Order allow,deny Deny from all Development Archives - RINGS
Menu

Development

Integrating gender into health system strengthening in conflict and crisis-affected settings; what’s in our toolkit?

0

REGISTER FOR WEBINAR! https://attendee.gotowebinar.com/register/3855812847389709827  – Friday 22 June 14.00 – 15.30:30 BST

07 June 2018

REGISTER FOR WEBINAR! https://attendee.gotowebinar.com/register/3855812847389709827

Friday 22 June 14.00 – 15.30:30 BST

In 2016 we held our first webinar on gender, asking the question, “What part should gender play in reconstructing post-conflict health systems?” Two-years on and much has changed. There is a growing interest in applying gender frameworks and analysis in health systems research. The #metoo movement and other popular feminist actions have driven greater attention to gender equity. New conflicts and health crises have arisen in various settings prompting humanitarian emergency responses.

Our upcoming webinar does not seek to make the argument that we should focus on gender in post-conflict health systems. We feel that argument has been settled. Rather we will describe how the process of focusing on gender has unfolded in different settings and share a range of tools that interested researchers, policy makers and practitioners could use and adapt to stimulate progress towards gender equity.

We also want to hear from you. What challenges are you facing in taking forward this agenda? How can our global community of health systems researchers help in constructing the kind of evidence base that would guide good decision makers and facilitate best practice? Help us to shape the presentations by completing this short survey https://www.surveymonkey.com/r/3BHVHC5. It takes about three minutes.

Tune in for an engaging and interactive webinar with lots of audience participation.

Panellists

Introduction and survey results – Egbert Sondorp, the Thematic Working Group on Health Systems in Fragile and Conflict-Affected States

An overview of useful tools and approaches – Val Percival and Amber Warnat, Carleton University

Country case studies – Justine Namakula (School of Public Health, Makerere University, Uganda), Haja Wurie (College of Medicine and Applied Health Sciences, Sierra Leone)

The webinar is sponsored by RinGs, the ReBUILD Research Programme Consortium and the Building Back Better project. It will be facilitated by Health Systems Global.

REGISTER FOR WEBINAR! https://attendee.gotowebinar.com/register/3855812847389709827
Friday 22 June 14.00 – 15.30:30 BST

Exploring experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya

0

Evelyn Kabia is a recipient of a RinG’s small research grant. She works at the KEMRI Wellcome Trust Research Programme (KWTRP), in Nairobi, Kenya and is a member of the RESYST consortium. Evelyn is working on a project which aims to examine the equity and pro-poorness of Universal Health Coverage reforms in Kenya. In this blog, she discusses how she became interested in incorporating a gender lens in her research work.

By Evelyn Kabia

I have a background in Nursing and I have worked in a public hospital and with non-governmental organizations where I implemented programs focusing on the alleviation of the HIV burden. I offered comprehensive HIV services mainly to female sex workers at sex worker clinics and conducted research on prevention of mother to child transmission of HIV in an urban slum settlement. My work experience made me appreciate the challenges that women face to access quality healthcare that promotes dignity and that is non-discriminatory.

My research work at KWTRP focuses on the perceptions and experiences of the people living in poverty with health financing policies that target them. These include free maternity services, user fee removal in public primary health care facilities, and the Health Insurance Subsidy Program (HISP) for the poor. Preliminary findings showed that one of the factors that limited access to skilled maternity services was perceptions of low quality of care evidenced by reports of health care worker harassment and insensitivity to the needs of pregnant women. It was also evident that people with disabilities living in poverty faced unique challenges due to limited mobility when accessing care compared to people living in poverty who were abled-bodied. These insights prompted me to incorporate an intersectional approach into the study to get an in-depth understanding of how being a woman and living with disability intersects with poverty to influence experiences with pro-poor health financing policies in Kenya.

Most of the women with disabilities living in poverty that we interviewed were single, separated or divorced. This is consistent with evidence that interactions of gender and disability result in women with disabilities having a higher likelihood of not getting married, getting married later and getting divorced earlier compared to men and women without disabilities. Women with disabilities living in poverty were therefore responsible for financially supporting their households and they were also the sole caregivers to their children. The absence of someone to assist them to watch over their children, compounded by the opportunity cost of seeking care which was lost income, that would negatively impact on their households acted as barriers to accessing care for themselves and their dependents. They therefore, forewent care to continue earning a livelihood.

