Asha George

Engendering International Health: The Challenge of Equity

Engendering International Health presents the work of leading researchers on gender equity in international health. Growing economic inequalities reinforce social injustices, stall health gains, and deny good health to many. In particular, deep-seated gender biases in health research and policy institutions combine with a lack of well-articulated and accessible evidence to downgrade the importance of gender perspectives in health. The book?s central premise is that unless public health changes direction, it cannot effectively address the needs of those who are most marginalized, many of whom are women.The book offers evidence and analysis for both low- and high-income countries, providing a gender and health analysis cross-cut by a concern for other markers of social inequity, such as class and race. It details approaches and agendas that incorporate, but go beyond, commonly acknowledged issues relating to womens health; and it brings gender and equity analysis into the heart of the debates that dominate international health policy.

Understanding careseeking for child illness in sub-Saharan Africa: A systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

People-centred science: strengthening the practice of health policy and systems research

Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context. Change occurs at many layers of a health system, shaped by social, political, and economic forces, and brought about by different groups of people who make up the system, including service users and communities. The seeds of transformative practice in HPSR lie in amplifying the breadth and depth of dialogue across health system actors in the conduct of research – recognizing that these actors are all generators, sources, and users of knowledge about the system. While building such a dialogic practice, those conducting HPSR must strive to protect the autonomy and integrity of their ideas and actions, and also clearly explain their own positions and the value-basis of their work. We conclude with a set of questions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change.

Going beyond the surface: Gendered intra-household bargaining as a social determinant of child health and nutrition in low and middle income countries

A growing body of research highlights the importance of gendered social determinants of child health, such as maternal education and womens status, for mediating child survival. This narrative review of evidence from diverse low and middle-income contexts (covering the period 1970-May 2012) examines the significance of intra-household bargaining power and process as gendered dimensions of child health and nutrition. The findings focus on two main elements of bargaining: the role of womens decision-making power and access to and control over resources; and the importance of household headship, structure and composition. The paper discusses the implications of these findings in the light of lifecycle and intersectional approaches to gender and health. The relative lack of published intervention studies that explicitly consider gendered intra-household bargaining is highlighted. Given the complex mechanisms through which intra-household bargaining shapes child health and nutrition it is critical that efforts to address gender in health and nutrition programming are thoroughly documented and widely shared to promote further learning and action. There is scope to develop links between gender equity initiatives in areas of adult and adolescent health, and child health and nutrition programming. Child health and nutrition interventions will be more effective, equitable and sustainable if they are designed based on gender-sensitive information and continually evaluated from a gender perspective.

The dynamics of gender and class in access to health care: Evidence from rural Karnataka, India

This is the second part of the special section, edited by Professors Margaret Whitehead and Göran Dahlgren, on the equity impacts of different health care systems, which includes studies conducted within the framework of the Affordability Ladder Program. In the early 1990s, India embarked upon a course of health sector reform, the impact of which on an already unequal society is now becoming more apparent. This study sought to deepen understanding of equity effects by exploring gender and class dynamics vis-à-vis basic access to health care for self-reported long-term ailments. The authors drew on the results of a cross-sectional household survey in a poor agrarian region of south India to test whether gender bias in treatment-seeking is class-neutral and whether class bias is gender-neutral. They found evidence of “pure gender bias” in non-treatment operating against both non-poor and poor women, and evidence of “rationing bias” in discontinued treatment operating against poor women overall, but with some differences between the poor and poorest households. In poor households, men insulated themselves and passed the entire burden of rationing onto women; but among the poorest, men, like women, were forced to curtail treatment. There were economic class differences in continued, discontinued, and no treatment, but class was a gendered phenomenon operating through women, not men.

Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey

BackgroundTo plan for a community case management (CCM) program after the implementation of the Free Health Care Initiative (FHCI), we assessed health care seeking for children with diarrhoea, malaria and pneumonia in 4 poor rural districts in Sierra Leone.MethodsIn July 2010 we undertook a cross-sectional household cluster survey and qualitative research. Caregivers of children under five years of age were interviewed about healthcare seeking. We evaluated the association of various factors with not seeking health care by obtaining adjusted odds ratios and 95% confidence limits using a multivariable logistic regression model. Focus groups and in-depth interviews of young mothers, fathers and older caregivers in 12 villages explored household recognition and response to child morbidity.ResultsThe response rate was 93% (n=5951). Over 85% of children were brought for care for all conditions. However, 10.8% of those with diarrhoea, 36.5% of those with presumed pneumonia and 41.0% of those with fever did not receive recommended treatment. In the multivariable models, use of traditional treatments was significantly associated with not seeking outside care for all three conditions. Qualitative data showed that traditional treatments were used due to preferences for locally available treatments and barriers to facility care that remain even after FHCI.ConclusionWe found high healthcare seeking rates soon after the FHCI; however, many children do not receive recommended treatment, and some are given traditional treatment instead of seeking outside care. Facility care needs to be improved and the CCM program should target those few children still not accessing care.

Using accountability to improve reproductive health care.

Abstract Accountability is best understood as a referee of the dynamics in two-way relationships, often between unequal partners. The literature on accountability distinguishes between political, fiscal, administrative, legal and constitutional accountability. This paper focuses on accountability mechanisms in health care and how they mediate between service providers and communities and between different kinds of health personnel at the primary health care level. It refers to case studies of participatory processes for improving sexual and reproductive health service delivery. Information, dialogue and negotiation are important elements that enable accountability mechanisms to address problems by supporting change and engagement between participants. In order to succeed, however, efforts towards better accountability that broaden the participation of users must take into account the social contexts and the policy and service delivery systems in which they are applied, address power relations and improve the representation of marginalised groups within communities and service delivery systems.

