By: Svea Closser (Johns Hopkins University), Kenneth Maes (Oregon State University), and Sarah Fossett (Middlebury College)
Women’s Development Army
This Wednesday, as usual in this small town in rural Amhara, Eleni was running a weekly meeting with 30 women. The meeting was delayed in the midst of a spontaneous downpour, but as soon as the weather passed, women began to gather in the communal meeting space, where large sticks supported a straw roof. The women chatted easily, and many of their children played and yelled nearby. Eleni commanded the center of the room. Her first role of the day was bookkeeper for a lending circle; she collected small sums of money from each woman, signing a notebook to record every transaction.
Eleni is a leader of the Women’s Development Army (WDA), a government sponsored organization of volunteer community health workers in Ethiopia. The Ethiopian government created the WDA in 2011 to supplement its Health Extension Program, which aims to expand primary health care to rural communities. We’ve been doing field research in Amhara to understand this program better, interviewing government officials, health workers, and women in the WDA.
The core workforce of the Health Extension Program is made up of over 30,000 paid female Health Extension Workers. But the workload far exceeds their capacity to meet it: to reach the number of paid CHWs per capita that the 1 Million CHW Campaign recommends, there would need to be about four times as many Health Extension Workers. The Women’s Development Army is meant to help bridge this gap.
Community health work and empowerment
The government has promoted the WDA as a move towards women’s empowerment. Ethiopia’s 2010 Health Sector Development Plan says that participants in the WDA “are being empowered to monitor health and well-being.” District-level government officials told us that the WDA was increasing womens’ autonomy vis-à-vis their husbands. They asserted that by helping women to increase their knowledge, expand their social networks, and “develop their leading ability” through new social interactions, the Development Army was “keeping women happy, even without payment.”
Eleni was raising her children on her own. She earned a meager income by distilling areke (moonshine) to sell at the weekly market, and her parents helped her out a little. Eleni had little to share, but she enthusiastically invited us over. The tiny stick-and-mud room she rented was furnished with a bed, a small coal stove, and two wooden benches. No matter how much we protested second and third helpings, she fed us until we could barely move.
After dinner, Eleni shared some of the difficulties she had overcome. She was raped in 9th grade and married to her rapist. After five years, the local Women’s Affairs office helped her secure a divorce. Eleni worked as a WDA leader because she wanted to help other women in similar ways.
Eleni said she was glad to work for the WDA: she would rather “do something beneficial for another woman, like teach her to read, or help my community, instead of sit around all day.” Yet, being unpaid, this work came with its own set of limitations. Eleni wanted to start her own business, but this was almost impossible for her to achieve. She had started savings circles in her WDA groups, but the women were only able to scrape together 5 birr (25 cents) per week. One of Eleni’s groups dreamed of purchasing a motorcycle rickshaw, but saving up the money to buy one could take them nearly 70 years.
The relationships between community health work and empowerment are complex, and shaped by high-level policy decisions as well as on-the-ground dynamics. Eleni is the driver of a beneficial social network of women in her community. The implementation of the WDA program has fostered the creation of a well-functioning lending circle (even if the amounts that women are able to save are painfully small). And arguably, Eleni has benefitted from her work in the WDA as well. Yet she remains trapped in severe poverty, giving substantial labor for little monetary reward.
Other WDA leaders told us that there was little opportunity for women to set their own goals for the nature of their volunteer work or the trajectory of their careers. In response to whether she could ask questions of or make suggestions to her government supervisors, one WDA leader said, “It would get no answer. We can ask questions, but the problem is, there are some questions that can’t be asked.” The WDA provides new opportunities for limited professionalization for women in rural Ethiopia. But WDA leaders are largely unable to set their own agendas, instead expected to carry out government demands. And their lack of pay means that most remain trapped in severe poverty.
These complicated dynamics are not unique to WDA leaders. Health Extension Workers experience many of the same problems (though as they tend to be a bit better off, their problems with poverty are less acute). And across the world, many unpaid and poorly paid CHWs are at once empowered and profoundly limited by their work. Yet most reports and newsletters put out by NGOs, donors, and governments ignore these complexities, instead portraying happy, sacrificing CHWs.
Stories like Eleni’s lead to a new set of possible ways to make CHW programs stronger. Ethiopia’s Health Extension Program is frequently touted as a model. But acknowledging its complexities as well as its strengths points to some ways it could be further improved. What if programs like the WDA were given much greater investments by donors and governments, so that women like Eleni could be paid a living wage? What if workers were allowed to organize and demand accountability from states and donors? Such steps would be far from simple in the Ethiopian context. But the question of how to better serve CHWs is worth attention and thought.
More honest representations of the complex effects of community health work are important: not to tear down these important programs, but to point to ways that they could be stronger. Empowering CHWs can begin within the health system that employs them. In the case of Ethiopia’s WDA, this group of women in high poverty situations could use more support. Providing CHWs with just pay, opportunities for advancement, and representation in high-level policy decisions for both would motivate and truly empower them.
- Does volunteer community health work empower women? Evidence from Ethiopia’s Women’s Development Army, Health Policy and Planning, czz025, https://doi.org/10.1093/heapol/czz025