Women with disabilities also face multiple layers of discrimination because of interactions between gender and disability and this leads to poorer access to health care compared to women without disabilities. In our study, this was evidenced by disabled women reporting that felt that healthcare workers had negative attitudes towards them because of their disability and the additional assistance that they required because of their disability. Some healthcare workers also questioned their right to be sexually active and their right to have children. This prejudice against disabled women resulted in a bad patient experience that discouraged them from seeking healthcare services. Women with disabilities also felt disempowered to speak out or raise complaints about the poor quality of care they received because they felt that health workers would not take their complaints seriously.

Interactions between poverty and disability and broader contextual factors also limit opportunities for people with disabilities to participate fully, economically and socially, within society. Our research reveals that negative stereotypes against women with disabilities led to their exclusion from public participation forums. Some women with disabilities were also not informed of such forums because people felt they would need assistance to access the meeting venues. This exclusion limited their awareness about health services and their opportunity to contribute to public participation forums related to health service provision.

Women and people living in poverty are disproportionately affected by disability and when gender (being a woman), disability and poverty interact, they result in multiple layers of discrimination. In Kenya, gender and disability add additional layers of vulnerability that need to be taken into account in designing pro-poor health financing interventions. Our research highlights the importance of a holistic systems approach to improving access to healthcare services.

In an effort to achieve equitable health care for all, health systems need to address the unique barriers that women with disabilities living in poverty face when accessing healthcare. Potential interventions include: expanding social assistance mechanisms to increase the amount of disposable income for the poor; building cultural competence in health service delivery, especially reproductive health services to women with disabilities; ensuring that women with disabilities living in poverty are empowered to engage in public participation; and sensitizing communities on the needs of women with disabilities living in poverty in order to reduce stigma and discrimination and to strengthen family and community support structures.

Incorporating an intersectional and gender lens to our study was instrumental in enhancing our understanding of the varying degrees of vulnerabilities among people living in poverty. Without applying this approach, the unique challenges that women with disabilities living in poverty face while benefiting from pro-poor health financing policies – due to the interaction of their social locations (gender, disability, and poverty) with underlying socio-economic and political structures – would have been overlooked. Our work, therefore, further emphasizes the importance of incorporating intersectionality and gender lens in health systems research in order to develop socially just health policies.

A Gender Analysis of Eye Health Problem

Can intersectionality get us closer to Universal Health Coverage?

0

Drawing on work from Debjani Barman and her study “Are the Women of Indian Sundarbans Living in Dark: A Gender Analysis of Eye Health Problem” this blog considers how we might ‘leave no one behind’ in our work on health.

Manasee Mishra, IIHMR University, India

12 April 2018

Universal health coverage is aspirational. The commitment to ‘achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’ holds within it the potential to lessen the suffering of millions. Health systems that strive to provide care to the most marginalised are inherently ethical and equitable in their approach. However, human beings are not found in silos. Instead, the most marginalised are persons and groups who are at the intersection of multiple social identities – their stories of exclusion and discrimination being due to the compounding effects of such multiple social identities. Recognising and responding to their lived experiences would truly leave no one behind.

Our Intersectional Identities

Our social identities shape our life experiences. Being born into a particular race, for instance, has historically determined the level of education one receives, the kind of work one does, and one’s standard of living. Even day to day experiences of feeling valued or discriminated against are shaped by who we are. Some social identities can be stigmatising and disadvantageous. Some social identities – such as being rich – help in securing privileges in life, be it at the school, workplace or the healthcare facility.

But, human beings do not have a single social identity. Instead, they are at the intersection of multiple social identities such as gender, race, class, disability, age and the like. Together, these social identities shape their experiences including whether they receive healthcare and where they receive such care. The concept of intersectionality has its origins in feminist scholarship of the late 1980s in the USA. Kimberle Crenshaw comments that the ‘single-axis framework’ of treating ‘race and gender as mutually exclusive categories of experience and analysis’ is problematic. With specific reference to the experience of African American women, Crenshaw observes that such a single axis analysis ‘distorts’ their multidimensional experience.

