Health

16 05 2018

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

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

By Evelyn Kabia

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

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

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

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

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

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

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

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

10 05 2018

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

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

Rebecca Racheal Apolot

10 May 2018

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

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

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

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

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

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

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

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

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

12 04 2018

Can intersectionality get us closer to Universal Health Coverage?

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

Manasee Mishra, IIHMR University, India

12 April 2018

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

Our Intersectional Identities

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

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

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

Towards More Mindful and Responsive Health Systems

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

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

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

29 03 2018

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

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

Julie L. Evans

29 March 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Examples:

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

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

Examples:

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

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

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

Examples:

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

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

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

08 03 2018

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

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

Kate Hawkins (Director of Pamoja Communications)

08 March 2018

The health and social workforce needs gender-transformative reform

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

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

Women health workers face violence and sexual harassment at work

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

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

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

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

Fragile and conflict affected states have particular problems

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

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

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

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

Promising practices

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

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

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

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

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

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

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

21 12 2017

Ten reasons to be cheerful

If you work on women’s rights and gender you may be feeling a little deflated by the last twelve months. It is easy to be demoralised by the stories which rush past our Twitter feed or jump out from newspaper headlines. To cheer myself up I decided to put together a list of RinGs’ top ten accomplishments in the hope that as we head out for the holidays we can keep our chins up and our heads high. I would love it if you could share some of your gender triumphs with us in the comments below. It is nice to celebrate the positives.

Kate Hawkins (director of Pamoja communications)

21 December 2017

1. We have a new partner!

We are delighted that the original partners in RinGs have been joined by a new consortium, COMDIS-HSD, represented in RinGs by Helen Elsey and Rebecca King. COMDIS-HSD are working on the prevention, diagnosis and treatment of TB, malaria, HIV and communicable diseases, within primary care and community settings in Nepal, Bangladesh, Pakistan, Swaziland and Ethiopia. They got off to a flying start with an intersectionality training which was a big hit!

2. The European Commission launched guidance on gender and health systems

With Sarah Hawkes (UCL), Sally Theobald and Jo Raven provided training to the European Commission. Reflection across staff at headquarters and in their country offices led to the publication of a report to galvanise gender analysis in policy and practice.

3. The launch of the WHO Gender and Equity Hub

The Global Forum on Human Resources for Health was a great opportunity to meet with colleagues from around the world who are working on gender equity. Sarah Ssali, Rosemary Morgan, and Sally Theobald attended and went to some great panels on community health workers, how to do gender analysis, and more. The launch of the WHO Hub on Gender and Equity in the Health Workforce was warmly welcomed. Do submit evidence to their ongoing consultation if you can.

4. Kui Muraya became a film star

OK, this may be a bit of an overstatement. However, we are delighted that Kui appeared in a film about her work on gender and health system governance and leadership in Kenya, South Africa and Nigeria.

5. Our Health Policy and Planning supplement

We just can’t stop tweeting about these journal articles! It takes years to get a supplement published so when it finally arrives it brings a great deal of joy. Check out this collection which explains how gender intersects with other axes of inequity within specific contexts to shape experiences of health and health seeking within households, communities and health systems.

6. The World Health Summit

With our esteemed partners, Women in Global Health, we took part in a panel at the World Health Summit in Berlin on gender equality within the global health workforce. We were represented by Sally, Sreytouch, and Linda Waldman. A lot of discussion focused on the need to support individual women as well as addressing broader social, political and power dynamics that act as barriers, and for the need to take action at all levels – institutional, political and individual – to promote gender equity in the global health workforce.

7. Sreytouch Vong became a Heroine of Health

Sreytouch was named a Heroine of Health by Women in Global Health. ‘These women are working tirelessly to improve global health with dedication and passion to champion better healthcare for all.’ Much deserved! Check out her brief on women’s leadership in the Cambodian health system on the Building Back Better website.

8. Rosemary and Kui were published in the Lancet

Rosemary and Kui are authors of the widely read commentary on the ways that women are missing out on receiving medicine and public health awards. Thanks to the Lancet for publishing this work. We are glad to see that they have launched a call for papers on women in science, medicine and global health. Do send in your research!

9. New brief on intersectionality

Rebecca Wolfe, Sassy Molyneux and Rosemary worked with their colleagues to put together an excellent brief on the main tenets of intersectionality analysis, its value to health systems research, and how it relates to notions of everyday resilience.

10. An extension to our work

We are thankful to the UK Department for International Development for providing another two years’ worth of financing to RinGs so that we can continue to develop our work. Much appreciated. We have lots of ideas about how to keep gender at the top of the health systems research agenda as we move forward together in solidarity.

supplement of gender and health systems research

14 12 2017

NEW SUPPLEMENT Leaving no one behind: the role of gender analysis in strengthening health systems

We are delighted to announce the publication of our journal supplement on gender and health systems research!

RinGs

14 December 2017

This supplement brings a gender lens to bear on the health system, uncovering new learning which can help us to build more equitable and people-centred research, policy, and practice globally and in different low- and middle-income countries. The papers cover a range of health issues and health systems areas and use a range of methods. The findings demonstrate that gender intersects with other axes of inequity within specific contexts to shape experiences of health and health seeking within households, communities and health systems. The supplement is an important step in drawing together emerging evidence on gender and health systems and encouraging others to adopt a similar lens.

