Informal work, informal mobilisation? The lateral paths of health volunteers in Senegal Open Access

Community health workers (CHWs) are neither a profession nor a volunteer group, but a hybrid professional group, receiving modest allowances that vary according to the reference authority (states or non-governmental organisations). Their identities are manifold, depending on whether their work brings them closer to the hospital, the population, or the municipality. Sometimes loyalist, sometimes rebel, CHWs oscillate between municipal clientelism (to gain access to employment) and illegal practices (surreptitiously selling medicines or even conducting clandestine abortions). It is such empowerment and professional frustration that justifies their organisation to preserve their activity. It goes from the creation of associations to negotiate with public authorities, via more radical mobilisations in parallel, up to protest, boycotts of health campaigns, or sit-ins for improved status.

Les agents de santé communautaires (ASC) ne sont ni une profession ni un groupe entièrement bénévole, mais un groupe professionnel hybride, touchant des indemnités modiques variant avec la tutelle de référence (État ou ONG). Leurs identités sont multiples, selon que leur travail les rapproche de l’hôpital, de la population ou de la municipalité. Tantôt loyalistes, tantôt rebelles, ils oscillent notamment entre le clientélisme municipal (pour accéder à l’embauche) et le recours à des pratiques « illégales » (ventes parallèles de médicaments, avortements clandestins). Cette autonomisation et la frustration professionnelle qui l’accompagne trouvent un prolongement dans l’organisation de la défense de leur activité, avec la création d’associations pour négocier avec les pouvoirs publics, tandis que des mobilisations plus sauvages voient parallèlement le jour, au travers d’activités de freinage, de la mise en place de boycotts des campagnes sanitaires ou de la tenue de sit-in pour faire reconnaitre leur activité et accéder à un meilleur statut.

Under the supervision of local health authorities, Community Health Workers (CHWs) play an interface role between the formal health system and the population receiving care. Two-thirds female, CHWs use their local anchorage to get involved in their local area to improve collective health (Piermay, 2012) at the peripheral level (the lowest level of the health pyramid in direct contact with the poorest populations). Since the Alma-Ata conference (1978), several health programmes have involved CHWs to improve access to health care for difficult to reach populations (Walt et al., 1989). As volunteers, they occasionally supplement paramedic staff by providing nursing care and assistance to surrogate mothers, selling consultation discharge, prescriptions and medicine in public pharmacies, or canvassing the population as a preventive measure, as part of a vaccination campaign or other health program.

However, the shortage of health care personnel in hospitals forces those in charge of health centres and health posts (especially nurses and midwives) to resort to the assistance of CHWs on a permanent basis to ensure the continuity of health services (Fall & Vidal, 2005). Even a modest background in nursing (Hane, 2018) during professional socialisation can give opportunities to achieve social status in a context of underemployment: the combination of these various elements leading to a shift in the meaning attached to this activity. Being a CHW generates feelings of local rootedness and participation in public life, in the dual sense of commitment and ordinary interest in public affairs (Ion, 2005). To repeat the well-known aphorism, the struggle to be heard (voice) and the commitment to maintain the status quo (loyalty) become more important than the exit from the activity (Hirschman, 1995). At the same time, the fragile status of this semi-professional activity leaves these actors with few established resources to defend their interests, even exerting a symbolic pressure in favour of the status quo.

By highlighting the socio-professional mobilisation of CHWs and valorisation measures of low-level repression (Talpin, 2016), we seek to show through an ethnographic approach (see Methodology), that although CHWs are often considered volunteers in the community health system, they take on a markedly different function. They use lateral paths of resistance or attachment to work to defend their occupation. If we know that for many of them there is a stake in recognition and stabilisation of status, we can legitimately inquire into how this hybrid and precarious status shapes their capacity to contest their situation? How do their claims (or expectations) feed into modest or more open forms of mobilisation?