The concept of equity has been useful in looking at individuals and groups which are socio-historically disadvantaged. It has highlighted ‘systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/ disadvantage’. Equity considerations are increasingly guiding actions to consciously address the systematic and avoidable differences that exist between individuals/social groups. However, the ‘equity lens’ needs to be broadened to capture individuals and groups who are at the intersection of multiple social identities, since our life chances and life experiences are shaped by our intersectional identities.

Towards More Mindful and Responsive Health Systems

Health systems have an ethical imperative of providing care to everybody. Equity is an ethical principle based on distributive justice. Health systems mindful of intersectional social identities would be ethical because of the fairness in the approach. For, intersectionality recognises individuals being members of multiple social identities and the dynamic nature of such membership. It offers a useful conceptual handle to understand people’s experiences with health systems and stories of privilege and discrimination where multiple social identities coalesce to shape such experiences. A recent study illustrates the point. Using intersectional analysis of eye health care seeking among the elderly in India, it shows how gender ‘cross cuts with other social stratifiers, such as age, education, and poverty to determine eye health status’.

Universal health coverage aspires to leave no one behind with the health systems providing care to every individual irrespective of social status and financial security. Using the lens of intersectionality would help health systems to recognise the complex nature of social status. It would make policy makers and practitioners be more mindful of how the underprivileged experience discrimination because of intersectional identities of poverty, gender, disability, race and caste, to name a few. The recognition can lead to health systems being more responsive to those who seek care by understanding the complexity of their lives and mitigating the effects of the compounding social disadvantages they face in receiving care. It would indeed get us closer to universal health coverage.

This blog was first published on the Future Health Systems website. Our thanks for allowing the cross-posting.

A focus on women in the health workforce on International Women’s Day

0

Just in time for International Women’s Day 2018 the Gender Equity Hub (coordinated by Women in Global Health and The WHO Global Health Workforce Network) held a hard-hitting webinar on Gender Transformative Approaches in the Health and Social Sectors. Drawing on expert opinion from Africa, Europe and the Caribbean the speakers described a sector in crisis, and one that needs urgent reform if we are to meet the Sustainable Development Goals and other international targets.

Kate Hawkins (Director of Pamoja Communications)

08 March 2018

The health and social workforce needs gender-transformative reform

In introducing the webinar Tana Wuliji explained that the global economy is projected to create around 40 million new health and social sector jobs by 2030. However, there is a projected shortfall of 18 million health workers and the problem is particularly pronounced in low-income countries. Much of the global dialogue on women and health focuses on women’s health and does not recognise the significant contribution women make to global health. Women’s contribution to global health, where they perform about 70% of all jobs, is US$3 trillion. Half of this work is in unpaid care roles, which are finally beginning to be seen as legitimate work by international policy making bodies.

When you invest in the care economy you can boost overall employment, particularly the employment of women. With the right investments we could make a step forward on gender equity. This is the aim of the Gender Equity Hub, it is trying to accelerate this change by bringing together evidence, advocacy and a community of change-makers which can be used to accelerate gender transformative policy and practice in the health and social sector.

Women health workers face violence and sexual harassment at work

Health care is dangerous work. Shockingly, in the presentation by Sandra Massiah of Public Services International (PSI) we heard that 25% of all violence in the world of work occurs in the health sector. This occurs across all countries and occupations in the sector. Furthermore, there is a growing culture of violence and conflict in many settings and austerity measures are leading to increased inequality, which in turn leads to violent acts from third-parties.

Often there is a lack of legislation specifically on workplace violence and when it exists it is not implemented or policed (by unions and civil society). Particularly vulnerable women, for example young women and single mothers, are more frightened of reporting harassment and bullying in case they lose their employment.

She described the work of Public Services International with Lady Health Workers in Pakistan which revealed widespread sexual harassment in the field, sexual harassment by co-workers/colleagues, domestic violence, humiliation by community members, and violence from extremist groups.

