous opportunity to reshape the balance of power in significant and meaningful ways.
In 2015, Hope Through Health announced that we would be prioritizing women to be hired as Community Health Workers as part of an integrated primary healthcare delivery program. Almost immediately, we were met by a range of complaints:
“You won’t find qualified women.”
“Women don’t want those jobs.”
“Women are illiterate.”
“The work is too complicated for women.”
“There are no women.”
Community Health Workers in Togo, and in many other countries, have traditionally been male. Our preference for women was a shocking break from the norm.
We had a hypothesis that there was tremendous untapped potential for human capital in the women of rural, remote communities in places like Togo. These women were highly intelligent, motivated, and hard-working, but had never had the opportunity to receive a formal education. Fortunately for us, this hypothesis bore fruit. When we launched an initial recruitment for 25 Community Health Worker positions, 98 women presented themselves as candidates to their local village chiefs. Of these 98 women, who received the nomination and support of their communities, 36 were selected to undergoing training. Ultimately the highest performing 22, and 3 men from communities where no female candidates applied, were selected to work full-time as paid, equipped, and supervised Community Health Workers.
A Community Health Worker is recruited from her local community, equipped with skills, and charged with providing services to her fellow community members. Hope Through Health’s Community Health Workers work full-time. They go door to door to find and treat sick children and pregnant women, providing referrals for those they cannot treat to a local clinic for more advanced care. In areas throughout the world where distance is a significant barrier to care, Community Health Workers are the great equalizers.
While we expected to find women motivated to fill the role of Community Health Worker, we did not fully grasp, at the time, the myriad of social benefits that would be generated by creating this source of employment for rural women. On the most basic level, this source of employment reinforced women’s sense of self-worth. Kassan, a warm, motherly Community Health Worker with slightly greying hair, explained how her days previously consisted of a repetitive cycle of eating, caring for her family, and sleeping. “Now I have to read and write. I feel like a young girl again,” she exclaimed with pride. When asked if anything had changed for her since becoming a Community Health Worker, the confident and eloquent young Rebecca replied, “Well, they used to call me little girl, now they call me Mama.”
Research shows that women are more likely than men to spend their incomes close to home, to invest in small businesses, and to fund their children’s healthcare and education. This bears out in the experience of our Community Health Workers in Togo, who self-organized into savings groups in order to pool their incomes and grant loans on a rotating basis to enable investments in other income-generating activities. This source of income creates opportunities for these women, their children, and their families, but more importantly, it generates power, which after all is the imbalance at the root of all inequity, including gender inequity.
On her first day on the job, Veronique arrived in tears. As she entered our office, her hand was bleeding. “He doesn’t believe I earned this job; he thinks I slept with someone to get it,” she cried. Her husband had beaten her and stolen her work materials hours before. This wasn’t the first time. Veronique had endured years of violence at the hands of her husband. But this time, she had had enough. She wanted to report him, she told our team, and our staff accompanied her to the police station to file a report.
Undeterred, Veronique has gone on to become one of Hope Through Health’s most effective Community Health Workers. She decided to remain with her husband, but when asked if he still abuses her, she replied with a laugh, “He wouldn’t dare.” Veronique goes on to explain how once she started earning an income, her husband began to treat her differently. “I have a voice now. I give my opinion. I pay for what my children need, and there’s nothing he can do about it.”
While the nuances and complexities of overcoming domestic and gender-based violence, sexual assault, and gender discrimination both inside and outside the workplace should not be understated, it is worth acknowledging the inherent power in creating meaningful employment as a means to help women gain a more equal footing.
The increased attention on gender inequities in global health coincides with a growing recognition of the value of Community Health Workers. The African Union recently called for two million Community Health Workers across Africa. The Gates Foundation, World Health Organization, TED, and others are highlighting the importance of Community Health Workers in achieving Universal Health Coverage, or health for all. Fortunately, there is also increased recognition that Community Health Workers should be paid. A recent report, which Hope Through Health co-authored along with five other organizations, put forth eight critical design principles for effective Community Health Worker programming, which included competitive compensation. We must now be explicit about the tremendous potential for the Community Health Worker movement and broader movement for Universal Health Coverage to advance gender equity in significant ways.
While they are not on social media, nearly every Community Health Worker I know has a #MeToo story. In fact, for too many, their lives have been defined by the things they could not do because of their gender. Beyond simply sharing their stories, these Community Health Workers are changing their realities. Now, their daughters’ lives will not be defined by the things they cannot do as women; they will be defined by the opportunities created for them by their own mothers, through intelligence, determination, and hard work. Not only are these Community Health Workers our best hope for ensuring health for all, they’re a pretty darn good way to put some big cracks in the walls standing between us and a healthier, more equal world.