This article examines how an intermediary position between volunteering and salaried work underpins limited mobilisations. In this sense, this works seeks to highlight the end of African exceptionalism in terms of collective mobilisation and social change coming from the ‘bottom’ (Siméant-Germanos, 2013). The informal work of CHWs is articulated around informal mobilisation: taking lateral paths to the high way of professionalisation that functions within an established body of work, struggling for recognition through the control of degree courses, and constructing strictly professional organisations (Dubar et al., 2015). The focus of this article will be more specifically on (i) mutations in social and health work in West Africa; (ii) the link between changing statuses and forms of resistance at work; (iii) loyalist and transgressive empowerment; (iv) limited resistances and public contestations.

The community health approach has spread around the world, but the situations of CHWs vary from country to country. In Canada, for example, they are paid a regular salary and treated as professionals. In West Africa, they are often viewed as volunteers insofar as their action does not involve financial remuneration as a matter of course and is conducted without constraint or official sanction. It is directed towards the local population, regardless of the CHW's level of professional qualification.

CHWs participate in the health system as volunteers, but the literature has shown that people rarely become volunteers from the outset; they become volunteers or learn to become volunteers through compliance or non-compliance with the ethical and deontological principles that govern them (Ferrand-Bechmann, 1992). Volunteer work is therefore not a unilateral process, but rather a protean transaction (Archambaul, 2002; Prouteau, 2001; Simonet, 2002). The characteristics of CHW work and the set of action they use show this dynamic, both through the changing orientation of their activity and evolving logic of other relevant actors. The analysis of this situation of sub-Saharan CHWs should not be disconnected from the wider political and historical context of their place within the health system.

In West Africa, the use of community health workers as support staff dates to independence in the 1960s. The aim was to reduce regional disparities in the provision of care between urban and rural populations (Gobatto, 1999). Then, in the 1980s and 1990s, the role of CHWs was reinforced through the development of primary health care (PHC) policy, which promoted popular participation in the financing and management of health care as a response to structural adjustment programmes (Fall & Vidal, 2005). In the 2000s, community health further evolved through the creation of a new occupational status, the bàjjenu gox (neighbourhood/village godmothers), specifically dedicated to women, in order to compensate for the low representation of women amongst volunteers and to improve maternal and neonatal health by using traditional skills. The mobilisation of these ‘indigenous intermediaries’ was designed to ensure that individuals would rally to Western medicine (Cornet, 2011) by linking it to intergenerational experience (Ridde et al., 2018).

The presence of CHWs in the health system at the district level has become widespread in West African countries (Mali, Niger, Burkina Faso, Tchad, and Senegal). However, the data presented in this article relates more specifically to fieldwork conducted in Senegal. Senegal was one of the first countries to experiment with popular participation in health care management. Already in 1967, before PHC policy’s development, mobile teams of mothers were set up by the nuns of the ‘Notre Dame’ congregation to those who had been resettled from Dakar-Plateau to the suburbs of Pikine. In 1977, as part of the USAID Sine-Saloum project, 200 villages organised themselves to have health huts built in Kaolack and Nioro, entrusted to care assistants, to provide basic care (Faye, 2012). The country participated in several pilot projects carried out in West Africa, mobilising local actors to drive the development of community health (Jaffré, 2003; Pinaud, 2016), although the formal status of these local actors was never clearly defined. The reforms meant that CHWs, despite working the same number of hours as paramedic staff, did not and do not currently enjoy the same professional status or social rights.

In Senegal, CHWs remain in this intermediate situation. Caught in a process of professionalisation and resistance to reforms, new evolutions are often perceived as a reappraisal of their work’s contribution to the local health system, even though their numbers are increasing (33,000 in 2021 compared to 25,000 in 2017). Some have argued, they are part of a logic of empowerment (Faye 2012): the privatisation of the health system brought about by the Bamako initiative in 1987 has made community participation unavoidable (Fournier & Potvin, 1995; Tizio & Flori, 1997). Thus, a link has inexorably been established between CHWs, both in preventive and curative work (Strauss, 1992). For example, in maternal and paediatric care, different types of CHWs work successively to remind parents of vaccination dates, to assist with hospitalisation, to administer vaccinations, and to fill in health records. Bàjjenu gox (or godmothers) and matrons work together to accompany women of reproductive age through, pre- and post-natal care, childbirth, and in the use of contraceptive products. The bàjjenu gox live close to these women, are responsible for detecting maternal health or contraceptive needs, and then relaying information to the matrons and midwives for the acquisition of sanitary products. Similarly, relay-workers and home-based care providers often work directly with individuals in their residences, whilst more formal health assistants and nurses work in the health centres and posts. As we shall see later, this systemic interdependence in the work nourishes a group consciousness from which the socio-professional mobilisations of the CHWs are built.