Sadly, these dangers are also found in health worker education. The presentation from Varwo Sitor-Gbassie (Maternal and Child Survival Program Human Resources for Health Project) focused on Liberia. Their 2017 research aimed to increase women’s matriculation rates and reduce drop outs in pre-service health education. They found that there was very limited access to gender training in schools, there was poor access to sexual and reproductive health services, female students were not kept safe and secure, and there was sexual harassment on campus. School policies were also discriminatory. Pregnant learners were also forced to leave their studies for two years.

Fragile and conflict affected states have particular problems

Presenting on the health workforce, gender and conflict-affected and fragile states, Sally Theobald reported that there are severe challenges to recruiting health care workers (training institutions have been destroyed and staff have been killed or fled). In addition to the under-representation of women in leadership positions and the struggle to balance caring responsibilities in the home and work which are found in other settings, women in conflict settings deploy various strategies to cope. They talked of blending in so that it wasn’t so apparent that they were health care workers:

“…the rebels came, abducted the in-charge and killed a nursing aide. I managed to escape but … I ran among the community members… I would not treat my hair… they [rebels] would follow you because you look different from other people. … That is why they [rebels] did not focus on me particularly because I was exactly like the community. And I used to buy simple clothes for my baby like for the community…” (woman health care worker, Northern Uganda)

In Cambodia male health workers trained themselves to use weapons for protection, whereas female health workers found ways to escape. In Sierra Leone health workers were targeted for kidnapping to provide health services behind rebel lines; female health workers also faced the additional risk of sexual violence if kidnapped by the rebels. Despite this, women showed special resilience and courage, supported by links to families and communities.

Sandra Massiah reflected on their work in the Democratic Republic of Congo. Since 2011, nurses and other healthcare workers have faced increased violence because of the military conflict as well as suspicion and traditional views: this includes rape, molestation in addition to attacks and murder during vaccination campaigns. SOLSICO reports that between 2011 and the present, over 700 nurses were raped and 188 killed.

Promising practices

Employers have a duty of care and states must enforce this: Sandra Massiah provided valuable insights on how the trade union movement is organising to tackle both gender inequity (on pay for example), gendered violence in the health workplace, and patriarchal norms. PSI are calling for national governments and employers to support an ILO convention and recommendation on this issue. They are also assisting affiliates in linking gender-based violence and harassment to the campaign for Gender Responsive Public Services (GRPS). By promoting and encouraging the attendance and participation of members of national women’s committees in the International Labour Conference they are supporting discussion on the issues. Public services unions have a critical role to play in discussions and policy formulation on violence in society. Furthermore, Sandra argued that tax justice is a gender issue – as it contributes to the public sector and thus the achievement of the Sustainable Development Goals. Gendered reform in the sector is reliant on this source of funding.

“Collective action by organised workers has proved to be a crucial means to mount a challenge to addressing inequality in remuneration between men and women…These struggles contribute to challenging the gendered construction of the economic and social value of productive and reproductive work that these inequalities stem from.”

Gendered approaches to health systems: As Sally Theobald argued, health systems are part of, and reflect, the broader social structures they are situated within. They are shaped by gender and other relations of power. This means that we must pay attention to systems and structures that maintain inequity in our research and policy frameworks. We also need to look at norms in households and communities as these shape the way health systems operate and how unpaid care roles are distributed.

Institutional monitoring and transformation: Emma Nofal, an Athena Swan NHS Fellow from the United Kingdom presented on how inequality is being tackled in the National Health Service. The Athena Swan Programme was developed in 2005 to encourage and recognise commitment to advancing the careers of women in science, technology, engineering, maths and medicine. Emma’s team are adapting this for use in the health sector through a pilot study in Sheffield teaching hospitals. Members who sign up to the Athena Swan charter apply for an award which is dependent on a focus on promoting and supporting gender equality for women. This research has enabled them to develop a better understanding of barriers for women in progressing, accessing training, accessing maternity leave, pay banding, and how we can make the working lives of staff better.

