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Gender in Health Systems Research: Some progress but more to do

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We attended the 3rd Global Symposium on Health Systems Research in the beautiful city of Cape Town. We both work in the field of gender and international health and it was great to see some notable discussion of gender in both the plenaries and as well as at dedicated panels. Despite this, we also felt that gender could have been mainstreamed throughout the conference and discussed in the Cape Town Statement.

Eleanor MacPherson and Rosemary Morgan

15 October 2014

 

The three dedicated gender panels (Gender Rights Equity and Access; Gender and rights-oriented health systems research; New frontiers in advancing gender analysis in health systems research) provided a forum for lively and engaged discussions about gender and how it relates to people-centred health systems.  In addition, gender in relation to health systems research was also showcased at the Symposium through a photo competition sponsored by RinGs (Research in Gender and Ethics). The aim of the competition was to capture the everyday stories of how gender plays out within health systems around the world and the winning photo, along with the honourable mentions, were showcased during the conference. The winning photo and honourable mentions can be viewed here.

Despite this, we also felt that gender could have been mainstreamed throughout the conference and discussed in the Cape Town Statement(the statement produced at the end of the conference). Here are some of the themes that we thought were important when thinking about how gender was discussed at the conference, some of which were highlighted within the three gender panels:

Moving beyond just seeing gender as heterosexual women  

In theory, gender studies is about understanding how power relations shape the lives of women, men, boys, girls and people of other genders. However, within health systems research gender has often been equated to heterosexual women and the barriers they face in accessing services. It was therefore great to see a presentation by Albert Dube on the barriers men in Malawi faced in accessing health services. In the same panel Alexandra Muller’s excellent presentation discussed the barriers to health service access that LGBTI people face in South Africa. During her presentation and in the discussion afterwards she described how poorly sexual and gender minorities were received and treated in health care settings in South Africa.  When thinking about gender it is therefore important to move beyond just thinking about women, and instead expand this to include men as well as people of other genders, as it is the relationship between these different groups which shapes lived experiences, including experiences related to health.

Sexual and Reproductive Health Rights is not just for pregnant women

During the conference particularly outside of the gender panels, women were predominately discussed in relation to their gendered roles (as mothers or carers). While maternal health is extremely important, particularly as maternal deaths are one of the leading causes of death of women of reproductive age, it is important to think about women’s overall health, including all aspects of sexual and reproductive health and rights within a woman’s life cycle. During her panel, Sofia Gruskin, as well as the rest of the panel discussing sexual and reproductive health rights, emphasized the need to ensure that provision of services are much broader than simply maternal health. Discussion following the presentations included an engaged dialogue on how the millennium development goals (MDGs) focus on reducing maternal mortality has often left little space and funding for taking a wider rights-based approach to sexual and reproductive health. The discussion ended with a reflection on the need to incorporate more rights-based approaches in the post-MDG agenda, as, according to Marge Berer, one can’t have sexual, reproductive, or maternal health, without first having sexual, reproductive, and maternal rights. It is therefore important to recognize that women’s health is more than just maternal health, and that integrated services, which incorporate a rights-based approach, are needed to women’s health is to be fully recognized.

Ensuring intersectionality is taken seriously

When thinking about gender relations, it is important to think about how intersectionality affects every day lived experiences. According to Parthasarathi Ganguly, an intersectional approach assesses how multiple systems of disenfranchisement intersect to produce health inequalities – such as gender, age, education, ethnicity, disability, or income. For example, the experience of an older highly educated woman from a high income group will be very different to that of a younger lower educated woman from a low income group. The new frontiers panel showcased how intersectionality could be researched in different contexts. For instance, one presentation showed how poor women in India were reluctant to access formal health facilities, while another showed how young men’s social marginalisation in Malawi could place them at an increased risk of HIV. Intersectionality can also be applied to the research process in relation to how it shapes how data is collected within the field. For example, the panel also included a presentation from Dorcas Kamuya about the challenges that field workers in costal Kenya faced gaining consent in relation to different groups and how complex power relations shaped this process. For many, gender analysis often means collecting, analysing and disaggregating data in relation to men and women; however, gender analysis must expand beyond this and go a step further, incorporating multiple systems of disenfranchisement and analysing how this affects lived experiences.

Overall, during the symposium we felt there was some interesting and engaging debate about gender and how it shaped different aspects of people-centred health systems. However, we hope to see in Vancouver gender more mainstreamed throughout the conference, including further focus on gender in the plenaries and new innovations in the conference sessions. We hope that this includes increased incorporation of gender analysis within overall health systems research, expanding beyond the common notion of gender equating to a women-only approach and the narrow focus on maternal health, as well as including intersectional approaches within the collection, analysis, and disaggregation of data.  If a people-centred approach to health systems is to be truly people-centred, it must recognize the lived experiences of different groups and how this shapes health and health inequalities.

To find our more about RinGs visit our webpage.

