Health

24 02 2015

mHealth and sexual and reproductive health rights

Ed: This post first appeared on the Interactions website. Thanks for allowing us to cross post.

Linda Waldman and Marion Stevens

24 February 2015

Few people doubt that information and communications technology (ICT) innovation offers massive potential for changing the way health is delivered and health systems operate. The possibilities seem infinite – earlier this month it was announced that smart phones will soon be able to offer an HIV or Syphilis diagnosis, just as accurate as laboratory blood tests, and in only 15 minutes.

There are already many successful mHealth (health initiatives typically involving mobile phones) programmes and pilots such as the Mobile Alliance for Maternal Action, or MAMA, which operates in Bangladesh, South Africa and India. MAMA uses social networking and mobile services to provide pregnant women and new mothers with stage-relevant health information. There is considerable excitement – with good reason – around the potential for mobile phones to provide solutions to health system challenges and to address the needs of poor women around the world.

Yet ICTs embody a dual promise. They facilitate increasing commercialisation and privatisation with the general exclusion of women and social development values, while simultaneously offering great potential to subvert these same hierarchies and exclusions. This Janus-faced characteristic – of upholding power relations and simultaneously subverting them – makes ICT technology an incredibly powerful and attractive tool. And, because it is available throughout the developing world, mobile phone technology is the most attractive of all. So, given this possibility of both subverting and reinforcing, what are some of the hidden power relations and challenges around the use of mHealth for SRHRs? Drawing from new IDS research exploring the intersection between sexual and reproductive health rights (SRHR) and technological means of enhancing health, the key points are:

Privacy

As long as people don’t have to share phones and are literate, mHealth offers fantastic opportunities to ensure that patients’ privacy is protected. Health workers can relate directly to the patient and share confidential information which the patient can revisit and reread in his or her own time. In addition, mHealth allows people – especially young adolescents – the opportunity to ask questions anonymously.

This provides them with protection while enquiring about stigmatised or taboo behaviours. But, while mHealth protects the patient’s information from friends and family, it also disseminates information to telecommunication companies and private companies that fund these projects. As long as the messages are relayed through SMS (Short Message Service) formatting or through mobile platforms online, companies can access a wealth of information about the people using the platforms or services. This includes names, ages, numbers of children, sexual interests, health and illness. How this information is used is not obvious and the long-term consequences of tailored marketing for the poor, on issues of sexuality, pregnancy and ill-health, have yet to be explored.

Hardware deficits

One of the main attractions of mHealth is its ability to supplement the lack of health services and health information in rural and remote areas. Mobile phones, now ubiquitous throughout low- and middle-income countries, offer an attractive combination of speed and remote telecommunication technology. Telemedicine, referrals, health apps and the provision of timely information can all help poor rural communities, reducing the need for clinic visits and out-of-pocket health expenses.

Yet, while many of the rural poor (particularly men) might own mobile phones, there are few political or financial incentives to address the hardware deficits. There remains a lack of broadband connectivity in many rural areas as privately-owned telecommunication companies benefit little from ensuring infrastructural developments in ‘the last mile’ and governments do little to help women access and own mobile phones. Without political will, or incentives, will mHealth create new forms of rural health inequity?

Limits of one-way health information

Mobile phones are great for sending out information, either as SMS or as IVR (Interactive Voice Response). Much of this information focuses on Maternal and Child Health, with the real success stories in mHealth being around pregnancy and child birth. The information which mothers receive through mobile phones and apps focuses almost entirely of medical and official understandings of pregnancy and childbirth.

There is little awareness of local information, of mothers’ own understandings of health or pregnancy. In this world of mHealth, women and mothers’ understandings and knowledge about their own bodies is not acknowledged. In addition, much of this information focuses on motherhood and childbirth, with far less attention to controversial topics such as sexual orientation, abortion, contraception, and sex-positive work within a Sexual and Reproductive Health Rights framework.

Adolescents’ sexuality and safe spaces

Online there are lots of forums and platforms for adolescents to find out about sexuality and associated health issues. Available on both smart and feature phones, these spaces offer opportunities for youth to ask questions anonymously, to experiment with their identity and sexuality and to receive related health information from experts. As such, this might be construed as a relatively safe space. However, these online spaces are also areas of sexual predation. Many providers constantly monitor the discussions and shut down communications when ‘things get raunchy’.

There is no official guidance on the use of ICTs for the provision of adolescent sexuality information and the sites tend to me moderated by technical as opposed to content experts. Finally, there is little opportunity or incentive for the developers of these online platforms to follow up with health-related information around contested areas (abortion, contraception, porn) or to better connect online forums with health systems.

ICTs and mobile phones have already changed our world and more transformation lies on the horizon. But will mobile phones provide solutions to health system challenges and address the needs of poor women around the world? The answer lies in whether we can address underlying power relations, recognise hidden challenges and foresee long-term unanticipated consequences.

By Linda Waldman (IDS) and Marion Stevens (WISH Associates and Africa Gender Institute, University of Cape Town)

Find out more

‘Sexual and Reproductive Health Rights and Information and Communications Technologies: A Policy Review and Case Study from South Africa’, IDS Evidence Report 113 (2015).

Photo courtesy of dotpolka.

18 02 2015

Introducing Kelly Muraya: Exploring leadership in health systems in Kenya with a gender lens

A new Resyst project is looking at leadership and gender. Find out more about the work in Kenya.

Kelly Muraya

18 February 2015

Kelly Muraya

I work at the KEMRI-Wellcome Trust Research Programme (KWTRP) as a post-doctoral researcher. My most recent work has been on household gender relations and the implementation and use of community-based child nutrition interventions in rural areas of the Kenyan Coast.