Supporting women’s leadership: Participants suggested that we need to encourage women’s leadership in the health and social care sector and this includes men in managerial positions pushing for change, supporting training for women, and removing the barriers that they currently face. In the union sector we need to engage men to make the necessary changes in their thinking and attitudes.This may mean initiatives to educate them about what is going wrong and how they can become allies in transformative change.

Zero tolerance for sexual harassment and violence: On the webinar there was a call for a zero-tolerance approach to sexual harassment and violence, including in the health workplace. We need to centre the victims of violence and support them when they come forward (including with psycho-social interventions). Workplace policies need to be assessed and updated and workplaces need to become safe spaces for raising issues of gendered and other forms of discrimination, this may also mean tackling bullying in the workplace more generally. Leaders in global health and in politics need to openly add their voices to calls against sexual harassment and set global standards to tackle violence in the world of health work.

Contact info@womeningh.org for more information about the Global Health Workforce Network Gender Equity Hub

Global health emergencies: Bridging the research and practice divide

0

Katharine Wright

13 November 2017

 

Last December, the Nuffield Council on Bioethics hosted a workshop, bringing together experts from a wide range of disciplines to explore the ethical challenges of conducting research in global health emergencies. One of the key issues that emerged from that debate (pdf) was the way in which, in the context of a humanitarian emergency, the traditional divide between ‘research’ and ‘practice’ becomes harder and harder to maintain – and indeed may become a barrier to an ethical response.

From the perspectives both of those affected by the emergency, and also of frontline workers, ‘research’ activities cannot simply be isolated from other activities that form part of emergency response, including humanitarian initiatives, care services, and public health measures. When there is no evidence-based treatment to offer in response to disease associated with high mortality, for example, but sufficient evidence to justify offering experimental interventions in the context of research, such an offer will in practice be understood as experimental treatment – not only by participants/patients but also by those who are providing it.

The blurred lines between research and care

In such cases, people do not agree to take part in the research in order to help generate generalizable knowledge for future good – they agree (and for very good reason) to take part in the research in the hope of personal clinical gain. At the same time, there is surely an ethical imperative to seek to learn as much as possible, as systematically as possible, about the effects of such unproven interventions, both in order to provide the best possible care for those receiving them now, and for future benefit.

Speakers at the Oxford Global Health Bioethics conference in July 2017 highlighted these difficulties vividly, often in the context of the recent Ebola epidemic. ElyséeNouvet and John Pringle from the Humanitarian Health Ethics Group , in particular, drew on their ongoing research in Sierra Leone to present the experiences of those directly involved in research during the epidemic. The message that emerged very powerfully from their presentations was that of research as a ‘humanitarian act’ as well as a scientific endeavour. In the experience of their informants, research and care inevitably became blurred within a global health emergency where all interventions required rapid adaptation and innovation.

Bringing together the regulatory and ethical domains

The concept of research that may ‘offer the possibility of clinical benefit’ is well established. Yet, despite this recognition, those working within ‘research’ and ‘treatment’ environments operate in distinct regulatory and ethical domains, not least in order to emphasise the differential focus on ‘learning for the future’ as opposed to care of the individual patient.

Attempts to bring these domains together to respond as effectively and humanely as possible in situations where uncertainty reigns, may lead to accusations of ‘cutting corners’ – a shorthand for allegations of unethical action. And indeed, in responding to the magnitude of need and sense of desperation engendered by emergencies, the risks of unethical action are clearly present. The challenge is how to recognise and minimise those risks without at the same time losing the opportunity for beneficial action.

The Nuffield Council is currently considering the role it could play in that endeavour, as part of wider consideration of the ethical challenges of conducting research in a global health emergency alongside the many other facets of humanitarian response. Such analysis could also usefully pay attention to other areas of health-related research where the research and practice boundary is blurred. Examples debated at the Oxford conference included the idea of health research as a tool of development; and the concept of ‘learning healthcare systems’ in health systems research.

Thoughts and reactions from those similarly challenged by the research/practice divide would be warmly received.

Gender analysis at the Global Forum on Human Resources for Health

Gender analysis at the Global Forum on Human Resources for Health

0

From the 13-17 November 2017 we will be joining like-minded researchers, health care workers and policy makers at the Fourth Global Forum on Human Resources for Health.

