Abstract
BackgroundMozambique’s community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). The Government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique.MethodsWe employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise the findings.FindingsIn-depth interviews (n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband’s consent. Training programmes outside of the community were viewed positively as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain.ConclusionGender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo Province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.
Highlights
Community health workers’ gendered experiences Community health workers (CHWs) are increasingly relied upon to supplement human resources for health shortages in low- and middle-income countries
Both districts in our study area had greater numbers of women working as Agentes Polivalentes Elementares (APE), which is at odds to what is seen in the country as a whole and the dynamic in the north of the country
Research on health systems often focuses on social determinants, such as gender, as isolated factors
Summary
Community health workers’ gendered experiences Community health workers (CHWs) are increasingly relied upon to supplement human resources for health shortages in low- and middle-income countries. CHWs occupy a unique interface position between communities and the health system and can reach marginalised communities. Voluntary programmes reinforce the gendered segregation of the caring role, where women and girls constitute most of the informal care workforce [13, 14] and may be difficult for men, often perceived as breadwinners, to commit to [1]. These supply-side gender dimensions are not reflected in policies which establish and guide CHW programming. This study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique
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