Gender

18 02 2020

Adopting a gender lens in health systems policy

By Lynda Keeru

Momentum is building towards International Women’s Day marked and celebrated around the world on the 8 March. This indeed coincides with the general international interest among policy makers in knowing what practical steps to take to move towards a more gender-equitable and transformative health system.

This year will also mark 25 years since the Beijing Declaration and Platform for Action adopted at the Fourth World Conference on Women (Beijing, 1995). This conference sought to remove all the obstacles to women’s active participation in all spheres of public and private life through ensuring women a full and equal share in economic, social, cultural and political decision-making.

In the spring the creators of the cult “Sex and the City” are preparing to shoot a sequel to the series, which has already become a classic. The familiar heroine-friends will tell us a fascinating story about the life of a modern woman after 50 years. Sarah Jessica Parker, Kristin Davis, Cynthia Nixon and Kim Cattrall have changed a lot since their first appearance on small screens. But that makes it all the more interesting to see how they look now, and to find out what treatments help them maintain Kristin Davis bad plastic surgery their beauty. Carrie Bradshaw closet: making your dream come true without losing space. Surgery to reshape the nose was performed by those actresses of the show, who confirmed their participation in the announced project. Sarah Jessica Parker, Kristin Davis and Cynthia Nixon. But Kim Cattrall, who unfortunately refused to participate in the upcoming shoot, did not resort to rhinoplasty.

As the buzz around Universal Health Coverage continues to build, bringing on board the gender lens to policy deliberations cannot be more timely. In this common spirit, a number of advisers and researchers were brought together in Nairobi in February 2019 and developed this guide (Adopting a gender lens in health systems policy: A guide for policy makers) which does a few things:

Defines what a gender-equitable health system might look like
Provides a set of benchmarks that health policy makers can work towards
Features case studies from a range of countries, including Cambodia, Democratic Republic of Congo, Kenya, Liberia, Malawi, Sierra Leone, South Africa, Tanzania and Uganda. These illustrate how decision making that does not take gender into account leads to sub-optimal health systems and provide practical examples of strategies that have been effective in addressing gender barriers in health systems.
Lists further resources which are accessible online

Gender is everyone’s business

To start with, it is important to note that gender is everyone’s business and not only about women and girls and excluding others as is often misinterpreted. Owing to gender biases, norms, and power relations, some groups of people are often not factored in decision making processes and this means that their needs and rights are not identified, recognized or prioritized.

Likening the health system to that of a computer, it has both the hardware and software system. The hardware components include the six building blocks identified by the World Health Organization (WHO). These building blocks include: health service delivery, governance, medical products and technology, health systems financing, human resources and health information systems. The software system on the other hand is hard to see but it is critical as it cements and informs the success of work on the building blocks and includes relationships, values, trust, and power. As the authors in this guide: state: “Both the hardware and software of the health system are affected by gender. Gender norms, roles, and relations are also shaped by the health system.”

The building blocks

On the second page of this very enlightening guide, the authors delve deeply and even graphically into what gender-equitable health systems look like, providing detailed information on the aforementioned six building blocks. Take for example the importance of providing accessible, acceptable, affordable and available health services as a core function of a health system. Further down that page as you’ll see when you read, there is an illustration of how the divergent needs, rights, access, and experience of health services for men, women, and people of other genders affect the range of demand- (patient-led) and supply-side (health service-led) factors. For instance, a case study from Kibuku district in Uganda demonstrates how health facilities are making life more bearable for physically disabled women.

The second building block is very important as it focuses on health workers who are the backbone of the health system. The policy brief in this section outlines very fundamental recommendations for policy makers based on experience from the different implementers as reflected in the case studies and recommended resources like the WHO (2011) Gender mainstreaming for health managers: a practical approach.

An inclusive health system should, by definition, place fairness and equity at its core. However, many health systems’ governance structures and processes fall short of their potential when it comes to gender equity. There is a lack of goal setting for higher representation of women in leadership and policy spaces in the form of targets, quotas and affirmative action. The guide underscores the key issues in gender and accountability and also suggests ways in which these issues can be addressed by policy makers like ensuring gender balance and gender sensitivity of governance structures at all levels down to the facility and community level.

The brief also features a very well written and interesting case study on “Gender analysis of community health data in Kenya”. It documents the direct impacts of gender on the quality of data reported by Community Health Volunteers due to gendered barriers in data collection. Case in point, what many would regard as a “simple” issue like the fact that some health issues are perceived to be the domains of men or women; consequently, inform trends like that of Community Health Volunteers collecting data from women. This leads to men’s perspectives missing from the data routinely reported. These gendered elements of data collection impact on dimensions of data quality such as accuracy, completeness, reliability and confidentiality. There’s a wealth of resources put together by the authors of the brief on the same. Check it out!!

‘The phone is my boss and my helper’ – A gender analysis of an mHealth intervention with Health Extension Workers in Southern Ethiopia, mHealth and Gender: Making the Connection and ‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information are some of the works in the brief that have been done by researchers in the area of medical products and technologies and are useful for actors in this field.

Finally, we turn to health financing which is the accumulation and allocation of funding by and within the health system to ensure service quality and access is very important. As quoted in the guide:

The extent that financial protection is available to different groups needs to be considered, in addition to how out-of-pocket expenditure is experienced differently by men, women, and people of other genders. This affects policy makers’ ability to deliver Universal Health Coverage.