I have always been interested in gender issues. I come from a family where male and female children were treated equally but I realised pretty early on that society as a whole was not like that. I remember when I was young I saw a TV programme about a woman who had experienced domestic violence and I was touched by the injustice of it. I wanted to learn and do more. So whilst studying for my undergraduate degree in Adelaide, Australia, I did volunteer work in domestic violence centres and women’s referral services. Later, as part of my Honours Degree I undertook a research project that focused on the experiences of domestic violence amongst African refugee women who had resettled in Australia. Undertaking this project sparked my interest in research and I was keen on doing research closer to home. I was therefore thrilled when I was offered an advertised PhD studentship with KWTRP in Kilifi, Kenya; and used that opportunity to learn and explore more on gender issues but focusing on a different topic area. Importantly, the specific topic area was geared towards better understanding the delivery and use of public health nutrition interventions (from the perspective of intervention beneficiaries), which can hopefully contribute to informing future practice. It was an enriching and great learning experience working within a community in Kenya that was different to my own.

I have just started a project on gender and leadership in the health care system together with Sassy Molyneux and Benjamin Tsofa, as part of the RESYST Consortium. This provides a fantastic opportunity to still focus on the topic that I am most passionate about – gender – but exploring this in a very different area of the health system compared to my PhD topic (and now focusing on the providers of health services). The project is a multi-country study working with colleagues in South Africa and Nigeria. A multi-country design will enable mutual learning across the three sites as well as cross-country comparisons. In Kenya specifically, we will focus on senior health managers at the county level. Kenya has recently moved to a devolved system of governance and as such many functions have passed to the county level. In this context of devolution, we are interested in better understanding the role, if any, of gender in healthcare leadership. Furthermore, literature from high-income settings suggests that despite a significant proportion of health care workers being female, they tend to be under-represented in leadership positions. We would like to explore whether similar dynamics exist in Kenya, and understand factors that shape the leadership experiences of both male and female senior healthcare staff including: career trajectories; management of roles and responsibilities; and views on healthcare leadership. This work will employ an intersectional lens to gender, recognising that gender intersects with various other social factors such as ethnicity, social and economic status, and age to create specific positionings for individuals. The work will utilise a qualitative case study approach, interviewing male and female senior healthcare staff using life histories, and plotting critical incidents that shaped the way that they manage their responsibilities and view their leadership positions.

We hope that the findings of this work will contribute to shaping and informing policy and practice issues such as; supportive supervision, training and career development, mentorship, and contribute to the country’s commitment to gender equity as stated in our constitution.

12 02 2015

RinGs Small Research Grants Recipients: Gender, Ethics, and Health Systems

12 February 2015

RinGs recently held a competitive call among our three RPCs – Future Health Systems, ReBUILD and RESYST – to submit proposals for small research grants on gender, ethics and health systems issues relevant to low and middle-income countries (LMICs). The small grants are part of a larger initiative and learning platform which aims to galvanise gender and ethics analysis within health systems research and improve the knowledge base on gender aware approaches to health systems research.

The research projects address one of the core spheres of health systems research addressed by the RPCs: care-seeking and service delivery; financing and contracting; governance; human resources; and deepen gender analysis approaches by pursuing one or more of the following:

Embedded approaches (making sure analysis is relevant and owned by local partners);
Cross-cutting work (exploring how gender intersects with other axes of inequality, such as age, poverty, geography, disability and sexuality);
Ethics in addressing power relations and social exclusion in health systems research.

We are delighted to announce the recipients of our small research grants, which will be carried out between March 2015 and February 2016:

Care-seeking and service delivery

Are Women of Indian Sundarbans Living in Dark: A Gender Analysis of Eye Health Problems, Debjani Barman – Institute of Health Management Research, Kolkata, India
Applying intersectionality to explore gender dynamics in access and utilisation of maternal and newborn services among internal migrants settled in the sugar-cane growing region of Masindi district, Uganda, Richard Mangwi – Makerere University, School of Public Health, Uganda
Strengthening male involvement in the prevention of mother to child transmission of HIV/AIDS (PMTCT) in Enugu State, Nigeria, Ezumah Nkoli Nwakego – University of Nigeria, Nigeria
Gender Difference in Family Health Care for the Elderly in China, Xiaoning Hao and Liu Tianyang – China National Health Development Research Centre, China

Financing

Understanding male involvement in the implementation of maternal and child health care interventions: The case of National Health Insurance Fund (NHIF/KfW) prepaid insurance card for pregnant women in Pangani District-Tanzania, Fatuma Manzi, August Kuwawenaruwa, Tani Kassimu, and Jitihada Baraka – Ifakara Health Institute, Tanzania

Governance

Examining gender and gender mainstreaming in the policy and regulatory environment of nursing training institutions in Kenya, Christine Ngwawe and Ravi M. Ram – Amref Health Africa
Examining gender mainstreaming in governance of health service delivery in Tanzania: the case of Mwanza Municipal Hospital, Tumaini Nyamhanga – Muhimbili University of Health and Allied Sciences, Tanzania

Human resources for health

Gender mainstreaming in rural posting and deployment systems in the health sector in Zimbabwe, Stephen Buzuzi and Yotamu Chirwa – Biomedical Research and Training Institute, Zimbabwe
Use of photovoice to explore gender and ethics in health systems by community health workers in rural Uganda, David Musoke – Makerere University, Uganda
The career pathway for health workers in Cambodia: the role of gender, Sreytouch Vong and Bandeth Ros – Cambodia Development Resource Institute, Cambodia

For more information about RinGs visit our website.

