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03 11 2017

Gender Equality in the Global Health Workforce – working for a new status quo

In this blog post, Linda Waldman discusses a recent session at the World Health Summit on Gender Equality within the Global Health Workforce, exploring key themes which emerged, how far we’ve come, and what we can do to bring about change in this area.

Linda Waldman, Institute of Development Studies, University of Sussex

03 November 2017

Women leaders speak out

The World Health Summit took place in Berlin in October 2017, with one of the very first panels investigated Gender Equality within the Global Health Worforce. The organisers – Women in Global Health and Monash University, supported by RinGs – and chaired by Sally Theobald from RinGs – organised an impressive panel to debate the challenges, and how far we have come, in promoting women as leaders in health.

Women need to stand together and support each other

Keynote speaker, Dr. Heidemarie Wieczorek-Zeul, former Federal Minister of Economic Cooperation and Development, Germany offered a policy perspective, arguing that it is important to strengthen women’s collective position and bring forward their ownership and support. Heidemarie pointed out that one woman alone can’t change things, rather women need to stand together and support each other to take up strategic leadership roles such as finance and health ministers. Only in this way will women be able to change policy priorities and bring about real change for women in Africa and elsewhere.

Gender equality starts in the household

Dr Tana Wuliji, from the World Health Organisation, reminded us that women learn that they are not leaders at a young age. She stressed how gender equality starts in the household when kids are small, with the words we use to talk to our children, for example whether we encourage them and say that they can be CEOs or presidents; and with the resources and opportunities that we offer these children. The importance of ‘decent work’ – which is productive, pays fairly, offers security, creates opportunities to progress, embraces the right to express concerns and which ensures fair treatment between men and women was discussed as an entry point into gender transformative change both within the health sector and beyond.

‘My mindset was the solution’

Ms Olawumni Oduyebo, Founder of All Things Health Africa, offered a private sector perspective. Picking up on the theme introduced by Tana, Olawumni explained how she, as a young girl, could not imagine herself as a leader of a company as there were no women CEO role models to look up to. Olawumni spoke about the barriers and challenges she experienced as a young woman entering the world of business and of how she had to work longer, harder, and smarter, to constantly prove herself. She relied on inner strength – ‘my mindset was the solution’ – and refused to accept the conventional roles reserved for women. Today Olawumni is herself a role model for other women, showing them that solutions do not need to be limited by the constraints society places on women and girls and supporting them to achieve their visions.

A sense of un-belonging

Professor Charlotte Rees, from Monash University, spoke about the medical and academic context. She discussed how this traditionally masculine work environment creates a sense of un-belonging for women who, despite registering in high numbers as students, are under-represented as leaders. Like Olawumni, Charlotte explained how she too needs to over-perform, and women academics have to ensure that they are research active (while enjoying less access to resources and fewer collaborations) alongside a tendency to undertake more teaching and administration. These teaching and administration roles are, however, not recognised for promotion.

Gender, Power and Patriarchy

Heidemarie, Tana, Olawumni and Charlotte – Doctors, Professors and CEOs – are four amazing women working to promote women’s leadership in diverse areas of health, academia, policy, business and international organisations. Their testimonies showed the complex, yet common ways in which gender, power and patriarchy play out to limit gender equity in health and to constrain women’s leadership opportunities in health systems. Underlying all their presentations were two questions: how far have we come and what can we do to bring about further positive change?

How far have we come?

In 1992, when the UK delegate of the UN’s Advisory Committee on Science and Technology for Development raised the issue of working on gender in science, in preparation for the Fourth World Conference on women in Beijing, in 1995, the idea was met with considerable resistance. The delegates struck a bargain, support for another issue in order to get agreement to promote gender equality in science. The resulting report was reviewed by developing country policy makers – who claimed that there wasn’t nearly enough evidence in the report – and by academic feminists – who thought the report under-theorized. The UN Advisory Committee realised the need to build its case for evidence and to build the links between knowledge and action. This need to build links between knowledge and action continues to this day.

Yet, there is no shortage of research and evidence of women’s exclusion from all areas of leadership. Popular books address the topic in business (Lean In) and in academia (Why so slow?); and an endless succession of academic papers examine women’s performance in social and natural science, in business , and in global health.

There is also no shortage of metaphors to describe the processes that lead to women’s exclusion:

The term ‘glass ceiling’, refers to obstacles, often invisible, which prevent women’s ascent to positions of leadership and status. The ‘glass cliff’, introduced by Ryan and Haslam in 2005, refers to the fact that women executives are more likely than men to be put in leadership roles during periods of crisis, when the potential for failure is highest.
A ‘chilly climate’, used by Dugan and colleagues, describes male-dominated environments in which both structural conditions and relationships marginalise and devalue women, creating psychological barriers about women’s ability and efficacy.
Women have to navigate a ‘crystal labyrinth’ in which networks and relationships are critical to achieve scientific prowess and status, yet as McCullough argues, further disorientation stems from the lack of transparency around work relationships and with unequal access to mentors.
‘Sticky floors’ – a term used by Freehill and colleagues – refer to the difficulties women experience in progressing to senior leadership and ‘glass escalators’ delineate the lack of senior women in some professions, particularly health and nursing, despite large numbers of women working in these domains.