Make policy change

Policy makers can give women their rights on international women’s day by taking up this recommendation to:

Ensure that financial protection packages (i.e. prepaid health services under Universal Health Coverage schemes) include essential and routine sexual and reproductive health services, such as childbirth and emergency obstetric care, family planning, cancer care, such as for prostate cancer, and safe abortion.

Gender mainstreaming is a challenging and ambitious process but we have no choice if we hope to achieve a gender equitable health system and this guide is a gift to all policy makers who are trusted to lead the process.

13 11 2018

Gender and health systems strengthening: Reflections from the World Health Summit

Our recent session at the World Health Summit allowed us to reflect on how gender influences all dimensions of the health system – the workforce, financing, service delivery, governance, medical products and supplies, and information systems.

Health workforce

Globally, over 70% of the workforce in the health and social sectors is comprised of women. Women deliver care to around 5 billion people worldwide. However, women’s empowerment and economic participation are limited by gender inequities within the health workforce. These include:

The gender pay gap
Lack of gender parity in leadership and low representation of women in policy-making positions
Concentration of women in low skilled jobs
De-valuing of women’s work
Overdependence on unpaid or underpaid care provided by women
Inadequate policies that promote women’s participation in the labour market.

Financing

Gender influences economic status which in turn affects access to care. In many low- and middle-income countries, the majority of women work in the informal sector and in unpaid work. This leads to lower health insurance coverage levels, higher risk of incurring out of pocket payments and greater exposure to financial hardship. Men have a higher likelihood of getting jobs in the formal sector with health insurance. Gender intersects with other social locations such as age, race, (dis)ability status, education to bring about varying degrees of vulnerability in terms of access to care. In Kenya, women’s caregiving roles, negative healthcare worker attitudes towards pregnant women with disabilities, and exclusion from public participation forums limit the extent to which poor women with disabilities benefit from free healthcare provided through pro-poor health financing reforms.

How can health systems be gender sensitive?

To prioritize gender inequities within health systems we need greater political will and commitment. There is need for greater advocacy for policies that promote women’s labour market participation. In addition, equal representation of women in leadership positions and health cadres, equal pay for work of the same value and valuing women as change agents in the health system are important.

An intersectional gender lens should be incorporated to better understand how gender and other social demographic factors interact to aggravate health inequities. We also need to generate and use gender and sex-disaggregated data to facilitate service delivery that is responsive to the needs of women, men, other genders, different age groups, and minority and vulnerable groups. In low- and middle-income countries resources are limited and there is reliance on external funding. We should channel scarce resources towards gendered policies and initiatives and to the meet the needs of the most vulnerable.

To eliminate discrimination, disrespect, and stigma we need to increase the number of health workers and build their capacity to offer gender-sensitive health services. Because current reproductive health services have a strong focus on antenatal, maternity and postnatal services we also need to create male-friendly reproductive health services and expand reproductive health benefit packages to cater to the needs of all genders, adolescents, and elderly people.

Moving forward

There is a commitment to achieve the Sustainable Development Goals. We will not be able to achieve many of the other Goals, including achieving Universal Health Coverage (UHC), without addressing gender equality. Evidence has shown that unless there are targeted interventions for vulnerable and marginalized groups within UHC initiatives, they stand to benefit last. Applying an intersectional gender lens to our research and interventions allows us to ensure that UHC is truly universal and no one is left behind.

By Evelyn Kabia, Rebecca Racheal Apolot, Rosemary Morgan

06 11 2018

Gender bias in the health workforce: why few women attain leadership positions

The emergence of global movements and women’s marches have set gender equality at the forefront of the global agenda. We are now in the era of deep reflection and discussions, and there is a recognized need for doing things differently. The health workforce is a great example of the need for change. Women are the majority of frontline health workers, delivering health care to their communities worldwide and in crisis; and yet global health leadership remains skewed towards men. Women remain an untapped pool of talent and brainpower in global health leadership, largely ignored by both men and women, reflecting the subtle biases that are prevalent in the field. Moreover, women are more represented in overburdened cadres, not to mention unpaid work. Thus, what remains alarming is that despite momentum to make advancements to achieve gender equality, progress remains slow.

Global Symposium on Health Systems Research

During the Fifth Global Symposium on Health Systems Research, HRH2030, Research in Gender & Ethics (RinGs): Building Stronger Health Systems, and Women in Global Health (WGH) collaborated to host an event on “Deconstructing Gender Bias in the Health Workforce: why few women attain leadership positions”. The session included research conducted in Kenya, Cambodia, and Jordan on women’s leadership within the health system, exploring barriers and enablers to women’s career progression and leadership development, methodological challenges to conducting research on women’s leadership, and future research needs and questions.

The participatory session engaged health systems policymakers, researchers, and practitioners in dialogue, exploring structures of power and privilege that favour men in leadership roles. Research in Cambodia explored gender norms and how they shape the journey of health workers in their careers; research in Kenya looked at mid-level health care managers to understand career trajectories and leadership experiences of male and female health leaders; the research in Jordan was the first national comprehensive study on perceptions of women’s leadership in health care settings; and global research is underway to better understand the impact of women’s leadership as favourable to achieving Universal Health Coverage.