10 02 2015

Ethics in #resupmeetup: Six things that people are talking about

Some initial feedback from the meeting on research uptake that is taking place in Kenya.

Kate Hawkins and Sally Theobald

10 February 2015

We are really enjoying our time at the ResUpMeetUp which is currently taking place in Kenya. There have been a diverse range of conversations, sessions and presentations, and we are only half way through! One of the things that struck us were the discussions about ethics and research uptake. Here are six things that people are talking about:

1. The tyranny of impact

In one of the first sessions of the conference Eliya Zulu (Afidep) cautioned us to consider ethics in research uptake. An increasing donor demand that researchers demonstrate ‘impact’ has the potential to encourage research generators to overstate the importance of their findings. What can be done?

2. What is quality?

We have heard from an all-male panel of experts in systematic reviews that the only form of research worthy of uptake is, well, systematic reviews. Being more charitable one panellist suggested that we could communicate around research – but only after it passes peer review. However, this view is at odds with the notion that research uptake activities should begin at the start of the research process to ensure the questions being posed are appropriate and address real world problems, challenges and gaps and that the work is fit for purpose more generally. Furthermore systematic reviews often fail to take qualitative research fully into account or indeed the whole range of relevant, context embedded, knowledge that decision makers should factor into their thinking.

3. Who funds? Who studies? Who uses?

There has been much talk at the #resupmeetup about the importance of generating evidence to inform the decisions of national level policy makers. Whilst this isn’t everyone’s focus audience, this is the default position that the conversation tends to fall back on. This is perhaps understandable as this is a DFID sponsored meeting of mainly DFID funded researchers and communicators: and this mirrors the priorities of research programmes funded by this donor. Taken to its extreme however this perpetuates a cycle of middle class, university educated funders – supporting middle class, university educated academics – to inform the perceived knowledge needs of middle class, university educated policy makers. Of course this is a crude characterisation but we need to ask ourselves, will this cycle of knowledge generation best meet the needs of the poor and marginalised? A body of research and learning on power and participation suggests not.

4. Competition or collaboration?

Many of the presentations we have seen have been given by particular projects and have showcased either the methods that they have used or their impact. Yet there has been little acknowledgement that we are sometimes in competition with each other to influence the same targets. There is a tension between encouraging projectised research uptake work and encouraging researchers to make available for consideration the breadth of research and to discuss what their work means in the context of a broader set of evidence. We need to talk more about this.

5. Who assesses the ethics of research uptake?

As Milly Natimba from ReBUILD has pointed out our proposals for research ethics review rarely capture the detail and content of our actual implementation when it comes to research uptake. Are Ethics Review Boards made up of academics actually the right people to pass judgements on communications outputs and activities? Might a multi-stakeholder group be more appropriate, one that includes communities affected by the issues that are being explored and experts in communications?

6. Practice what we preach?

For a group of research uptake experts to put forward an all-male panel is deeply regrettable.

19 01 2015

Calling Time on Urogenital Schistosomiasis

I spent many of my teenage years living in Malawi, enjoying swimming in beautiful Lake Malawi. Wind on to age 30, and I was struggling to get pregnant. Eventually, following illness, I was diagnosed with schistosomiasis by a consultant and colleague at the Liverpool School of Tropical Medicine. I was told that I had probably been infected for a while and that it might be affecting my fertility. So I took praziquantel, the only available drug against the parasite, and soon after I was pregnant. Today my first born daughter is 10 years old.

Sally Theobald, COUNTDOWN Consortium & Research in Gender and Ethics: Building stronger health systems (RinGs)

19 January 2015

Whilst the links between urogenital schistosomiasis, sub-fertility and HIV have become increasingly well-established over my first born daughter’s life time, a combined and robust health systems action that brings together neglected tropical disease, sexual and reproductive health and HIV communities to address and scale up treatment for urogenital schistosomiasis is sadly lacking.

It is 20 years since the Beijing Women’s Conference and the International Conference Population and Development and the sexual and reproductive community have been taking stock on progress, challenges and future priorities. I attended a research agenda setting meeting on sexual and reproductive health, rights and gender at the WHO on 12th and 13th of January, where we discussed how to best decide priorities for action. Scaling up treatment for urogenital schistosomiasis is arguably a win-win.

The global burden of disease

Schistosomiasis is wide spread and there are two forms of disease, intestinal and urogenital. An estimated 600 million people are at risk of being infected and approximately 200-220 million people are living with schistosomiasis in Africa. Of the people infected with urogenital schistosomiasis it is thought that between about 100 and 120 million suffer from urinary and reproductive tract damage, which also impacts directly with HIV co-infection and sub-fertility in general. Typically many adolescent girls and women exhibit several symptoms in their lower genital tract where overt bleeding and unpleasant discharge, general discomfort and pain during sex can lead to low self-esteem, depression and stigma.

Peter Hotez estimates that globally there are between 67-200 million cases of urogenital schistosomiasis among girls and women. Hotez argues that between 20 million and 150 million girls are affected, possibly making it one of the most common gynaecological conditions in sub-Saharan Africa but unfortunately much under-reported. Urogenital schistosomiasis, as in my experience, also affects fertility and it is estimated to reduce a woman’s reproductive health capacity by up to 75%.