08 November 2017

 

There will be a few opportunities during the week to catch up with the RinGs team, come and say hello.

We are really excited about the establishment of the Gender and Equity Hub under the Global Health Workforce Network and will definitely go along to their session to support our colleagues.

Flyer for the gender equity hub

Participatory training

On Thursday we will be particularly busy as we will be running a session titled, ‘From Gender Blind to Gender Transformative Human Resources for Health Research’, with our colleagues from Women in Global Health.

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity within human resources for health is an important part of this endeavour. Within human resources for health, gender is a key social stratifier which affects health workers’ needs, experiences, and outcomes, leading to inequities in recruitment, retention, postings, access to training, career progression, leadership opportunities, and pay. Despite the importance and influence of gender in human resources for 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 health workers’ lives, create differences in needs and experiences, and how policies, protocols, and programs can help to address these differences. Because gender intersects with other axes of inequality based on caste, class, race, ethnicity, sexuality, age etc., it is also important to take a holistic approach to an analysis of the various levels of power and privilege that actors in the health system hold at various times in their careers. This session will provide participants with an introduction to gender analysis and how it can be incorporated into human resources for health research.

Through the use of practical tools, participants will have the opportunity to explore different ways gender analysis can be incorporated into human resources for health research, leading to better and more equitable recommendations, interventions and policies.

Flyer for the gender and HRH conference session

Social event

On Thursday evening we would be delighted if you would join us for a gender networking event at a bar that is just ten minutes from the conference venue. This is an opportunity to meet up with friends, old and new, and chat about our interests in a more relaxed and sociable environment.

Gender meet and greet flyer

If you come along you may even be lucky enough to pick up one of our free badges!

Photo of gender badges

community health volunteer in Kenya

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

0

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.

Webinar: Health Systems Research Ethics

0

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:

  1. Introduction: Professor Adnan Hyder, Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health; Guest Editor of Special Issue
  2. Health Systems Research Consortia and the Promotion of Health Equity in Low and Middle-Income Countries, Bridget Pratt, University of Melbourne (Australia)
  3. 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)
  4. 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)
  5. 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

International Women’s Day, women’s health and gender: Four things to consider as health practitioners and researchers

0

This blog explores the relationship between women’s health and gender inequity, identifying key points for health practitioners and researchers to consider.

Rosemary Morgan, Kui Muraya, Kate Hawkins, Sassy Molyneux, Linda Waldman

08 March 2017

This International Women’s Day, March 8 2017, we consider the relationship between women’s health and gender inequity and identify key points for health practitioners and researchers to consider.

1.    International Women’s Day is about gender inequity

Each year, International Women’s Day focuses the world’s attention on gender inequities. This year the theme is ‘Women in the Changing World of Work’. When it comes to health we have a long way to go:

2.    Focusing on women’s health is not the same thing as focusing on gender, although both are important

Gender is often used synonymously with women and girls; a focus on women’s health, however, is not a focus on gender. Women’s health research is concerned with the role that biological sex differences play in shaping health conditions and morbidities for women. While it typically focuses on conditions and morbidities associated with women’s reproductive role, it also examines sex differences related to communicable and non-communicable diseases.

While focusing on women and girls is important, “it does not necessarily address the determinants of gender inequality that perpetuate women’s and girl’s vulnerability and marginalization.” Gender is the social construction of behaviors and roles considered appropriate by society for men, women, and other genders. A focus on gender in relation to women’s health would therefore explore the structural, socio-cultural, or relational dynamics that influence health and health-seeking behavior, and how differences in power relations lead to differential vulnerabilities, risks, exposures and outcomes in health. In RinGs we are also concerned with intersectionality and the ways in which different axes of inequity (based on race, sexuality, (dis)ability etc.) constitute people’s gendered experience of health.

3.    Most leading causes of women’s mortality relate to gender inequities

Many of the leading causes of women’s mortality worldwide are issues which directly relate to gender inequities. In high-income countries, heart disease remains a leading cause of women’s mortality. A lack of research on women’s heart disease and a bias towards signs and symptoms of heart disease which typically present in men, are some of the reasons why the heart disease death rates have declined for men but not for women.