Policy challenges facing integrated community case management in Sub‐Saharan Africa

To report an in‐depth analysis of policy change for integrated community case management of childhood illness (iCCM) in six sub‐Saharan African countries. We analysed how iCCM policies developed and the barriers and facilitators to policy change.

Persistence of High Maternal Mortality in Koppal District, Karnataka, India: Observed Service Delivery Constraints

Rural women with obstetric complications access many health providers in Koppal, the poorest district in the state of Karnataka, south India. Yet they die. Based on insights derived from case studies of women seeking emergency obstetric care and participant-observation of government health services, this article highlights service delivery constraints that underlie the persistence of high levels of maternal mortality in Koppal. Weak information systems, discontinuity in care, unsupported health workers, haphazard referral systems and distorted accountability mechanisms are identified as critical service delivery problems. For example, maternal deaths are under-reported and not reviewed, antenatal care and institutional delivery are not linked to post-partum or emergency obstetric care, and health workers use inappropriate injections but don’t treat anaemia or sepsis. Families waste valuable time and resources accessing many providers but fail to get effective care, and blame is laid on lower-level health workers and women for not accessing institutional delivery. Lastly, the role of administrators and politicians in ensuring functioning health services is obscured. While important supply and demand-side reforms are being implemented, these do not constructively engage with informal providers nor address systemic service delivery constraints. Critical managerial change is required, without which new budgetary allocations will be squandered with little impact on saving women’s lives. Résumé À Koppal, le district le plus pauvre de l’État de Karnataka en Inde méridionale, les femmes rurales présentant des complications obstétricales ont accès à de nombreux prestataires de soins. Pourtant, beaucoup d’entre elles succombent. Utilisant les données d’études sur des femmes ayant demandé des soins obstétricaux d’urgence et les observations des participants sur les services de santé gouvernementaux, cet article dégage les facteurs de la persistance de taux élevés de mortalité maternelle à Koppal; faiblesse des systèmes d’information, discontinuité des soins, soutien insuffisant aux agents de santé, manque de rigueur des systèmes d’orientation des patientes et mécanismes biaisés de responsabilité. Par exemple, les décès maternels sont sous-notifiés et ne sont pas étudiés, les soins prénatals et les accouchements en milieu institutionnel ne sont pas liés aux soins post-partum ou obstétricaux d’urgence, et les agents de santé utilisent des injections contre-indiquées, sans vraiment traiter l’anémie ou la septicémie. Les familles perdent des ressources et un temps précieux pour consulter de nombreux prestataires, mais n’obtiennent pas de soins efficaces; elles en rendent responsables les agents de santé du niveau inférieur et les femmes pour n’avoir pas accouché dans un établissement de soins. Enfin, le rôle des administrateurs et des politiciens pour garantir des services de santé efficaces est dissimulé. Des réformes importantes de l’offre et de la demande sont mises en oeuvre mais elles n’associent pas constructivement les prestataires informels, pas plus qu’elles ne s’attaquent aux obstacles systémiques. Un profond changement administratif est nécessaire, faute de quoi de nouvelles allocations budgétaires seront gaspillées, sans parvenir à sauver la vie des femmes. Resumen A pesar de tener acceso a numerosos prestadores de servicios de salud en Koppal, el distrito más pobre del estado de Karnataka, en la India meridional, muchas mujeres rurales con complicaciones obstétricas continúan muriendo. Basado en estudios de casos de mujeres que buscan cuidados obstétricos de emergencia y en la observación participante en servicios de salud gubernamentales, este artículo destaca las limitaciones de la prestación de servicios implícitas en la persistencia de los altos índices de mortalidad materna en Koppal, por ejemplo: sistemas de información débiles, discontinuidad de los cuidados, trabajadores de salud sin apoyo, sistemas de referencia al azar y mecanismos distorsionados de responsabilidad. Por ejemplo, las muertes maternas son subreportadas y no revisadas, la atención antenatal y el parto institucional no son vinculados con los cuidados obstétricos posparto o de emergencia, y los trabajadores de salud utilizan inyecciones indebidas pero no tratan la anemia o sepsis. Las familias desperdician tiempo y recursos valiosos cuando acceden a muchos prestadores de servicios sin obtener cuidados eficaces, y la culpa recae en los trabajadores de salud de nivel inferior y en las mujeres por no tener un parto institucional. Por último, no queda clara la función de los administradores y políticos en garantizar servicios de salud en buen estado de funcionamiento. A pesar de que se están implementando importantes reformas relacionadas con la oferta y demanda, éstas ni implican constructivamente a los prestadores de servicios extraoficiales ni tratan las limitaciones sistémicas de la prestación de servicios. Se necesita un cambio administrativo fundamental, sin el cual nuevas distribuciones presupuestales serían derrochadas con poco impacto en los esfuerzos por salvar la vida de las mujeres.

Nurses, community health workers, and home carers: gendered human resources compensating for skewed health systems

Abstract This review examines the experiences of nurses, community health workers, and home carers in health systems from a gender analysis. With respect to nursing, current discussions around delegation take place over layers of historical struggle that mark the evolution of nursing as a profession. Female community health workers also struggle to be recognized as skilled workers, in addition to defending at a personal level the legitimacy of their work, as it transgresses traditional norms proscribing morality and the place of women in society, at times with violent consequences. The review concludes by exploring the characteristics of, and challenges faced by, home carers, who fail to be recognized as workers at all. A key finding is that these mainly female frontline health workers compensate for the shortcomings of health systems through individual adjustments, at times to the detriment of their own health and livelihoods. So long as these shortcomings remain as private, individual concerns of women, rather than the collective responsibility of gender, requiring public acknowledgement and resolution, health systems will continue to function in a skewed manner, serving to replicate inequalities in the health labour force and in society more broadly.