Understanding the link between informal work and forms of mobilisation necessarily requires an examination of the socio-professional environment that structures collective action, especially when it takes place in a ‘local arena’. Olivier de Sardan & Bierschenk (1993) defines this as the place ‘where heterogeneous strategic groups clash, driven by more or less compatible (material or symbolic) interests’ (p. 13). Out of this view, it is possible to analyse the role of CHWs as a development project that generates competition for access to local (economic, political, and social) resources. The aim is then to understand the dynamics around volunteering beyond the imperatives of time and efficiency (Eliasoph, 2011). In this context, each actor has his or her own expectations about health volunteering, making the choice of both field and participants important in this study’s research design.

CHWs are a heterogeneous and fragmented group. As we shall see, the fragmentation of the group is based on training (certified or not), proximity or remoteness to the hospital sector, practice setting (health institutions/NGOs), and type of activity (care work, management work, or prevention work). Volunteer work for CHWs is not always a self-chosen occupation. Although the institutional selection criteria state that the choice should be a combination of individual and popular will volunteers are designated within local networks by local authorities who make it a matter of access to work. This client list model known as PAC (Parents Amis et Connaissances)³ is a kind of transformation of volunteering that maintains professional cleavages between elected CHWs and designated CHWs (Caremel et al., 2016; Faye, 2017), leading to professional frustrations.

The institutionalisation of volunteers is disjointed because the different groups of CHWs are not integrated into public health institutions in the same way. It is based on involvement modalities passing from election to designation, each with its own intrinsic responsibilities. The choice of CHWs, made by the local authorities, is explicitly based on addressing underemployment referencing altruism, helpfulness, empathy, availability, and personal competence as criteria. In fact, the head nurses in rural areas request support in terms of manpower from the borom dëk or jom wuro (head of the village/neighbourhood in Wolof and Fulani respectively). The latter, together with the neighbourhood delegates, imams, priests, customary guides, and municipal authorities, propose someone based on their affinity with certain people around them. Members of the health committees, care assistants, and matrons endowed with ‘political legitimacy’ from the local strongmen (Fassin & Fassin, 1989), are thus enlisted in the health system.

At the same time, the CHWs chosen by the population rise to their position according to quite different criteria. The choice is based on the need to involve actors – relay-workers and bàjjenu gox – with ‘popular legitimacy’, capable of participating significantly in improving health care. In other words, it is not efficient to implement programmes aiming at improving women's health without involving key people, considered by the population to be players in women's activities in the locality. From this point of view, the bàjjenu gox is the focus of attention, as a resourceful woman⁴ and a privileged intermediary for interventions looking for women's health development. This popular process gives importance to antecedents of social utility.

Despite these formal arrangements for CHWs’ involvement, the need for community support is becoming ever more pressing for health professionals. Hence, health professionals take the initiative to enlist new individuals in the health care delivery system in order to realise their missions. CHWs are thus enlisted on an ad hoc basis by qualified personnel to ensure the continuity of care services. Such selection is based on a ‘legitimacy of proximity’ and refers to the involvement of people, most often women, to perform specific tasks during a health intervention. This type of involvement is most often observed with individuals who have an affinity with qualified personnel: care assistants, matrons, relay-workers. This time the reference point is no longer democratic engagement, but rather a selective involvement that allows for better participation of women in the health care system.