Barriers and enablers to women’s career progression

Despite differences in the cultural contexts of these studies, there were many similarities in barriers facing women:

Women face gender discrimination in promotions and lack of clear promotion criteria e.g. positions not advertised in transparent ways or male bosses encouraging other men to apply
Lack of women in line management positions which becomes a cyclical problem e.g. as a result policies that respond to women’s realities are not implemented
Intersections of gender and race especially
Unfair division of labour at home with women having greater caring responsibilities that affects their work-life balance.
Lack of female role models and networking opportunities

These barriers in the workforce must be understood using an intersectional lens to explore how gender intersects with other social stratifiers such as age, race, religion, and professional cadre to influence individual women’s leadership experiences. For example, in Cambodia, women are opting out of becoming specialists as it may take six to ten years of education and could delay their marriage or child birth. They are instead enrolling in nursing courses that could be completed in a shorter time period of four years. This occupational segregation of women in certain jobs leads to a gender pay gap and exacerbates gender inequities in the health workforce.

Enablers of women’s advancement

Key enablers to women’s career advancement included:

Female role models, mentors, sponsors, and networks in the workforce that help advance women’s career by providing access to opportunities that are traditionally reserved for male networks.
Creation of supportive environments starting from the home, where both men and women share caring roles and have provision to seek domestic help.
Creating safe spaces for women to network, meet potential collaborators or sponsors, and engage in meaningful ways are important enabling factors, as is having male allies and engaging them in conversations on gender diversity.
Maternity policies are important for women to take time off without penalization, but it is likewise important to recognize paternity policies and change the dialogue from child-care being solely a woman’s responsibility.
Provide capacity building for those in decision making roles to those in line management positions e.g. on how gender barriers impact on their daily work.

Methodological challenges to conducting research on women’s leadership

Research on women’s leadership is methodologically challenging. Firstly, the factors influencing women’s careers are longitudinal, interlinked and interconnected; at times the boundaries are blurred in relation to what exactly helps or hinders women’s career progression and entry into leadership. While interviewees often point to individual characteristics or actions which influence their career progression, it can be difficult to distinguish individual actions from wider system level determinants and norms that contribute to gender bias at different stages along a woman’s career path.

At the same time, measuring systematic factors and identifying larger trends compared to collecting individual stories and experience is challenging. Within such research it is also difficult to isolate variables that contribute to leadership and success; we often look at the specific initiatives that contributed to a greater number of women in leadership, while it is a combination of factors which influence women’s career progression and leadership experiences. Careful attention to these issues is needed when conducting similar studies.

Looking to the future

Future research needs to make the case for why women in leadership matters, and this needs to be grounded in empirical evidence of the effectiveness of women’s leadership, as well as the benefit (to society as a whole) of having gender equity in health leadership. As much as there is a lot of positive energy and momentum around increasing women’s leadership, in some contexts there continues to be backlash, with some people feeling that women are not ‘truly competent’ but are just ‘handed/given’ leadership positions to tick a box. This is especially the case in settings where there is a constitutional requirement to have women in leadership positions.

Sentiments like this undermine women’s power and authority in the spaces where they are not only qualified but are required to provide leadership. Participatory and innovative research methods, including Photovoice and Appreciative Inquiry, could be a powerful means of presenting how gender norms shape career trajectories of female health workers and leaders.

Going forward, more evidence is needed to guide policy and practice. Applying a gender lens to global health system research has the potential to stimulate discussions on addressing gender gaps. There is need to shift the narrative from fixing women to shifting structures and systems that limit women’s career advancements. Addressing gender gaps in global health leadership is not only a human rights issue but also a smart strategy as evidence shows that gender equity in leadership leads to better decision-making and outcomes. If global health systems are to achieve the Universal Health Coverage and the goal of ‘leaving no one behind’, then women must be equitably represented within health system leadership.

By Mehr Manzoor, Kui Muraya, Sreytouch Vong, Samantha Law and Rosemary Morgan

29 10 2018

Including marginalised people in ‘people-centred health systems’

How do ‘people-centred health systems’ incorporate marginalised groups?

Older models of health systems research tended to focus on the core elements, also known as ‘building blocks’ or ‘hardware’, for understanding and shaping the system – financing, health workforce, governance, medicines and other supplies, services and information systems. More recent work has explored the software of health systems, which have been described as the ‘institutions (norms, traditions, values, roles and procedures) embedded within the system’. The relationship between the hardware (the provision of clinics and medicines etc) and the software (the desire to address marginalisation or create programmes for specific health issues) are mediated by power relations. Social accountability offers a mechanism for health system users to reveal, review and redirect these power relations to achieve more equitable health outcomes.

Tools used to encourage social accountability include: citizen report cards, participatory monitoring, social audits, public hearings, and community scorecards. For any of these tools to be effective, there is a need for citizens to engage and demand accountability. Yet not all citizens are in the same position or equally able to do this: power relations also limit voice and decision-making space.

Women with disabilities

Emerging research from RinGs shows that women with disability may be marginalised from local accountability mechanisms. In Kenya women with disabilities were not asked to be part of public participation forums because people thought they couldn’t access the venue and/or considered them uneducated. As one visually-impaired woman explained,

“There are public meetings of certain kinds that we are excluded from. That’s why you find that if we go to hospitals we don’t know even where to start…we have never been invited and told this and that or gathered together with others and told these are the developments, so you find some of us are discriminated against.”

In Kibuku district Uganda, research examined the community scorecard processes and the opportunities for women with walking disabilities to be included. It found that there are no provisions within health facilities to cater for women with walking disabilities – there are no ramps so women have to crawl up the steps, there is no suitable seating so women are sitting on the floor. Here is how one woman described using the toilet,

“Our health facility does not have separate places of convenience for the disabled people. I used to go to those available but I would often find them dirty … but I had nothing to do. I would still crawl in that messed up place like that.”