Women’s routes to success are thus filled with dead ends, wrong turns and backtracking before being able to, ultimately, achieve success. These metaphors are evidence of the depth and breadth of research on women’s inequality in business, academia, policy, international organisations associated with health and act as a reminder of the power of gender stereotypes to shape women’s experiences of work and leadership and of the fact that, while some women are able to become high-profile leaders, the general environment in which they operate is hostile.

What can we do to bring about change?

How can women’s leadership and gender equality within the Global Health Workforce be promoted? Delegates shared ideas of how to bring about positive change through a series of case studies presented by Prof. Jan Coles, Ms Sonia Singh, Dr. Sharyn Tenn and Ms. Sreytouch Vong, respectively. They emphasised the importance of getting gender-based violence education embedded in medical curricula; and recognised the opportunities for change in the private sector, the value of new innovations – controlled by women – that protect women from HIV and strategies to promote gender equity in the workforce. Emerging from these case studies were several proposals for change, such as policy interventions, male support for women’s activities, specific gender champions, designated committees to ensure equal opportunities, and flexible training structures.

A lot of discussion focused on the need to support individual women as well as addressing broader social, political and power dynamics that act as barriers, and for the need to take action at all levels – institutional, political and individual – to promote gender equity in the global health workforce. More importantly, the panel and discussion reminded me how actions, big and small, can contribute to better equity for women, of the need to link the wealth of evidence now available to action, and most importantly, of how we all – junior staff members, senior women, men, mothers, academics, boys, politicians, guardians, girls, colleagues, teachers, fathers, collaborators – have a role to play in bringing about positive change to promote gender equality in the global health workforce.

01 11 2017

How does gender impact the quality of community-level health data? Examples from rural and urban settings in Kenya

Community health workers labour at the frontline of the health system, yet there is little discussion of the ways in which their role is gendered. In this blog we explore how gender norms and relations effect the quality of data that community health workers collect.

Regeru Njoroge, Rosie Steege and Kate Hawkins

01 November 2017

A key role of Community Health Volunteers (CHVs) in Kenya is to refer women and children to primary healthcare facilities for essential health services such as antenatal care, skilled delivery, postnatal care, immunization, and growth monitoring. As they carry out this role, CHVs collect data at community level in a tool designed by Kenya’s Ministry of Health – they are expected to report this data on a monthly basis. This should be a source of data provided at regular intervals that is used by policy- and decision-makers.

However, for data to be useful it needs to meet certain standards in terms of quality. Some of the most commonly referred to dimensions of data quality include accuracy, reliability, completeness, timeliness, integrity, and confidentiality. Numerous frameworks and tools exist to measure data quality, these often assess the hardware elements of community health programmes such as availability of data collection and reporting tools, training in data management, supervision systems, accountability and communication structures. They often neglect the software elementsof community health programmes that relate to the ideas, interests, relationships, power, values and norms of the health system actors.

There is an increasing body of literature (and here, and here) that documents how gender norms and relations impact on community health programmes; with many examples of how community health workers of a certain gender, may or may not be, accepted by the community that they serve. Still, the implications of gender on CHV performance have been less explored.

Gendered effects

Focus group discussions to explore data quality, conducted with CHVs in rural and urban sites in Kenya, as part of the five-year international REACHOUT research project, revealed direct impacts of gender on the quality of data reported by CHVs due to gendered barriers in data collection.

Particular health issues are seen as the domains of men or women: Both men and women CHVs felt that certain issues should only be discussed with either men or women. Because of this it is likely that the data that was collected would reflect a very gendered view of the health issue under discussion. For example:

“There are things that are associated with women – for example, if a woman is pregnant you know you can’t tell a man she should go to the clinic so you have to speak with the pregnant woman about her health status so that she can visualize what you are saying and if it’s something like latrine you know women are not the one who dig latrines- this is done by men. That is home affair and is something that a man should know.”(Male CHV at Museve Community Health Unit)

CHVs tend to collect data from women: Although men were consulted on issues like latrines, CHVs tend to interact more with women, and as such men’s perspectives may be missing from the data routinely reported. CHVS reported that frequently, men in households do not engage with CHVs because they do not see this as part of their roles as men:

“When they see you entering they say it’s a woman thing, even when you ask questions they call out to the women – ‘Mama please come there is a service provider here who is asking questions about what you know’, and they don’t want to know what you have brought and just put the burden on the Mama.” (Female CHV at Maili Saba Community Health Unit)

Men who are CHVs avoid discussing pregnancy with female community members: Kenya’s community health programme has a strong focus on maternal and child health. Yet many men CHVs in focus group discussions said that pregnancy is an uncomfortable and culturally inappropriate topic for them to directly address:

