Back in 2024, former Chief Executive Officer Jennifer Schechter wrote a piece she called “There Can Be No Health Equity Without Gender Equity.” The issue she named reached far beyond Togo, and far beyond Community Health Workers (CHWs): working women everywhere carry a triple burden: at home, in their communities, and on the job. They hold a disproportionate share of household responsibilities, face suspicion and cultural resistance in their own communities, and are still expected to meet every professional obligation on top of it. The title was more than a statement of values. It captured a reality we had been confronting for years.
Integrate Health’s gender equity journey started with a simple conviction: women could be great CHWs. When we launched the Integrated Primary Care Program (IPCP) in Togo, we hired accordingly. Today in Togo, 95% of our CHWs are women.
But gender equity doesn’t stop there. Giving women knowledge and economic opportunity is the easy part. What comes after is the real equity work, and the heavy lift, because we didn’t just give women a job. We gave them power. We handed authority and income to people who, structurally, weren’t supposed to hold either. In communities built on strict gender norms, that shift provokes a reaction: from husbands, in-laws, and community leaders, no matter how carefully we prepared the groundwork. As such, gender equity carries real opportunity, and it carries a duty of care and protection that has to be built in.
So in 2024, we started thinking in earnest about what it actually takes to build interventions that are gender-transformative, not just gender-aware. We began with an in-depth literature review alongside a like-minded peer, Last Mile Health, which became the Gender Framework for Action and its sixteen recommendations for implementers and policymakers. A few months later, we took those recommendations back to the people living them and asked our thirteen CHW Ambassadors in Togo what their own experience had been. We listened. What we heard was hard, and it was exactly the reality we needed to hear: mockery and jealousy between health workers, husbands who needed convincing to become allies, women labeled “traitors” by their own community for reporting violence. And alongside it, something we chose to hold onto just as tightly: other women naming these Ambassadors as role models, the ones who dared, the ones showing what was possible.
The grant that turned conviction into action
In July 2025, Integrate Health was awarded a grant from the UBS Optimus Foundation, a multi-year initiative to build gender-transformative primary healthcare delivery in West Africa. The idea was to use the funds to reinforce our IPCP: addressing the gender inequities CHWs face in their professional and personal lives, and engaging men and communities as active partners in improving them. Across Togo and Guinea, the grant has three objectives:
- Design the interventions with the most transformative impact possible for our own CHWs
- Replicate and adapt what we learn into new interventions in Guinea
- Synthesize what both countries teach us into something we can hand to government partners so that it informs national policy rather than staying inside one organization’s program.
Grants like this one are rare. Almost everyone in global health will agree that gender and health are intertwined, but very few will fund work that treats that as true, because it’s hard to prove with data that our systems were never built to capture. Gender isn’t a variable sitting outside the health system waiting to be tested; it’s part of how the system already operates. It shapes who delivers care, who receives it, who makes decisions, and who carries the risk.
This is the gap that the UBS Optimus Foundation grant helps fill. The foundation invested before every part of the case had been proven, making it possible to test, learn, and build the evidence responsibly. Meaningful change rarely begins with perfect proof. It begins when someone is willing to act on what communities, health workers, and years of experience are already telling us, and then create the evidence needed to go further.
The formative study: listening before acting
This grant is ultimately about creating more gender-transformative primary health systems, so its first year was about something more fundamental: understanding the barriers women face before deciding how to remove them.
Rather than beginning with predefined interventions, Integrate Health started by conducting a formative gender study in December 2025 among 156 female CHWs across five districts in the Kara region of Togo. The study explored seven dimensions of CHWs’ experiences, including sociocultural norms, institutional barriers, gender-based violence and harassment, interpersonal relationships, social support, and professional aspirations. Conducted anonymously through mobile phone using KoboToolbox, the study gave CHWs a safe space to describe challenges that are often difficult to unearth through routine program monitoring.
