Rosemary Morgan

How to do (or not to do)… gender analysis in health systems research

Gender-the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders-affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs and policies; and the inclusion of gender analysis into HSR is a core part of that endeavour. We outline what gender analysis is and how gender analysis can be incorporated into HSR content, process and outcomes Starting with HSR content, i.e. the substantive focus of HSR, we recommend exploring whether and how gender power relations affect females and males in health systems through the use of sex disaggregated data, gender frameworks and questions. Sex disaggregation flags female-male differences or similarities that warrant further analysis; and further analysis is guided by gender frameworks and questions to understand how gender power relations are constituted and negotiated in health systems. Critical aspects of understanding gender power relations include examining who has what (access to resources); who does what (the division of labour and everyday practices); how values are defined (social norms) and who decides (rules and decision-making). Secondly, we examine gender in HSR process by reflecting on how the research process itself is imbued with power relations. We focus on data collection and analysis by reviewing who participates as respondents; when data is collected and where; who is present; who collects data and who analyses data. Thirdly, we consider gender and HSR outcomes by considering who is empowered and disempowered as a result of HSR, including the extent to which HSR outcomes progressively transform gender power relations in health systems, or at least do not further exacerbate them.

Performance of private sector health care: implications for universal health coverage.

Although the private sector is an important health-care provider in many low-income and middle-income countries, its role in progress towards universal health coverage varies. Studies of the performance of the private sector have focused on three main dimensions: quality, equity of access, and efficiency. The characteristics of patients, the structures of both the public and private sectors, and the regulation of the sector influence the types of health services delivered, and outcomes. Combined with characteristics of private providers-including their size, objectives, and technical competence-the interaction of these factors affects how the sector performs in different contexts. Changing the performance of the private sector will require interventions that target the sector as a whole, rather than individual providers alone. In particular, the performance of the private sector seems to be intrinsically linked to the structure and performance of the public sector, which suggests that deriving population benefit from the private health-care sector requires a regulatory response focused on the health-care sector as a whole.

Can service integration work for universal health coverage? Evidence from around the globe.

Universal health coverage (UHC) is at the heart of the new 2030 Agenda for Sustainable Development. Health service integration is seen by World Health Organization as an essential requirement to achieve UHC. However, to date the debate on service integration has focused on perceived benefits rather than empirical impact. We conducted a global review in a systematic manner searching for empirical outcomes of service integration experiments in UHC countries and those on the path to UHC. Sixty-seven articles and reports were found. We grouped results into a unique integration typology with six categories - medical staff from different disciplines; patients and medical staff; care package for one medical condition; care package for two or more medical conditions; specialist stand-alone services with GP services; community locations. We showed that it is possible to integrate services in different human development contexts delivering positive outcomes for patients and clinicians without incurring additional costs. However, the improved outcomes shown were incremental rather than radical and suggest that integration is likely to enhance already well established systems rather than fundamentally changing the outcomes of care.

Factors in use of family planning services by Syrian women in a refugee camp in Jordan

Background The Syrian conflict presents the fastest growing refugee crisis in the world today, with over four million people now displaced outside the country. Existing literature suggests that family planning services are often still neglected in crisis response efforts. Methods A small-scale qualitative study conducted in May 2013, interviewing Syrian women residing in a Jordanian refugee camp about use and barriers to accessing family planning services. Results The study shows that significant barriers remain, and suggests that international attempts to address refugees’ family planning needs remain inconsistent. Conclusions Several practical measures are identified to address barriers to access, making the article of both practical and academic relevance.

Gender dynamics affecting maternal health and health care access and use in Uganda

Abstract Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women’s access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women’s lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.

Snap shots from a photo competition: what does it reveal about close-to-community providers, gender and power in health systems?

In this commentary, we discuss a photography competition, launched during the summer of 2014, to explore the everyday stories of how gender plays out within health systems around the world. While no submission fees were charged nor financial awards involved, the winning entries were exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. Anyone who had an experience of, or interest in, gender and health systems was invited to participate. Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement and in venues where their perspectives are often missing. The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. In total, 54 photos were submitted by 29 participants from 15 different nationalities and country locations. We unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. Three themes emerged: women active on the frontlines of service delivery and as primary unpaid carers, the visibility of men in gender and health systems and the inter-sectoral nature and intra-household dynamics of community health that embed close-to-community health providers. The question of who has the right to take and display images, under what contexts and for what purpose also permeated the photo competition. We reflect on how photos can be valuable representations of the worlds that we, health workers and health systems are embedded in. Photographs broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways but also reflect the politics, values and subjectivities of the photographer. They represent stereotypes, but also showcase alternate realities of people and health systems, and thereby can engender further reflection and change. We conclude with thoughts about the place of photography in health systems research and practice in highlighting and potentially transforming how we look at and address close-to-community providers.

Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries

This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.

Recognition matters: only one in ten awards given to women

Receiving an award is an accolade. Awards validate and bring visibility, help attract funding, hasten career advance ment, and can consolidate career accomplishments. Yet, in the fields of public health and medicine, few women receive them. Between seven public health and medicine awards from diverse countries, the chances of a woman receiving a prize was nine out of 100 since their inception (appendix). If women encompass the majority of the clinical and public health workforce, why do so few receive awards? The answers reflect gender biases in the health field and beyond. One element is the extent to which women are underrepresented in decision making in health. Only 24% of directors of global health centres at the top 50 US medical schools are women. In the policy arena, women constitute only a quarter of health ministers globally, and only two of the six agency heads of the health-related UN agencies are women. Although striving for gender equality requires long-term efforts across society, it does not preclude immediate and targeted action for women, men, and other genders. Our focus on awards within the wider context of gender discrimination is to call attention to one area that is highly visible yet largely uncontested. Some might think that as more women enter the workforce, we should eventually see the demographic profile of awardees change. Yet during the past 10 years, only 19% of the awards from these seven awards bodies were presented to women. The Women in Focus awards announced at the Neglected Tropical Disease Summit and the Royal Society Africa Prize are a good start, but more must be done. We call on awards bodies and academic institutions to introduce four measures to redress gender bias (panel). If we don’t address gender biases in public health awards, women will remain in a Catch 22—they will not receive awards because of their lack of representation in senior and leadership positions, and their lack of awards will impede their advancement towards such posts. This matters in terms of fairness (recognising merit where it is due) and innovation (recognising creativity wherever it arises), but also in helping to ensure that future generations of health workers and leaders are able to unleash their potential, no matter who they are.

Gender dynamics in digital health: overcoming blind spots and biases to seize opportunities and responsibilities for transformative health systems

Abstract Much remains to ensure that digital health affirms rather than retrenches inequality, including for gender. Drawing from literature and from the SEARCH projects in this supplement, this commentary highlights key gender dynamics in digital health, including blind spots and biases, as well as transformative opportunities and responsibilities. Women face structural and social barriers that inhibit their participation in digital health, but are also frequently positioned as beneficiaries without opportunities to shape such projects to better fit their needs. Furthermore, overlooking gender relations and focussing on women in isolation can reinforce, rather than address, women’s exclusions in digital health, and worsen negative unanticipated consequences. While digital health provides opportunities to transform gender relations, gender is an intimate and deeply structural form of social inequality that rarely changes due to a single initiative or short-term project. Sustained support over time, across health system stakeholders and levels is required to ensure that transformative change with one set of actors is replicated and reinforced elsewhere in the health system. There is no one size prescriptive formula or checklist. Incremental learning and reflection is required to nurture ownership and respond to unanticipated reactions over time when transforming gender and its multiple intersections with inequality.

How do gender and disability influence the ability of the poor to benefit from pro-poor health financing policies in Kenya? An intersectional analysis

BackgroundHealth inequity has mainly been linked to differences in economic status, with the poor facing greater challenges accessing healthcare than the less poor. To extend financial coverage to the poor and vulnerable, Kenya has therefore implemented several pro-poor health policy reforms. However, other social determinants of health such as gender and disability also influence health status and access to care. This study employed an intersectional approach to explore how gender disability and poverty interact to influence how poor women in Kenya benefit from pro-poor financing policies that target them.MethodsWe applied a qualitative cross-sectional study approach in two purposively selected counties in Kenya. We collected data using in-depth interviews with women with disabilities living in poverty who were beneficiaries of the health insurance subsidy programme and those in the lowest wealth quintiles residing in the health and demographic surveillance system. We analyzed data using a thematic approach drawing from the study’s conceptual framework.ResultsWomen with disabilities living in poverty often opted to forgo seeking free healthcare services because of their roles as the primary household providers and caregivers. Due to limited mobility, they needed someone to accompany them to health facilities, leading to greater transport costs. The absence of someone to accompany them and unaffordability of the high transport costs, for example, made some women forgo seeking antenatal and skilled delivery services despite the existence of a free maternity programme. The layout and equipment at health facilities offering care under pro-poor health financing policies were disability-unfriendly. The latter in addition to negative healthcare worker attitudes towards women with disabilities discouraged them from seeking care. Negative stereotypes against women with disabilities in the society led to their exclusion from public participation forums thereby limiting their awareness about health services.ConclusionsIntersections of gender, poverty, and disability influenced the experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya. Addressing the healthcare access barriers they face could entail ensuring availability of disability-friendly health facilities and public transport systems, building cultural competence in health service delivery, and empowering them to engage in public participation.