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

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RinGs aims to synthesize existing research, stimulate new knowledge generation, and support a learning platform that brings people together to work collaboratively on gender and ethics. The Global Symposium on Health Systems Research which happened a couple of weeks ago was a perfect opportunity to hook up with old friends and discover who else is working on the issues we care about.

Kate Hawkins

15 October 2014

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.

Honourable mentions in our photo competition

Honourable mentions in our photo competition

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We are delighted to announce the photos that received honourable mentions in our competition.

07 October 2014

Photos were selected for demonstrating diverse contexts from all regions of the world, representing different types of populations and settings.  The photos were selected for highlighting men and women actively on the frontlines of service delivery, whether in the community of facility-based, or for highlighting the collaborative efforts linking women and men in changing health systems.

Photographer: Polly Walker

Title: No na trabadja pa no tabanca (we are working for our village); Traditional Birth Attendants pose after newborn training in Guinea Bissau.

Location: Buba, Quinara region, Guinea Bissau

Photographer: Grace Wilentz

Title: Women of Many Generations (pictured in front of posters displaying information on gender-based violence and related services)

Location: Centro de Investigación, Educación y Servicios (CIES), El Alto, Bolivia

Photographer: Ralalicia Limato

Title: Village health volunteers (Kaders) are doing registration and data recording of a mother and a child in Posyandu (integrated health post)

Location: Posyandu in Cianjur, West Java, Indonesia

Photographer: LVCT Health

Title: Access for all:  Reaching the hard to reach, nomadic, young and old with HIV testing services in Kenya.

Location: Eremit Village, Kajiado, Kenya

Photographer: Chamroeun Som

Title: Nursing Equality Evolves In Cambodia

Location: Angkor Hospital for Children, Siem Reap, Cambodia

Photographer: Foglabenchi Lily Haritu

Title: Focus Group of Rural Indian Men Brainstorming on Spousal Communication and Family Planning Decision-making Strategies

Location: Ujjain Village, Madhya Pradesh, India

Photographer: Amy Iftekhar

Title: Waiting for Care in Northern Nigeria

Location: Outside Maiduguri, Nigeria

Photographer: David Musoke, FHS young researcher

Title: Women take lead in a drama session on health promotion in rural Uganda

Location: Wakiso district, Ssisa subcounty, Bulwanyi parish, Uganda

Photographer: Htet Nay Lin Oo

Title: Me and my project motorbike – A nursing officer arriving at district office on the project motorbike to help review progress on improving maternal and child health

Location: Kibuku District Health Office, Kibuku District, Uganda

Photographer: Bhargav Shandilya

Title: A Teenage Single Mother and Community Health Worker: An Urban Story

Location: Bangalore, India

Photographer: Amref Health Africa, staff photographer

Title: Changing roles: Women helping women to ensure their babies’ health and nutritional status. Women are no longer the passive recipients of health care in Africa, and are now the agents of empowerment.

Location: South Omo, Ethiopia

Photographer: Amref Health Africa, staff photographer

Title: Taking charge of destiny: As well as actively participating in the health workforce, women in Africa are being empowered and are happy to continuously monitor their own and their children’s health and nutritional status, as opposed to seeking medical attention in times of ailment only.

Location: Kitgum, Uganda

Photographer: Shibaji Bose – FHS India

Title: My lens my voice. Minority community woman – who rarely ventures out – learns to use a camera during a Photo Voice fortnightly group meet

Location: Dakhshin Durgapur village of Patharpratima Block in the Indian Sundarbans

Photographer: Carol Bales, CapacityPlus and IntraHealth International

Title: Future Obstetric Nurse?

Location: Kumasi, Ghana

Photographers: Katherine Lin & Anita Thurakal

Title: I’m a feminist because…

Location: Johns Hopkins School of Public Health, Baltimore, Maryland, USA

 

To find our more about RinGs visit our webpage.

The power of a midwife

Winning photo announced

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The aim of this competition was to capture the everyday stories of how gender plays out within health systems around the world. Through these visual stories we hope to inspire imagination and provoke assumptions about what gender means for the health systems we engage with. Capturing nuances or startling us; images communicate powerfully and symbolically; in ways that are sometimes more enticing, convincing and memorable, than the tomes of written evidence that may or may not be read or remembered. The photo was taken by Amref Health Africa.

Asha George

07 October 2014

The winning photo resounds with the strength, dignity and confidence of a woman proud of her contributions despite the challenges faced. She shines like a ray of hope parting the stormy clouds of circumstance in Uganda. While the child almost yawns in the comfort of her cradle, she is unlike other madonnas. We look up to her and she is wearing the gloves and a uniform of a female vocation and profession that is under negotiation and transformation. The photo presents a strong, positive image, taking a conventional role and presenting it in an unconventional and affirming manner. It was scored unanimously by the judges as the winning photo.