The links between urogenital schistosomiasis in women (female genital schistosomiasis) and HIV are well established. Writing in the Lancet, Stoever and colleagues argue that up to 75% of girls and women infected with female genital schistosomiasis develop often irreversible lesions in the vulva, vagina, cervix, and uterus, creating a lasting entry point for HIV and discuss how research in Zimbabwe showed that women with female genital schistosomiasis had a threefold increased risk of having HIV. In a recent review of the evidence Martha Mbalazi and colleagues argue that “Studies support the hypothesis that urogenital schistosomiasis in women and men constitutes a significant risk factor for HIV acquisition due both to local genital tract and global immunological effects”.

Gender, equity and rights

There is remarkable overlap between the maps showing high HIV prevalence in Africa (particularly amongst women and adolescents girls) and those showing cases of female genital schistosomiasis. A complex interplay of biological, social and cultural factors means that young women are particularly vulnerable to HIV in sub-Saharan Africa. Gender norms also shape exposure to urogenital schistosomiasis, with women being particularly responsible for activities involving water in many communities (washing, cleaning, collecting water etc). Drawing on work from Ghana, Vlassoff and Manderson have shown that women interact with water significantly more often than men.

What to do?

Several tens of millions of praziquantel tablets are now donated each year by Merck-KGaA for mass drug administration campaigns as a cost-effective method to protect people from the urogenital schistosomiasis. Hotez argues that by preventing female genital schistosomiasis in sexually active women we have an innovative and timely opportunity to reduce and likely much reduce HIV transmission throughout many rural areas of sub-Saharan Africa.

But in infected communities treatment also needs to start early.

Stoever and colleagues argue that periodic and regular treatment with praziquantel from when children are first infected should prevent the development of genital lesions, which increase HIV risk and cause gynaecological problems. Treatment, however, may need to be started even earlier as the extent and burden of schistosomiasis in pre-school-aged children is being more fully described.

To make progress in this area we need joint action between the HIV, sexual and reproductive health and neglected tropical disease communities. Health workers and communities need more information on the multiple impacts of urogenital schistosomiasis and how it can be treated.

The lack of action to date on urogenital schistosomiasis clearly illustrates the importance of new partnerships and new approaches to scaling up strategies to address neglected tropical diseases. COUNTDOWN, a new initiative in Cameroon, Ghana and Liberia, will be paying close attention to the potential role of close-to-community providers such as drug distributors in providing an interface between communities and health systems. We will also evaluate how to deliver equitable drug delivery for schistosomiasis through the inclusion of preschool-aged-children, out-of-school-children and adults. The Director of COUNTDOWN is helping to co-organise a meeting in South Africa (see www.fgsworkshop.org) later in the month where several members of COUNTDOWN will also attend that brings together world leaders in the field of schistosomiasis, HIV and paediatrics to present on the current state and future direction of research on female genital schistosomiasis.

COUNTDOWN is set to foster and to stimulate others in thinking of innovative ways of prompting a synergistic approach to neglected tropical diseases which crosses sectors and builds strength in national health systems.

If you would like to find out more follow us on Twitter or email Rachael Thompson.

To find our more about RinGs visit our webpage.

16 12 2014

How do we make the post-conflict moment work for improving gender equity in health?

From press headlines, television debates and online commentaries, the whole world seems to have understood the significance of building strong and resilient health systems given the recent catastrophic events occurring in Sierra Leone, Liberia and Guinea. But how does gender play a role in health systems reconstruction and how might a gendered lens make health systems more robust after conflict?

Esther Richards and Val Percival

16 December 2014

Estimates by the World Bank suggest that by 2015 just under one third of the global population will live in conflict-affected settings. At the same time, cross-national quantitative analysis suggests that states with higher levels of gender equity exhibit lower levels of violence in international crises, and are less likely to initiate the use of force. Despite this, the health systems literature does not sufficiently address the issue of gender equity, let alone in conflict-affected and post-conflict settings.

A paper we have recently published in Conflict and Health explores this very issue: how health systems can best integrate gender equity considerations during this important post-conflict period.

Building a gender analysis into health system strengthening

Our paper set out to explore if and how the rebuilding and reform of health systems in conflict-affected and post-conflict contexts addresses gender. We used the six WHO building blocks as a way of framing our findings, so we explored available literature on gender equity aspects of 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance. Using this framework we reflected on the key components of a gender-equitable health system that should be considered as part of health system reform in conflict-affected and post-conflict states.

Our review highlights key areas where work needs to be done to develop gender-sensitive approaches relevant to conflict-affected settings and based on each of the building blocks, for example:

A key area of action in the development of human resources is to address gender disparities in advancement, planning, retention, supervision and remuneration across all areas of the health workforce.
In the critical area of health financing there is a need from a gender perspective to pay more attention to those working in the informal sector; to move to public financing mechanisms, to enrol entire households, not simply male ‘breadwinners’, to include comprehensive sexual and reproductive health services, and to prohibit exclusion due to pre-existing conditions, which may particularly affect women.
And in the area of leadership, that there should be more input from gender advocates to ensure that gender-specific health needs are considered in the governance of health systems. We argue that this is particularly relevant to post-conflict settings, where greater opportunities for social reform – such as promoting the advancement of women to health leadership positions – often exist.

Why did we focus on gender?

The paper in Conflict and Health describes how we explored the literature, but in our broader report we also undertook desk studies of gender equality and equity in health system reconstruction in four countries, Timor-Leste, northern Uganda, Mozambique and Sierra Leone. But why did we choose to focus on gender equity in the rebuilding of health systems in these settings? Especially as fragile health systems require transformation in so many areas and with many structural and social factors taken into consideration – why was gender so important to us?