The findings confirmed what many CHWs had experienced but had rarely been asked to articulate systematically:
- 83% reported that men remained the primary decision-makers within their households,
- 77% felt women and girls are treated unequally in their communities,
- 71% reported facing harassment from people in their own community while discussing contraception or family planning as part of their work,
- 70% said women experiencing violence often remain silent because of fear or shame.
At the same time, the findings revealed an important source of strength. CHWs expressed high levels of trust in Integrate Health, with 85% believing the organization would act if concerns were raised and 88% supporting community discussions on gender-based violence. That trust creates an essential foundation for introducing more ambitious gender-transformative interventions in the years ahead.
Perhaps the most important outcome of the study was not the data itself, but what the data now makes possible. Rather than designing interventions based on assumptions or global best practice alone, Integrate Health can now tailor its approach to the realities that CHWs identified themselves. The study directly informed four priorities for implementation: strengthening community engagement around gender and violence prevention, working with community leaders to improve the safety of CHWs, establishing clearer professional development pathways, and expanding access to mental health support.
One important gap remains. The formative study was conducted in Togo, not Guinea. While many of the barriers community health workers face are shared across both countries, we cannot assume they are experienced in the same way or require the same solutions. As we continue our gender equity journey, we will need to deepen our understanding of the Guinean context.
From evidence to action
In Togo, gender equity work started downstream of a workforce that was already mostly women: hire first, then figure out how to protect and support the women already doing the job. Guinea flips that order. Community Relays (CRs) are government employees, embedded in Ministry of Health staffing structures, and the traditional norms in Kouroussa, where men work and women stay home, make recruiting women into the role the harder step, one that has to happen before any of the protection or leadership work that Togo taught us even applies. That’s the lesson we carried over directly: don’t wait until after women are hired to address the norms keeping them out: build for it starting at recruitment.
Beyond the formative study, Integrate Health in Guinea exceeded its first-year recruitment target, identifying 25 women against a goal of 22. Before we started, only 39 CRs were women out of 200. Rather than build Guinea’s programming from scratch, we carried over the two mechanisms that Togo’s own gender work had already tested: the Community Health Worker Ambassador Program, now launching for CRs, and the Male Peer Educator initiative, following the same approach IH piloted in Togo to engage village chiefs, imams, and other male leaders as partners rather than obstacles.
These early results and findings from the formative study are already shaping what comes next: Transformational Roundtables for female CHWs.
Unlike many gender programs that ask CHWs to change norms, these roundtables begin by investing in the women themselves. Before asking them to transform their communities, we create a protected space for them to reflect, build confidence, strengthen leadership, and support one another. The curriculum follows a deliberate progression, beginning with identity, confidence, and self-worth before moving through healthy relationships, gender-based violence, psychosocial wellbeing, leadership, and collective action. It also integrates practical safeguarding tools including protocols for responding to gender-based violence and regular mental health check-ins.
Although informed by proven approaches such as SASA!, Stepping Stones, and GALS, the program was not imported wholesale. It was designed around what CHWs themselves told us they needed.
The next phase of the work will test those interventions, measure their impact, and continue refining them with CHWs themselves with a post-intervention survey planned for April 2027 to measure what actually changed from the baseline. If successful, the goal is not simply to improve Integrate Health’s own program, but to generate evidence and tools that government partners and other peer organizations can adapt and scale as they strengthen community health systems of their own.
We all know that the journey towards gender equity is long and difficult. But as a global health organization, we have a duty to protect those at the heart of what we do. And today, the women who deliver care in some of the world’s most remote communities have told us, in their own words, what makes their work harder, what puts them at risk, and what they need to thrive. That knowledge is now shaping every intervention that follows.
Gender-transformative primary healthcare is not about adding gender to community health. It is about building community health systems that recognize, protect, and invest in the women who already sustain them. Because there can be no health equity without gender equity.
*In Guinea, a Community Relay is the equivalent of a Community Health Worker in Togo. A Community Health Worker in Guinea is the equivalent of a Community Health Worker Supervisor in Togo.