Other photos were listed for honourable mentions for highlighting women actively on the frontlines of service delivery, whether registering other women and children in Indonesia, weighing them in Uganda or immunizing them in Ethiopia. They did so with vigour and humour as shown by the TBAs in Guinea Bissau. Although many photos featured women working in communities as volunteers or community health workers, there were fewer photos of them as facility based health professionals. While many of the photos highlighted women serving other women primarily through community or preventive services, very few highlighted possible gendered training or working conditions of these frontline health workers. Furthermore, only one photographer documented a woman in a managerial role: a nursing officer in Uganda resting on her motorcycle, self-assured while straddling a vehicle typically associated with men. One photo not selected for honourable mention showed an immunization officer and health committee member who were nursing mothers themselves. These images remind us of the varied roles that women play in health systems.

Men were also highlighted in gender transformative ways by the photo competition. Men in a group listened and discussed spousal communication and family planning in India, while another photo captured a young man studying obstetric nursing in Ghana. While these were good examples, there were not many submissions documenting the role of men in engaging in gender issues as a way of transforming health systems.

Other photos listed for honourable mention highlighted collaborative efforts linking women and men in changing health systems. In Cambodia, a hospital offering training for both male and female nurses emphasized positive images within facility based care. A student activist campaign within a public health training institution in the USA challenged them to think about gender norms in their personal and professional lives.

Photos were selected for demonstrating diverse contexts, whether ranging from HIV testing and peer education among nomadic populations in rural Kenya or home visits by community health workers supporting adolescent mothers in Indian urban slums. Only one photographer submitted photos within a hospital ward setting and very few photo submissions were about the training institutions that support health systems. Women of different generations in Bolivia, sitting in front of gender based violence health education material, remind us of the variety of needs women have even within the same context. Photos were selected from all regions of the world, representing different types of populations and settings.

The competition elicited a range of photographers, from professional photographers, project managers, donors, researchers, activists and lay community members. Two of the submissions winning honourable mention were photovoice entries, where community members themselves get behind the photographic lens to document and narrate their stories. One highlighted the role of women in street performance peer education activities for maternal health in Uganda and another profiled a woman from a marginalised community learning how to use a camera to document community resilience in an ecologically vulnerable region in India.

The question of who has the right to take and display images, under what contexts and for what purpose permeated the photo competition. Although, we disseminated guidelines on the ethics of informed consent for photography, only one photographer made reference to a code of conduct with regards to use of images. Most photographers reported verbal consent or written consent where possible. One reason why written consent was not possible in some instances was because of a plethora of local languages. Nonetheless, several photo submissions did not detail consent, or reported consent that was more casual in manner: people seeking consent by pointing at the camera and seeking consent non-verbally. There is a difference between seeking consent for taking a photo, whether for personal memories or for professional imperatives, and seeking consent for disseminating the image publically, whether for profit or non-profit motives.

Ethical principles in photography and use of images, go much beyond issues of consent. They span issues of justice, autonomy, non-maleficence, beneficence and fidelity. Are we representing subjects respectfully, in ways that do not further marginalise, stigmatise or exploit them personally, but that raises questions about their health system realities and broader public health priorities to support constructive social change?

Who benefits from the dissemination of images? As researchers, we were surprised by the number of photographers who objected to our photo competition, because it did not offer a financial reward of some kind. We offered dissemination of the photos with due credits at the Cape Town Health Systems Global Symposium and through other means where possible. It was heartening to learn about the struggles faced by professional photographers, yet I am not certain that affirming exclusive royalty agreements necessarily serve the broader public good, anymore than they do for research.

Photos are even more personal than research findings, because they can be more irrefutably identifiable or contextually revealing. It is striking to me that photo credits are usually for the photographer alone, and don’t always acknowledge the photographee or organisation sponsoring the photographer. Feminist research ethics interrogates who has the right to be an author representing the realities of others. How do we apply such principles to photography?

Several photos that were not selected for honourable mention but that were still striking were those that chronicled women’s hard, back-breaking labour: whether carrying heavy loads, undertaking agricultural work, fishing or crab collecting, at times when pregnant. In direct contrast, several submissions also portrayed women passively, often as motionless mothers and children, despite the terms of the photo competition. And finally, there were a few photos, which we were not clear what they were meant to be about. Such is the fate of opening a call for anyone to participate!

We thank everyone for participating, those who gave consent for their photos to be taken and disseminated, and those with cameras for their interest in submitting photos, despite not having monetary prizes, and look forward to profiling the photos with credits at the Cape Town health systems symposium. Hope the images spur further interest, conversation and engagement in transforming health systems for the better!

To find our more about RinGs visit our webpage.

 

When communications on social media go wrong, and then they go right again, or, how to run a better photography competition in the future

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Kate Hawkins

06 October 2014

A few weeks ago at the Resyst annual meeting we had a long conversation among researchers about blogging and social media more generally. As a communications professional who has worked with academics or a long time I found myself nodding in sympathy as researchers voiced their fears about these new mediums of engagement. Worries clustered around losing control of information, intellectual property, emerging ideas and data being misappropriated and misconstrued, and the possibility of negative reactions to the work they put out. Simultaneously we were holding a capacity building meeting on how to use images and film in research communications. It was great to get academics, communications staff and professionals from the creative sector together to stimulate some excitement about these types of mediums.