“You know since I’m a man it becomes a challenge when I find a woman who could be pregnant and I’m not the husband or her fellow woman, so it becomes difficult for me to ask things like if they are pregnant and this makes me approach another CHV and tell them of the visit that I made and that I did not find her in a good mood and when I asked whether she is okay she didn’t tell me and that’s when I get another CHV or the neighbor who can tell me that you know what, that woman is not okay and I’m told the situation causing the changes in the mood and they suspect that they are pregnant or maybe there is something that is disturbing her so we just wait- for men, when it comes to pregnant women, we just wait.”– Male CHV in Bangladesh Community Health Unit

Women CHVs have to be cautious when discussing sexual and reproductive health with male community members: Women CHVs also have challenges when it comes to issues of sexual and reproductive health – family planning was the most commonly mentioned challenging topic. They described how this was not always a topic that could be discussed openly in households between two women due to husbands’ disapproval:

“There are many young men who don’t want to hear about family planning and even when you tell them they disregard it, there was another one (woman) that was found and (the family planning) was thrown in the toilet, she went and bought others put in a paper and hid it and a rat ate it, they were discovered and thrown away with the husband saying: ‘I told you I don’t want those things’. You see this person is challenged and you cannot ask her about family planning in front of her husband- you have to meet in a corner and ask them.” (Female CHV at Bangladesh Community Health Unit)

Women CHVs struggle to visit households of men: Some CHVs felt that it was difficult for women to visit households of men, especially bachelors and especially at night, due to concerns around safety and negative impact on their reputation:

“You find most of them (CHVs) are women and the houses belong to men. You see now the women cannot go alone and they usually look for me to accompany them and if there is a man there he will see that there are two of us and that way the CHV is able to get the information that they want to know.” (Male CHV at Bangladesh Community Health Unit)

Men struggle to visit households: Young men reported facing difficulties in conducting household visits in that they are often treated with suspicion of having ulterior (possibly criminal) motives, due to their gender and age:

“Another challenge is for someone like me. You know how our area is – it is famous that all criminals come from here. So, when they see me come to their place to check on them…you will either hide your Bravia (television) or give me a stool to sit outside.” (Male CHV at Maili Saba Community Health Unit)

It is clear to see that the examples provided here impact immediately on dimensions of data quality such as accuracy, completeness, reliability and confidentiality. When CHVs are not able to openly discuss important health issues due to cultural or gendered norms, they are unable to fully assess the health status of their clients, which is reflected in the data collected. There is a need to explore and further establish the effects of gender on data collection and what this means for reporting, so that findings are incorporated in training and supervision of CHVs. Sensitization of communities to the role of CHVs is also important so CHVs are able to comfortably and effectively deliver the full set of services to all community members regardless of their gender, and collect the complete sets of data that they are expected to. With appropriate support, CHVs may be uniquely positioned to able to work together with their communities, both in rural and urban settings, to transform these harmful attitudes that prevent CHVs from fulfilling their roles.

06 09 2017

We’re editing a new book on women’s leadership in global health

There is a growing interest in women’s role in global health leadership. We know that women are the majority of people working to improve health outcomes in communities, health facilities, non-governmental organizations, and multilateral organizations. So why is it that when it comes to leadership positions we have a governance system that privileges men and what can we do to redress the balance?

Kate Hawkins

06 September 2017

We are delighted to announce that together with Women in Global Health, with the support of Springer, we will be publishing a book that explores women’s leadership in global health.

This ground-breaking collection will explore the leadership roles that women currently play in global health, teasing out the routes that women have taken to leadership, the challenges that they have faced, and what has facilitated their journey. It will bring to the fore the stories of women on the frontlines of this struggle from around the world, highlighting and complimenting these stories with theoretical and analytical explorations of the structures and systems that help or hinder the process. Empirical studies in this volume will demonstrate how women’s leadership is thwarted or supported from a range of different contexts, positions, and starting points.

The authors come from various academic and professional disciplines and have been purposefully selected to show the range of types of leadership in global health. The book will form a rallying call to arms to redress gender inequality and celebrate the many ways in which women are taking the lead in supporting the health of their communities internationally. This book will be a must read for those working in global health or studying the topic. It will also be a feminist primer that aims to support other women in their efforts to succeed in a highly unfair and unequal world.

The editors are Kate Hawkins, Rosemary Morgan, Roopa Dhatt, and Mehr Manzoor.

For more information watch this space! If you have any questions, just drop us a line.

09 08 2017

RinGs at the 23rd Canadian Conference on Global Health

On October 31 we will be running a training, “From gender blind to gender transformative global health research.”

09 August 2017

The 23rd Canadian Conference on Global Health will take place from the 29-31 October in Ottawa. The theme of the conference is Leaving no one behind? Reflections for action in a changing world.

RinGs will be running a training on how to adopt a gendered approach to global health from 08.30-10.00 in Cartier 2 on October 31.

By the end of the session, participants will:

• Have an understanding of gender analysis within global health research.
• Be able to use a continuum to assess the gender responsiveness of global health research.
• Be able to identify activities needed to move global health research along a continuum towards gender transformative research.