These women are also excluded from accountability processes because of the difficulties they experience in securing transport. As shown in the comments above, this reinforces their exclusion, discrimination and humiliation within the health system and limits their ability to make the health system more accountable to their needs. This cannot be allowed to continue.

Moving beyond the one-size-fits-all approach

Accountability mechanisms often focus on homogenous categories of users, which can result in certain categories being elevated to the norm (i.e. male, urban, educated, heterosexual users). When an attempt is made to include ‘marginalized’ groups, token individuals – such as poor women, disabled men or adolescents – are often included to represent an entire group of ‘marginalised’ people. At the same time, little effort is made to ensure that their participation is meaningful. For example, young women may not feel able to speak up if certain men (e.g. male family members or male partners, or men who occupy a supervisory position) are in the room, or a disabled woman’s unique experience of discrimination may be disregarded for the sake of consensus. The inability of some citizens to effectively participate, or the lack of inclusion of certain citizens, means that needs and experiences specific to them are unlikely to be addressed in improvements resulting from social accountability processes.

Accountability offers communities the opportunity to influence health systems, making them more responsive to local needs. Yet, as the examples above demonstrate, there is a very real need for health systems researchers to take a critical look at social accountability mechanisms, to examine if and how marginalised people are included in such processes. This might include forming more nuanced, precise and contextually appropriate definitions of marginalisation (potentially in communities that already have poor and marginalised populations). We need more reflection on those accountability mechanisms that have been shown to work in relation to inclusion of marginalised peoples; on accountability mechanisms that move beyond tokenism and address power relations within communities and between communities and health systems. We need to be better aware of potential barriers to inclusion and how to overcome them.

There is a lot of talk about ‘people-centred health systems’ but if our accountability mechanisms only cater to certain types of already-privileged people, it seems unlikely that they will take us further towards social justice.

By Kate Hawkins, Linda Waldman, Rosemary Morgan, Sabrina Rasheed, Rebecca Racheal Apolot, Chandani Kharel, Sushil Baral, Kunle Alonge

18 10 2018

Amplifying the voices of marginalized groups: What does intersectionality lens add?

By Sabrina Rasheed and Aazia Hossain

Universal health coverage (UHC), is a top priority for the Government of Bangladesh. If universal health coverage is achieved, everyone would have access to quality healthcare services without any hardships. However, although Bangladesh has an extensive rural public healthcare infrastructure throughout the country, challenges still persist in the access and use of health services especially for marginalized groups such as adolescent women and poor working mothers.

To ensure the inclusion of marginalized groups in primary healthcare Bangladesh government has spelled out specific policies. To cite an example at the community clinics (CC), the frontline primary health care facilities, Community Support Groups (CSG) are convened to support CC services. The CSGs consist of local government leaders, community leaders and members of specific interest groups such as poor, women and adolescents. Due to the Government of Bangladesh’s prioritization of marginalized groups, representation of the poor, female and adolescents are mandatory in these CSGs.

icddr,b initiated a study in rural Chakaria sub-district of Bangladesh to activate these CSGs to strengthen community participation. Within the larger study supported by Future Health Systems and RinGs we used the intersectionality lens to understand the nature of the barriers faced by poor working women and adolescent females in accessing the CC services. In addition we also wanted to understand how the representatives of working women and adolescents in CSGs help to get their voices heard in the delivery of CC services.

Health needs

From the community end we found that the services offered by the CCs in many cases did not meet many of the health needs of the adolescents (reproductive health) or working women (acute health problems, and occupational health) although availability of free medication was appreciated. Adolescent mothers lacked awareness of CC services and their access to healthcare were mediated through the household decision makers which made it hard for them to utilize CC services as it exists. For the working women the operational hours of the CC which coincided with their work hour and were therefore inconvenient. Women in the rural areas are mostly day laborers and going to the clinic means that they have to miss a day’s work. This prevents them from seeking primary care. When acute health problems occur, mothers did not feel that CCs provided adequate service.

Representation

Both these marginalized groups – adolescents and working women – are not aware of their representation in the CSG. In the CSG group the members who represent adolescents and women were often chosen quite arbitrarily. They are family members of the political or social leaders. This becomes an issue in case of adolescent members of CSG group. During the CSG meetings the adolescent did not feel that she can voice her opinion. The presence of elders in the meeting creates a barrier for the adolescents to ask questions or express opinions. Although we already knew that adolescents and working women lacked access to primary health care, the use of intersectionality lens allowed us to understand the nuances of the marginalization.

If the voices of the marginalized groups are to be taken into account as mandated in the policy, then the roles and responsibilities of their representatives in the CSG group need to be made real. The adolescent and women members must be supported so that the voice of their groups can be brought forward to make primary healthcare more accessible. The use of intersectionality lens therefore, has a potential to contribute to the achievement of UHC.

11 09 2018

We are excited to support a range of gender sessions at the Global Symposium on Health Systems Research 2018

This year we are involved in a range of panels, skills building sessions and poster presentations which bring a gender and ethics lens to health systems research. Browse the full list below and do consider coming along to meet us!