After spending some time soothing the troubled brows of academics about the low risk of negative backlash on social media it was ironic that a week later our photography competition on gender and ethics was in the firing line on Twitter. The competition had been ReTweeted by DFID Research team prompting Nick Cavanagh, a photographer who works on international development, among other topics, to send us an email criticising the prize (a chance to have your work displayed at the upcoming Global Symposium) and suggesting that it would be more appropriate to offer a prize with some monetary value.

We decided to have a chat with Nick to understand how we can do things better next time.

As I understand it you became aware of our photo competition when DFID ReTweeted us. You have some criticisms of the terms of the competition, could you explain more?

Initially, as a working photographer, I thought the competition looked really interesting. You are always searching for ways to increase your profile. But when I looked closely at the terms and conditions the competition didn’t seem to offer anything in return. It strikes me as an imbalanced transaction between the client and photographer to request images without paying for them. You would never go into a shop and ask for a pair of jeans and say I will wear them, and this will raise your profile, but I’m not prepared to pay for them. It devalues the worth of the photography. Photographers need to earn a living too, and you need to bear this in mind. We will never progress if we can’t afford to buy a lens or take a trip to field sites. Because I am passionate about international development I am probably more irked than others would be.

I was interested by your comment, “images have an ability to carry narrative but it’s a mistake to see them as simply a communications tool.” I have worked with research projects which used photography as a method for enquiry but could you explain more about your views on this?

To me communications is all about how fantastic everything is, it is marketing. I’ve worked on a number of projects that used photography as a method for evaluating programmes and knowledge management. If you see a photo of a clinic on opening day it is clear what it is a picture of. The photos during the renovation process tell a story. But true evaluation is to return and look at sustainability. Photographers observe things others might not – the chart on wall that’s out of date the sexual violence centre which has no woman police officers. In these cases nobody was hiding the evidence because nobody had noticed it until they saw the image.

We are encouraging researchers to adopt innovative ways of communicating their research – particularly when it concerns issues which are impenetrable to some. It is hard to communicate around gender, ethics, and health systems. What are your thoughts on researchers using photography?

I can’t do a professional research job, it is not my field. But if I took an image of a polio clinic I would want to flush out the narrative. Professional photography is methodical and technical, it takes time and effort to learn these skills. The importance of an image means there’s no short cut. You need to understand light and composition and you can’t get this by just being enthusiastic. Of course you want to encourage creativity in everyone – if you’ve got a camera in your hand you are a photographer. But often the images you are left with are of poorer quality. Also people may put themselves or their subjects in danger in the course of documenting their work – people can react to cameras in strange ways.

Talk to me more about the transaction between photographer and subject.

Amateurs tend to say that they are ‘taking a photograph’. A creative would say they are ‘making the photograph’. If you are taking you say, ‘look down the lens.’ The person being photographed is not getting anything. But if the subject and the photographer work together on an image it is different. People are part of the creation of the image – that is why people often steer away from stock photography – it can feel extractive.

Could you explain more about the incentive structures for international development photographers in different settings?

When you are starting out as a photographer there are certain fixed costs. International development photography often has higher costs because it can involve travel and you have insurance costs. Cameras are expensive too and in places like Sub-Saharan Africa they don’t have a long shelf life. It’s not like studio photographers you are often in dusty places and need to safely transport equipment. Many photographers starting out in low-income countries get into the work through fashion and wedding photography – that is where the market is.

So what should projects like RinGs do differently in the future?

If you can’t afford a photographer on a daily rate then you can purchase stock images – but they probably won’t work and will have been over-used. If you want to appeal to photographers you either have to offer a really good prize or profile. Your audience is very niche and so you are unlikely to get a gallery to run images. Photo equipment might be a good alternative. For many photographers in low-income settings a £500 camera would be gold dust. However with a monetary prize you are likely to get fraudulent entries.

We are thankful to Nick for taking the time to talk to us. His comments are food for thought. It would be interesting to hear what others think. Please feel free to comment below.

 

To find our more about RinGs visit our webpage.

How participatory is participatory modelling for complex adaptive systems?

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[Editor’s note: This blog is part of a series of reflections emerging from a workshop on complex adaptive systems research methods held in Baltimore in June 2014.]

Asha George

12 September 2014

 

The Partido Revolucionario Institucional, or PRI, is a political party in Mexico with something of a confusing name. It literally means the  ‘Institutionalized Revolutionary Party’, and when I first heard the name I couldn’t help but laugh. Institutionalized revolution, huh? It sounds like something straight out of a Monty Python sketch, something completely contradictory!.

At a recent workshop on methods for understanding complex adaptive systems (CAS) in the context of health systems strengthening, I was struck by a similar thought. We looked at a number of modelling techniques, like agent-based modeling and causal loop diagrams, some purporting to be participatory in nature. But, like the PRI, is the idea of participatory approaches to complex systems thinking inherently contradictory? Inherently confusing? Or are they revolutionary, altering how we see the world and empowering us to transform health systems radically?

