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Table 2 Key areas for policy change based on factors influencing recruitment and retention from the conceptual framework relevant to our findings

From: Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique’s community health workforce

Health system goals

Policy changes and rationale

Recruitment factors

 Training

Modular, flexible training options support both men and women who balance APE work with other paid employment opportunities and domestic obligations. This can also help to reduce issues around the length of training APEs face in being away from family obligations.

Residential training can create a sense of solidarity but can be limiting for women with childcare responsibilities, and men who feel a duty to provide for their families. On-site childcare should be offered to support this.

 Household dynamics

Community sensitisation programmes to encourage women to have autonomy in decision-making over livelihoods and challenge patriarchal norms.

 Selection

Training with community leaders on gender and power relations as well APE roles, programme aims and importance of accountability to ensure women have equal opportunities for selection.

Retention factors

 Remuneration and social security

Remuneration for APEs commensurate with working hours and skills (in hand with strict selection criteria to ensure equal selection of women). This will help reduce attrition and improve motivation.

Social security in the form of employment-based health insurance, a component of universal health coverage, should be provided.

Contracts should ideally be issued to formalise labour rights for CHWs, such as maternity and paternity leave and holiday and sick pay. This provides security to APEs and does not discriminate against women for their reproductive roles.

 Career progression

Sufficient educational opportunities to improve literacy for female CHWs who want to go on to further education would contribute positively to the development of communities.

Sufficient sponsored courses for eligible female and male APEs to undertake further training to enter into the health system.

Opportunities for a career structure, e.g. promotion to supervisor or senior APE. This should be considered alongside barriers women may face to get there and be accompanied by mentorship, supportive supervision and preferential selection of qualified female candidates until gender parity is achieved.

 Working conditions

Provision of formal, stocked health posts for APEs to support the safety and legitimacy of the cadre.

Sensitisation on gender-based violence with community members.