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.
By Asha George, Sally Theobald, Rosemary Morgan, Kate Hawkins and Sassy Molyneux
Sally Theobald, Rosemary Morgan, Kate Hawkins and Sassy Molyneux
Human Resources for Health: 57
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.
Introduction
Research in Gender and Ethics (RinGs): Building Stronger Health Systems is a partnership across three health systems research consortia1, developing a platform for learning and research on gender, ethics and health systems. During the summer of 2014, RinGs launched a photography competition to explore the everyday stories of how gender plays out within health systems around the world. Given that gender is often not considered relevant to health systems or understood in simplistic ways 1], we hoped that the photography competition would generate visual stories that would inspire imagination and provoke contemplation among health system researchers and practitioners about what gender means for their work.Photos, like written outputs, are representations of the social and ideological worlds we, health workers and health systems are embedded in. As such, they are an important data source to communicate and understand complex issues and diverse contexts 2, 3], particularly in the increasingly visually saturated and globalized economy we are situated in. Photographs can broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways. However, they do not simply mirror reality but also reflect the politics, values and subjectivities of the photographer, through what they choose to highlight and how they frame their images. They can either represent stereotypes or provide an opportunity to showcase unique and vivid alternate realities of people and health systems, and thereby engender further reflection and change.In this commentary, we reflect on the photos submitted and the ensuing judging process and email dialogue with participants who reacted to the photo competition. We are a team of health systems researchers and a communications and research uptake manager. We have little experience in photography beyond personal use and no expertise in the various academic fields that engage with photography, beyond work with participatory photography as a research methodology. As researchers, our incentive structures may prioritize academic publications over other ways of supporting and documenting community voice and social change. Nonetheless, we strongly feel that photography is an important medium that health systems researchers and practitioners must critically engage in.Within this paper, we seek to 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. The latter include “health workers who carry out promotional, preventive and/or curative health services and who are often the first point of contact at community level…[and] are strategically placed as the interface between health systems and the communities they serve” 4]. In examining our experience of the photo competition, we discuss our interpretation of the narrative and politics underlying the images and the potential of photography to better understand and therefore inform more effective and equitable ways of supporting close-to-community provision of health services. We describe the photo competition, analyse the three main themes that emerged, consider the ethical issues that arose and conclude with thoughts about the place of photography in health systems research and practice.
The photo competition
The RinGs photography competition was advertised widely through twitter, email list serves and several websites between 22 July and 1 September 2014. The deadline for entries was 1 September 2014. The competition was particularly targeted at health systems researchers within our own networks and potential Global Symposium on Health Systems Research participants. The aim of the competition was to capture the everyday stories of the ways that gender plays out within health systems around the world. In particular, we were looking for images which challenged stereotypes, encouraged the viewer to learn more and act differently, and which respected the integrity of any people who may be photographed. We welcomed images of people of all genders from all areas of the health system and from all around the world 5]. While advertising the competition, links were included to discussions on the ethics of photography in international development, which dealt with issues of consent, motives, respect and portrayal of subjects. Participants were asked to describe the level of consent obtained for each submission, and photos which were taken without consent were not considered. Additional submission requirements and information required from participants is presented in Table 1.
Table 1: Submission requirements and information supplied by participants
Submission requirements
Information supplied by participants
1. Size: at least 1 MB
1. Name of participant
2. Print resolution: 300 dpi
2. Participant’s email
3. Format: JPEG or tiff only
3. Participant’s phone
4. Landscape and portrait images are acceptable
4. Title of photograph
5. Although some digital enhancement is acceptable, we cannot accept images that have been digitally altered to change what is portrayed
5. Location (country and city/town/village where the photograph was taken)
6. The date (if unknown, please provide the year) each photograph was taken
7. The level of consent provided from any people pictured in the photo (see informed consent guidelines for more information)
While no submission fees were charged nor financial awards involved, it was advertised that the winning entries would be exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. In addition, RinGs stated that it would use the images to illustrate our website and other published materials with credit to the photographers. Based on learning from the competition process, we removed this last condition, as discussed later.Up to three photos could be submitted via email to RinGs and were displayed online through a Flickr account. In total, 54 photos were submitted by 29 participants of 15 different nationalities and country locations (see Table 2). We were pleased to see the breadth of geographic participation and that so many of the participants were female. The repository of images was actively disseminated via social media by the RinGs steering committee to stimulate interest and discussion on the subject matter among health systems researchers and practitioners.
