‘Only God Can Thank You’: Female Health Workers Fight to Be Paid

On a given work day, Misra Yusuf might vaccinate a child against polio, inject a woman with a long-acting contraceptive, screen a man for tuberculosis, hang a bed net to protect a family from malaria and help dig a pit latrine. Over the past few years, she has administered some 10,000 coronavirus vaccines in her community in eastern Ethiopia. She has also spotted and snuffed out a measles outbreak.

She works far more than the 40 hours her contract requires of her each week. For her labor, the Ethiopian government pays her the equivalent of $90 a month.

“The payment is discouraging,” she said. “But I keep going because I value the work.”

Ms. Yusuf is one in a legion of more than three million community health workers globally and is one of a small minority that are actually paid anything at all. Eighty-six percent of community health workers in Africa are completely unpaid.

But now, spurred by frustrations that arose during the Covid pandemic and connected by digital technologies that have reached even remote areas, community health workers are organizing to fight for fair compensation. The movement stretches across developing countries and echoes the labor actions undertaken by female garment workers in many of those nations 40 years ago.

“Community health workers in some countries like Rwanda and Liberia are treating half of malaria cases, they’re doing huge feats of curative care, of promotive care, of preventive care — and yet the vast majority of community health workers around the world are not paid or supported,” said Madeleine Ballard, the chief executive of Community Health Impact Coalition, an advocacy group that is helping with organization and strategy. “This is a gender issue, it’s a public health issue and it’s a labor issue.”

The new pressure is starting to produce results. In Kenya, 100,000 female community health workers recently started to receive stipends — $25 a month, paid by the government — as a newly formalized group of health promoters. The win followed a campaign, coordinated on WhatsApp, in which women posted pictures on social media of themselves doing their jobs and used an app to learn strategies for lobbying politicians.

Margaret Odera, who formed the first WhatsApp group, said she relished her successes helping pregnant women in Nairobi, the Kenyan capital, shield their babies from H.I.V. But she was tired of a decade of being told that “only God can thank you” for the work.

“If you can pay a doctor for saving a life, you can pay me,” she said.

Touting cheap labor costs

For more than a billion people in low-income countries, community health workers deliver the main, and sometimes only, health care they receive over their lifetime. Health and aid organizations, such as the Bill & Melinda Gates Foundation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and USAID, depend on the workers to carry out programs that often have multimillion-dollar budgets. Yet little or nothing in those budgets may be allotted for so-called last-mile delivery.

Current and former senior staff members at those organizations described meetings in which executives applauded programs that could be put in place by unpaid community health workers, celebrating what they called the “cost effectiveness” it would represent. But in the past year or two, that idea has become less publicly acceptable, the staff members said.

“There is no doubt that women’s labor is underpaid and undervalued in the global health work force,” Theresa Hwang, deputy director for gender equality at the Gates Foundation, said. “Currently, there isn’t enough money in national health systems to ensure women get fairly compensated. As a donor in global health, we’re thinking critically about how we can support strengthening those systems and ensure community health workers receive their due.”

“It happens in many of the global health programs, they don’t budget for what it will cost for somebody to do that work,” said Dr. Samukeliso Dube, the executive director of FP2030, an advocacy organization working to expand access to contraceptives globally. Delivery of family planning services relies on community health workers in Ethiopia and many other countries.

In fact, it is often considered a selling point of a program that the delivery can be added to the workload of women who are paid little or nothing, Dr. Dube said. And because the people doing the work are isolated and marginalized women, there is little pushback, she said.

Only 34 of the 193 member states in the United Nations have formalized the role of community health workers with training, accreditation and minimum wages. On Thursday, the U.N. General Assembly, gathering this week in New York, is expected to adopt a declaration on universal health coverage that recognizes the importance of paying community health workers and emphasizes gender equity.

Other prominent international organizations have made such declarations, to little effect. In 2018, the World Health Organization published guidelines for the deployment of community health workers that included a recommendation for fair pay. The World Health Assembly endorsed the idea in 2019.

But, Dr. Ballard said, “pressure is being ratcheted up.”

Community health workers typically have limited formal education, and many live in remote rural areas, factors that have made it difficult for them to organize.