In order to address gender inequities in global health, gender analysis must be incorporated into global health research; yet, global health research often fails to sufficiently consider gender as a social relation. Gender analysis is the process of analyzing how gender power relations and inequities affect people’s lives, create differences in health needs and experiences, and how policies, services, and programmes can help to address these differences. Gender analysis also explores how sex interacts with other social stratifiers, such as age, race, socio-economic status, sexuality, and disability, to create different experiences of vulnerability and marginalization. When gender analysis is incorporated into research, however, it is often incomplete, either focusing only on women, or does not go beyond sex disaggregation. In addition, gender analysis is increasingly becoming a requirement of many donor driven research projects; however, instead of gender analysis being effectively mainstreamed into research, it is often treated as an add-on or additional cumbersome activity. The aim of this participatory session is to provide participants with an introduction to gender analysis and how it can be incorporated into their global health research. Through the use of practical tools, participants will have the opportunity to explore different ways gender analysis can be incorporated into global health research.

If you like the sound of the session do come along and say hello. The workshop will be run by Rosemary Morgan from Johns Hopkins School of Public Health.

27 07 2017

Global health ethics frameworks, embedded ethics and new approaches to vulnerability

We recently attended the 2017 Oxford Global Health and Bioethics International Conference, aimed at promoting multidisciplinary and inclusive discussion of critically important ethical issues in global health. We were excited about several issues pertinent to health policy and systems research ethics discussed during this excellent meeting.

Bridget Pratt and Sassy Molyneux

26 July 2017

The importance of health system strengthening was highlighted right from the opening keynote of the Oxford Global Health and Bioethics International Conference. Devi Sridhar in her talk ‘Governing Global Health: Who Runs the World and Why?’ emphasised that power in global health governance lies with three main actors—the United States, United Kingdom, and the Bill and Melinda Gates Foundation. Several high-profile attendees commented on the distinction between technology or disease-focused versus systems-focused approaches, and asked how donors can be incentivised to be more systems-focused. They also raised concerns about “reverse priorities” where health systems are a central focus in high income countries (e.g. Obamacare and the UK National Health Service), but relatively neglected for Low- and Middle-Income Countries. Power, politics and equity were thereby raised as critical ethical issues in global health; issues that were also central concerns in the 2016 Health Systems Symposium.

Jeff Khan in his keynote ‘Ethics on the horizon: A proposal for a future-facing global bioethics’ included health systems research ethics in his list of priorities. He also had two suggestions that we think are especially relevant for the emerging field of health policy and systems research ethics. First, that global bioethics should make far greater use of existing global health ethics frameworks such as Benatar, Daar, and Singer’s that emphasise values such as solidarity, equity, democracy, and sustainability. We agree, and have regularly referenced this framework in our own HPSR materials.

Second, he suggested ethicists practice more “embedded ethics”. Reflecting on this, we understand embedded ethics could come in a variety of forms. For example, Bridget is an ethicist co-located within an ethics institute and a global health institute, and Sassy is a social scientist studying ethics issues as part of several multi-disciplinary research projects and on behalf of the institution she is part of. Being a co-located ethicist or social scientist can be invaluable in ensuring there is regular, open and honest dialogue and deeper learning between ethicists and health policy and systems researchers. Ethics issues can potentially be identified and responded to more efficiently and effectively. However, there are potential challenges: ethicists’ foci may be shaped by the research they are linked to, and they may lose objectivity and the ability to be critical of the studies or institutions they are part of. We have already begun to reflect on some of our embedded work, and would value ideas and experiences from others.

The meeting closed with keynote presentations given by three inspiring women: Ruth Macklin, Florencia Luna and Maureen Kelley. Maureen Kelley presented last, giving a rich example of an international collaboration conducting diverse forms of embedded ethics research. That research aims to feed into policy and practice and conceptual thinking on a hotly debated topic in bioethics: vulnerability. The collaboration takes forwards conceptual work by Luna and others who have argued that vulnerability should be understood as a layered conceptrather than a label given to sub-populations . We were struck in Luna’s presentation with some overlaps in her conceptualisation of vulnerability with intersectionality analysis in other fields and with concepts of systematic/corrosive disadvantage from philosophy. We had described intersectionality analysis earlier in the meeting when introducing the partnership for research on gender and ethics (RinGs). Moving forwards, we think it would be exciting to see how Luna and others’ ideas on vulnerability and disadvantage might feed into our intersectional analyses in RinGs, and consider whether an intersectional lens could enrich our reflections in RinGs and the ethics TWG at HSG on embedded ethics, vulnerability, resilience and empowerment. Watch this space (or, ideally, fill it!).

17 07 2017

RinGs at the Oxford Global Health and Bioethics International Conference

From the 17-18 July RinGs will be attending the Oxford Global Health and Bioethics International Conference in the UK where we will be represented by Sassy Molyneux.

The conference is an opportunity to talk across different disciplines, areas of health, and geographical locations to explore ethics in global health and find areas of overarching concern.