Monday 8 October

SATELLITE! Deconstructing the Gender Bias in the Health Workforce: Why Few Women Attain Leadership Positions, 12.00-14.00, ACC Room 11C

THEMATIC WORKING GROUP! Health systems in fragile and conflict-affected settings, ACC Room 1B

SKILLS BUILDING! Navigating day to day ethics dilemmas in health policy and systems research, 13.00-17.00, Exhibition Centre Room 24

Tuesday 9 October

SKILLS BUILDING! Using participatory visual methods to understand and support health systems with a focus on marginalized populations, 08.00-12.00, Exhibition Centre Room 19

SKILLS BUILDING! Applying intersectionality within health systems research: looking inwards and outward, 13.00-17.00, Exhibition Centre Room 22

Wednesday 10 October

PANEL! Context, gender and sustainability in introducing and scaling up essential health care packages in fragile and conflict-affected countries, 16.00-17.30, ACC Hall 2E

Thursday 11 October

THEMATIC WORKING GROUP! Incorporating a social justice lens into HPSR ethics: Implications for policy and practice in the Global South, 16.00-17.30, ACC Room 12

FILM! Are women in the Indian Sundarbans Living in the dark?, Future Health Systems stand, Exhibition Hall

Friday 12 October

PANEL! Addressing Social Inequalities Through Social Protection, 09.00-10.30, ACC Room 3B

PANEL! Amplifying marginalized voices: towards a meaningful inclusion in social accountability mechanism for health, 11.00-12.30, ACC Hall 2L

03 08 2018

A reflection on gender issues across programmes in Liberia, Sierra Leone and Democratic Republic of Congo

The findings of the ReBUILD/RinGs Community Health Worker (CHW) project were shared and discussed at a one-day dissemination meeting in Freetown, Sierra Leone. The research, used a gender lens to try to identify how CHW cadres in Liberia, Sierra Leone and the Democratic Republic of Congo can be better supported to play an effective and long-term role in broader health systems in fragile contexts. During each country’s presentation sensitive issues surrounding gender surfaced and are reflected on here.

By Georgina Zawolo

Country presentations
The presenter from College of Medicine and Allied Health Sciences in Sierra Leone, Haja Wurie, described how social cultural norms and the potential earning power presented by the new CHW policy meant that men came forward to become CHWs. Women were also influenced by gender norms, e.g. they had to care for their homes, some were shy, while others had to obtain approval from their husbands to become CHWs. Also, men in Sierra Leone are more literate then women, and so reading and writing CHW reports posed challenges for some women. Another issue for some women was the amount of time required by CHW duties and how they balanced this with their other duties.

The Liberian presenter, Gartee E Nallo from the University of Liberia Pacific Institute for Research and Evaluation, emphasised the roles of CHWs in health promotion, health campaigns, and in the treatment of illnesses in children aged under five. As was found in Sierra Leone, most women find it difficult to travel long distances which is expected in the CHW position and are unable ride a motor bike. Community preferences also play a role in who becomes a CHW and women were uncomfortable explaining their health problems to a man.

In the Democratic Republic of Congo, the CHW situation is slightly different to that of Liberia and Sierra Leone. According to Amuda Baba of the Institut Panafricain de Santé Communautaire et Medecine Tropicale, there are more women working as CHWs but they still need to obtain consent from their husbands. When it comes to community development, women are fully engaged. He demonstrated this through images showing women CHWs transforming dirt into bricks to build a new maternity centre.

There are some similarities across the three countries; more men than women are literate and this, as well as gender norms, shapes selection. There are also some inspiring practices here, e.g. in Grand Bassa county in Liberia the community level adult literacy programme has given women the confidence to put themselves forward as CHWs or community health assistants.

Lessons learnt
My learning from the meeting, and from being part of the research in Liberia, is on the importance of gender when researching human resources for health, not just with CHWs but at all levels of the health system.

In terms of methods and approaches, I was really interested in the photovoice approach because the photos provided a really clear overview of CHWs’ own experiences at the community level. We really saw through their eyes. Strategies to encourage both women and men to become CHWs and be supported by the health system are important.

The photo above is of CHWs from Sierra Leone who were part of the project – (left to right) Dauda Rogers (Bonthe district), Hawa Kamara (Kenema district), Mohamed Koroma (Kenema district) and Bernadette Thomas (Bonthe district).

13 06 2018

The vulnerability and health research paradox: Ethics, gender, trust and power

We were delighted to be part of a rich set of discussions on vulnerability, agency and resilience in a meeting organised by REACH in Oxford in May.

Sassy Molyneux and Sally Theobald

13 June 2018

Maureen Kelley kicked off the day highlighting an important paradox in health research: on the one hand research can be powerful tool for social justice in ensuring that interventions are evidence based; but on the other, there is need to protect ‘the vulnerable’ and ensure research does not worsen vulnerabilities. Current ethics guidelines do not adequately unpack or address this paradox leading to potential for all children, all women or the very poor/marginalized to be labelled as “vulnerable” and excluded from research. Yet it is these groups for whom evidence-based health interventions are most needed, raising important challenges for social justice in health. Unpacking complex intersections between dignity, vulnerability, agency and abilities in different health research contexts, and researchers’ responsibilities in designing and conducting global health research, is a key aim of the REACH collaboration. Here we share some of our key learning from the meeting:

1. CONTEXT MATTERS in how the vulnerability paradox is experienced, and contexts are fluid and changing. This can affect the vulnerabilities experienced by research participants and communities, and researchers’ responsibilities. For example, the Kenya team showed how health worker strikes in Kenya (one lasting seven months!) brought new dilemmas for researchers in face of diminished health care, with poor and marginalized groups particularly adversely affected. In other REACH study sites, where borders are contested and fluid, many research participants are migrants with specific economic and political vulnerabilities. For example, Thai colleagues highlighted that in the border regions of Mae Sot (next to post-conflict Myanmar) people are constantly shifting across borders in efforts to seek care and livelihoods. In so doing they encounter new legal and political threats. Research studies on malaria and other endemic diseases in the region offer promise of better interventions for these populations but teams face challenging dilemmas in deciding how best to respond to complex social, political and health needs.