The formal method for choosing CHWs proposed by the World Health Organisation (WHO) remains marginal. All CHWs are selected directly or indirectly by local authorities, based on their previous effective social engagement or membership in local networks. Voluntary commitment of CHWs to collective health is underpinned by a recognition on the population’s part of the services rendered by an individual. CHWs benefit from a recognition by virtue of his/her social trajectory, his/her experience, and his/her interactions with all or part of the population. CHWs are chosen as representatives of the population to the care staff and, because of the gatekeeping role they inevitably play, it is perceived as a legitimate step towards earning a living. These unofficial modes of involvement not only lead to a lack of congruence in the paramedic work pathway but accentuate the invisibility of the CHW profession which is already materialised by an atypical training.

CHWs have a shorter formal training than health workers. Before being assigned to a health facility, CHWs receive initial training (3–6 months) organised with the assistance of the district management team. The health education officer and the primary health care officer of the health centres are responsible for providing the certified training. These trainers are appointed among the paramedic staff based on their experience working with CHWs.

Training in nursing, midwifery, and management skills are reserved for nursing assistants, matrons, and pharmacy workers. They do a 6-month internship in the health centre to learn the paramedic trade and the management of health structures. They are trained for receiving patients (orientation, information), taking vital signs, performing minor surgery (circumcision, dressing wounds, treating burns, giving injections), sterilising instruments before and after use, conserving stocks of drugs, and storing equipment (surgery gloves, syringes, etc.). Less time-intensive, the training of relay-workers, bàjjenu gox, and home care providers lasts 3 months. The core training is mainly focused on counselling, awareness, hygiene standards, and disease prevention (PSNSC, 2014-2018).

These training courses follow the institutional boundaries drawn up by the community health unit. They therefore do not allow a single subcategory to capitalise on all the technical (paramedical acts), social (raising awareness and mobilising the population), and managerial (managing the stock of medicines) skills. In some health structures, the shortage of qualified personnel has reached a point where only permanent recourse to volunteers can ensure the continuity of care. It is in these contexts that training by paramedic personnel is then carried out to optimise the service of CHWs. More in line with the requirements of each health facility, the training provided by health personnel to CHWs goes beyond the institutional attributes of the community health unit. Doctors, nurses, and midwives, who are the primary supervisors of CHWs, believe that the support of volunteers should not be confined to this specialisation based on intermittent work, but rather that CHWs are more useful as permanent, multi-skilled workers.

There exists a clear opposition between institutional and operational governance that shows an important point of contention, which has led to the emergence of a ‘care function’, but which is still a cumbersome part of the status quo. The expansion of CHWs’ professional field of action, particularly through the delegation of tasks from above in the division of paramedical work (Hughes, 1984), is not accompanied by an improvement in their status. Consequently, each sub-category follows its own path of professionalisation to consolidate its professional achievements and protect itself from external competition, following a specific work identity.

The different ways in which CHWs are integrated into the health care delivery system has a negative impact on professional relationships in health districts, resulting in contrasting CHW identities. Three segments of CHWs can be distinguished: the specialised (working in health centres, posts, and huts), the multipurpose (working with individuals in their residences), and the municipal (dependent on the town hall). Such professional segments each carry a form of identity at work (Sainsaulieu, 2014) that has an impact on their mobilisations.

Firstly, at the micro-professional level (in the health centres and especially inside health posts), competition over the legitimacy of offering paramedical services is a point of discord that adds to the reasons for CHWs’ mobilisation. It pits state-qualified paramedics against CHWs with experience and practical knowledge.

These comments indicate that, in the eyes of the CHWs, proximity recognition is as important as institutional recognition. It provides a sense of personal satisfaction to a volunteer engaged in local health. In this respect, an ‘affinity identity’ characterises the specialised CHWs. It is formed around their supervisor who hold the keys of professional development opportunities such as empowerment, increased financial rewards, sharing channels of professional opportunities offered by NGOs, and even being recommended to other health structures. The search for status within health facilities leads the specialised CHW to become more dedicated and loyal to their supervisor. Personal existence in the professional field here follows unanimous norms around the orders of the qualified personnel, which ensures a regular income for the specialised CHWs from the revenues of the health facilities. However, it’s an income that is fluctuating, because most (around 80% of them) are not ensured a fixed salary, but rather a proportion of the income received by the local health unit based on how many hours they worked. Health authorities have set the rate of remuneration for specialised CHWs at 25% of the revenue from services and 10% of the revenue from medicine. This gives them an average monthly income of around 25,000 CFA francs (approximately 50 US dollars). However, while the professionalisation model of specialised CHWs is part of the organisation of health centres and health posts, that of municipal health agents and multipurpose CHWs is part of the political and associative registers respectively.

