This article is written by Jennifer Schechter, chief executive officer, Marie Sahaletou Yelebo, development and communications assistant, and Jessica Cook, Communications Associate at Integrate Health

On a normal day, Nako wakes up early to walk from Togo to Ghana to sell produce.

Her livelihood depends on her ability to sell from village to village and across borders. Due to the recent travel restrictions enacted to protect against Covid-19, Nako has lost her economic livelihood and subsequently her ability to meet her family’s basic needs, like food and healthcare. Without legal or financial protection, Nako is unable to find support during this time.

Nako’s story is far from unique. 92% of women’s employment in Sub-Saharan Africa is informal. Like Nako, over 70% of cross-border traders in Africa are women whose incomes rely on their ability to travel long distances to sell products. Informal jobs leave female workers without insurance or access to financial support, including loans.

While Africa may not be the pandemic epicenter, it will be the epicenter of pandemic induced poverty. Women will bear the brunt of this burden.

The United Nations warns that re-prioritisation of resources during the pandemic away from the provision of sexual and reproductive health services may have a consequential impact on maternal mortality and morbidity, and the rates of HIV and sexually transmitted diseases

In this way, the pandemic is once again exposing the systemic injustices that have historically disadvantaged women across Sub-Saharan Africa. As the world’s attention remains focused on the pandemic, this is an opportune moment to overturn these injustices.

By applying a gendered lens to enact transformative health and economic policies, countries can build a more resilient health system in the short term and ensure the wellbeing of their entire population for the long-term.

Health and Economic Barriers

Even prior to COVID-19, women faced multiple barriers to accessing quality healthcare services, especially in under-resourced communities across Sub-Saharan Africa.

The Covid-19 pandemic has entrenched these barriers, further limiting women’s access to care. The United Nations warns that re-prioritisation of resources during the pandemic away from the provision of sexual and reproductive health services may have a consequential impact on maternal mortality and morbidity, and the rates of HIV and sexually transmitted diseases. Worryingly, supply chain disruptions are now severely limiting the global supply of contraception. The UNFPA projects that close to 47 million women who rely contraception may not be able to ensure continued access, which could result in over 7 million unintended pregnancies.

A World Bank study found that women’s labour force participation changes greatly in response to an economic crisis in low-income countries, whereas men’s labour force participation remains “largely unchanged.” Following the Ebola epidemic in West Africa, men’s income returned quicker to what they had made pre-outbreak than the women’s income. These consequences do not impact women alone, as women are often more likely to take on caregiving roles in the family. Financial insecurity will delay care-seeking for children and could exacerbate food insecurity. This has been illustrated during the Ebola epidemic in the DRC, where access to healthcare was cited as the number one concern amongst women. As a result of the pandemic, cost of transport greatly increased, leaving women unable to seek care due to financial insecurity.

So how can policymakers strengthen health systems and begin to rectify the systemic injustices that rendered women more vulnerable in the first place? Below are the first steps that all governments can take.

1. Hire, train, equip and pay a cadre of women as Community Health Workers to respond to immediate health needs

Covid-19 has revealed the crucial role Community Health Workers (CHWs) play in the health system. CHWs are trusted community members trained to work as frontline healthcare providers in their communities.

Countries must enact policies that ensure the provision of basic healthcare free of charge to the most vulnerable members of the population, women and children

Research has shown that because CHWs are members of the community, they are able to garner community trust, leading to more effective communication. As a result, CHWs are more likely to possess information about who is falling sick, be able to identify clusters of disease and encourage compliance with public health regulations. Vital during pandemics, CHWs extend access to basic health services at all times to areas that lack sufficient healthcare providers. CHW programs are most effective when they adhere to core design principles. Countries with existing CHW programs should leverage CHWs in their Covid-19 response.

Countries without or with nascent CHW programs can use the current focus on health to drive policy changes and secure the resource allocation necessary to expand effective CHW programs. Well-designed and managed CHW programs can deliver broad health benefits, enhance pandemic preparedness and serve as an essential job creation mechanism for women ⁠— who are disproportionately left out of education and leadership opportunities, especially in the healthcare sector.

2. Remove point of care fees for women and children both during and after the pandemic

Despite significant decreases over the past two decades, women and children still face unacceptably high mortality rates. 52% of maternal deaths globally are attributable to preventable causes and 43% of deaths of children under 5 are due to infectious diseases, which are primarily preventable. This burden is concentrated in sub-Saharan Africa where the maternal mortality rate remains high at 533 deaths per 100,000 live births and 1 in 13 children die before their fifth birthday.

Research has shown that user fees present a barrier to accessing care for women and children. During economic hardship, these consequences will be exacerbated both during and long after the end of the pandemic. In countries where user fees have been eliminated for certain maternal and child health services, including Ghana, Sierra Leone, Senegal, and Burkina Faso, we’ve seen an increase in the utilisation of those services. Right now, it is imperative that countries stop charging women for the cost of essential primary healthcare services for themselves and their children. Countries must enact policies that ensure the provision of basic healthcare free of charge to the most vulnerable members of the population, women and children.

3. Aim economic interventions at women engaged in the informal sector

Informal labour leaves workers with little protection, including insurance or access to financial services. During a pandemic, the consequences of this are exacerbated. One solution, which is currently being piloted in Togo, is targeted cash transfers. Research has shown that when women receive cash transfers, it will benefit the entire household and community.

These recommendations are not comprehensive, nor exhaustive. But they are a start

Furthermore, women’s economic empowerment is associated with greater investment in preventative services for women and children. Economic interventions such as cash transfers or access to credits or loans must not only include women but must be aimed at women. Financial training must also be easily accessible in the immediate while prioritising educational opportunities for young girls. In the long-term, countries should support and involve organisations and businesses that are women-led for long-term economic success.

  1. Prioritise women in leadership roles, particularly in government roles

Women make up more than 70% of the health and social sector workforce but only 25% of the leadership globally.

This is unwise for both pandemic response and overall well being of a country. By incorporating women into a pandemic response, greater attention will be paid to the consequences of the pandemic on women. Women must also be elevated to government leadership positions. Although the number of government leaders in Africa has increased in the last 20 years, women leaders still only make up 22% of the total. Electing women to leadership roles may have an important impact on health system resilience. Research has shown that women leaders give priority to health which suggests that by electing women in leadership roles, health systems will be stronger in the long-term.

These recommendations are not comprehensive, nor exhaustive. But they are a start. Covid-19 provides a window of opportunity to rebuild stronger, more resilient health and economic systems. We must begin the process of unravelling the injustices that have held women back and made them more vulnerable to the current pandemic. In doing so, countries will unlock the full potential of their populations and emerge from this global pandemic stronger and more resilient. ⁠— Jennifer Schechter, Marie Sahaletou Yelebo, and Jessica Cook

(Picture credit: Unsplash)

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