Table 2: Summary of photo competition participants’ profile
Gender
Nationality
Photo location
Female
17
United States
6
Nigeria
5
Male
11
Kenya
4
Uganda
4
Unknown
1
India
3
India
3
Total
29
Nigeria
2
United States
3
Indonesia
2
Indonesia
2
United Kingdom
2
Mozambique
2
Ireland
1
Kenya
2
Germany
1
Cambodia
2
Cameron
1
Bolivia
1
Uganda
1
Ethiopia
1
South Africa
1
Tanzania
1
Cambodia
1
Guinea Bissau
1
Myanmar (Burma)
1
Bangladesh
1
China
1
South Africa
1
Taiwan
1
Ghana
1
Unknown
1
Total
29
Total
30
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. We saw the competition as one way to increase their visibility at an international health systems research conference where the perspectives of communities, health workers and other non-academics are often missing. Anyone who had an experience of, or interest in, gender and health systems was invited to participate.The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. Two of the submissions that were given an honourable mention were photovoice entries, where community members themselves got behind the lens to document and narrate their stories; these photos where submitted by researchers who were involved with the photovoice projects. One highlighted women in street performance peer education activities for maternal health in Uganda, and another profiled a woman from a marginalized community learning how to use a camera to document community resilience in the Sundarbans, an ecologically vulnerable region in India.All photos were judged on the basis of their content (their relevance to the subject), their ability to tell the story of gender and health systems and the technical merit of the photo by five judges. The judges included academics working on gender and health systems drawn from the RinGs steering committee, and a research communications consultant independent of RinGs who has extensive experience in international research on women’s empowerment. Each judge scored the photos on a scale of 1 to 3 (from not meeting the criteria to fully meeting the criteria) in relation to the three criteria listed above. The scores were then totalled and averaged across the five judges. The photos were subsequently ranked according to their overall score. All photos that received a score of 2.3 and above were given an honourable mention.As stated above, photos often reflect the politics, values and subjectivities of the photographer, through what they choose to highlight and how they frame their images. How photos are interpreted by the viewer is also subjective, grounded in his/her own social and ideological world. The judges therefore interpreted the photographs in a way that was congruent with their own knowledge, backgrounds and interests, which may or may not have matched the intent of the photographer or resonate with other viewers. All the judges had expertise relevant to gender and community health systems; three were based in high-income countries (the United Kingdom and the United States) and two were based in a low- and middle-income country (Kenya).
One winner was unanimously selected 6], and 15 photographs were given an honourable mention by the judges 7]. The winning photo was submitted by AMREF Health Africa and is a professional portrait of an older woman who used to be a traditional birth attendant, who has retrained as a midwife in Uganda (Figure 1). The image resounds with the strength, dignity and confidence of a woman proud of her contributions despite the challenges faced. She shines like a ray of hope parting the stormy clouds of circumstance. As the photograph is taken from below, we look up to her with respect, which is in contrast to the many photos where we look down on women. She is wearing the gloves and a uniform of a female vocation and profession that is under negotiation and transformation. The photo was selected because it presents a strong, positive image that pushes boundaries. It takes a conventional role and presents it in an unconventional and affirming manner, while valuing women as wise and weathered agents, rather than objects of passive beauty.
Figure 1 Winning photo: The power of a midwife. Photo credit: this photo was taken during a collaboration between the Guardian UK and AMREF Health Africa. Caption: the traditional birth attendant, trained as a professional midwife, is leading the maternal and neonatal care revolution in Africa. What was once a neglected role of women has now taken the attention of international health NGOs and global policymakers working toward a healthier Africa. Photo location: Katine, Uganda. Images submitted and the themes they portray
Women active on the frontlines of service delivery and as primary unpaid carers
Women on the frontline of health service delivery was a theme portrayed by 17 photos. This is representative of global statistics that show that human resources for health are gendered. In many countries, women make up more than 75% of the health workforce, primarily at the lower tiers closest to communities 8]. Many of the 17 photos feature women working in communities as volunteers or community health workers, highlighting their roles in serving other women primarily through community or preventive services. This included being trained as peer educators in Nigeria, as Kaders registering women and children in Indonesia, weighing children in Uganda, or immunizing children in Ethiopia. Often, these tasks were undertaken with vigour and humour, as shown by the traditional birth attendants (TBAs) in Guinea Bissau who are pictured in a line seemingly staring down the photographer (Figure 2).