Sassy will be presenting a paper that was developed with Freddy Kitutu, Bridget Pratt, Hayley McGregor, Sarah Saali and Dorcas Kamuya. ‘Building the field: Developing networks to support ethics research and practice for health policy and systems research (HPSR) in sub-Saharan Africa’ argues that the ethical governance of the field of health systems research – including guidelines, recommendations and associated accountability processes – is contested. The uncritical application of bioethics guidelines, recommendations and accountability processes in health systems research processes is problematic as:

Human subjects’ guidance focuses on individual protections, whereas a lot of health systems research focuses on populations and systems;
The research-practice distinction fundamental to much biomedical research guidance is often blurred in health systems research; and
The dominance of managerial/bureaucratic approaches to hold researchers to account (e.g. reviews and audits) can create particular hurdles or perverse outcomes for health systems research

In the presentation, she will share some of the past and planned activities of two networks with an interest in ethics and health systems research: RinGs and the ethics thematic working group of Health Systems Global. She will include reflections on the ethical dilemmas they have faced over the course of conducting diverse qualitative health systems studies in sub-Saharan Africa, focusing on dilemmas related to three sets of relationships: between researchers working in multi-disciplinary consortia; between researchers and health managers/providers; and between researchers and community members

22 06 2017

Evidence to accelerate progress toward meeting the need for family planning

Our colleague Sally Theobald will be presenting on building gender equitable health systems in post-conflict and crisis settings.

22 June 2017

To coincide with the 2017 Family Planning Summit, the London School of Hygiene & Tropical Medicine is hosting a research symposium in London, in collaboration with the DFID-funded Research Programme consortium Strengthening Evidence for Programming for Unintended Pregnancy (STEP UP) and the Maternal Healthcare Markets Evaluation Team (MET).

The research symposium will:

Share the latest evidence on unmet need for family planning,
Review evidenced-informed programming for addressing unmet need for family planning,
Discuss a research agenda aligned to the global architecture for family planning.

Webinar: Health Systems Research Ethics

Health systems research ethics is a relatively new and emerging field, with numerous normative and descriptive questions that have largely not been considered. This webinar will explore the ethical issues arising in health systems research projects which may be unique or nuanced relative to biomedical research.

29 May 2017

Join: 05/30/2017 8:30 AM – 9:30 AM Eastern Time (US and Canada)

To further build the field of health systems research ethics and promote scholarship in this area, a special issue of Developing World Bioethics was devoted to it in 2016. This webinar brings together the authors of papers published in the special issue (Sassy Molyneux (from RinGs), Bridget Pratt, Hayley MacGregor, Gerry Bloom, and Abbas Rattani) as well as one of its co-editors (Adnan Hyder) to share their findings and work.

The webinar is one hour and will consist of an introduction, four short presentations by the authors discussing their papers, followed by a question and answer with the authors and a broader discussion on the ethics of health systems research moderated by Joe Ali (Berman Institute of Bioethics).

Presenters:

Introduction: Professor Adnan Hyder, Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health; Guest Editor of Special Issue
Health Systems Research Consortia and the Promotion of Health Equity in Low and Middle-Income Countries, Bridget Pratt, University of Melbourne (Australia)
Health Systems Research in a Complex and Rapidly Changing Context: Ethical Implications of Major Health Systems Change at Scale, Hayley MacGregor, Institute of Development Studies (UK)
Research Involving Health Providers and Managers: Ethical Issues Faced by Researchers Conducting Diverse Health Policy and Systems Research in Kenya, Sassy Molyneux, KEMRI-Wellcome Trust Research Programme (Kenya)
What Makes Health Systems Research in Developing Countries Ethical? Application of the Emanuel Framework for Clinical Research to Health Systems Research, Abbas Rattani, Meharry Medical College (USA)

To join the webinar: https://connect.johnshopkins.edu/hsr2017/

Please RSVP: https://goo.gl/forms/Kfwj7NX9vm8myZvz1

27 04 2017

Women and Global Health Leadership: Three things to consider

This blog discusses key themes that emerged during a session on women and global health leadership at the recent Consortium of Universities for Global Health Conference.

Rosemary Morgan, Research in Gender and Ethics (RinGs): Building Stronger Health Systems, Johns Hopkins Bloomberg School of Public Health

27 April 2017

Gender inequity with global health leadership is becoming an increasingly recognized issue. Calls to action are being made to increase women’s representation in the global health policy arena, health sector, and academia. Despite this, the women’s representation remains low across these sectors.

Women, for example, “constitute only 25% (14/54) of African ministers of health and 24% (12/50) of directors of global health centers at the top 50 U.S. medical schools”. These numbers are surprising as women in general comprise over 75% of the health workforce, cover roughly half of medical school graduating classes, and make up the vast majority of those working in global health. If women encompass the majority of the global health workforce, why are so few making it to the top?

This was a question addressed at this year’s Consortium of Universities for Global Health Conference. During the conference women leaders in global health came together to discuss barriers to women’s advancement and how we can support more women entering leadership positions. Three important themes emerged from the discussion:

1. Gender equity at the leadership level leads to better decision-making and better health outcomes

It is well known that diversity at within the workplace leads to better and more effective decision-making across sectors. Global health is no exception.

