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IntroductionAcross a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced.MethodsWe are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews).ResultsCHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes.ConclusionTaking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs’ vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.

Household survey data from 27 sites in 22 countries were collected in 2017–2018 in order to construct and validate a cross-cultural household-level water insecurity scale. The resultant Household Water Insecurity Experiences (HWISE) scale presents a useful tool for monitoring and evaluating water interventions as a complement to traditional metrics used by the development community. It can also help track progress toward achievement of Sustainable Development Goal 6 ‘clean water and sanitation for all’. We present HWISE scale scores from 27 sites as comparative data for future studies using the HWISE scale in low- and middle-income contexts. Site-level mean scores for HWISE-12 (scored 0–36) ranged from 1.64 (SD 4.22) in Pune, India, to 20.90 (7.50) in Cartagena, Colombia, while site-level mean scores for HWISE-4 (scored 0–12) ranged from 0.51 (1.50) in Pune, India, to 8.21 (2.55) in Punjab, Pakistan. Scores tended to be higher in the dry season as expected. Data from this first implementation of the HWISE scale demonstrate the diversity of water insecurity within and across communities and can help to situate findings from future applications of this tool. HIGHLIGHTS We present comparison scores of the Household Water Insecurity Experiences (HWISE) scale, a novel household water insecurity index validated for use in low- and middle-income countries.; These scores can aid interpretation of future implementation of the HWISE scale.; The HWISE scale should still be evaluated in new contexts, such as high-income settings.

Background Substantial evidence supports community health workers' (CHWs) contributions to improving health and reducing inequities. Common evaluation indicators can strengthen the evidence base and support the profession. Objectives We describe the development of a 6-year community-academic partnership to identify common CHW process and outcome indicators. Methods Methods include interviews, focus groups and a survey conducted in Michigan, a Summit in Oregon, consultations at national conferences, and regular conference calls. Results Using popular education as a primary strategy, we have honed our original goal, identified a set of 20 recommended constructs, developed a national constituency with international connections, and obtained dedicated funding. Conclusions Participatory identification, development, and uptake of a set of common indicators (CI) for CHW practice will allow data to be aggregated at multiple levels, potentially leading to more sustainable financing of CHW programs. Given that measurement drives practice, a set of common CHW indicators can help to preserve the flexibility and integrity of the CHW role.

Recently developed scales aim to advance understanding of household water insecurity and inform interventions to address this critical global problem. The relative severity of items included in household water insecurity scales has been established as an inverse of the proportion of the population that reports experiencing the item. Here, we assess subjective perceptions of scale item severity among people who experience household water insecurity. In 2017, we surveyed 259 women in Amhara, Ethiopia, assessing both experiences of water insecurity and perceptions of item severity using a pictorial scale. The mean subjective severity of most items was at the high end of our pictorial scale. Subjective severity of items was not associated with whether or not a participant experienced the item in the last thirty days, with a participant’s summary household water insecurity score, or with rural versus peri-urban residence, but was consistently associated with community of residence. Item severity as defined by the proportion of the population experiencing the item aligned with average perceptions of item severity, with one exception: drinking water that might not be safe. We discuss these findings’ implications for water insecurity measurement, evaluation of interventions, and studies of the relationship between water insecurity and psychological distress.

Despite progress in documenting the outcomes of interventions led by CHWs, the lack of standardized measures to evaluate CHW programs and policies has made it impossible to aggregate data across programs and regions, impeding commitment to sustainable, long-term financing of CHW programs and positions. Lack of comprehensive and easy-to-use indicators hampers the ability of many community-based programs to reliably report outcomes to funders. Lack of attention to the processes by which CHWs achieve outcomes has made it difficult to conclusively demonstrate the importance and effectiveness of particular CHW core roles, skills, and qualities. To address these issues, in 2015 researchers (including CHWs) from five states formed the national CHW Common Indicators (CI) Project. The purpose of the CI Project is to contribute to the integrity, sustainability, and viability of CHW programs through the collaborative development and adoption of a set of common process and outcome constructs and indicators for CHW practice and CHW program implementation. Since its organizing Summit in 2015, CHWs have been at the forefront of the CI Project. Supported by funding from the Centers for Disease Control and Prevention in 2019-2020, the CI Project was able to enhance the engagement of CHWs through a series of stakeholder engagement activities. These activities, along with a systematic literature review, were used to develop evaluation indicators for 10 of the 24 constructs previously identified through a participatory process. Results of the work conducted during 2019-2020 indicate that it is possible to actively engage CHWs in a project that aims to identify common evaluation indicators in the midst of a pandemic. However, doing so effectively requires thoughtful planning, skillful use of popular education methodology, and a team that is aligned around common goals and principles.