Figure 2 Traditional birth attendants pose after newborn training in Guinea-Bissau.
Photo credit: Polly Walker. Photo location: Buba, Quinara Region, Guinea-Bissau.
Women’s role as unpaid carers for family members was also prominent 9, 10]. Caring for sick or elderly family members is often not recognized as work by the health sector. Many photos documented women waiting for service at health systems with babies and other family members. Sometimes, they were seemingly passive recipients, while others were in a more interactive role, for example, in dialogue with other women and different healthcare providers.
While many images came from rural contexts, one photo showed a female community health worker visiting an adolescent mother and her child in a low-income urban settlement in India 3, arguably portraying the trust that can enable positive patient–provider relations. Urban contexts provide different challenges for community-based work, given that populations are more mobile, settlements often illegal, and programmes non-existent in contrast to rural areas 1112.
Figure 3 Community health worker and stories of the urban poor.
Photo credit: Bhargav Shandilya. Photo location: Bangalore, India.
While demonstrating the importance of women as close-to-community providers, very few highlighted the working conditions of these frontline health workers. Women systematically are paid less than their male counterparts in the health workforce 1314, at times receive unequal non-pecuniary benefits 15 or work in contexts that are highly constrained and disempowering 16]. A photo of the Employment Equity Policy Guiding the Appointment of Staff in Health Facilities in South Africa quite explicitly raised concerns about employment terms. Only one photo showed an immunization officer and health committee member who were nursing mothers themselves. Strikingly, there were very few photos of women as facility-based health professionals, and only one photographer documented a woman in a managerial role: a nursing officer in Uganda resting on her motorcycle, self-assured while straddling a motorcycle typically associated with men. These images starkly reflect the multiple ways that hierarchy and gender intersect to stratify the health sector in inequitable ways 1718.
Where are the men in gender and health systems?
Men were also highlighted in gender transformative ways by the photo competition. Male peer educators provided HIV testing and counselling to couples from nomadic communities in rural Kenya (Figure 4). Another image showed a group of rural Indian men in a circle happily chatting, some leaning forward to engage, others listening, all seemingly relaxed. The photo captures them brainstorming on spousal communication and family planning decision-making. Another photo is of a young man in the library in Ghana attentively and quietly engrossed in a journal of obstetric nursing. From Cambodia, we received images of male nurses being trained alongside female nurses, caring for children in a Cambodian hospital that prides itself in promoting a more equitable work environment. And in the US, male and female public health students collaboratively engaged in a campaign to raise awareness of gender-based violence. These examples highlight the important role men play in working alongside women, engaging with women’s health concerns and advocating for gender equality. Given the social vulnerability of men to chronic diseases and injuries, attention to men’s gendered risks underpinning these imbalances is also critical 19.
Figure 4 Reaching the hard to reach, nomadic, young and old with HIV testing services in Kenya. Photo credit: LVCT Health. Photo location: Eremit Village, Kajiado, Kenya.
While these were good examples of the ways that men are supporting their communities and societies to combat ill health, there were very few submissions documenting the role of men as health providers, managers or politicians engaging in gender issues as a way of transforming health systems. Fewer still documented the role of men as frontline and close-to-community providers of healthcare. One image from Mozambique starkly depicted a male provider sitting at a desk out in the open facing a multitude of women waiting to see him. Given the influence of men in health systems – particularly the politics, policy and decision-making processes from the global to the household level – the relative absence of men photographed in these roles is interesting. This perhaps reflects the ways in which gender is so often equated with women but also how the visible face of frontline health and community systems is often female.
What issues arise being close to communities?
