The problem: a dual human rights issue.

Wuqu’ Kawoq

A moral dilemma and moral imperative.

Despite decades of global health investment, 1 billion people cannot access essential health services. They live in both rural and urban areas, commonly defined as the hardest-to-reach communities.

The traditional model demands that families find their way to a doctor or hospital for their healthcare needs. But millions of families live hours—sometimes days—from the nearest clinic. It’s an automatic death sentence.

The standard solution—building more clinics and hiring more doctors—is insufficient. New clinics have conspicuously failed to reach those living in the most remote communities. Health for all requires delivery for every person in every village. And we can get there by seeking new opportunities in an old idea: community health workers (CHWs).

CHWs are an integral occupational group of the primary healthcare workforce. But are neglected and disconnected from the formal health system—unsupervised, unequipped, and unpaid.

So it’s a moral failure too.

By 2030, the WHO estimates a global shortfall of 18 million health workers. CHWs are poised, ready, and key to filling that gap. So there’s not a shortage of labor. Instead, there’s an excess of exploitation.

The global community seeks to provide healthcare “on the cheap” at the expense of the CHWs delivering it. The status quo perpetuates a nasty cycle where CHWs are underpaid and consequently devalued.

Financing remains one of the most significant systematic barriers to scaling and sustaining community health services. Africa alone sees a $4 billion financing gap for community health.

Then worldwide, CHWs face essential medicine stock-outs 1/3 of the time. These widespread shortcomings in community health programs result in CHWs being absent, ill-equipped, or facing grave dangers—like the lack of PPE during COVID.

But this needn’t be the case. Think about it if you had a factory. And you didn’t supervise, pay, or equip your employees. What type of product do you think you would get? Probably a non-existent one.

And that’s precisely what we see too often regarding CHW programs.

Linked causes of misery

It’s a dual-sided human rights issue: CHWs are exploited and less effective for patients.

“Structural violence” describes how these economic forces and social arrangements put people in harm’s way. Nothing is broken. The system we’re all caught up in is set up to exploit.

Hard-to-reach communities shouldn’t have to wonder if, how, and from whom they will access healthcare. And CHWs shouldn’t have to carry the health system on their backs. Both are an indictment of the system we built.

From Bangladesh to Uganda, the global community faces a moral dilemma and moral imperative. Will we commit to decent work in community health? Or will we continue to build health systems on the backs of an unpaid, predominantly female workforce?

Muso woman in vest

The debate is over

An inequitable system of unpaid labor.

The debate is over. It’s fundamentally exploitative to expect the poor to volunteer as a condition to guarantee their own right to health.

Fighting one injustice (lack of access to health) by perpetuating another (not paying CHWs) is not justice. Demanding that individuals volunteer to access healthcare for themselves and their families is an act of coercion.

In contexts of high unemployment and poorly resourced health systems, the risk for exploitation is high. Time-use studies prove it. CHWs are not spending five or 10 hours per week volunteering in their communities. Most CHWs are spending 30-40 hours per week.

What motivates community health workers? No surprise, monthly payment is the most important motivational factor named.

Look a CHW in the eye and tell her the malaria cases she treats, the vaccines she distributes, and the chronic disease support she provides is not work.

Recognition is the icing, but there is no cake. We’re applauding health workers as heroes. To then not pay them is an affront to decency. CHWs want lasting social contracts, not pats on the back.

For decades, insufficient incentivization has been cited in primary studies as a barrier to the sustainability and scaling of CHW programs.

Half of all CHWs in low- and middle-income countries (LMICs) are not salaried, including 86% in Africa.

85% of CHWs in India reported spending as much as half their salary to buy their own COVID safety gear.

A 2018 report shows that CHWs in Sierra Leone receive soap and batteries as the main form of incentive.

From performance-based incentives in Rwanda to volunteer models in Ghana to contracting models in Nigeria, CHWs remain underpaid in direct contradiction to what the evidence says we should do. Specific approaches to CHW compensation are more promising than others. Particularly, public sector or models with public sector wage floors.

But countries’ legal frameworks are not the only problem. For decades, donor-funded programs have signaled that delivering healthcare via unpaid labor is an acceptable option.

The steep gradient of inequality.

Some frame “whether” to pay community health workers as a “key financing policy choice.” We wonder: is the same true of doctors? Nurses? What about the various consultancies, academies, and foundations that employ much of the global development sector? Do they face similar policy choices?

How do we know your program is “cost-effective” if it’s delivered by unpaid labor?

“Whether” to pay community health workers can no longer be framed as a policy choice about which reasonable minds can disagree. CHWs from south Asia to southern Africa have long demanded fair compensation. It is well past time to cease technocratic cover for those blocking their efforts.

To be a member of the working poor or a CHW is to be an anonymous donor. A nameless benefactor to everybody else. We look forward to when CHWs are no longer the leading philanthropists.

“It’s hard to think of a better set of people that you would want to be paying if you think about it from both the point of view of creating good jobs as well as maximizing the health impact,” says Peter Sands, Global Fund’s executive director.

Now is the time to dismantle this inequitable system. One that depends on unpaid labor from socio-economically disadvantaged communities. And put in its place a system in which we guarantee every CHW fair pay.

Community Health Impact Coalition

Connected struggles: gender equality

A minimum of six million women work unpaid or grossly underpaid in community health roles, in order to prop up health systems.

The Lancet Commission on Women and Health estimated that women contribute $3 trillion to global health annually—half in the form of unpaid work. And it’s primarily women of color.

The debate around professional CHWs is more than a public health issue. It’s also inherently a gender equity and labor rights issue.

We fail to empathize with women’s severe social and economic constraints in specific marketplaces. Gender norms and power relations disadvantage women and lead them to this form of wage slavery. CHWs accept no or low wages for what should clearly be waged work.

Women from low-income families and with low levels of education often view unpaid work as an opportunity. One that might lead to some paid work or an asset like a mobile phone or bicycle. Unpaid work in health can also bring women social recognition. And in many contexts, it is seen as “honorable work” that families will approve of for a woman.

Research shows that for others, it offers free passage out of the home to move about for a positive purpose. An opportunity to learn. And also to achieve personal and professional rewards.

The bottom line is that women do this work because of being backed into a gendered corner. Their choices are constrained simply by being women. Men have greater mobility, more options. And, although many women benefit in ways and might choose to continue doing this work, CHWs want to be fairly paid.

Community health workers have been around for more than a century. Yet, the vast majority are unpaid. Then we dare to focus on a woman’s curious choices. Rather, we should demand why state actors, charities, bilaterals, and philanthropies—that are supposed to be supporting women—fail to accept the financial responsibility for healthcare delivery. And instead, pass on the cost to financially disempowered individuals—impoverished women who are asked to volunteer to guarantee their own right to health.