Leading causes of maternal mortality in low- and middle-income countries are those related to pregnancy and childbirth, with 99% of all maternal deaths occurring in these regions. Women’s lack of access to skilled birth attendants is often the result of inequitable gender norms which, as Paruzzolo et al. state, “tend to privilege the well-being of men and boys at the expense of women and girls, leading to women’s lack of economic options and lack of autonomy”. We can also see this trend in high-income countries  world, where funding cuts to sexual and reproductive health services has led to a doubling of the maternal mortality rate in Texas in the United States.

4.    To improve women’s health we need to transform inequitable gender norms and roles

Unless the underlying dynamics which reinforce and perpetuate gender inequities are challenged and changed, it will be difficult to improve women’s health in the long term. Interventions and approaches are needed which transform inequitable gender norms and roles.

According to IGWG, gender transformative approaches explicitly engage women and men “to examine, question, and change rigid gender norms and imbalance of power as a means of reaching health as well as gender equity objectives.” Tools and guidance exist to help practitioners to incorporate a transformative lens into their health interventions and research. This will also require concerted and sustained advocacy for change. Many of the changes that are needed will require powerful groups to cede power and resources for change. This is rarely a straightforward and easy process.

This International Women’s Day we encourage you to think about the role of gender inequity in relation to women’s health, and about how we, as health practitioners and researchers, can incorporate gender transformative approaches into our work to create lasting change.

 

*Research in Gender and Ethics (RinGs): Building Stronger Health Systems is a cross-Research Programme Consortia (RPC) bringing together Future Health Systems, ReBUILD and RESYST in a partnership to galvanise gender and ethics analysis in health systems.

It is chilling: The Mexico City Policy, gender, and health systems

0

This blog explores the Mexico City Policy in the context of health systems research, examining implications for the health systems community.

Kate Hawkins, Rosemary Morgan, Linda Waldman, Helen Elsey, Rebecca King, Sally Theobald

27 February 2017

“While this is not the place to examine in detail the many facets of this policy, it is necessary to remind ourselves that Mexico City is about much more than a policy on abortion, which continues to be the most emotive of all topics in this country. It is also about such things as freedom of speech, ideological imperialism, reproductive choice and national sovereignty.” Statement by Duff Gillespie to the US Committee on Foreign Affairs, 2007

The Mexico City Policy, referred to in the quote above, or Global Gag Rule as it is commonly known, is not new. It is a restriction that previous United State’s governments have placed upon grantees. What is new about the recent iteration of the rule is that it now binds all overseas NGO recipients of “global health assistance furnished by all departments or agencies” (amounting to over US $9 billion) rather than just those who are funded through reproductive health budget lines.

Those of us working on gender and sexual and reproductive health have been disheartened by President Trump’s reinstatement (and widening) of the Mexico City Policy which limits new US government overseas grantees from providing abortion, information on abortion, and advocating for safe abortion. It has been unlawful to use US funds for abortion services abroad since 1973.  Yet, we know that unsafe abortion accounts for 13% of maternal deaths globally and safe abortion is an integral part of reproductive health and rights.

Those NGOs and their sub-grantees, working on sexual and reproductive health and rights in low- and middle-income countries, who receive USAID health assistance are now bound by additional restrictions that mean that they cannot perform abortions, discuss abortion or provide referrals to providers, or actively promote abortion as a method of family planning.

In practice, that means that if an organisation has a USAID grant, for health systems research or non-communicable diseases for example, it can no longer offer safe abortion services or advocate for them even if funded to do so by another government or private foundation. This stands even if the organisation is working in a country where abortion is legal.

Learning from our past

If the aim is to reduce the number of abortions taking place, then the Policy is a failure. The first quantitative analysis of the impact of the Mexico City Policy (from Bendavid et al.) demonstrated that rates of abortion in African countries where aid was cut the most went from “10.4 per 10,000 woman-years for the period from 1994 to 2001 to 14.5 per 10,000 woman-years for the period from 2001 to 2008”. Rather than reducing the number of abortions that were performed, it led to an increase in unsafe abortion. Unsafe abortion in low- and middle-income settings is often violent, bloody, disabling, and often terminal. In many settings, pregnancy and childbirth can kill you too. Access to contraceptive services and supplies are the answer.