Many photos pictured women in active roles farming, buying, producing and processing food stuffs. For example, women in Nigeria were pictured processing forage powder using local stub to fry soya beans, groundnut and millet for weaning children. While these images were not immediately obvious “health systems” images to the staff judging the competition, they demonstrated the importance of nutrition to health in the minds of photographers and are a reminder of the importance of inter-sectoral action for health.For some of the women pictured, the livelihoods they relied on entailed extremely arduous working conditions and serious occupational risks. Female crab collectors from the Sundarbans, who were predominantly from households where men had out-migrated for formal sector employment, stood deep in mud and braved tiger attacks. Fisher women from the same community were pictured thigh high in water risking skin diseases and reproductive tract infections. One image was of women who journey approximately 10 hours from Cameroon to Nigeria carrying heavy loads of corn by foot to get it milled and then return to Cameroon with the flour. While all the photos of close-to-community health provision focussed on maternal and child health needs, these photos highlight the ways in which gender roles shape livelihoods and food production, which in turn shape health experiences and outcomes. Close-to-community health providers are embedded in communities and may therefore be strategically placed to understand intra-household gender and power dynamics and how social determinants, such as poverty and food security, shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood 20
Ethical considerations related to power
The question of who has the right to take and display images, under what contexts and for what purpose permeated the photo competition. Although we disseminated guidelines on the ethics of informed consent for photography, only one photographer made reference to a code of conduct with regard to use of images 21]. Most photographers reported verbal consent or written consent where possible. Nonetheless, several photo submissions did not detail consent or reported consent that was more casual in manner: photographers pointing at the camera and seeking consent non-verbally. However, this fails to distinguish between seeking consent for taking a photo, whether for personal memories or for professional imperatives, and seeking consent for disseminating the image publicly, whether for profit or non-profit motives (in this case, there were no direct financial gains from the competition). We cannot guarantee that all the photos submitted to the competition followed the recommended ethical principles with regard to consent. However, in the case of the photography competition, only photos that more clearly outlined consent for dissemination were considered for honourable mention and further publicity. Further follow-up with photographers was also undertaken before disseminating the images more broadly.Ethical principles in photography and use of images go beyond issues of consent 3, 22, 23]. They span issues of justice, autonomy, non-maleficence, beneficence and fidelity. Are we representing subjects respectfully, in ways that do not further marginalize, stigmatize or exploit them personally? Do the images raise questions about health workers, their health system realities and broader public health priorities to support constructive social change? It was striking that several photographs submitted did present traditional images of women as passive beneficiaries of maternal and child health services. Certain aspects of community health provision may be so normalized that they remain invisible. How does this influence policy and programme considerations for close-to-community providers? When reviewing lay health worker policy in South Africa, for example, policymakers failed to see the gendered origins of the working conditions that were acknowledged to be problematic 24].Who else benefits from the images being shared and in what ways? It is striking how photo credits are often for the photographer alone, without acknowledgement of the person or people photographed or the organization sponsoring the photographer. This may be to protect individual identities, but photos can be even more personal than research findings because they can be more irrefutably identifiable or contextually revealing. Feminist research ethics interrogate who has the right to be an author representing the realities of others and how; but how do we apply such principles to photography and photography competitions?Most of the photos submitted were by photographers who remained in control of shaping what was included in the images. The photos highlighted, while positive, do not necessarily express the active voice and perspective of close-to-community service providers themselves – their views, struggles and dilemmas. Large-scale participatory projects, such as the World Bank’s “Voices of the Poor”, even with their limitations, demonstrate that policymakers can be moved by participatory methods 25]. Participatory approaches are increasingly recognized as a vital part of health systems research 26]. For example, photovoice offers important opportunities for community members and health workers to contextualize photos in relation to the individual and institutional realities that they experience.But there are tensions within participatory approaches, and politics and power play out in multiple ways. The two photovoice submissions were not initially selected by the judges as they were not as well composed as those submitted by professional photographers. Without understanding the transformative process behind those images, photovoice submissions can be dismissed as being of poor quality and can fail to present a compelling argument in an increasingly crowded communications environment characterized by large marketing budgets, high-specification technology and vastly more professional outputs. Within this environment, it may be difficult for the messages conveyed through participatory photography projects to gain traction.In response to this, some researchers have explored how partnerships between creative professionals and poor and marginalized groups can generate more compelling products for a general audience with no particular interest in alleviating poverty. For example, the Pathways of Women’s Empowerment Consortium has reimagined old fairy tales in Egypt and pop music in Ghana in order to challenge established narratives about women 27]. This kind of storytelling is a powerful medium for changing critical consciousness. Can such avenues also be explored to celebrate the heroes that hold up community health systems the world over? Close-to-community providers are critical foundations for communities and health systems but rarely are given opportunity to decide on the images that portray them or their perspectives.Finally, while we purposefully framed the terms of the competition to encourage lay and amateur photographers to get involved, particularly supporting further creativity and visibility among health systems researchers, this had the unintended consequence of further marginalizing some professional photographers. In a world of skewed financial resources, some professional photographers struggling to maintain their livelihoods found the non-financial terms of our photo competition an affront to their expertise, skills and profession 28]. This raises questions about the nature of photography competitions and participation in general, something which development organizations have been criticized for in the past. Photography competitions are sometimes used as a way to solicit unpaid work. As a result, they can create false incentives among the photographers who enter and can be unfair for those who look to make their living from photography.One response to our photo competition suggested that if the aim of the competition is to generate discussion, provide a voice to the otherwise voiceless or help researchers better communicate their research, then not offering a monetary prize or financial incentive may not be problematic. However, if the aim of the competition is to obtain professional photographs to use within publicity campaigns, then prizes should be offered which recognize the costs of producing the images and help contribute to the livelihood of the photographer 29]. Based on this feedback, we agreed to not use the photos for publicity purposes beyond the confines of the photography competition. Greater transparency is needed within photography competitions regarding the aim and purpose of the competition, and participants should be made aware of what the intended use of the photographs is. This would help to ensure that competitions do not add to the exploitation and maltreatment of photographers.