2. COMPLEX POWER RELATIONSHIPS OPERATE AT ALL LEVELS, and are shaped by context. To support ethics practice in research and identify interventions that support social justice, complex power relations need to be unpacked and understood. For example, within households, intersecting inequities related to gender, age and education interplay to shape vulnerabilities, and are in many contexts shaped by patriarchal norms and values. These intersecting influences affect interaction with and uptake of health services, social support and research. In South Africa for example, Busisiwe Nkosi cautioned that the current emphasis by funders on girl centered interventions (for example of adolescent girls and HIV) can leave adolescent boys feeling excluded, with negative implications for everybody. As researchers learning about such influences and effects, we have to think about our responsibilities to respond: if, when, how and through whom? Complex power-relations also operate at many other interfaces in ways that have important implications for ethics practice, including between researchers of different seniority in institutions, between institutions, and between researchers and funders.

3. TRUST, VALUES AND RELATIONSHIPS are critical in negotiating how gendered power relationships play out in different contexts. Navigating these relationships is a challenging and often under-recognised job. It is often left to ‘fieldworkers’ or front line research staff from local communities to juggle the role of insider roles (as community members) and outsider roles (linked to the institutions that employ them). This critical interface role in conducting health research needs to be recognized, and staff consulted and supported in identifying and handling the multiple ethical dilemmas that can emerge.

As researchers we ourselves are part of these complex power relationships. As Bobbie Farsides noted in the discussion around the inclusion of children in research, in planning and conducting our research we should ensure that vulnerability does not function as a stop sign, but rather as an alert. This alert should be to ensure we understand the issues at stake, minimize any potential to exacerbate vulnerabilities, and work ourselves – or through appropriately placed collaborators – towards a more just society through action or advocacy. Intersectionality analysis, with its focus on power and how this plays out in multiple ways, as well as the structural factors that underpin power (political, economic, institutional) can offer a helpful way forward.

10 05 2018

Not business as usual: Make health facilities in Uganda friendly for the women with walking disabilities

It is very important for us to remember our commitments towards health care delivery like equitable health systems. Most efforts to improve Maternal and Newborn Health (MNH) outcomes in Uganda have focused on access and quality of care for women in general, paying no attention to special populations like women with walking disabilities with a high likelihood of poor MNH outcomes.

Rebecca Racheal Apolot

10 May 2018

Makerere University School of Public Health are members of the Future Health Systems consortium. As part of a project funded by RinGs we have had an opportunity to listen to the voices of the women with walking disabilities during meetings with the community in Kibuku district-Uganda as part of a community scorecard project. The experience shows that the MNH needs of women with walking disabilities have been given very little attention. Approximately 12.5% of the total population of Uganda is living with one form of disability. Given that 51% of total population is female, disabled women would therefore account for approximately 6.25% of the total population. There are 1,578 physically disabled people in Kibuku district of which about 789 of these are women. Somebody might say these are few, but where have you forgotten your equity lenses? They may be few but they are contributing to the maternal mortality of Uganda, which is at 336 per 100,000 live births. We should remember that the fertility rate of the women with disability in Uganda is 6.3 while that of women without disability is 5.6; these statistics speak volumes, let’s not bury our heads in the sand, let’s face it and sort it.

In the public health facilities especially in the rural districts like Kibuku, which might be the case to an extent in some urban districts, there are no provisions for facilities to cater for the women with walking disabilities. Let us look at the MNH needs of a woman with walking disability from the time she is getting into a health facility; there is no ramp she has to crawl up the steps with such difficultly to access the facility. When she gets in, there is no seat suited for her height, so she has to seat down on the often-dirty floors to queue as she waits for the service. When she is called to the examination room, the bed is too high for her to climb so she will be examined on the floor where other mothers and midwives walk with their shoes (often dirty floors). Then the mother feels like a short or long call and goes to the sanitary facilities, there is not one room with facilities for the disabled so she crawls into the soiled shared latrines with her hands and knees. If the mother came to the health facility for delivery, the delivery bed is too high for her to climb so the midwife must carry the mother unto the bed (but how easy is this for the midwife?). The resting beds after delivery are equally too high for her so she will lay her bed on the floor to take a nap with her newborn while other mothers are on the comfortable facility bed. How about the midwives, do they know what the needs of the disabled women are and how to handle them?

The voices of the women with walking disabilities in Kibuku district-Uganda

“I was asked by the health provider to go to the examination room for checking but the bed there was too high. I could not climb it by myself”.

“Our health facility does not have separate places of convenience for the disabled people. I used to go to those available but I would often find them dirty … but I had nothing to do. I would still crawl in that messed up place like that”.

“I went to the midwives for help because I feel a lot of pain in the hip joint. They simply rubbished it off and said it is because you delayed to go for an operation that leg would have been put right, so just remain with your situation”.

What does it mean having no ramps, seats, examination beds, delivery beds, and maternity beds and latrines adapted for the disabled women in the public health facilities and midwives being rude? The women with walking disabilities will see no benefit in seeking MNH care at the health facility since a nearby Traditional Birth Attendant (TBA) might be a better refuge. The TBA is very close, the latrine is not adapted to the disabled but at least clean with few users, she is extremely friendly to the mother and they will deliver from the a ‘clean’ floor. This will contribute to maternal and newborn deaths that could otherwise be avoided if we acted on our commitments and promises.