Converts to complex adaptive systems and participatory approaches can be equally zealous. They do have that in common. But what else do they share?

  • Modelling complex systems involves visualizing relationships andarticulating assumptions between factors that are dynamic and non-linear. Participatory research approaches also use visualization to reveal connections and linkages that may not be readily apparent.
  • They also both involve iterative interrogation of phenomena.
  • Certain communication techniques also allow for layering of information.
  • And perhaps the most beneficial aspect of both approaches is that they allow for an appreciation of context.

Yet, when colleagues claimed they were participatory because the modeling efforts they undertook involved multi-disciplinary and multi-stakeholder teams developing and discussing diagrams, I was startled by my skepticism.

Participatory approaches don’t just involve people visually mapping and discussing phenomena, they are radically about people. They are about purpose. And ultimately, they are about power.

The diagrams, methods, language, all pale in comparison to key questions such as:

  • who is involved,
  • who is in charge,
  • why and for what?

Issues of power, representation and agency are paramount. Assessing whether research or modeling is participatory or not, would require interrogating who defines research problems, facilitates the analyses, presents data, owns and acts on the information generated.

Participatory approaches elicit narratives, enable people to tell their stories and collectively build foundations for action not just through better understanding, but by fostering discussions and relationships that fuel change. Participatory researchers are facilitators ensuring that those who are otherwise marginalized find their voice, are able to exert their agency and are in dialogue with other power brokers in society. This may mean working with groups separately, before bringing everyone together. For instance, community scorecards in Afghanistan first had women specific meetings, before women felt they could and should participate in the men’s meetings to ensure their perspectives got heard.

A parallel and complimentary stream of work in FHS is that led by the RinGs partnership. We emphasize for health systems research to seriously tackle social complexity that involves gender and other social determinants, we need to pursue approaches that are embedded in local context so that it is owned by local stakeholders, that it consider how social relations such as gender intersect with other forces of social marginalization, and that the ethical implications of such power relations be examined more closely.

Keeping these three tenants from RinGs in mind, complex systems modelling may or may not be participatory. Their methods do not seem to me to be as intuitive as drawing body maps, charting seasonal calendars or ranking priority using pebblesor chapatis. Though, I certainly see potential.

Joshua Epstein, as part of his talk on ‘Why model?’, did suggest that anyone who has a projection of the world – of a social dynamic – is already modeling. Indeed, it does strike me that modeling can be an inclusive task that is mainly about making one’s assumptions explicit.

But rather than assuming that complex systems modelling are participatory by default, we should be asking tougher questions for both modelers and ‘participatory’ facilitators: for and by whom and for what ends?

 

To find our more about RinGs visit our webpage.

Join us in Cape Town for our panel on gender, ethics and health systems

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Like many others we are getting excited about the upcoming Global Symposium on Health Systems Research which will take place in Cape Town at the end of September/beginning of October. If you are attending please do come and join us for our panel presentation, “New frontiers in advancing gender analysis in health systems research: context embedded approaches; intersectionality; and engagement with power and ethics.” The panel will take place on the 3 October, from 0930 to 1100 on the Roof Terrace.

20 August 2014

Gender in health systems research needs to go beyond approaches that “add women and stir” or analyses health indicators by sex

The panel will illustrate three methodological approaches: 1) embedded approaches (analysis that is relevant to context, owned by local partners and where appropriate cross-sectoral); 2) intersectionality (presenting research that assesses how gender intersects with other axes of inequality, such as age, poverty, education, geography, disability and sexuality); and 3) the inter-related nature of gender and ethics in research, policy and practice.

Super speakers

We will be led by an excellent panel of specialists:

Panel themes

The target audience for the session includes health system researchers and research users. Key lessons from the panel will be documented in a learning brief, containing key references and resources and shared with all. Discussions will be clustered around key themes:

Context embedded approaches:

  • To what extent can we generalise lessons from context embedded approaches beyond their immediate contexts.
  • What research approaches can best assess broad structural drivers of health determinants and build evidence to support  multi-sectoral engagement  beyond health.
  • What are the implications for sustainability and reflective practice in health systems research and practice?

Intersectionality:

  • What are the lessons learnt on methods, processes and capacities for intersectional research which capture how gender interacts with other axes of inequity (e.g. age, disability and poverty).
  • What are the implications for analysis and engagement of different stakeholders in the research process and for translating such research into action?

Gender, power and ethics:

  • How do power relations, gender and other axes of inequality feature within key ethical concerns in health systems research?
  • What are the approaches taken by researchers to strengthen ethical practice when inequitable power relations, gender and social exclusion are observed?

We hope to see you there. If you have any advance questions or comments about the session please contact us on rings.rpc@gmail.com.

To find our more about RinGs visit our webpage.

Where is gender in health systems research?