Conclusion
Photos can capture nuances or startle us and communicate issues powerfully and symbolically in ways that are sometimes more enticing, convincing and memorable than in tomes of written evidence that may or may not be read or remembered. Writing on the importance of creative communication in the uptake of research on women’s empowerment, Lewin 30: 223] has argued that, “good empirical research; intellectual work and compelling arguments are not enough to provoke change. People need to see alternative realities; utopian visioning is a political project. We need to see the world presented in different ways – our emotional and visceral responses are very important in shaping how we think, and more importantly, how we feel”. This is particularly important in relation to gender and health systems where the generation of political will to develop and act on an evidence base is necessary. It is also particularly relevant to close-to-community providers, who are too often treated as “resources for human health” rather than as people with needs and rights themselves 17, 24].The health system research field has begun to wake up to the potential of online social media in research communication (as exemplified by the recent Social Media awards at the 2014 Global Symposium on Health Systems Research). Looking to the future, the role of social media – such as Instagram and snap chat – which encourages the rapid exchange of photos and video images in unmediated ways will increase rapidly 31]. Key opportunities of this include activism, challenging stereotypes and breaking news of abuses. At the same time, issues of consent, agency and justice are of critical importance to ensure that photos are not taken out of context and do not objectify or disempower health workers and other health system actors who are at times on the margins of health systems. This is a fast changing world posing challenges to health systems researchers to stay with the curve, let alone get ahead of it to shape future trends. The opportunities and challenges of evolving media and mobile technologies for democratizing photography to highlight gender, human resources for health and health systems in transformative ways need further attention, analysis and action. Endnotes 1RESYST: Resilient and Responsive Health Systems, REBUILD Consortium, Future Health Systems: Innovations for Equity
tion id=”Declarations” class=”Section1 RenderAsSection1″ data-test=”declarations-section”>Declarations Acknowledgements
The authors would like to acknowledge everyone who took part in the photo competition. We would also like to acknowledge the Global Symposium on Health Systems Research for allowing us to showcase the photos during the conference in Cape Town. All authors are members of Research in Gender and Ethics (RinGs): Building Stronger Health Systems, funded by the UK Department for International Development (DFID) for the benefit of low and middle income countries. The views expressed are not necessarily those of DFID. We would also like to thank Future Health Systems (FHS), ReBUILD and RESYST for contributing to photo printing costs so that the photos could be displayed at the symposium. In addition we would like to thank FHS, RESYST, and REACHOUT for supporting open access publication costs. Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAG made substantial contributions to the conception and drafting of the manuscript; ST and KH have been involved in drafting the manuscript or revising it critically for important intellectual content; RM and SM have been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.
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Many countries in Sub-Saharan Africa have undergone a process of decentralising health system planning and management, shifting authority to varying degrees from central government to local districts. There are gaps in research on health worker performance at the district level. To strengthen the evidence base, PERFORM – a research consortium of three European and three African universities – has applied action research using a holistic “systems approach” to explore how improving management skills can enhance workforce performance at district level. The project aimed to boost the capacity of health managers in three districts in Ghana, Tanzania and Uganda to identify health workforce related problems themselves, understand the systemic factors affecting performance (including uneven distribution of health workers, inappropriate allocation of tasks and lack of training, management and support) and apply and monitor strategies.
This blog post is part of a series on people-centred research methods for health systems development published in conjunction with a Twitter chat on the same topic. Please see below for links to other blog posts in this series.