Leadership at Ministry of Health, districts, health facilities and sub-counties should look into innovations to provide ramps, seats, beds and latrines for the disabled. The innovations don’t actually need a lot of money from the budgets; it is just prioritization and using the resources we already have to serve all people equitably. If we have four latrine stances in the health facility, lets modify one to have rails for disabled support. Carpenters and welders around us in our trading centers can make climbing supports for our beds at very reasonable cost. Midwives can be given continuous medical education session on handling women with walking disabilities without warranting training allowances. It doesn’t have to be big budgets; it got to be prioritization. We need to prioritize the needs of the women with walking disabilities to make our celebrations more inclusive, let women with walking disabilities in Uganda also say ‘YES IT IS INDEED WORLD HEALTH DAY!

This blog was first published on the website of the Makerere University Centre of Excellence for Maternal Newborn and Child Health.

29 03 2018

The use of social network analysis to conduct gender analysis in health systems research

This blog explores the use of social network analysis to conduct gender analysis within health systems research, and explores the question: How has social network analysis been used to uncover “hidden” or “soft” influence and power in health systems research?

Julie L. Evans

29 March 2018

On 8 September 2015, RinGs held a cross-RPC webinar on “How to do gender analysis within health systems research” for members from Future Health Systems, ReBUILD, and RESYST.

A female participant from South Africa asked if we know of any studies within the gender literature that use social network analysis to uncover and understand who is important, who has power, who has influence, etc? In-depth interviews are great at identifying the obvious but I wonder if social network analysis has been used to uncover “hidden” or “soft” influence and power in health systems research?

In response to this question, another member offered the following thoughts:

There are several related bodies of research which have touched on some component of this question (e.g. social networks in healthcare organizations, gender in organizations, or social networks and gender in health-seeking behaviour at community level) but we are not aware of any studies that combine all components and use social network analysis to explore gender and power within health care organizations and systems in low-income settings. (If you do – please let us know!)

Some gender studies certainly identify the importance of social relations in institutions even if not using a social network approach. Indeed, institutional gender audits seek to understand the existing distribution of power and resources in organizations and can offer extremely valuable formative data. All of these different bodies of literature (and many more!) provide useful methods, theories and lessons to draw from. Some examples are given at the end to provide a very brief snapshot of what they contribute. (There is also a connection between complexity theory and social network analysis, which has been explored in health care organizations, but that is not explored here.) The first key point is that, as with any research study, the design and data collection methods should always be chosen to fit and answer the overarching research questions, and not the other way round.

Social network studies are, by their nature, concerned with influence and power because a key focus of network studies is to understand the resources and directional influences that flow through and between social ties – whether at household, community or institutional levels – and to understand how these affect behaviour, choices, opportunities. Resources such as information, financial or practical help, introductions to useful others, or opportunities for exerting influence or getting promotion. The role of power, in turns of who knows who, who has access to or controls resources, and decision-making power, is therefore implicit in all network studies but whether researchers have sought to explicitly tease out this aspect in regards to gender relations and inequalities is another matter and depends on the research questions being asked.

The examples of social network studies given below, and what they manage to achieve, or not, through the methods used demonstrate that the key issue to consider, if wanting to use a social network approach to understand gender and power in health care institutions, is that a multi-faceted approach is needed in terms of both methods and theory. Designing a social network study needs careful consideration and some understanding of the limitations of available approaches. Mixed methods are essential.

The focus of most social network enquiry has been, and continues to be, on assessing the structure of social relations (which produce the famous sociogram diagrams of interconnectedness when, and only when, whole network data is collected). Structural measures can tell us a lot about things such as the similarity, or not, between people, who holds power through influence, multiplexity, and reciprocity amongst a network. Ultimately, however, structural data alone leaves both authors and readers hypothesizing about the meaning of findings. In addition to structure, the other two sets of characteristics important to understanding networks are the content and function of relationships, and these require good qualitative methods, which could be in-depth interviewing or/and a range of participatory methods. These together help paint a much more complete and rich picture of what social networks exist and what role they play in the phenomenon of interest.

It is also the case that different approaches for asking people about their network ties actually elicit different responses, i.e. different names and networks. This is clearly a major issue since it will directly affect a study’s findings. Many social network studies gather network information by asking people proxy questions about their network ties (for example: “Please name # people you talk to when … your child is ill / there is an emergency / to make decisions about XYZ, etc). Responses from interviewees will invariably depend on how the respondent interprets the question. It is possible that studies on institutional networks (rather than personal networks) might be easier to capture because there are clearer boundaries around the networks of interest. Overall, though, different qualitative approaches, including observation, can greatly enhance the capturing of network ties. In fact, almost all of the classic studies that have shaped the development of social network research have used mixed methods, many of them privileging qualitative data. Combining types of data does bring tensions about how to read and analyse the supposed factual, deductive data that comes from social network interviews compared with the more inductive data that comes from qualitative methods with respondents.

But the world is rapidly changing and it would be remiss to not mention the role of telephones, email and social media as important shapers of social networks everywhere in the world, and also as social spaces which produce large amounts of network data. These are clearly communication channels which need to be explored when asking people about their social ties – including people working in health systems in LMICs. (There are also several rapidly growing areas of research that explore all kinds of personal and professional networks online, including patient health networks, but this falls outside of our area of interest here.)

Lastly, interpretation of findings from network data also benefit from existing theory, which is especially important when exploring questions around gender power relations.

