The Gendered Experience of Close to Community Providers during COVID-19 Response in Fragile Settings: A Multi-Country Analysis

Many countries, and particularly those including fragile contexts, have a shortage of formal health workers and are increasingly looking to close-to-community (CTC) providers to fill the gap. The experiences of CTC providers are shaped by context-embedded gender roles and relations. This qualitative research study in Lebanon, Nepal, Myanmar and Sierra Leone explored the gendered experiences of CTC providers during the COVID-19 pandemic in fragile settings. We used document review, in-depth interviews or focus group discussions with CTC providers, and key informant interviews with local stakeholders to generate in-depth and contextual information. The COVID-19-associated lockdowns and school closures brought additional stresses, with a gendered division of labour acutely felt by women CTC providers. Their work is poorly or not remunerated and is seen as risky. CTC providers are embedded within their communities with a strong willingness to serve. However, they experienced fractures in community trust and were sometimes viewed as a COVID-19 risk. During COVID-19, CTC providers experienced additional responsibilities on top of their routine work and family commitments, shaped by gender, and were not always receiving the support required. Understanding their experience through a gender lens is critical to developing equitable and inclusive approaches to support the COVID-19 response and future crises.

Supporting community health workers in fragile settings from a gender perspective: a qualitative study.

OBJECTIVE: To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. SETTING: Two districts in three fragile countries. Sierra Leone-Kenema and Bonthe districts; Liberia-two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)-Aru and Bunia districts in Ituri Province. PARTICIPANTS AND METHODS: Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). RESULTS: While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. CONCLUSIONS: Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre.

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone.

INTRODUCTION: The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone. METHODS: Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis. RESULTS: From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. CONCLUSION: The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.