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Improving the gender dynamics of social enterprises to support volunteer health workers


“She’s like a sister to me,” Sulaina Nassaka says about Ruth Nakuya, a community health promoter in Lwengo District, Uganda. Nakuya, who works with the non-governmental organization BRAC International, recently visited the young mother and treated her son for malaria. “I saw women dying because the hospitals are far away and I knew that my village really needed my help,” Nakuya says.

She is one of 180,000 community health workers in Uganda, according to government statistics. In many developing countries, health promoters like her are the foundation of the health system and the first point of contact with formal healthcare for isolated communities. Serving as the vital link between health facilities and communities, they provide a range of essential health services from prenatal consultations to malaria screenings.

From health volunteers to entrepreneurs

It is estimated that 70% of community health workers worldwide are women, and many are volunteers from the poor areas they serve. Their motivation comes from the good they do and community respect for their position, but given their responsibilities for their own households and families, it is difficult for them to continue their work without being paid.

A growing response to this problem is providing a way for community health workers to earn income through health-related social enterprises that combine income-generating activities with achieving social good. But how do gender inequalities affect their work? Women often live with entrenched gender roles and cultural practices that limit their decision-making power in the home, including their own healthcare needs. Little research has looked at how these gender norms affect their performance in health social enterprises.

BRAC International has partnered with Cape Breton University to study this question in Uganda and Kenya, with support from the Innovating for Maternal and Child Health in Africa (IMCHA) initiative, which is funded by IDRC, Global Affairs Canada, and the Canadian Institutes of Health Research. Their goal is to help identify good practices, training programs, and other interventions to best support community health workers.

“This is the first study of its kind to identify key unanswered research questions relevant to gender equality in health social enterprises using community health workers in Africa,” notes project co-leader Kevin McKague, Canada Research Chair in Social Enterprise and Inclusive Markets and associate professor of Entrepreneurship and Strategy at Cape Breton University.


Improving gender dynamics in health-related social enterprises

The research partners developed case studies of the two main forms of health-related social enterprise to improve understanding of the gender-based challenges that prevent community health workers and social enterprises from achieving their full potential: the clinic and the sales agent models.

Looking at Access Afya, which sells primary healthcare services in Nairobi slums through small clinics and pharmacies, and LifeNet International health centres in Uganda, the case studies of BRAC International in Uganda and Healthy Entrepreneurs focus on the work of community health promoters to sell medications and other health supplies in their communities.

The research found four areas where gender dynamics can be improved:

Social enterprise policies: Developing fair and inclusive workplace policies in social enterprises that support the work-life balance of community health workers can improve gender equality and health outcomes. For example, policies that recognize and support maternity leave or provide opportunities for leadership development and upward mobility within the organization are ways to support the needs of female health workers.

Enterprise-health worker relationship: Support and training provided by the social enterprise can improve gender equality. For example, a social enterprise could provide training in areas such as negotiations and conflict management to help health workers  support pregnant mothers who may be straying from their treatment plan.

Relationships in the home: Engaging the partners and fathers of beneficiaries in maternal and child health initiatives has become a priority recently, but little or no attention has been paid to the partners of community health workers. The health workers surveyed reported that their partner’s support was crucial and even determined their decision to assume their voluntary roles. Greater communication and opportunities for partners to learn about this role would help to pre-empt any misunderstandings within the household and strengthen their support for community health workers.

Community health worker-patient relationship: Gender disparities may occur when products and services do not meet the needs of patients. For example, it may be necessary to provide a private place for female patients and community health workers to meet when discussing intimate issues such as family planning or partner violence. Access Afya, for instance, pairs male and female community health workers to facilitate men-to-men and women-to-women discussions.

Gender equal practices for greater impact

This research is developing an understanding of the gender inequalities faced by community health workers, particularly women workers.

“Gender — the social roles, activities, characteristics, and behaviours that society prescribes for men and women — is an important dimension in human resources for health that has not been given due attention,” says project co-leader Jenipher Twebaze Musoke of BRAC International. Her collaboration with McKague at Cape Breton University and Sarah Harrison, a Canadian gender equality expert, is also identifying ways to overcome gender inequalities.  

“Recognizing and addressing the gender-based issues and constraints at each level would benefit all actors and provide opportunities for win-win strategies to improve both health and business outcomes,” states Harrison.

As the researchers point out, a serious look at gender issues enhances the effectiveness of health-related social enterprises, but it also creates more sustainable impact overall, including greater gender equality for community health workers that can have positive ripple effects throughout society.

Watch a video of Ruth Nakuya and Sulaina Nassaka in Lwengo District, Uganda

Read about another BRAC International and University of Cape Breton research project supported by IMCHA