There is a growing critical social science literature on volunteering in health programs in non-western, low-income countries, yet few have mixed quantitative and qualitative methods to examine the psychological and social wellbeing of unpaid community health workers in such contexts. We address this issue with data from unpaid community health workers (CHWs) and other women who comprise Ethiopia's state-organized Women's Development Army. We draw on qualitative and cross-sectional survey data collected between 2013 and 2016 to test links between various aspects of psychosocial and economic wellbeing and volunteer status in a rural context. We surveyed 422 adult women in Amhara state, 73 of whom were unpaid CHWs in the “Army”. We also conducted interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women. Analyses of our qualitative and quantitative datasets show that volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects, and that CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women—especially unmarried women—vulnerable to negative gossip and high levels of psychological distress. To a limited extent, the volunteer CHW position also bolsters married women's subjective socioeconomic status and confidence in achieving future gains in status. By showing that unpaid CHWs do not necessarily enjoy psychosocial benefits, and may experience harm as a result of their work, these findings reinforce the recommendation that CHWs in contexts of poverty be paid and better supported.

Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia’s Women’s Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands—and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA—that women’s empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy—allowed the Ethiopian government and its donors to pursue ‘empowerment’ without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.

Water sharing between households could crucially mitigate short‐term household water shortages, yet it is a vastly understudied phenomenon. Here we use comparative survey data from eight sites in seven sub‐Saharan African countries (Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Malawi, Nigeria, and Uganda) to answer three questions: With whom do households share water? What is expected in return? And what roles do need and affordability play in shaping those transfers? We find that water is shared predominantly between neighbors, that transfers are more frequent when water is less available and less affordable, and that most sharing occurs with no expectation of direct payback. These findings identify water sharing, as a form of generalized reciprocity, to be a basic and consistent household coping strategy against shortages and unaffordability of water in sub‐Saharan Africa.

The 2010 Affordable Care Act provided new impetus and funding opportunities for state Medicaid agencies to integrate community health workers (CHWs) into their health systems. Community health workers are trusted community members who participate in training so they can promote health in their own communities. This qualitative study shares lessons and strategies from Oregon's early efforts to integrate CHWs into Medicaid with concomitant financing, policy, and infrastructure issues. Key informant interviews were conducted with 16 Coordinated care organizations (CCO) and analyzed using an iterative, immersion-crystallization approach. Coordinated care organizations found CHW integration a supportive factor for Medicaid-enrolled members navigating health and social services, educating members about disease conditions, and facilitating member engagement in primary care. Barriers to CHW integration included a lack of understanding about CHW roles and their benefits to health systems, as well as a need for more intensive guidance and support on financing and integrating CHW services.

In March 2020, the World Health Organization (WHO) issued a set of public guidelines for Coronavirus Disease 2019 (COVID-19) prevention measures that highlighted handwashing, physical distancing, and household cleaning. These health behaviors are severely compromised in parts of the world that lack secure water supplies, particularly in low- and middle-income countries (LMICs). We used empirical data gathered in 2017-2018 from 8,297 households in 29 sites across 23 LMICs to address the potential implications of water insecurity for COVID-19 prevention and response. These data demonstrate how household water insecurity presents many pathways for limiting personal and environmental hygiene, impeding physical distancing and exacerbating existing social and health vulnerabilities that can lead to more severe COVID-19 outcomes. In the four weeks prior to survey implementation, 45.9% of households in our sample either were unable to wash their hands or reported borrowing water from others, which may undermine hygiene and physical distancing. Further, 70.9% of households experienced one or more water-related problems that potentially undermine COVID-19 control strategies or disease treatment, including insufficient water for bathing, laundering, or taking medication; drinking unsafe water; going to sleep thirsty; or having little-to-no drinking water. These findings help identify where water provision is most relevant to managing COVID-19 spread and outcomes.

Billions of people globally, living with various degrees of water insecurity, obtain their household and drinking water from diverse sources that can absorb a disproportionate amount of a household's income. In theory, there are income and expenditure thresholds associated with effective mitigation of household water insecurity, but there is little empirical research about these mechanisms and thresholds in low- and middle-income settings. This study used data from 3655 households from 23 water-insecure sites in 20 countries to explore the relationship between cash water expenditures (measured as a Z-score, percent of income, and Z-score of percent of income) and a household water insecurity score, and whether income moderated that relationship. We also assessed whether water expenditures moderated the relationships between water insecurity and both food insecurity and perceived stress. Using tobit mixed effects regression models, we observed a positive association between multiple measures of water expenditures and a household water insecurity score, controlling for demographic characteristics and accounting for clustering within neighborhoods and study sites. The positive relationships between water expenditures and water insecurity persisted even when adjusted for income, while income was independently negatively associated with water insecurity. Water expenditures were also positively associated with food insecurity and perceived stress. These results underscore the complex relationships between water insecurity, food insecurity, and perceived stress and suggest that water infrastructure interventions that increase water costs to households without anti-poverty and income generation interventions will likely exacerbate experiences of household water insecurity, especially for the lowest-income households.

Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from $1.50 to $2.40 per day. International officials defended per diems for CHWs with an array of arguments, primarily that they were necessary to defray the expenses that workers incurred during campaigns. But high-level ministry of health officials in many countries were concerned that even small per diems were unsustainable. By contrast, CHWs saw per diems as a wage; the very small size of this wage led many to describe per diems as unjust. Per diem polio work existed in the larger context of limited and mostly exploitative options for female labor. Taking the perspectives of CHWs seriously would shift the international conversation about per diems toward questions of labor rights and justice in global health pay structures.

Global health is a field of expertise that has emerged at the turn of the twenty-first century alongside changing disease profiles, health technologies, and governance structures. This entry provides an overview of the historical conditions that have given rise to the field. It illustrates the new political and financial transformations that have made global health 'global', in contrast to earlier work on international, world, or tropical health. It also charts new undertandings of wellness and disease, which have been shaped by global pandemics including HIV, the increase in non-communicable illnesses, and the recent concern for planetary sustainability. While anthropologists have played a central role in global health since its inception, the fields of anthropology and global health also operate in an 'awkward relation' (Strathern 1987) with one another. In the second part of the entry, we overview how anthropologists work within, against, and in-between the expertise of other global health practitioners. We suggest that insofar as the field of global health is emergent, so too are the ways that anthropologists engage with it. ​

Little empirical research exists on the effects of health work on Community Health Workers' (CHWs') social relationships and status, yet these factors are important in understanding the broad social and behavioral drivers and impacts of CHW programs. This is particularly true for unpaid CHWs. Engaging with others as a CHW might help a worker to embody a valued role in society as a selfless, caring individual; or it might strengthen bonds with others and improve social networks and social capital. By combining qualitative, ethnographic, and survey data collected in rural Amhara, Ethiopia from 2013 to 2016, we evaluated the extent to which unpaid female workers in Ethiopia's Women's Development Army (WDA) were better able than their peers to achieve cultural consonance by building desired social connections or fulfilling locally salient models of virtuous womanhood. We conducted a cultural consensus survey (n = 74) and measured cultural consonance in a larger survey of adult women, including WDA leaders (n = 422). We also conducted participant observation and interviews with health officials, local health staff, and WDA leaders. In our study site, WDA leaders were more able than other women to fulfill the cultural ideal of having connections to various government officials. Yet these connections often did not lead to the benefits that WDA leaders hoped for. Also, in contrast to the findings of many other studies, achieving greater cultural consonance was not significantly associated with reduced psychological distress in this population. For women in this rural context, meanwhile, psychological distress is strongly associated with food and water insecurity, stressful life events, and social support. These findings point to the importance of social, economic and psychological support for rural women in Amhara, and specifically for unpaid CHWs.

Many of medical anthropology's most pressing research questions require an understanding how infections, money, and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This article describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior.

Water sharing offers insight into the everyday and, at times, invisible ties that bind people and households with water and to one another. Water sharing can take many forms, including so-called “pure gifts,” balanced exchanges, and negative reciprocity. In this paper, we examine water sharing between households as a culturally-embedded practice that may be both need-based and symbolically meaningful. Drawing on a wide-ranging review of diverse literatures, we describe how households practice water sharing cross-culturally in the context of four livelihood strategies (hunter-gatherer, pastoralist, agricultural, and urban). We then explore how cross-cutting material conditions (risks and costs/benefits, infrastructure and technologies), socio-economic processes (social and political power, water entitlements, ethnicity and gender, territorial sovereignty), and cultural norms (moral economies of water, water ontologies, and religious beliefs) shape water sharing practices. Finally, we identify five new directions for future research on water sharing: conceptualization of water sharing; exploitation and status accumulation through water sharing, biocultural approaches to the health risks and benefits of water sharing, cultural meanings and socio-economic values of waters shared; and water sharing as a way to enact resistance and build alternative economies.