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In the lead up to the Global Symposium on Health Systems Research in a few months’ time we’ve seen a renewed focus on health systems from the international development sector in the UK. Is gender a feature of these conversations?

Sally Theobald

06 August 2014

 

In the lead up to the Global Symposium on Health Systems Research in a few months’ time we’ve seen a renewed focus on health systems from the international development sector in the UK.

The International Development Select Committee has just run an enquiry into the Department for International Development’s (DFID’s) efforts to improve health systems in low- and middle-income countries. The Guardian recently hosted a web debate on how to make health systems work in poor countries.

As a health systems researcher who has focussed on equity and power issues I’ve been keeping an eye out for how women’s health and gender featured in these debates. Disappointingly parliamentarians asked few questions relating to gender in the enquiry – this seemed a strange oversight given that equity is a key focus in the post-2015 goals. The impact of gender roles and relations on health systems did emerge from the Guardian debate where I was one of 10 panellists.

So how did gender feature?

Intersectionality in action: Gender, power and access to health services

Gender and other social inequalities intersect to shape individual and community vulnerability to a wide range of health problems. In the debate there was a clear agreement that equity is important – whether people are talking about gender, poverty, disability, marginalised groups or sexuality; we need to seek opportunities to bring these perspectives together and build responsive health systems that are sensitive to these different needs. Some of the perspectives that were brought out during the debate are outlined below.

Sian Maseko (former Director of Sexual Rights Centre, Zimbabwe) talked about their research with LBT women and male, female and transgender sex workers. She pointed out that the main barrier that they faced in accessing healthcare was the attitudes of health care workers, particularly high levels of stigma and discrimination.

Elaine Ireland of Sight Savers pointed to the barriers in accessing health care that are experienced by people with disabilities, but she also elegantly brought intersectionality into the conversation. She explained that people with disabilities are often seen as asexual by service providers and as a result:

Information on priority health issues such as HIV, TB, malaria, sexual and reproductive health doesn’t reach this marginalised population. Information is rarely produced in accessible formats, such as large-print or braille for people who are visually impaired or blind, or in the case of SRH and HIV, it is often assumed that people with disabilities are not sexually active and so therefore don’t need access to this information.

Sian was able to speak to a particular example of these intersections from her work in Zimbabwe:

I absolutely agree that gender is a key issue and that inequalities are often deeply embedded or reflected within the healthcare systems. I think multiple discriminations is a key barrier to accessing healthcare. A case has just been taken against a state hospital in Bulawayo that turned a woman with a disability away four times while she was trying to have a Pap smear because they said the services were on the fourth floor and as she couldn’t use the stairs then she would have to wait until the elevator was working. A simple example about physical access, but equally psychological access – how willing would she be to return for a critical SRH service?

Health systems: Challenges and opportunities for gender analysis?

There is a need for greater gender analysis within health systems research, however, this can only be effective through the collection of appropriate, high quality, and context-specific disaggregated data. During the debate, Elaine made the excellent point that:

[A] key challenge is data – how can a government know how to prioritise its limited resources for health if it doesn’t know what its greatest health problems are and who in the population is at greatest need of those services – post-2015 offers a fantastic opportunity to emphasise the importance of quality data collection (including disaggregation by gender, age, disability, ethnic group) and continuing investments in health management information systems.

We need to showcase good examples of how gender disaggregated data has been used to improve health systems. For example, in Mozambique gender focal points meet with national and provincial health officers, health workers and community representatives on a monthly (at national level) or trimestral (at provincial level) basis to discuss the implications of their disaggregated data sets. This enables the team to embed the findings within the local context, to discuss important intersections such as how gender and cultural norms, literacy and age may be interacting to shape women’s and men’s health and service access for malaria, HIV, other diseases, and following violence. These discussions develop ownership over the data and enable the team to critically develop context embedded approaches to address the challenges and inequities uncovered.

Context is key

Gender roles and relations vary across contexts. Contexts matter and some contexts pose particular challenges and opportunities for building gender equitable health systems. Drawing on her experiences of working and researching in Northern Uganda and elsewhere, Sarah Ssali of the ReBUILD consortium discussed the particular challenges and realities of health systems in reconstruction in post-conflict contexts. In post-conflict contexts we need to understand how health systems can best play a part in building recovery and peace and dealing with challenging issues such as strong and holistic services for survivors of sexual and gender based violence; whilst ensuring that gender is considered in all aspects of health systems and not only sexual and other forms of gender-based violence (SGBV).

Sara Bennett (Future Health Systems) suggested that sometimes issues get neglected because we don’t know enough about them and how they play out in specific contexts. She went on to say:

It is easy to talk about cultural barriers in general terms, but it is the specifics that bring it home to us what the issues are. I was at a presentation yesterday where a speaker was talking about the cultural barriers that prevented Nepali widows from accessing reproductive health services – they were scared of being raped, or that their presence might be taken to indicate that they were sexually active. In the Sundarbans India, Future Health Systems has been examining the barriers to access among marginalized populations that live in the delta region. By providing some real illustrations of the nature of these barriers perhaps we can bring this issue “alive” for people.

