Economic and livelihood conditions of women community health workers in Ethiopia: implications for workforce sustainability—a mixed-methods study

Abstract Background Women community health workers contribute substantially to community-based health systems, yet many perform these roles with limited or irregular compensation while also managing unpaid care work and household livelihoods. The economic conditions surrounding their work may influence their capacity to sustain community health responsibilities. This study examined the livelihood, financial, household and market conditions experienced by women community health workers in three Ethiopian regions. Methods We conducted a convergent mixed-methods study in Amhara, Oromia and Somali regions. The quantitative component included 516 women community health workers and an exploratory comparison group of 60 women who had graduated from the Productive Safety Net Program. The qualitative component drew on 38 available focus-group discussion, in-depth interview and key-informant interview transcripts involving community health workers and household, community, financial-sector, market and government stakeholders. We used descriptive statistics, regional comparisons, multivariable logistic regression and thematic analysis. Results Among women community health workers, 63.0% participated in an income-generating activity, 41.5% saved regularly and 33.1% saved occasionally. However, only 39.0% had a bank savings account, 19.0% had borrowed from a bank or microfinance institution during the preceding two years and 45.7% reported neither saving nor borrowing through a formal financial institution or savings and credit cooperative. Financial and livelihood decisions were constrained by repayment risk, joint-liability arrangements, unpaid household responsibilities, limited capital, unstable markets and supply-chain barriers. Patterns differed across regions, reflecting variation in livelihood systems, market access and financial-service availability. Conclusions Women community health workers’ health responsibilities are embedded within gendered household economies and local livelihood systems. Health-workforce policies for unpaid or minimally compensated community-based workers should recognize these economic conditions and avoid relying on standardized credit-based solutions. Longitudinal research is needed to determine whether strengthening economic resilience contributes to sustained participation, retention or performance in community health work.