Some reflections on our session on gender and ethics at the Health Systems Symposium

To bring people together we hosted a panel on context embedded approaches, intersectionality, and ethical approaches to power relations. Our session was on the last day in the morning – an unenviable slot as almost all the delegates had been out until the early hours the night before at the conference reception. Photos doing the rounds on Twitter of health systems researchers in a Conga line enjoying Freshly Ground had crushed my hopes of a large turnout.

But I was pleasantly surprised and we managed to fill our fairly large meeting room with a crowd of energetic and inspiring audience members.

I’ve written these notes of the session with the help of Linda Waldman – someone who has been behind the scenes a little bit but who we hope will become a prominent member of RinGs as we develop our work. I was too busy Tweeting in the session to get down the main points!

Context embedded approaches

First up on our panel was Moses Tetui from the MANIFEST programmewho talked us through their participatory research project which uses vouchers to try and stimulate the use of maternal and new-born health services in Uganda. At the outset of the project they held 30 community dialogues with men, transporters (bodaboda drivers), and adolescent mothers around how to increase mothers’ access and how different stakeholders can play a critical role in relation to this. This fed into six district level consultations which NGOs, politicians, and religious leaders and engagement with District Health Management Teams. He explained that they looked at who has what, who does what and what women are valued for. Ownership of resources informs whether women can access maternal health services. They found that women depend on men for money. Men are slow to join savings groups – and when they do they often become leaders. Most bodaboda drivers are men, who were very keen to be part of the study as receiving vouchers to connect women to health services was good for business.  They proved very active in following up on the women who needed to visit the clinic, they made sure that they were treated, often jumping the queue to ensure their clients were seen. In terms of decision making around maternal health it is men and mothers-in-law that wield a lot of power and how you bring them on board is critical in terms of reproductive health. Women in the study site were valued for the children that they could bear. They were often pressured to prove their fertility in ways that men were not.

Eleanor MacPherson presented on her work in fishing communities in Malawi where there are high rates of both poverty and HIV. Fishing is very important livelihood strategy and makes up 70% of all animal protein consumed there.The fishing industry is highly gendered – men fish and women process and sell them. Boat crew members are young men (often migrants) who work in poorly maintained conditions, sleeping on the beach. They are often the victims of gender based violence perpetrated by older men, this was often projected onto their female partners and others. Boat managers sell the catch and tend to be better off which makes them very desirable sexually.Female traders and processors travel a lot and can be away from home for two months at a time. Transactional sex – or sex for fish – where women trade sex for more favourable fish prices is common. The participatory research uncovered that people’s vulnerability was shaped by the gendered environment.Not all men and women were equally powerful, social and economic positions shaped their involvement in the fish trade.Transactional sex offered both comfort and power to men working in trying circumstances. But poorer and younger female fish traders struggled to negotiate with men around transactional sex.  Interventions such as micro-credit had been introduced to try and foster resilience. However sometimes women engaged in transactional sex to repay these loans so it was not always successful.

Parthasarathi Ganguly (Indian Institute of Public Health Gandhinagar) provided an intersectional approach to understanding demand for maternal health care services in rural Gujarat, India. 1800 maternal deaths happen in Gujarat state each year, these are mostly avoidable with interventions like good antenatal care and safe institutional deliveries (childbirth). A government scheme was started in 2005 to increase access to institutional child birth for poor and tribal women, through partnering with private sector obstetricians having widespread presence across the state.  The study aimed at finding out the influence of this scheme on the families about deciding the place of delivery.   As the findings reveal, some women’s positions meant that there were additional barriers to accessing this benefit apart from the financial barrier. Those girls who got married early, and were working at home, didn’t have time to get information about the scheme. The scheme had complicated administrative procedures and migrant women didn’t have the necessary documents to register(after marriage their BPL records remained in in their parents’ home). Many women lacked decision making power – they had to go with husband’s choice or those of senior women. Feeling apprehensive about travelling and not wanting long absences from home due to family responsibilities also limited uptake. An interrelation of all these factors added to the vulnerability of rural and tribal women in relation to access to better maternal health services despite the innovative scheme from the Govt.

Tamanna Sharim talked us through work that icddr,b, IDS and Gamos have been doing on information and communication technologies and health in Bangladesh. Tamanna and colleagues used a mixed method approach to explore how social determinants shape use of mobile phones and other information and communication technologies in rural and urban Bangladeshi settings.  The quantitative data showed key rural –urban differentials in watching TV, with both urban women and men having more access than their rural counterparts. In all settings men were the most prominent users of the internet and using SMS were more aware of vaccination campaigns and health advice and had greater access to and ability to use mobile phones. Education and age also matter; both educated women and men used SMS with men showing more use; and older women had the least access to ICTs in all settings.  Tamanna concluded by highlighting the importance of (1) methodologies to capture and understand the complex interplay of different factors and how they shape access and use of ICTs across different environments and (2) action to address marginalization and promote social inclusion within the fast moving world of ICT.

Gender power ethics social exclusion

Dorcas Kamuya (KEMRI-Wellcome Research Programme and The Ethox centre, Oxford University) provided an overview of her work on gender, power and ethics within research processes. She suggested that when it comes to research ethics there is an excessive reliance on international obligations and too little focus on how well these guidelines work in practice. Her study explored the nature of interactions between fieldwork and research participants in community-based studies – the challenges fieldworkers faced, and how these were resolved. Household arrangements in the context in which her research was based, in coastal Kenya, tended to be both extended households and nuclear households. They were largely patrilineal, and women were expected to obey male household heads. Although there were some exceptions with increasing education, income, and outmigration. When it came to considering whether to be participate in research, factors that seemed important in influencing decisions taken including adhering to normatively ascribed gender roles (e.g. male elderly household heads expected to make those decisions, even for their wives, children and other adult household members residing in their household). Other important considerations were who would be blamed if things went wrong and who might benefit from the study.  This led to considerable time spent on consultation and negotiation about research participation.  Sometimes, it was unclear whether consent for participation had been given and by whom. When there was ambiguity it was often because people were trying to find ways to ensure that relationships within the household were being maintained harmoniously.  Saying no was considered being impolite, others wanted to participate but had been refused permission from the household head or wanted more time to persuade others in the household to support the decision.  This raises some dilemmas for fieldwork. Whose decision should be considered? Do they prioritise the participants’ or the researcher’s needs? In the cases she studied fieldworkers were very keen to avoid damaging their relationships with the household but they also wanted to meet targets and numbers for the study. How do we reconcile this?

What all of the papers uncovered where the complexity of people’s lives. The challenge for health systems researchers is how they understand and integrate this complexity into their work.

To find our more about RinGs visit our webpage.