For additional information about this supplement read Kate Hawkins’ blog on the Health Policy and Planning website, or listen to this podcast where authors Sally Theobald and Kui Muraya discuss why they think gender analysis is important within health systems research.

To view the supplement visit Health Policy and Planning.

Articles in the supplement

Editorial (Sally Theobald et al): The importance of gender analysis in research for health systems strengthening

Original article (Sophie Witter et al): Minding the gaps: health financing, universal health coverage and gender

Original article (Rosemary Morgan et al): Gender dynamics affecting maternal health and health care access and use in Uganda

Original article (Tumaini Nyamhanga et al): Prevention Of Mother To Child Transmission Of Hiv In Tanzania: Assessing Gender Mainstreaming On Paper

Original article (Kelly Muraya et al): “If it’s issues to do with nutrition…I can decide…”: Gendered decision-making in joining community-based child nutrition interventions within rural coastal Kenya

Original article (Fiona Samuels et al): Psychosocial support for adolescent girls in post-conflict settings: beyond a health systems approach

Original article (Sophie Witter et al): The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts

07 12 2017

Gender trends at the 2017 Global Forum on Human Resources for Health

A few weeks have passed since the 2017 Global Forum on Human Resources for Health which has given some space to reflect on what we heard about gender at the event.

By Kate Hawkins, Sally Theobald, Roopa Dhatt, Sarah Ssali, Rosemary Morgan, Kerry Scott, Kelly Thompson, and Rosie Steege

07 December 2017

Overall the prognosis is very positive: there was a strong contingent of ‘gender champions’ at the event, issues like women’s leadership were at the heart of one of the main framings of the conference, ‘decent work’, and the launch of the World Health Organization Hub on Gender and Equity created a buzz about this work and represents a promising step forward for the field.

Gender champions

The week began with a moving and stirring event which was organised by Women in Global Health to enable health care workers to tell stories about their careers. Unsurprisingly, given most of the speakers were women, many of these stories uncovered the gendered realities of work on the frontline of health systems. This included having to deliver services in very insecure settings where the risk of ambush was high, being shot at, and being assaulted. Personal stories help us understand deep rooted power structures in the health system and how they can be transformed. The issue of gendered violence, raised here, was returned to later in the conference as a key concern. The voices of health care workers and their ability to speak truth to power are important mechanisms for honouring their service and pushing their concerns up the political agenda.

Many of the most passionate advocates at the conference were young people who were active in their own side sessions and integrated into the main sessions of the conference. Their side sessions included conversations about women in leadership, ideas of equity, and the role of nurses in health decision making. Their Call for Action included strong content on gender in which they:

“Call for attaining equal gender representation and female empowerment within the health workforce, and strongly urge all relevant stakeholders to make concrete commitments in order to minimize gender inequalities, add a gender perspective to all strategic decisions, and actively enable the fuller participation of women.”

Decent work

Decent work was one of the main themes of the Forum and as such it was unsurprising that many of the gender sessions focused on this topic. Many speakers queried whether it was possible to carve out a decent work agenda if we don’t focus on gender. The topics raised included visibility, compensation, and accountability frameworks to ensure gender equity at work. Speakers pointed out that despite making up the majority of the health workforce women are under-valued, under-paid and make up less than 10% of the health leadership.

The issue of decent work was also raised in relation to women’s unpaid care in the household and community health workers (who are sometimes volunteers and if paid are paid poorly). It was noted that because unpaid care is seen as women’s work community health workers have limited opportunities for progression and are employed precariously.

Overall, addressing ‘decent work’ was linked with addressing the currently indecent gender and power relationships within the health system – creating policies that are supportive, work environments that are enabling, and training structures that reflect women’s inputs and boost their possibilities. This is only possible with larger societal change which aims to alter the harmful norms and structures that underpin discrimination against women.

Gender and Equity Hub

Undoubtedly discussions about gender and health workers were given tremendous energy and vibrancy by the launch of the WHO Gender and Equity Hub on the first day of the Forum. This enabled likeminded delegates to come together to share evidence and experience which helped shape their interventions over the rest of the week. It was also a great opportunity to build a movement of solidarity across different stakeholders in the health system. It is warmly welcomed.

While the Hub puts in place plans for a thorough mapping of stakeholders, initiatives, and evidence the meeting enabled us to identify some key themes that participants felt were crucial. Unsurprisingly equal pay, education and training, a decent working environment and equal leadership were prioritised. But also preventing discrimination (in particular violence and harassment in the workplace), social protection, and transforming our systems of unpaid care. There was also a focus on intersectionality – how different women’s experience are shaped by race, ethnicity, age, sexuality etc. – and how this must inform our strategies moving forward. This may require more contextually nuanced methods of gathering data (led by marginalised women themselves) and interventions that consider people of different genders as a heterogenous group with differing experiences, needs, and desires.