The fact is, for the vast majority of the world’s population, social and cultural views on gender norms and roles devalue and denigrate women and girls, and undermine and restrict their social status, livelihood opportunities, behaviours and freedoms. These same norms encourage excessive risk taking behaviour among boys and men which has negative consequences for their health outcomes too. It is well documented the health service provision itself is not gender neutral and can exacerbate or alleviate gender inequities.

By identifying what’s required in a gender equitable health system, and making those changes, health system reform can contribute to a foundation of gender equality. But how will states implement these changes without clear guidance or incentives to implement gender sensitive reforms? Our paper argues that given the opportunities for implementing change during the post-conflict period, and the importance of gender equality to broader social well-being. It is time for policy makers, advocates and researchers to investigate and establish much-needed policies, guidance and indicators required to ‘build back better’.

The paper is part of a wider report that was commissioned by the Stockholm International Peace Research Institute (SIPRI) on the opportunities and challenges of building gender sensitive health systems in post conflict contexts. The report was also a joint output from the ReBUILD project: re-building health systems in post conflict states in Cambodia, Sierra Leone, Uganda and Zimbabwe, funded by the UK Department for International Development (DFID). Views represented in this blog are not necessarily those of DFID. If you would like to be part of this debate you can join the Working Group on Health Systems in Fragile and Conflict Affected States which is part of Health Systems Global.

To find our more about RinGs visit our webpage.

regugee women in DRC dancing andré thiel medium

12 12 2014

Ten arguments for why gender should be a central focus for universal health coverage advocates

To make universal health coverage (UHC) truly universal we need an approach which places gender and power at the centre of our analysis. This means we need a discussion about who is included, how health is defined, what coverage entails and whether equity is ensured. To celebrate Universal Health Coverage Day RinGs has put together a list of ten arguments for why gender should be a central focus within UHC. If you agree, spread the word. Mail this list to a colleague or put it up on your website. If you think of other arguments in favour of a gender approach do let us know!

RinGs Steering Committee

12 December 2014

1. Gender affects both vulnerability to illness and access to health care.

Gender influences how women, men, and people of other genders perceive, behave, interact and this impacts the social experience of being sick, seeking and receiving care. For example, gender norms and relationships in the Dominican Republic mean that women with lymphatic filariasis experience more social exclusion and shame than men, which in turn affect their health care seeking.

2. Gender combines with other social determinants in varied ways.

How gender is experienced can change when interacting with other forms of inequality, such as age, poverty, geography, caste, race, ethnicity, disability, and sexuality. Women and men from different socio-economic or ethnic groups can have vastly different experiences of the health system, which influences their access to health care, their treatment by health professionals, and their health outcomes. In rural India, while nonpoor men and poor women were at opposite ends of ability to access care, among middle groups, non-poor women and poor men had similar health care seeking outcomes, but their decision-making and pathways differed significantly.

3. Recognise power if you want to tackle inequalities in health systems.

Marginalized people (ethnic minorities, inhabitants of informal settlements, people employed in illegal occupations, etc.) may have different access to health care or receive different treatment by health care workers compared to others. Power relations between individuals (for example, husbands and wives or health care professionals and patients) influences the effectiveness of policies and programmes to achieve universal health coverage. Despite being inclusive of the poorest, community based insurance in India still generated inequities among rural populations with those more financially better off, closer access to care and men submitting more claims than other populations. Moreover, access facilitated by insurance was not always appropriate with insured women having higher rates of hysterectomies and hospitalisation for fever due to the lack of effective and quality primary care services.

4. Coverage can’t be universal if some services and service users are routinely left off the list.

Financial protection packages (i.e. prepaid health services under universal health coverage schemes) often exclude essential and routine sexual and reproductive health services, such as delivery and emergency obstetric care, family planning, and safe abortion. Where sexual and reproductive health care is offered, it often exclusively focuses on maternal health and doesn’t address the needs of adolescent girls and older women or men. Trans people all over the world survive despite inadequate provision of services and financial coverage.

5. Coverage can’t be universal unless it extends to all contexts.

Universal health coverage will not be achieved without additional research, resources and health system development in fragile and conflict affected contexts. Realising universal health coverage in these neglected contexts means understanding and addressing the ways in which gender, power and conflict shape the experiences and needs of different communities and their ability to access services, as well as ensuring efforts to support and rebuild health systems meet the needs of all citizens.

6. Paying out-of-pocket expenses for services adversely effects women.

This reflects hardship and injustice as women tend to have less income and less control over it and yet have to pay for health services that are more likely to not be covered by financial protection schemes.

7. Health system researchers must factor gender into their research.

To properly understand whether health systems are universal, we need data disaggregated by sex as a matter of good practice, regardless of whether sex or gender is perceived to be a factor. Once identified, inequities need to be recognised and addressed. If this doesn’t occur we will continue to put in place policy and programmes which are inefficient and discriminatory.

8. Policy makers need to use evidence that incorporates gender and power in their decision making around access to services.

For example, social roles for women in many societies include childcare and infant feeding and a potential consideration would be whether health facilities provide services for women and children at the right times (daylight, after school timings), with appropriate conditions (shelter from sun/rain in the waiting area, functional toilets, separate lines or waiting rooms for men and women), and with appropriate staff (breastfeeding consultants, female clinicians). When health centres are predominantly seen to cater to maternal and child health, mechanisms need to be explored to ensure access for men and other people.