Background Many Community Health Workers (CHWs) experience the same socioeconomic and health needs as their neighbors, given that they are by definition part of their communities. Yet very few studies aim to measure and characterize experiences of deprivation, poverty, and wellbeing among community health workers. This study quantitatively examines deprivation and wellbeing in Ethiopia’s Women’s Development Army (WDA), a massive unpaid community health workforce intended to improve population health and modernize the country. Methods We conducted a survey of 422 volunteer WDA leaders and community members in rural Amhara state, part of a mixed-methods ethnographic study of the experiences of women in the WDA. The survey asked a variety of questions about respondents’ demographics, education, assets, and access to government services. We also used survey measures to evaluate respondents’ levels of household food and water security, stressful life events, social support, work burden, and psychological distress. Results Volunteer WDA leaders and community members alike tend to have very low levels of schooling and household assets, and to be heavily burdened with daily work in several domains. Large proportions are food and water insecure, many are in debt, and many experience stretches of time with no money at all. Our survey also revealed differences between volunteer WDA leaders and other women that warrant attention. Leaders are less likely to be married and more likely to be divorced or separated. Leaders are also more likely to experience some aspects of food insecurity and report greater levels of psychological distress and more stressful life events. They also report slightly less social support than other women. Conclusions In rural Amhara, women who seek out and/or are sought and recruited for leader roles in the WDA are a population living in precarity. In several domains, they experience even more hardship than their neighbors. These findings highlight a need for careful attention and further research into processes of volunteer CHW selection, and to determine whether or not volunteering for CHW programs increases socioeconomic and health risks among volunteers. CHW programs in settings of poverty should stop using unpaid labor and seek to create more paid CHW jobs.

Creating community health worker jobs in the public sector is a prominent goal in the global health development industry. According to industry leaders, Ethiopia’s government has created community health worker jobs at a scale and in a way that other countries can look to as a model. Based on extensive document review and interviews with district, national, and international health officials, we show that narratives about saving lives, empowering women, and creating model citizens in a context of resource scarcity allow Ethiopia’s ruling party to obtain international admiration for creating salaried community health worker jobs and to simultaneously avoid criticisms of its concurrent use of unpaid women’s community health labor. Public sector community health worker investments in the twenty-first century reveal the layered narratives inherent in global development practices that entangle states, international donors, NGOs, and citizens.

In this article, we use semistructured interviews and documents produced by Ethiopian government officials and international health donors to examine two key features of the nation's community health worker (CHW) program: (1) the process and criteria of selecting community health workers; and (2) policies, rhetoric, and experiences of payment and empowerment. We examine these from the varied perspectives of district health officials, Health Extension Workers, and leaders and members within Ethiopia's so-called Women's Development Army, whom we interviewed during 2012–14. According to national policymakers and policy documents, the goals of the Women's Development Army are twofold: first, to reduce mortality and second, to produce “model” women, who discipline themselves and their neighbors to enact healthy behaviors. The Army is supposed to simultaneously “empower” these women to be more autonomous from husbands and more active in development-oriented work. Yet one of the key criteria sought by district-level health officials—willingness to “accept what we teach them and implement what we tell them”—highlights that Army leaders are to remain subordinate to government health officials. Many female members of the Women's Development Army expressed ambivalence about their selection, particularly as the position was unpaid. Some questioned why women were expected to volunteer when men had previously been paid to do similar work. These data emphasize the differences in goals, aims, and experiences among various actors involved in CHW programs, and the need for researchers to address whether or not respondents are comfortable to express perspectives that might question dominant goals and discourses.

Major global health institutions, public and private, currently see community health workers (CHWs) as crucial resources. But the daily experiences and complex motives of CHWs, as well as their concerns and criticisms, remain poorly understood by the institutions that promote their value and draw on their labor. Donors, states, NGOs, and other public health institutions often approach the motivations and performance of CHWs as problems that can be solved with a mix of psychological, economic, and management theories; novel incentive packages and supervisory structures; and surveys, interviews, and randomized controlled trials. This special issue shifts the goal toward documenting power inequalities, labor relations, and interactions among CHWs, donors, health officials, supervisors, and care recipients. The articles in this issue offer valuable ethnographic accounts of CHWs in 21st-century Africa, Latin America, and Asia, and deliver a clear message: CHWs participate in important relationships and politics, seeking change in their own job conditions and roles, and other social, political, and economic changes. These forms of “participation” are variable, evolving, and shaped by unique local histories as well as transnational policies and norms. The articles here aim to demonstrate that ethnography and mixed methods can help bring about improvements in policy and practice by explaining and interpreting CHW practices and governance and by encouraging global health actors to treat CHWs not as magic bullets or human resources, but as people with multiple skills, desires, and perspectives.

Many of medical anthropology's most pressing research questions require an understanding how infections, money and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This paper describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior. This article is protected by copyright. All rights reserved.