Secondly, the municipal CHWs (health fund managers and municipal health employees) have a ‘withdrawal identity’. They believe they are in the health system to better serve their political interests or to better show the opportunities offered by political affiliation. In so doing, municipal health agents have strained working relationships with other groups and feel less involved in their work.

These observations show that by adopting individual strategies to win the sympathy of the populations receiving care, the aim of municipal health workers is to achieve power in the political field according to partisan norms. Their remuneration is provided directly by the municipality or indirectly through the health development committees. It is fixed and amounts to 30,000 CFA franc (approximately US$54.6) per month. By instrumentalising the CHWs collective in this way, they act as free riders (Olson, 1978), less inclined to professional mobilisation than specialised and multipurpose CHWs.

Thirdly, the multipurpose CHWs, working with the inhabitants, face competition from seasonal health workers. They include husband circles, dimbatul (infertile women's group), grandmothers, community associations, and alert committees, nijaay gox (neighborhood/village godfather), and student volunteers. To guard against this direct competition⁵, multipurpose CHWs develop a ‘fusional identity’ through clustering and coalescence. The objective of multipurpose CHWs is twofold: one is to establish an avoidance relationship (Vollmer & Mills, ibid.) with seasonal health workers that guarantees them a monopoly on the delivery of health services in the countryside; the other is to control economic power in the local space. Unlike specialised CHWs and municipal workers who receive monthly salaries, multipurpose CHWs receive financial compensation per diem, when they are engaged in the implementation of preventive activities. The contrasting identities thus justify the multiplication of health volunteers’ grievances (Weller, 1999).

CHWs are workers on the margins of the health system who regularly participate in care and prevention activities, becoming quasi-permanent, like health professionals, but with less pay. This is not well received by multipurpose CHWs, especially those who have been volunteering for a long time:

However, CHWs are often viewed as social workers; relays-workers/home helps are asked to transport women in labor or the sick; the bàjjenu gox and matrons help some patients to raise money to buy medicines, by seeking economic resources for them from patrons. In demand but invisible (Hane, 2020), volunteers, engaged in the development of the population’s overall health, use their socio-health experience to access higher status, but in a discreet way.

Unbalanced integration and contrasting identities give rise to feelings of injustice or demands for greater recognition among some CHWs, forming the sub-political underpinning of informal mobilisations (Scott, 2006). Professional frustrations generate both active mobilisations to maximise the socio-economic benefits of volunteers at the local level (health district) and active mobilisations to improve CHW status and control access at the national level.

The informality of their work leads CHWs to resort to modest types of demands at the margins of contentious politics (Mcadam et al., 2001). They mobilise collectively and individually to reverse the stigma of being informal workers. Thus, their position and current status as intermediaries (volunteers with hybrid status) underpins mobilisations with a subversive potential that even allows them to play with the law. On the one hand, their loyalty is materialised through patronage and socio-political networking. On the other hand, their empowerment is backed by the supply of care in competition with the formal health system. How CHWs choose to mobilise depends on their profile.

CHWs are not all loyal to the same supervisory authority. Consequently, they favour different outlets: the orderlies, matrons, and pharmacy salespeople in the health structures are loyal to the nursing staff. CHWs develop strategies aimed at professional qualification, in particular the search for a diploma with the continuity of studies to become a nurse's aide and eventually a midwife.