Increasing women’s representation at the leadership level, for example, has been shown to improve maternal and child health outcomes. A study by Bhalotra and Clots-Figueras, showed that improvement in women’s political representation in India decreased neonatal mortality. In addition, female representation was found to have a positive effect on the “number of antenatal care visits a woman has, the probability of giving birth in a government facility (as opposed to at home), the probability of a child being immunized by the age of one, and the probability of breastfeeding in the first 24 hours after birth”.

Better decision-making leads to better health outcomes. By not having more women at the global health leadership level, the global health community is missing an important opportunity to improve health outcomes, particularly in the areas of maternal, reproductive, and child health.

2. There are parallel hierarchies within global health leadership that need to be addressed

Increasing women’s representation within global health leadership as a whole is an important goal; however, it is important that we consider which women are making it to the top. While the percentage of female leaders within global health is low, it is even lower for women of colour.

Much of the work that has been done to date about increasing women’s representation at the global health leadership level does not distinguish challenges faced by women of colour (or other minority women) from women in general. It is important that we recognize that while many challenges will be relevant to women as whole, such as sexual harassment and family responsibilities, women of colour face unique challenges as a result of their race. In addition, some of these challenges – like sexual harassment – may be even more acute depending on the context in which a woman works.

Geographical hierarchies must also be considered within global health leadership. The global health community must not put the expertise of women (and men) from high-income countries above those from low and middle income countries. During the discussion, for example, an African woman from a low-to-middle income country observed that despite her years of experience she often loses leadership positions to young less experienced white women from Western countries.

If we are to truly increase diversity at the leadership level solutions must be found which address the challenges of all women, with special attention paid to the parallel hierarchies that exist within the global health community.

3. Pragmatic solutions are needed if we are to reduce gender inequity within global health leadership

While individual stories of how woman leaders overcame barriers in their careers are important, these are not always helpful in addressing the systemic and underlying barriers to increasing women’s representation at the leadership level. More research is needed to explore the common and underlying barriers preventing women’s representation across global health sectors. Only then can pragmatic solutions to promoting women’s leadership be developed and implemented.

When solutions to increasing women’s representation are discussed, too often the onus is put on women themselves – they must act more like a man, find a supportive husband or partner, or make enough money to afford childcare – if they are to obtain and succeed in a leadership role. While it is important for women to recognize what might be holding them back at an individual level, it is equally if not more important that global health institutions implement appropriate policies and procedures to address the barriers which lead to inequities in global health leadership in the first place.

What Next?

Moving forward we are likely to see more discussion on these issues, particularly as organizations like Women in Global Health and RinGs work to advocate for increased representation of women in global health leadership. In addition, Stanford University’s upcoming conference on Women Leaders in Global Health will provide a forum to discuss these issues in greater depth. It is hoped that through such efforts we will begin to see greater representation of all women within global health leadership, and with that better health outcomes for all.

05 04 2017

Emerging issues related to gender and community health workers

To celebrate International Women’s Day the REACHOUT Consortium held a symposium in Nairobi on “women in the changing world of work”. This symposium grew out of a recognition that the sex of the Community Health Worker (CHW) influences their interaction with the health system.

Kate Hawkins, Sally Theobald, Rosie Steege, Maryse Kok, Mohsin Sidat, Kingsley Chikaphupha, Ralalicia Limato, Hermen Ormel, Daniel Gemechu Datiko, Robinson Karuga

05 April 2017

Gender norms also shape CHWs’ different experiences in the course of their work both with households and the health sector. We have argued that CHWs play a critical interface role – connecting the health sector with the community – and although an analysis of the ways that gender influences this was not explicitly built into our research design from the outset, it emerged as an important issue in our REACHOUT context analysis. To investigate further, a Liverpool based Masters student, Woedem Gomez, undertook a literature review on gender and close-to-community (CTC) providers. REACHOUT PhD student, Rosie Steege is exploring this topic in international policy discourse, as well as conducting empirical case studies in Ethiopia and Mozambique investigating how the health system can best support both male and female CHWs, recognising their differing needs. We also worked with the Health Systems Global Thematic Working Group on CHWs to hold a webinar to share learning on gender and CHWs in different settings, including Democratic Republic of Congo and Palestine; which triggered further debate and questions.

Based on this learning and the premise that we still have time in the last months of our research programme to further educate ourselves on this area (and at least encourage others to consider from our lessons learned, positive and negative) we decided to spark off the process with a dialogue that enabled our team to engage with other stakeholders in Kenya.