“They’re not in the same factory every day trading notes,” Dr. Ballard said.

The spread of smartphones and free messaging services such as WhatsApp has helped change that.

After women in a role called “lady health worker” in Pakistan won a battle to be paid, their counterparts in Nepal who watched that fight began campaigning for salaries, said Rajendra Acharya, the Asia and Pacific regional secretary of the trade union organization Uni Global, which helped organize the Pakistani workers.

“Now volunteer workers in Bangladesh are looking at some gains made in India and saying, ‘Why not also here?’” he said.

As news has spread to women about recent victories of their colleagues in other countries, “it’s harder for a government to say, ‘Oh no we can’t afford to pay you’ when your neighboring country, with similar circumstances, has brought in a minimum wage for their community health workers,” Dr. Ballard said. “Now we’re a rising tide.”

The Global Fund recently became the first major international health organization to require countries that receive its grants to budget what delivery would be done by community health workers and the funding gap for remunerating them.

A centuries-old model

The idea of delivering health care through community-based workers with minimal formal training goes back hundreds of years. It was seen as a way to serve people who lived in remote areas where physicians, nurses and midwives were scarce or nonexistent. Many countries model their programs loosely on China’s so-called barefoot doctors in the Cultural Revolution in the 1960s.

Health ministries often say they can’t afford to pay community health workers, said Dr. Roopa Dhatt, the executive director of a think tank called Women in Global Health. Resistance also comes from religious and political leaders with traditional views about the role of women and who resist paying them for their work.

“Many groups are interested in keeping women in traditional roles in the household, caring roles, whether it’s for children, their communities, their families, the elderly,” Dr. Dhatt said. “They don’t want to count that as work, they want that to be labeled what women like to do or what women are expected to do.”

Governments urge women to volunteer for community health roles, promising the positions will bolster their social status, or offering small benefits such as access to a bicycle or a mobile phone. Until recently, the idea of admirable volunteerism kept unions from trying to organize community health workers, Dr. Ballard said.

For all the progress made recently, success is still elusive in many places. In India, more than a million community health workers, all of them women, staged a first-ever strike in 2021. They were frustrated by their pay (about $35 per month) and, especially, a lack of personal protective equipment while they were on the front lines of the response to the Covid pandemic. In these first strikes, they had the backing of the powerful All India Trade Union Congress, but their demand for a guaranteed minimum wage has not yet been met.

Victories can also come with a downside for women: When work conditions and pay improve, men often move into the jobs. Liberia had an almost entirely female network of volunteer health assistants. In 2016, the country began a program of training and paying these workers — and soon more than 80 percent of the new jobs were held by men.

The Liberian government is working to rebalance the work force by setting quotas for the hiring of women. It modified the list of required qualifications so that women’s experience in the job is weighed alongside the formal education to which men have more access.

Ms. Yusuf, the community health worker in Ethiopia, has a 10th-grade education but trained for a year before she began her job. Her $90 monthly salary is about half that earned by her husband, a public-school teacher. She would like to transition to a formal nursing career — but she would not be able to pay for the training if she left her current job.

Dozens of studies have found that women who live in rural areas and have limited educational and job opportunities often take community health roles in the hope such work will lead to a paid job, Dr. Ballard said. But such volunteer labor rarely provides that pathway.

Nearly 20 years ago, Ethiopia became one of the first countries in sub-Saharan Africa to make widespread use of what it calls health extension workers. The program quickly produced results: Rates of malaria, AIDS deaths and maternal mortality plummeted. Those women were paid from the outset.

But when it became clear that the two-per-district work force would not be enough to close the primary care gap, Ethiopia opted not to hire more community health workers, instead recruiting an unpaid corps it called the Women’s Development Army. This strategy is now being emulated in other countries, such as Nepal and Ghana.

“You’re left with this: Either community health workers experience grotesque exploitation, given the number of hours and the complexity of tasks they are undertaking relative to their meager wage, or no wage — or, people are not getting health care,” Dr. Ballard said.

Ms. Yusuf said she and her colleagues were seizing every meeting with local officials to complain about their pay.

“Nothing has changed yet,” she said. “But it must.”