9. Gender permeates all aspects of the health system and must be dealt with on different levels.

Gendered norms affect the health workforce (whether informal care provided at home is recognized and supported, recruitment and retention policies, staff security in remote areas or slums, maternity policies, workplace harassment policies and procedures). We need to address the gendered needs of all health workers, including close-to-community health providers who act as bridges between marginalised communities and health systems and are critical to universal health coverage. Gender also affects health financing (budgets for gender audits, the extent of financial protection available to different groups, out-of-pocket expenditures of different groups); and governance (representation of women and men in planning and oversight of all areas of health care; male involvement in maternal and child health).

10. We need this conversation to take place within and beyond the health system.

For example, men usually have more power and privilege than women, but they also have particular health needs. Men may be more likely to do dangerous jobs which can cause illness and disability, they are often influenced by harmful gender norms which encourage risk-taking, and in many settings they are less likely to visit a doctor when they are ill. Addressing these harmful manifestations of gender norms will require work beyond the health sector. We need to work with government ministries tasked with dealing with financing, gender, employment, education, and equality. Universal health coverage truly is everyone’s concern.

Want to read more? This article is based on:

Baker P, Dworkin SL, Tong S, Banks I, Shand T, and Yamey G (2014) The men’s health gap: men must be included in the global health equity agenda. Bulletin of the World Health Organization 92(8): 618-20.

Desai S, Sinha T, Mahal A, Cousens S. (2014) Understanding CBHI hospitalisation patterns: a comparison of insured and uninsured women in Gujarat, India. BMC Health Serv Res. 2014 Jul 26;14:320. doi: 10.1186/1472-6963-14-320.

O’Connell T, Rasanathan K, Chopra M (2014) What does universal health coverage mean? Lancet. 2014 Jan 18;383(9913):277-9. doi: 10.1016/S0140-6736(13)60955-1.

Khanna R (2012) Gender and universal health care in India http://uhc-india.org/uploads/RenuKhannaUHC12April.pdf

Percival V, Richards E, Maclean T, Theobald S (2014) Health Systems and Gender in Post-Conflict Contexts: Building Back Better? Conflict and Health, 8(19).

Person B, et al., (2008) “Can it be that god does not remember me”: a qualitative study on the psychological distress, suffering, and coping of Dominican women with chronic filarial lymphedema and elephantiasis of the leg. Health Care Women Int,. 29(4): 349-65.

Raj A. (2011) Gender equity and universal health coverage in India, The Lancet, January 12, 2011 DOI:10.1016/S0140- 6736(10)62112-5.

Ranson MK, Sinha T, Chatterjee M, Acharya A, Bhavsar A, Morris SS, Mills AJ (2006) Making health insurance work for the poor: learning from the Self-Employed Women’s Association’s (SEWA) community-based health insurance scheme in India. Soc Sci Med. 2006 Feb;62(3):707-20.

Ravindran, TKS (2012) Universal access: making health systems work for women. BMC Public Health, 12 Suppl 1(Suppl 1), S4.

Sen G and Iyer A (2012) Who gains, who loses and how: leveraging gender and class intersections to secure health entitlements. Soc Sci Med. 2012 Jun;74(11):1802-11. doi: 10.1016/j.socscimed.2011.05.035.

Vlassoff C, and Moreno CG (2002). Placing gender at the centre of health programming: challenges and limitations. Social Science & Medicine, 54(11), 1713–1723.

The lovely image that accompanies this story is used courtesy of André Thiel https://www.flickr.com/photos/athiel/5109882423 and depicts refugee women dancing in DRC.

To find our more about RinGs visit our webpage.

26 11 2014

Community engagement to tackle maternal mortality in South Sudan

With 2,054 maternal deaths per 100,000 live births, South Sudan has the highest maternal mortality in the world. The SHARP Programme is using community dialogue to better understand and to challenge harmful norms related to gender.

Sally Theobald

26 November 2014

South Sudan is in transition. With years of conflict and the construction of a new nation, existing gender norms which mandate women bear many children have been intensified in order ‘to replace the ones that were lost’. Gender and societal norms are in transition. Elders complain that the young no longer listen to and respect their elders, couples do not keep to the traditional three years birth spacing, and marry younger and younger. Parents worry that their girl may get pregnant before marriage so they marry her off early, especially if she is not in school. Girls and boys have very limited access to sex education or contraceptives. These factors can lead to early pregnancy.

The SHARP Programme: community engagement for change

Korrie de Koning (Royal Tropical Institute) and Kingsley Chikaphupha (REACH Trust) have been working on the community participation component of the SHARP Programme in South Sudan. They provided some insights into how it is altering community norms around maternal health.

The SHARP Programme is funded by the Dutch Government and is a collaboration of the South Sudanese Ministry of Health, the Royal Tropical Institute, IMC, Healthnet TPO and Cordaid.

As part of the Programme the Royal Tropical Institute developed a curriculum for the training of community facilitators to support dialogue and reflection on norms and values shaping maternal mortality and health service access and use. The curriculum was shaped by various sources, but drew substantially on the GTZ developed generational dialogue The curriculum was further adapted with input from the Community District Health Department in Wau, WBeG and Aweil North in Northern Bahr el Ghazal, REACH Trust, Malawi, International Medical Corps, and Healthnet TPO . Training of facilitators focussed on dialogue between older and younger women and men, comparing social and gender norms and practices between present and past, sharing knowledge on maternal health and discussing what needs to be changed for maternal health to improve.

How does it work?

Groups used drawings, statements and proverbs to explore the relationships between communities by gender and generation. For some women, this was their first experience of holding a pen or pencil but they were skilled in drawing images of maternal health decisions, dilemmas and outcomes throughout their life cycle. The ‘but why’ technique was used to probe and understand the rationale behind different cultural norms, their meanings and whether they were seen as fair.