Gender norms and related attitudes and behaviours are not fixed

We heard that gender norms are contextually specific and subject to flux and change through time. Mohsin Sidat (Mozambique) pointed out that many years ago women were not allowed to learn and practice medicine and about 100 years ago female physicians were still exceptional in the medical world. Today the scenario is different and, for example, in Faculty of Medicine of University Eduardo Mondlane where he is Dean they have about 60% female students. This clearly indicates gender roles in medical study and practice have changed. Nevertheless, for centuries, the role of midwifery has been reserved for women and it continues to be so in recruitment and training of midwives. The midwifery role attributed to women is acceptable in most countries and few men take it up (in Sub-Saharan Africa). However, men and women are trained as Gyneco-Obstetricians and both perform deliveries and the role of men at this level is not questioned. These gender ascribed roles within health sector are certainly historical and perhaps also consolidated by social and cultural norms.

Miriam Taegtmeyer (UK) made a strong case that it is the responsibility of health systems researchers to challenge gender inequities – it is an ethical issue – and one that enables us to contribute to tackling the social determinants of health, as well as harmful practices such as gender-based violence and female genital mutilation.

CHWs are leaders

There is increasing focus on women and leadership in the global community, although this often focuses on leadership within the UN, WHO, donors, national parliaments and universities and is not extended to the community level. Sally Theobald (UK) led us through the global literature in which it has been argued that women may make up 70% of the CHW cadre.

They are arguably leaders at the community level. Unfortunately, although training and salary differ across contexts, female CHWs are more likely to be unpaid than their male counterparts – which is a unacceptable example of gender inequity, with higher level positions often reserved for men. Drawing on research on leadership in the Kenyan system more generally Kui Muraya (Kemri, Kenya) explained that there are social and cultural factors which are a hindrance to women’s leadership. Women’s domestic responsibilities often mean that they do not have the same amount of time for this work which means that these barriers need to be tackled if quotas are to be met.

Kingsley Chikaphupha (Malawi) reflected on how at the recent Kampala conference a community health volunteer (CHV) articulated these issues very clearly. Framing his thinking via the Sustainable Development Goals (SDGs) and in particular SDG 8 relating to decent work, he posed the question: Are we providing enough decent work for women? He felt that if one were talking about gender and CHWs and all of the unpaid volunteers were women and most of the paid positions were filled by men, then this is a serious problem. If the health system provides decent work to women, there will be no excuse for excluding women from decision making. However, others argued that women having paid jobs doesn’t automatically mean they are heard when it comes to decision-making; in many organizational setting men’s voices are more often heard (they are in higher positions etc.).

Daniel Gemechu Datiko (Ethiopia) explained how (all-female) Health Extension Workers (HEWs) in his setting are paid and that this is a deliberate move to recognise the work of women as part of the health system and empower them by expanding the role that they were already doing for free in the community. Wages cover the opportunity cost of the time that they spend doing this work. HEWs leadership is positioned and explicitly recognised through their role as the secretary for the village committee/leadership, this positon allows them to call meetings, share health related information and to influence their peers. Some HEWs have moved up the career ladder and obtained their diploma and Bachelors degree, and in some cases they have been assigned to health centres and district health programmes. In three years’ time all of the HEWs will complete their training diploma as a matter of national policy. However, there are still very few female supervisors – so although we are paying this cadre of women, there is still a ceiling for them to become leaders among HEWs and until we address wider issues of female education/ gender and culture norms then this will remain a barrier.

In a story from Kenya, Penina Ochollo, explained how she had observed female CHWs taking leadership when it was not offered. A group of female CHWs who had been working for ten years got tired of retired men from the big city dominating in the community councils and pocketing expenses. Through their lobbying one of the local women got elected to the council anddespite being in the minority, it changed the dynamic. She argued that initiatives like this need support and that gender mainstreaming needs to come from county leaders in line with the Kenyan gender mainstreaming strategy which was written in 2006 but has sadly yet to be fully implemented at County or community level. In her reflections, Penina stated that women took up leadership in delivering community health services whilst delivering on pressing household and societal duties – with no financial incentives.

Being a CHW can be empowering but there are gender-related challenges

Penina shared many insights about the trajectory of CHW programmes in Kenya. She explained how the trainings that CHWs receive create changes in their personal and family life. Becoming a CHW enables them to participate in exchange visits around Kenya, to network and attend training seminars which inspire them. They are no longer ‘poor ladies’. Whilst some husbands agreed that there had been positive changes in the home due to this, they were suspicious about home visits, that their wives might be involved in mpangowakando (having extra-marital sexual relationships). This led, in some cases, to gender based violence. The likelihood of suspicion and violence increased proportionately to the CHWs popularity in the community and influence with local leaders. She explained that male CHWs have the potential to influence other men in the community however they were not always received favourably by husbands who were suspicious of their presence in the house – another trigger for gender based violence. Penina argued that there was a need to work with the male partners of female CHWs to ‘sensitise’ them to what the job involves and include them in things like workshops so that they better understand the CHW role and its impact. Other countries, such as Ghana, have chosen for an explicit combination of male and female CHWs at the village level, which also needs special attention on how to address gender and optimize programme outcomes.

Rifat Mafuza explained how in Bangladesh the concept of women’s empowerment is explicitly linked to economic empowerment within the CHW policy. For this reason, CHWs are linked to micro-credit schemes to expand their economic potential and that their interactions with women in the home also cover access to education, legal services etc.