Alongside the loyalty of specialised CHWs, there exists the professionalised clientelism of multipurpose CHWs. The latter act as ‘local development brokers’ or traditional mediators (Olivier de Sardan & Bierschenk, 1993), by negotiating their position within the population to gain greater personal visibility, thereby widening their network and increasing their chances of being recruited by an NGO (as a community health supervisor) or local authority (as a municipal civil servant). Through loyalty or clientelism, jobs, socio-professional mediation, and curative tasks are reserved for a fringe group of CHWs, leaving the less well-connected ones behind (Burt, 2005). The latter, who do not benefit from the support of the incumbent staff and local employment opportunities, replace official standards of sales and health services with practical standards, more in line with their professional aspirations and the demands of the socio-professional context (Olivier de Sardan et al., 2017).

CHWs interact with the law to challenge both the marginalisation of their role and the inaccessibility of certain care to poor populations, especially women. Mobilising allows actions to be taken to improve CHWs’ working conditions and status, through alliances and challenges to institutional power, while responding to the unmet needs of individuals (Diallo, 2018). However, this mode of professionalisation outside the circuit instituted by health authorities is often in competition with the formal system, creating alternative services within the health system.

Considering that their work is under-appreciated, their aspirations often asphyxiated, specialised CHWs resist the system by individually exploiting the ‘windows of opportunity’ available in the health system (Kingdom, 1995). They use their strategic position in the health system to offer alternative health services to local populations to maximise their gains and strengthen their financial position (Tizio & Flori, 1997; Ridde, 2011).

Within health centres and health posts, specialised CHWs sell medicine to patients. In fact, nursing assistants and matrons have in many cases come to substitute the managers of pharmacies. In principle, only one or two people are trained to sell medicine. However, given the low financial reward, often considered derisory by CHWs, it’s a section of the health facilities that is sometimes deserted following repeated absences by incumbent staff. In order to remedy this situation, the qualified staff, members of the health committee, nurse’s aide, and matrons sell consultation discharge and prescribed medicines. Moreover, untimely changes in who manages the pharmacy can often encourage parallel practices such as the sale of medicine.

This practice, in competition with the formal system, is the prerogative of clientelists. But loyalists also engage in these transgressive practices at times. These practices are also linked to bifurcations in biographical trajectories (increases in family burdens following marriage, death of family supporters, etc.) and the relatively long duration of voluntary work (10 years on average).

The focus of operational actors on responding to high local health demand has thus contributed to non-compliance with regulations on the sale of medicines (Seck, 2010). It’s an unregulated practice which nonetheless favours a democratisation of access to medicine in a health system that functions mainly through direct payments (Alenda-demoutiez, 2016), due to the low level of health insurance coverage (18.47% according to ACMU 2019). This unofficial community solidarity allows patients to benefit from drug on credits at the depositories. But CHWs can incur social and criminal sanctions if irreparable mistakes are traced back to them.

Illicit use of generic drugs, which are sold in local health facilities and community pharmacies, sometimes leads to imprisonment, especially in cases of abortion. The debate on medical abortion is heated in Senegal. Human rights organisations have voiced support for medically assisted abortion by qualified personnel for women who have been subject to incest or rape, whilst civil society organisations (groups or associations referring to customary and religious law) consider abortion to be an open door to abuses that devalue human life. Moreover, Article 305 of the Penal Code punishes women who resort to this practice with sentences from six months to two years in prison and a fine between 20,000 and 100,000 CFA francs.

Nevertheless, some women have abortions in secret. Despite legal restrictions, abortion is therefore common in Senegal (Sedgh et al., 2015), and is performed clandestinely by community actors, notably matrons and care assistants following a commercial logic (Baxerres, 2013), without any exact knowledge of the number of failures or successes throughout the country.

The barriers to having an abortion in the formal health system thus opens a parallel market for CHWs to carry out clandestine abortions charging between 75,000 CFA francs and 150,000 CFA francs (i.e. between $136 and $272). They often use misoclear or misoprostol, a drug normally prescribed only to patients who have undergone an incomplete abortion. In so doing, CHWs are building a response to care needs not met by the health system.