As has been mentioned elsewhere, in conversations at the conference there was also an acknowledgement that gender is a men’s issue. For example, in the Gender and Equity Hub meeting there were discussions about the importance of not placing all the responsibility for creating gender equitable workplaces on women (e.g. assuming that increasing the number of female leaders will automatically achieve great gains, etc.) but recognizing that everyone perpetuates patriarchy and men must also be part of systemic change.

Moving forward

The Forum’s focus on transforming policies and guidelines is laudable. However, sometimes there is a tension between gender equitable human resources for health policy/law and social realities. For example, in India the Community Health Worker programme aims to create safe spaces for ASHAs to share issues of violence they are dealing with. Yet the likelihood of this happening in such an under-resourced environment, without adequate support, is very low. Similarly, ASHAs are taught about the legal rights of those subject to domestic violence, but accessing justice or the financial resources to leave a violent situation is not very realistic in Indian villages. In the future we may need to consider how health systems can reconcile or maximize the benefit of gender-equitable policy in light of challenging ground realities and the slow pace of social change. The health sectors relationship with other areas of the state, for example the criminal justice system, needs further exploration and strengthening.

With the momentum of health sector reform primarily being pushed by the Universal Health Coverage agenda we may need to better consider how a gender lens might alter the implementation and accountability mechanisms that are being proposed for this area.

Finally, while the Forum was a great space to share emerging evidence on issues related to gender and human resources for health there are still large gaps in our knowledge – notably on community health workers, migration, and the changes that occur when men enter previously woman-dominated professions within the health workforce. Building the research base in a manner that captures and boosts the voices and concerns of health workers is key to remedying this.

For further information on the Gender and Equity Hub please contact info@womeningh.org

Acknowledgements: This blog draws on the notes recorded by Twitter users during the Forum, we are extremely grateful for their diligent engagement and rapporteuring skills. You can read a roundup of all commentary here. The photo that accompanies this blog is of Edith Thaulo head nurse of Tisungane Clinic at Zomba. It was taken by Travis Lupick.

Photo of woman with child by Eduardo Arraes.

28 11 2017

An online learning resource on gender and health for the European Commission

We supported a new open access online learning resource on Gender and Health Systems, drawing on case studies developed in the Building Back Better project. This collaborative process helped to galvanise gender analysis in policy and practice.

Sally Theobald and Joanna Raven

20 November 2017

We recently had the opportunity to work with the European Commission – a major funder of health systems strengthening initiatives globally – to help expand the resources that they have on gender and health. We worked with Dr. Maryse Simonet of the EC’s DEVCO B4 team, EC central health staff, and those from country offices to develop resources to inspire and support further action on gender equity. We considered a range of health responses to promote gender equity which EC delegates could operationalise within their health systems strengthening projects. This led to the development of a new open access online learning resource.

The online learning resource defines key gender concepts and links to relevant open access tools, resources, and frameworks which can be applied to support gender analysis in different contexts and across different health systems issues. The health systems approach and frameworks provide opportunities to institutionalize gender equality in a sustainable manner and to enhance policy synergies amongst the four pillars of the EU second gender action plan:

Ensuring girls’ and women’s physical and psychological integrity
Promoting the social and economic rights/empowerment of girls and women
Strengthening girls’ and women’s voice and participation
Shifting the institutional culture to more effectively deliver on EU commitments

The online learning resource is supported by case studies, which explore how gender influences rates of risk exposure to common drivers of ill-health, patterns of health-care seeking for women and men, analysing and assessing the implications for health systems and global health institutions.

The resource draws from our Building Back Better work, illustrating how gender analysis can be applied in fragile and conflict affected settings. Additional case studies present health systems challenges from a gender perspective in Zimbabwe and Guinea Bissau.

It was an interesting process to collaboratively develop these case studies. We worked with health specialists and gender focal persons, in various EU delegations and people in charge of health development projects, mostly in low-income settings. We also had inputs from EC delegates from Nigeria and Tunisia to enable discussion on the extent to which challenges (and solutions) identified were context specific or had a wider applicability. A seminar was held with delegates to discuss the case studies and resources which triggered a range of reflections and critical questions: on strategies and approaches to ensure gender analysis also include a focus on men and boys; the importance and challenges of fostering intersectoral collaboration to promote gender equity in interventions such as those addressing gender-based violence; the challenges of fast paced change and multiple players in conflict affected contexts; and the importance of gender indicators, collecting and using sex disaggregated data and gender analysis to resist the “evaporation” of a gender focus in policy and practice at all levels of the health system.

The tool is now available as an open access resource for anybody to use. You can also watch the video to find out more!

We would like to congratulate the European Commission for developing a gender action plan and making strides to ensure that gender is part of their core work. We were very happy to be part of the process and learned a lot through it, and we hope you find the online learning resource helpful. We also hope that the French version, in the making (thanks to the EC), will trigger exchange and broaden involvement.

The Learning Resource – Gender and Health Systems – can be downloaded from this link.

Photo of woman with child by Eduardo Arraes.

13 11 2017

Global health emergencies: Bridging the research and practice divide

Katharine Wright

13 November 2017

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

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

The blurred lines between research and care

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

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

Bringing together the regulatory and ethical domains

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

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

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

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