This all paints social network analysis as a very complicated type of research, and one which requires a great deal of time. Social network interviews can take several hours to complete, in addition to any formative or follow-up qualitative interviews. Indeed, the project of social network research could continue for years, given the expansive nature of people’s networks. We must acknowledge, therefore, that not everything can be measured or captured at the same time. Smaller network studies are possible – as the literature demonstrates – but researchers need to be clear of the limitations of their studies and make these clear to readers of their work.

Below are some other related areas of research which offer potentially stimulating ideas if curious about developing a social network study of gender and power in health systems. The papers listed here are not suggested because they are “best of” or even comprehensive, but purely offered as examples to stimulate thinking.

Gender and institutions. Even without a social network approach, gender and power within institutions – whether at the level of household, community or health system – and how these interact to affect various outcomes in development processes have been the focus of a number of studies. Naila Kabeer’s early work on gender and institutions, and how to make policy and planning processes more gender aware, provides a good starting point, as well as Deniz Kandyoti’s work on bargaining. Plus the many studies that have conducted institutional gender audits. The literature on bargaining and gender relations by people such as Bina Agarwal and Amartya Sen also offers relevant questions which might be used to explore gender issues within institutions, or even to interpret institutional network findings – depending on the purpose of the research. These ideas updated and framed through current approaches to institutional analysis – such as the application of complexity theory to health care organizations – could prove very fruitful.

An additional area of research to explore is that on gender, or women’s networks, in the workplace, or women’s professional networks, of which there are a large number of studies based in high-income countries. There are also studies of women’s informal work networks in low-income settings, which forces us to consider the interesting differences between networks in a so-called ‘professional’ health care workplace, such as a policy-making health department, versus those networks which exist at the lower levels of the health system: the nurses and community health workers working at the coalface.

Examples:

Kabeer, N. and Subrahmanian, R. (1996). Institutions, relations and outcomes: framework and tools for gender-aware planning. IDS Discussion Paper 357. Brighton: Institute of Development Studies.
Kandyoti, D. (1988). Bargaining with patriarchy. Gender & Society, Vol.2, No.3, pp.274-290.
McGuire, G.M. (2002). Gender, race and the shadow structure. A study of informal networks and inequality in a work organization. Gender & Society, Vol.16, no.3, pp.303-322.
Multiple frameworks (& studies) on conducting institutional gender audits produced by and for various aid agencies.

Network studies of health care organizations or of intra-organizational networks have been around for some time and pre-date the study and application of complexity theory in understanding health service organization and public management. To the best of our knowledge, all of these are based in high-income countries and explore the role of social networks in the spread of innovations, and in governance and management structures, in order to assess their role in policy-making or health care effectiveness. Whilst power is considered as part of this work, gender is not (yet).

Examples:

Ferlie E., Fitzgerald L., Wood M., Hawkins C. 2005. The non-spread of innovations: the mediating role of professionals. Academy of Management Journal, 48(1): 117–134.
Ferlie, E., L. Fitzgerald, G. McGivern, S. Dopson and M. Exworthy. 2010. ‘Networks in health care: a comparative study of their management, impact and performance’. Report for the National Institute for Health Research Service Delivery and Organisation Programme. London: King’s College London.
Tasselli, S. 2014. Social networks of professionals in health care organizations. A review. Medical Care Research and Review, Vol 71, no. 6, pp. 619-660.

Social networks and health-seeking. There have been a number of studies exploring the role of social ties in health-seeking behaviour in LMICs, which inevitably highlight women’s roles in this area and the gendered nature of household bargaining, but all focus on the community level rather than the health service delivery side, especially for children’s health. The only exceptions are those studies which capture the ties that users of health services have, or develop, within the health system itself and therefore demonstrate the alternative interface between user and provider where ‘community’ segues into health system, and vice verse.

The point of sharing these is to show the more common use of social network approaches to health care and not because the methods used might prove relevant in a health systems study. The diverse methods used in these studies do highlight many of the limitations of social network studies when only structural measures are taken and proxy designations are used to capture someone’s network ties. The narrative review by Richards and colleagues is added because it provides an overview of these types of studies, identifies social networks as a common theme and provides some useful gender theory for interpretation.

Examples:

Adams, A.M., Madhavan, S. and Simon, D. (2002). Women’s social networks and child survival in Mali. Social Science and Medicine, 54, pp. 165-178.
Andrzejewski, C.S., Reed, H.E. and White, M.J. (2009). Does where you live influence what you know? Community effects on health knowledge in Ghana. Health and Place, Vol.15, pp. 228-238.
Friend-du Preez, N.; Cameron, N.; Griffiths, P. (2008). Stuips, spuits and prophet ropes: the treatment of Abantu childhood illnesses in urban South Africa. Social Science and Medicine; 68(2), pp. 343-51.
Gayen, K. and Raeside, R. (2007). Social networks, normative influence and health delivery in rural Bangladesh. Social Science and Medicine, Vol.65, pp. 900-914.
Richards, E., Theobald, S., George, A., Kim, J.C., Jehan, K. and Tolhurst, R. 2013. Going beyond the surface: gendered intra-household bargaining as a social determinant of child health and nutrition in low and middle-income countries. Social Science & Medicine, Vol.95, pp. 24-33.

The ideas in this work are taken from the author’s unpublished PhD thesis on the role of social networks in the management of children’s health and illness in urban slums, based in Kenya.

Julie Evans works in applied public health research and practice in low income countries, and is based out of Baltimore, MD. She has a PhD in Public Health from the London School of Hygiene and Tropical Medicine, and an MPA in public sector management in low-income and fragile contexts.