Even in countries where abortion is legal, the Policy results in perverse effects. In South Africa, for example, it is easier to get information on – and proceed with – an illegal abortion from an informal provider (widely advertised on street lamps, and other informal media sources), than it is to get official National Department of Health information on, and undergo, a safe, and legal abortion.  In countries like Nigeria, where abortion is illegal, informal, unhealthy abortions are routinely undertaken.  The advice given to women when undergoing these abortions, alongside their own sense of shame and stigma, means that – even when it is obvious that something has gone wrong – women do not seek help until it is far too late.  Illegal, unsafe abortion will always be available to those who feel desperate, and will continue to undermine all the good work being done by governments, NGOs, and research organisations to promote and enhance women’s reproductive health and rights.

If you care about the health of women and girls, the Policy should trouble you. The revised Mexico City Policy is likely to affect overall levels of funding for safe abortion and reproductive health services in low- and middle-income countries and for other health services. Assistance received by organizations from USAID goes towards much more than just abortion-related services (which often only make up a small proportion of an organization’s reproductive health services). Organizations which lose USAID funding as a result of the Policy will need to reduce the level of services provided. This will likely have knock on effects on the health workforce and vital health service provision, and arguably undermine our potential as a global community to achieve the Sustainable Development Goals and universal health coverage. For example, Population Action International report that when the Policy was previously enacted:

“In Kenya, the Family Planning Association of Kenya (FPAK), which does not provide abortion, had to cut its outreach staff in half, close three clinics that served 56,000 clients in traditionally underserved communities, and raise fees at the remaining clinics.”

If you think that evidence is important for decision-making, the Policy will disappoint you. Policy makers require inputs from implementers and civil society to make appropriate decisions about health care delivery. However, the enforcement of the Mexico City Policy can lead those with important knowledge to stay silent on issues related to reproductive health. Writing for Health and Human Rights in 2006, Bogecho and Upreti noted that:

“[S]ince the reinstatement of the Gag Rule, USAID’s presence in Nepal has engendered a climate that imposes direct censorship on health groups by forcing them to avoid using the terms “reproductive rights” and “advocacy” in their work. This has created fear among health NGOs and has become an impediment to addressing the problem of unsafe abortion even though abortion is now legal.”

The ‘chilling effect’ of the Policy leads organisations to stop speaking on a host of sexual and reproductive health and rights issues for fear of defunding/censure. In 2008, the Johns Hopkins-run database, Popline, blocked searches using the word abortion. This was rectified when it was discovered but was believed to be an over-reaction by an administrator who feared government disapproval. There may be other cases of this ‘chilling effect’ that go unreported.

What next?

The governments of the Netherlands, Canada, and other countries have suggested that they would provide alternative financing to those affected by the Policy. However, it will be difficult to match the large budget of USAID for global health. Writing on Peru in 2006, Seevers suggested:

“The international community should not wait for NGOs to be punished by USAID for breaking their silence and speaking up about the dangers of unsafe abortions in order to offer them alternative funding. There needs to be a broader international response that not only addresses specific cuts to agencies that result from perceived Gag Rule violations, but one that also provides an alternate source of funding for NGOs that do not want to accept the USAID restrictions.”

This recommendation stands true today.

The full extent of the Policy is still currently unknown as  guidance on how it should be implemented has not yet been issued. It is important that all scholars who believe in the right to health are vocal on this issue rather than leaving the onus of responsibility on women’s rights activists and those in the sexual and reproductive health sector.

As health systems researchers, it is important that we systematically track and research the impact of the Policy and that we are open about its effects on our own work. It has the potential to skew health financing, service delivery, governance, human resources for health, supplies of medicines and medical commodities, and the reliability of health information. As such, it is squarely a health system issue and one that should be of concern to all in our community.

Load More