Kingsley facilitated the men’s groups and explained at first there was complete refusal to even entertain the possibility of a discussion on contraception but use of the “but why” technique enabled discussion on the impact of multiple births on (especially young) women and child survival rates. This led to some shifts in viewpoints. Drama was also used, and women acted out what it is like to have obstetric fistula, and how women with urinary or faecal incontinence were treated within their communities. Following work in women and men only groups, the community fed back their ideas and experiences to each other, and for many women (who are very powerful within their own domains) this was their first experience of speaking publicly in front of men.

What changed?

Through the facilitated discussions between genders and generations statements for change were negotiated and agreed. Here are some examples:

“If a man with more than one wife is not looking after one of his wives and their children, the wife has the possibility to refuse to produce any more children without having to pay back the cows/bride price and also has the right to not be beaten.”
“We don’t want daughters to marry or be pregnant before 18 years old and we in our family will do all we can – we want to pledge this to our family and community.”
“Married women should be allowed to use contraception and have three year birth spacing.”

This is an inspiring example of how community engagement can shift gender and societal norms and shows great facilitation skills from Korrie and Kingsley. Facilitators are being trained at local level and the approach will be rolled out and hopefully continue to challenge and change views and practices that undermine women’s maternal health.

To find our more about RinGs visit our webpage.

17 11 2014

The problem is political. Is the solution technical?

[Editor’s note: This blog was originally hosted on the Interactions Eldis blog under the theme Empowerment of Women and Girls]

Linda Waldman (IDS) and Marion Stevens (WISH Associates)

17 November 2014

The world is becoming increasingly urban, with over half of the world’s total population now residing in cities. While urban areas offer many economic and livelihood opportunities, they are increasingly characterised by growing inequality. In South Africa, both former homelands and peri-urban areas have been severely neglected in terms of health care and services, resulting in very poor-quality care and extreme discrepancies between rural and urban health statistics. Yet, there is recognition of the need to address peri-urban sexual and reproductive health (SRH) in South Africa.

South African adolescents experience very high levels of pregnancy, due to uneven gender relations, limited comprehensive sexuality education, and poor access to sexual and reproductive health and rights (SRHR) services, including quality contraception options. Poverty and place of residence strongly affect outcomes of adolescent sexual health in South Africa. While it is recognised that women and girls living in low-income residential areas are negatively affected in relation to many aspects of health, including SRHR, very little information is available on health within peri-urban cities and on the interconnections between poverty, place and health. Given this, we set out to understand how ICTs in general, and mHealth in particular, might provide new ways of addressing adolescent sexuality, reproductive health and place in South Africa.

Mobile phones are ubiquitous in South Africa, including in rural, peri-urban and slum contexts. However, investment in infrastructure tends to be in middle class areas where those inhabiting the spaces pay for use, and South Africa is renowned for its high data costs. By contrast, peri-urban and township areas suffer from inadequate access to services, including poor network coverage, weak satellite signals, insufficient bandwidth and limited voice capacity due to congestion and demand. As high unemployment causes a lack of security, women do not carry mobile phones for fear of being attacked and robbed. In some instances women share mobile phones. Rural areas are plagued by uneven conditions of access: female-headed households have poor access to mobile phones, poor satellite reception, no broadband, high data costs, lack of infrastructure as well as health, education and transport inequalities. In general, women and adolescent girls also have less time to access ICTs due to the gendered division of labour and additional domestic burdens. It is also difficult, and often unsafe, to access internet cafes and other public places where ICTs might be freely available. Inequality in ICT access thus maps the pattern of apartheid inequality.

There are also constraints in terms of electricity, language, cost and design – as one responded said, ‘Space is not an issue, rather it is cost’. Patterns of inequality cannot be addressed simply through access. Special policy measures are needed to support infrastructural and other developments in rural areas, inner-city slums and peri-urban areas, but if left to market forces, these areas will remain under-resourced. Yet, as no such policy prescriptions exist, most technical interventions make no attempt to deal with this. For example, although the National Department of Health (NDOH) is aware of the challenges of rural and peri-urban health for women and adolescent girls, MomConnect – its new national Maternal and Child Health programme – does not address high-risk HIV-pregnancies in peri-urban areas, or offer ways of ensuring transport and places for safe delivery in rural areas. It was, as one member of the task force informed us, ‘too complicated to add any nuance at this stage’. Thus MomConnect deals with questions of space only in terms of connectivity. Implementers working with the NDOH argue that ‘technically on paper, there is no area [in South Africa] without connectivity’. While recognising that connectivity may sometimes mean climbing a hill to receive a signal – and putting aside the mental image of pregnant women climbing hills to read their pregnancy-related SMS messages – ‘MomConnect will deal with it by hoping that there is a facility to receive a signal and that women may have to try different sim cards and perhaps change their service providers’.

As technology improves and programmes expand, the challenges of addressing place-related health issues change. Increasingly, content is being dispersed to mobile phones throughout Africa, so it is not always possible to link subscribers to particular countries or places. As many SRHR topics – abortion, diverse sexual orientations and gender identity, sex work, adolescent sexuality, condoms – are highly politicised and possibly banned, implementers focus on neutral, uncontentious topics and health-related facts. As one implementer, running an Africa-wide, sexual health social networking forum for young people, commented: ‘What I did as a better-than-nothing solution is I hired an international sexual health advisor to produce information as neutrally as possible’. Yet, implementers still come up against place-related challenges: ‘I wrote a manual about being tested for sexual diseases, but found that the tests were not offered… Place is the biggest missing puzzle piece in our service’.