Through this discourse, they can justify illegal practices which are in fact necessitated by their precarious status and under-compensated work, despite the risks that this service entails. While cases of imprisonment are rare and under-publicised, informal sanctions are often meted out, notably through social isolation. Multipurpose CHWs are more at risk from this form of social punishment, as they are in direct contact with the population.

For example, during a weighing session to detect malnourished children, a 2-year-old child died in the Kaolack region. The mother and grandmother of the child filed a complaint against the relays and bàjjenu gox team involved in this activity. In the letter of complaint sent to the judicial authority, they blamed the latter for being responsible for the violent fall of their child (falling from the arms of the weigher) and for having communicated the child’s weight loudly in the presence of the other mothers. Dropping a child is viewed as a bad omen in the popular Senegalese imagination and an open door to witchcraft.

The combination of alleged cannibalism, risk-taking linked to the practice of illegal abortions, and the unequal treatment of volunteers underpins mobilisation, with a view to improving the CHW status and consolidating professional achievements. Thus, although specialised CHWs and municipal workers are better integrated than generalist CHWs, they are all seeking a better place in the health system. It is in this sense that they articulate some of their convictions to cooperate and thus gain power from collective action (Senier et al., 2007).

CHWs do not remain hidden in denouncing what they describe as the ‘devaluation’ of their profession (Simonet, 2018). They set up collective actions to bring their demands to the public space (Paradeise, 1985). The absence of trade-unions, which might otherwise coordinate these socio-professional demands, means that these activities are never scaled-up. Rather they take on a local form of resistance, depending on the socio-professional positions of each in the health system. The mobilisations of the CHWs are therefore in the form of a horizontal typology from the establishment of associations to the organisation of sit-ins, to boycotting daily health work.

Their struggle to gain more professional space in the local social and health fields, so as not to remain undocumented social health workers (Madelin, 2007), is based on social network (networks of bàjjenu gox – neighborhood/village godmothers), traditional groups (the intra-generational women's capitalised), and mixed associations. These frameworks of collective action allow for a shift from the margins to the centre (Bell Hooks, 2017) and the retention of their power (Beyer, 1998), through the control of municipal officials’ recruitment, the fight against competitive threats from above as well as below, and the reversal of their situation as dominated workers (Honneth, 2000).

While some CHWs mobilise to get out of the CHWs category, others seek statutory recognition of the group as a homogeneous entity (Sainsaulieu, 2006). Indeed, the CHWs who are members of the associations carry out actions in solidarity and develop a group conscience (Dubar, 1996). The Multipurpose Relay Associations (ARPVs) become frameworks for collective actions (Cefaï, 2001) that register all the sub-categories with legal recognition and a functional office (president, secretary general, and treasurer), authorising direct interactions with the donors of NGOs involved in health within the limits of the administrative district. With the duplication of training received by some CHWs with other members of the associations to carry out activities jointly, the tasks are no longer specific to one or another sub-category. This ‘group shooting’ process allows for mutual support based on collegial work involving a larger number of actors to save time and improve efficiency, even if the activities were originally intended for only a few actors.

Slow-downs have long been a means of struggle for the oppressed, especially factory workers (Taylor, 1911). A current example is taken from Senegal, where the non-statutory status of CHWs seems to put them in the same position as workers who are not allowed to openly show their discontent regarding working conditions. To circumvent retaliation from the health authorities, including layoffs, the protests of CHWs often takes the form of reduced productivity through absences or delays in daily work and partial coverage of certain areas. Instead of visiting all the targeted houses to carry out a preventive health activity, a CHW may decide to limit his/her activities to a few houses.

Although this practice raises a tension between political issues and stakeholder games which makes the epidemiological monitoring of health indicators difficult (Hane, 2017), it also reflects a way of negotiating the price of one's work without speaking out (Weber, 2003), especially when negotiations with sponsors do not result in an increase in per diem work pay.

Less occasional and more ritualised, CHW boycotts are non-confrontational, but remains a way of refusing to cooperate with local health officials (Balsiger, 2020) that have a chance of succeeding when it is in tune with a community of reference, in this case professional (Sainsaulieu, 2012).