How do we keep the momentum on health systems riding high?

Sara went on to pose an interesting question: What can we, as a community of people interested in health systems, do to make sure that they (health systems) don’t drop off the radar again?

We need to look for opportunities to further strengthen partnerships. Keeping health systems on the agenda means taking these conversations outside the usual suspects, bringing in neglected voices (including women, men and people of other genders, marginalised because of social position, whether due to gender, sexuality, age, geography, literacy etc.), civil society, advocates and researchers working on gender, equity and social determinants. We also need to build stronger links between the health sector and other sectors and social movements such as worker’s rights groups, feminist movements and social justice actors more broadly.

There is also need to develop the evidence base on gender and health systems and make this responsive to the needs of key actors within health systems. This is the focus of Research in Gender and Ethics: Building Stronger Health Systems (RinGs)which brings together three health systems focused partnerships: Future Health Systems, ReBUILD and RESYST to galvanise gender and ethics analysis and evidence in health systems.

As our work develops we hope to engage more with feminist networks and academics and hope to stimulate a dialogue about these issues that moves us out of our usual siloes and stimulates some fresh thinking. We hope you will be part of the debate. To find out more email us on rings.rpc@gmail.com

 

To find our more about RinGs visit our webpage.

We want your photos! Gender, ethics and health systems

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The aim of this competition, organised by Research in Gender and Ethics (RinGs), a new cross-RPC partnership between Future Health Systems, ReBUILD and RESYST, is to capture the everyday stories of the ways that gender plays out within health systems around the world.

22 July 2014

 

The aim of this competition, organised by Research in Gender and Ethics (RinGs), a new cross-RPC partnership between Future Health Systems, ReBUILD and RESYST, is to capture the everyday stories of the ways that gender plays out within health systems around the world. The winning entry will be exhibited at the Global Symposium on Health Systems Research, and be used to illustrate our website, and in other published materials with full credit to the photographer.

Gender-sensitive health policy is a feature of international commitments and consensus documents and national-level normative statements and implementation guidance in many countries. However, there are gaps in our knowledge about how gender and ethics interface with health systems. Our project shines a light on some of the ways that gender and health systems come together in a variety of settings. We are looking for photographers who can help us communicate this area of work visually. We welcome images of people of all genders from all areas of the health system, all around the world – be creative!

The deadline for entries is the 1 September 2014.
The judging

Photographs will be judged by a panel of gender specialists and a representative from the creative industry. They will be marked according to:

  1. Their content, i.e. their relevance to subject.
  2. Their ability to tell the story of gender and health systems, i.e. the message they contain, their creativity. We are looking for original and authentic visual representations of health systems in action.
  3. The technical merit of the photo, i.e. exposure, focus, colour, lighting etc.

We are looking for images which challenge stereotypes, encourage the viewer to learn more and act differently, and which respect the integrity of any people who may be photographed. There is a rich discussion on the ethics of photography in international development which should help guide entrants. Further information can be found here and here.

Who can enter and how to submit?

Those who have an experience of, or interest in, gender and health systems are very welcome to send images.

Send up to a maximum of three photos by email to RinGs.RPC@gmail.com

Submission requirements

  1. Size: At least 1MB
  2. Print resolution: 300 dpi
  3. Format: JPEG or tiff only
  4. Landscape and portrait images are acceptable
  5. Although some digital enhancement is acceptable we cannot accept images that have been digitally altered to change what is portrayed.

Send each photo separately and include in your message the following information:

  • Name of photographer:
  • Photographer email:
  • Photographer phone:
  • Title of photograph:
  • Location (country and city/town/village where the photograph was taken):
  • The date (if unknown, please provide the year) each photograph was taken:
  • The level of consent provided from any people pictured in the photo (see informed consent guidelines for more information):

Submit your entry

All images should be emailed to RinGs.RPC@gmail.com by the 1 September. We look forward to receiving your entries.

For more details please download the entry requirements and terms. Information about informed consent and a sample consent form are also available.

 

To find our more about RinGs visit our webpage.

Ethics & Gender: reflections from the Global Health Bioethics Network Summer School in Malawi by Sally Theobald

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Reflections on the Global Health Bioethics Network Summer School

23 July 2014

 

The Global Health Bioethics Network is a collaboration between the five Wellcome Trust Major Overseas Programmes (MOPs) in Kenya, Thailand-Laos, South Africa, Vietnam, and Malawi and the Ethox Centre at the University of Oxford. Funded through a Wellcome Trust Strategic Award, the Network aims to: promote and support ethical reflection within MOPs; carry out ethics research across the MOPs; and improve thecapacity of the MOPs to identify and address the ethical issues in their own research. To achieve these aims, the Network carries out a range of capacity-building activities which include: hosting an annual Summer School; providing annual capacity-building bursaries to researchers (Ethics Fellows) across the MOPs; providing education, training and mentorship to Ethics Fellows and other MOP staff; supporting MOP directors and other scientists in identifying and addressing the ethical aspects of their own research; supporting funding applications; and providing collaborative on-line ethics resources to promote cross-MOP discussion. In addition to its capacity building activities, the Network also conducts a number of important research projects into practical ethical issues relevant to the scientific and community engagement activities of the MOPs.