The problem is political – rural, peri-urban, and inner-city areas are underserviced because of past historical injustice, because the poor live in these areas, because there are no policy prescriptions forcing cell phone operators to provide technology and services to these areas, and because the poor have no purchasing power. Poor women’s and adolescents’ health as experienced in these areas is not eye-catching – gender-based violence, abortion, adolescent rape – and their rights to challenge these experiences are difficult, politically-sensitive topics which do not buy votes. Nor are they easily addressed through the sale of m-health products. The challenge of adolescents’ and women’s SRHRs in rural, peri-urban, and inner-city areas is political. Yet, for many, the solution proposed is often technical.

**To view the original blog visit the Interactions Eldis blog.

To find our more about RinGs visit our webpage.

05 11 2014

Opportunities and challenges for the world’s first national mobile health initiative

[Editor’s note: This blog was originally hosted on the Knowledge, Technology and Society blog, Institute of Development Studies (IDS), UK, and was first published Thursday, 21 August 2014]

Linda Waldman (IDS) and Marion Stevens (WISH Associates; and Africa Gender Institute, University of Cape Town)

05 November 2014

Today, to coincide with National Woman’s Month, the South African National Department of Health launch MomConnect – a bold initiative and one of the first national, at scale, mobile health (mHealth) initiatives in the world.

MomConnect is part of a project that seeks to register all pregnant women in the country for an SMS service that will provide information and advice on pregnancy. It’ll also act as a channel to notify the government about poor service.

While the academic and policy community continues to grapple with the many challenges of implementing mHealth initiatives in low and middle income countries, South Africa has taken the plunge and we commend the National Department of Health on its vision and commitment to address maternal and child mortality.

Potential benefits of MomConnect

There are a number of fantastic reasons to be excited about MomConnect:

It will help South Africa meet the Millennium Development Goals (MDGs) on maternal and child mortality.
It offers a way of improving South Africa’s data systems by recording all pregnancies as early as possible.
It helps to promote healthy behavior, help mothers identify risk factors and improve mothers’ knowledge of, and uptake of, available health services.
It enables pregnant women and mothers to ask questions and seek clarity on maternal health issues. It offers the opportunity for women to give feedback on the services that they have received from the clinics. This addresses supply side challenges, particularly discrepancies in the kinds of services provided by health clinics. Health workers throughout the country have already received some training in relation to MomConnect and this feedback mechanism enhances the demand for and recognition of good performance. SMS messaging will also be used to enrich health workers’ skills and augment their training.
Finally, all women can de-register at the time of their choosing.

3 important areas that must not be neglected

The rollout of mHealth at national scale will be watched by South Africans and others around the world. Can mHealth really be used to overcome health system challenges experienced in low and middle income countries? Will the results from MomConnect finally provide evidence that mHealth initiatives can be successfully scaled up and can meet the health needs of poor and marginalised populations?

But social science research calls attention to another dimension – how might MomConnect be experienced and used differently to policy makers’ expectations? We predict three areas where MomConnect implementation may differ from the ideal and where early attention may ameliorate undesirable and unintended consequence:

Unintended pregnancies

South Africa has a history of population control under the previous apartheid government. Attempts to redress this have focused on women’s sexual and reproductive health rights and South Africa has very progressive policies on sexual and reproductive health. Yet implementation is not always easy and this, coupled with strong cultural or religious commitments, may mean that MomConnect is seen as a means of committing women to motherhood. How will adolescent girls with unintended pregnancies be treated in relation to their attendance at clinics and MomConnect? Will they be informed of their right to access early safe abortion services and quality contraceptive options or will they be encouraged to register with MomConnect as pregnant women? What incentives will encourage clinic and health workers to ensure that women receive information about safe abortion or other services appropriate to their needs rather than assuming motherhood is always desirable?

Negative feedback

Research in South Africa has frequently pointed to the structural problems associated with delivering health services to all South Africans, for example lack of infrastructure, equipment and drugs, poor staffing ratios, lack of alternative services etc. This combined with the very personalized nature of the MomConnect service, may mean that pregnant women and mothers of young children do not use the feedback and complaint services for fear of retaliation or withdrawal of subsequent health services. What reassurance will they have that their complaints are anonymous? Also, how will information be disaggregated to ensure that health workers who need better management and support are provided with this?

Privacy

There is massive, and well-placed, optimism about the use of mHealth to address health system challenges such as maternal and child mortality. Nonetheless, feminist and political economy researchers remind us to pay attention to power differentials in access to, and control of, electronic networks. Extensive debates about gender and ICT technology point to the ways in which technology facilitates surveillance, commercialisation and privatisation. Private companies are invested in the ‘bottom of the pyramid’ and in accessing women through mobile phones. The role of the private sector – in public private partnerships on health – requires more interrogation. Who will have access to the data about which women are pregnant and how will this be used? What mechanisms will ensure women’s privacy against commercial exploitation?

South Africa, as a young democracy, has a legacy of pioneering health achievements aimed to redress the imbalances of the past and current challenges. We welcome this initiative and look forward to its success.

By Linda Waldman (IDS) and Marion Stevens (WISH Associates; and Africa Gender Institute, University of Cape Town)

Read more about our work on the Empowerment of Women and Girls in urban areas in low-income settings on our Interactions website.

Find out more about our case study on the role of technology in sexual and reproductive health policy.

Read our review of evidence review on The health of women and girls in urban areas with a focus on Kenya and South Africa.

See related IDS work on ICTs and the changing health knowledge economy.

**To view the original blog visit the IDS Knowledge, Technology and Society blog.