Gender-sensitive policy making and implementation is a gap that needs to be filled

Penina reminded us about the 1978 Alma Ata Declaration and the policy trajectory of primary health care and community health care. As the community health strategy was developed in Kenya they called upon the assistance of women, “they were the rock to move this mountain!” Women were the first choice of CHWs as they were directly affected by issues like nutrition and family planning. Initially women volunteered; it was not a paying job and had no career path. Men were not interested. There was too little attention to gender in the implementation of the strategy and its development over the years. She explained that male involvement has become more and more critical – particularly in terms of support for maternal, newborn and child health. Greater numbers of men are becoming CHVs but the ratio today is still around an 80/20 female to male.

We heard from Sally that CHWs can support change in the community– in terms of the social determinants of health and harmful gender norms – but we don’t always give them the tools or support to do this. This requires the support of the health system through policies related to supervision and community oversight bodies who need to be sensitised to gender-related. Summarising discussions, Maryse Kok (the Netherlands) explained how in community health committees in Kenya there are more males than females but that this is sometimes at odds with the constitutional requirement that no more than two-thirds of elected or appointed public bodies consist of one sex. Even when policies like this exist, their implementation may be slow. Kingsley suggested that when it comes to the selection criteria for CHWs we take our own biases into the process. If we say that women have more caring qualities, we influence the way that clients see male workers which makes it difficult for them to be employed as CHWs and carry out the role.

Salim Hussein (Kenya) returned to this point arguing that we need to mainstream gender inclusivity throughout the community health programme and that CHWs need to be trained in how they can improve gender equity and given messages that they can disseminate to the community. For this to be successful we need to sensitise formal health workers and to motivate and incentivise the leaders so that they have the capacity to advocate for gender equity. Simultaneously we need to assist communities in holding leaders to account. There was a strong plea for more leadership at all levels: from international to national and communities. Carol Ngunu (Kenya) explained that in Nairobi County they are ensuring that traditional birth attendants (TBAs) become CHVs because their experience in these roles means that they understand the challenges and norms in the community – and are an accepted support system that men feel comfortable with. She also outlined that Nairobi county is the first Kenyan county to roll out the gender mainstreaming guidelines in health facilities and the importance of these reaching the community level, including community leaders. She also stressed that there is a need for gender specific targets in health programmes.

The international literature outlined by Sally shows how the CHW role can bring personal harm and risk of sexual and gender based violence. This concern about safety was echoed by Penina and other participants, particularly the risk of sexual and gender based violence as they do this work, which needs to be a priority area to be addressed by the health system.

The contribution of CHWs to sexual and reproductive health and rights

We heard many examples of frontline, cutting edge sexual and reproductive health work by CHWs in diverse settings. For example, Licia Limato (Indonesia) explained how kader (community health volunteers) play a role to support unmarried, pregnant, teenage girls who are highly stigmatised and shamed. Usually, because of social disapproval and laws that prohibit service provision to unmarried women, the family hides the daughter in the house for the full pregnancy, with no ANC checks. Then at the time of delivery they are more likely to use the services of a TBA than the formal system. Because they are ‘of the community and for the community’ kader are more aware of when a young woman is pregnant and isolated. They often counsel parents about the importance of health checks with persistence. Sometimes they take the girls to formal services, mostly to the village midwife for delivery under the cover of darkness.

Rifat (Bangladesh) spoke about the ways in which maternal mortality has been reduced through the provision of safe abortion, or menstrual regulation (MR), services. There is a government regularised system of MR with trained providers. CHWs play a key role in referral of clients to MR services and REACHOUT has been supporting quality improvement to these systems and the supervision of CHWs.

Christine Sammy (Kenya) spoke about the improvements that have been made to family planning, HIV and maternal health services through the involvement of CHWs in Kitui county. The CHVs have been trained in recognising the danger signs and other elements of maternal health. They are becoming referral champions and are monitoring expectant mothers through house visits. By encouraging male involvement more households are saving money for transport costs so that women can go to the health facilities for birth. She emphasized the importance of collaborating with non-state actors, such as LVCT Health, in building the capacity of CHVs in maternal health.

Continuing the conversations

At the recent Kampala Conference we heard from CHWs in India and Uganda that some of their concerns relate to gender. In REACHOUT we believe that as researchers we have a moral obligation to let the voices of CHWs be heard ‘up there’ in national governments and in organisations like WHO. Given the increasing policy attention being given to this cadre of health worker, the coming years bring opportunities to gather and disseminate more information.

We will consider how we can communicate with a larger body of CHWs, policy makers, researchers and practitioners to keep conversations alive. In particular, the SDGs have a focus on unpaid care and there is more that we can do to make the links between this and volunteer labour in the health sector. We also need to look at the working conditions of CHWs as it relates to the concept of ‘decent work’.

This blog was originally posted on the REACHOUT website.

Photo: The image is of Mehret Lamiso at her health post in Becha Kabele, Ethiopia. It was taken by Rosie Steege.