What was the focus on the summer school?

The ‘summer’ school was held in the depths of the Malawian winter in the week Malawi celebrated 50 years of independence. Among the celebrations was a space for reflection about the challenges and opportunities the next 50 years will bring the country. The summer school which brought together an impressively wide range of perspectives, professions and disciplines through a series of presentations, discussion panels and fish bowls also offered a space for reflection on the theory, practice and ethics of community engagement across the different contexts. Key questions that emerged through the discussions, included:

  1. What are the goals of community engagement and whose agendas do they serve?
  2. What is the interplay or overlap between approaches fostering public engagement and those aiming to take forward community engagement?
  3. How can we define and deepen “appropriate” community and public participation across institutional practice and throughout research cycles?
  4. How can we ensure marginalised and hard to reach groups are not excluded in community engagement activities?
  5. How can promising and inspiring practices be shared across different MOPs and different contexts?

Given the recent launch of a sister network Research in Gender and Ethics in Health Systems – RinGs – I was particularly interested to learn from debates at the summer school about the interface between gender and ethics:

The interplay of gender and generation within households and communities

Rodrick Sambakunsi’s bursary project focused on social messaging and HIV in Malawi. He aims to use social network approaches to trace the production of knowledge on HIV and explore the ways in which relationships between close and loose knit social networks shape (re)productions of knowledge. Sampling participants through science café’s, counsellor interactions and community mobilising events his initial findings highlight how gender, age and class shape who attends which events and how messages are shared. Lindsey Reynolds and Miliswa Magongo’s bursary project will use historically grounded ethnographic research to explore community perceptions of research within KwaZulu Natal and the role of gender, generation and hierarchy in shaping views points on what constitutes just ethical research.  The interplay between gender, generation and cultural perspectives will also be explored in Claudia Turner’s bursary which will examine household and community decision making processes s and behaviours with respect to the care of poorly neonates in Cambodia. Claudia explained that globally neonatal mortality makes up 44% of deaths in children under 5 years but little is known about decision making processes in the first weeks of a baby’s life.

Benefits & payments through the lens of gendered household dynamics

The role of benefits in research also highlighted the role of gender and power within households. Maureen Njue’s bursary explored community perspectives on benefits and payments in coastal Kenya. She found that cash benefits were valued but had the potential to cause conflicts within families and in husband-wife dynamics, particularly when cash payments were made to the mother. Vicki Marsh also explained how in Kenya some participants felt that payments had the potential to undermine traditional gendered family values, although this was hotly contested and debated within the Kenyan community. Dorcas Kamuya explained how gender and power also shape consent processes in the household and how these are negotiated through ongoing interactions with fieldworkers.

Deconstructing communities – what are the challenges of representation?

Participants discussed the challenges and utility of trying to define fluid and dynamic communities. The complexity and fluidity of contexts and communities was beautifully illustrated by Khin Maung Lwin and Phaik Yeong Cheah who described the process of community engagement in the Shoklo Malaria Research Unit in Mae Sot on the porous Thai- Myanmar border area. Here with Decha Tangseefa they argue that the notion of community is shaped by space – whether people reside in refugee camps or border villages; subjectivities – including the role of collective and individual based memories and the realities of legal status, educational background and type of work.  Gender, generation and ethnicity overlay experiences of individual and communities making processes of community engagement and representativeness enormously challenging. Khin and colleagues have discussed the processes and challenges of establishing a community advisory board to represent community interests in Biomed ethics. CAB members speak Karen/Burmese live on either side of the border, are aged between 26-60 years old, are mainly male and include NGOs, casino workers and housewives.

Challenges and questions as we move forward…

There needs to be an ongoing critical reflection on the role of community engagement and whose interests are served and taken forward at different levels – with households, ‘communities’, research centres in the south and north, governments and donors. Given the fluidity of communities, how can different engagement activities that best represent or speak for diverse community interests be established? How can we deepen community engagement processes to include marginalised or had to reach groups? Sassy Molyneux pointed out that processes of informed consent and community engagement interact with complex power relationships within households and within communities. This poses a dilemma to the extent to which community engagement and informed consent interactions will intensify or offer opportunities to renegotiate gender and power relations, raising questions about the extent to which researchers – and front line field workers – should be attempting to engage with and/or change asymmetrical power relations?

The literature on social justice provides useful framing for some of these dilemmas. We need to think though and address ethical issues in research simultaneously at micro (e.g. informed consent and individual benefits) and macro levels (addressing structural inequalities and poverty). This means ensuring that our research and community engagement processes enhance, rather than undermine the rights and livelihoods of different women, men, girls and boys.

 

To find our more about RinGs visit our webpage.