In 2018, the Senegalese government undertook a reform to replace the health committees with health development committees. Through the involvement of administrative authorities (prefectures and sub-prefectures) to control the internal distribution of resources. The main objective of this reform was to establish better financial management of health facilities. However, this restructuring reduced the discretionary power of local health managers who were then obliged to pay 25% of the revenue from services and 10% of the revenue from drugs to specialised CHWs. In the eyes of the CHWs, this reflected a lack of recognition for their work, despite their dedication.

Faced with the drastic reduction in their monthly pay (almost 75%), the nursing assistants, matrons, and pharmacy attendants all agreed to refrain from working for the first 10 days after receiving their monthly allowances.

However, this way of claiming is not without repercussion from the authorities. It was precisely by leaving professional spaces vacant during this period of protest that the PAC model (cf. above) was developed by the regular staff and the municipal agents in order to avoid a break in the chain of health services and to achieve the objectives assigned by the national Ministry of Health. In such a framework that undermines the scope of collective action (Talpin, 2016), boycotts can turn into sit-ins when the CHWs are in high demand, as during pandemics.

Sit-ins are noisier than slow-downs and boycotting, becoming a mode of collective action for CHWs since their involvement in the management of Covid-19 cases. This collective action is the most federative, as it brings together all segments of CHWs and reflects the alignment of convictions to show the social utility of their profession (Snow et al., 1986).

By reporting on the sit-ins, the national press offered CHWs a privileged platform to explicitly express their professional aspirations to the ministerial authorities. The implementation of this demonstrative tool was facilitated by the support of health professionals as well as the favourable context of the Covid-19 pandemic during which the role of community health workers was decisive in the fight at the community level.

Finally, the sub-categories of CHWs came together to defend their common interest by highlighting their systemic interdependence in the delivery of care. This was a good example of the evolving and disparate nature of the mobilisations amongst CHWs. They use a mode of resistance adapted to changes in context: complaints against paramedics to improve the health service, denunciation of clientelist recruitment, and the depreciation of allowances in contrast with the increase in their workload. There is an increase in the generality of the problems posed by the CHWs by relying on a register of informal actions, built from a federative task force that has become a local political force.

In summary, we have sought to examine the various forms of professionalisation actions through mobilisations individual or public. Socio-professional positions determine the forms of mobilisation adopted by CHWs. Individual mobilisations make it possible to increase individual incomes, while collective mobilisations aim at institutionalising CHWs as a group. The forms of going public remain constrained by working conditions and fears of losing one's job, so discretion is always employed. However, it is precisely this fear of individual retaliation which incentivises individuals to join more collective-efforts such as boycotts and sit-ins.

CHWs recreate a community link through mobilisation, albeit that these attempts are often modest in nature. By aiming to strengthen the capacity of populations to take charge of their health, community empowerment has incidentally contributed not only to the emergence of a caregiving function (Hane, 2018), but also to the advent of a professional group composed of non-statutory social workers on whom most community health activities now rely. Voluntary work does not increase social inequalities (Eliasoph, 2011), but rather highlights the professional inequities. Deprived of the classic tools of workers’ demands (strike action, trade unionism), CHWs resort to relatively effective lateral channels to make their profession visible, even if it means breaking the law. Whilst it is true that CHWs are not only attracted by the lure of gain, their altruistic commitment is also often put to the test by professional aspirations, especially in a context of a breakdown in social mobility (Gadéa et al., 2011). The case of the health volunteers (CHWs) in Senegal shows that local commitments are a source of social change. Neither a social movement nor a struggle for a profession, the professional mobilisation of CHWs is an ‘atopy’ that relies on the promise that CHWs can advance themselves – individually and collectively – by pooling their means of struggle and their identity as CHWs. CHWs are an unacknowledged and under-compensated agents of change in community health systems of delivery. This bottom-up approach suggests that more emphasis should be placed on modest mobilisations in studies aiming at identifying the driving force of social change in sub-Saharan Africa.

No potential conflict of interest was reported by the author.