The ReBUILD Consortium is conducting health systems research in post-conflict contexts. This brings with it several challenges, including: lack of data, recall and memory lapses, ensuring confidentiality and the changing contexts of conflict and displacement. Often people have experienced multiple traumatic events which many may want to forget, although these memories could be of importance to the reconstruction process. Both conflict and post-conflict rebuilding are political processes. So, attempts to rebuild a health system will be influenced by power relations, which in turn are shaped by historical, regional and social inequalities, and there is need to ensure that the experiences and realities of affected populations feed into the rebuilding process: life histories bring particular opportunities here.
What are life histories?
Life history interviewing is a qualitative method of data collection where people are asked to document their life over a period of time. It is a personal account of their life, in their own words and using their own personal time lines. Accordingly, they tend to be selective, contingent upon remembered events that are amenable to being told, be they fact or fiction.
Our study involved 47 heads of poor households (aged 45 years and above) in Gulu District, northern Uganda. Of these, 26 were women and 21 were men. Each life history was conducted by a pair of researchers, one interviewing and the other recording both manually and electronically. The heads of households were asked to narrate the story of their life as far back as they could remember, from whichever year, as long as it was before the war. They were asked to mark significant life events on a timeline covering the three key phases: before the war, during the war and after the war. The aim was to document changes in their households’ ability to cope with household health care costs over the three time periods. For each phase, they identified their major life event, why they considered it significant, and what memories they attached to it. For illnesses, they named the illness, the treatment sought, where treatment was sought from, how much was paid and the treatment outcome. As they narrated their life story, the researcher in charge of recording drew the timeline, matching the events with the years (if the respondent could remember it) and the outcomes.
The choice of determining what was a significant life event and why, health, health events, treatment sought, cost, what was paid and what was foregone to pay the cost of health care was left to the respondent to define and articulate. This was considered more empowering than choosing for them. Having told us their life experiences, they went on to give us their expectations of what good health care meant and recommendations for reconstruction. That way, we ceded some of our power as researchers, to participants to tell their own story other than just reproducing knowledge as part of the post war research industry. In addition to the lifelines drawn, the results of these life history in-depth interviews were transcribed, translated from Acholi into English, and analyzed thematically using Atlas ti software.
Examples of extracts from life histories
“…just only two things stick out for me: the sodomy I endured and how we left home going to the camp. We were chased from our homes in a very bad way, we only survived by God’s grace, it was not a good experience at all. Also there was a time we were abducted by the government army and they tied us with ropes and they were pouring on us red peppers [red chilli powder] just direct on our faces. We just escaped death narrowly”. (70 year old man).
“… we were on the run. … Sometimes they seriously fought and killed people. Here in my home, I was captured three times [by the rebels]. That was the year when the Kony war was severe; it was in the middle years. It was very bad. I cannot recall the year very well. … If you slept in the house, they could come and knock the door…if you opened, they ordered you to take them where people are, you see. There they would go and kill people in that home. I stayed badly here. We really faced problems here. The year?…I was captured three times…They captured my boy and went with him. They went with him. We started sleeping in the mission for the three years. Then it ended we are now here.” (72 year old woman)
Challenges
Like any other method there are challenges and advantages to this method. It’s a lengthy process and given the traumatic nature of the events experienced including death, abduction, torture and rape of women, men, girls and boys, developing rapport and trusting relationships is critical. Conversations need to be carefully and sensitively carried out.
The transcripts created a lot of data which takes time to record and analyse. The ability of one person to textualise the life of another for unknown readers is a challenge the researcher has to be cognizant of as they translate the life story into research reports or participate in research engagement activities, deciding which aspects to highlight and which to omit. Furthermore, decisions have to be made on re-representing the private/intimate details on people’s lives. This can create ethical dilemmas. Ensuring the confidentiality of vulnerable groups discussing their experiences of conflict, including for example male rape, within a homophobic context is critical.
Advantages
But for all the challenges outlined above we found life histories to be useful. They helped us explore and identify the dominant narratives of people’s lives within particular events and situations. These narratives were contextualised – they described how a particular event came to be significant, and how opinions and decisions change over time.
Life histories are good at enabling people to recollect the past and document change, especially where some events could have been missed out through other methods requiring simple recall of facts. People may not remember the actual details but remember the significant events.
Furthermore it is participatory and gives the respondent more voice than other deductive methods. We found that it empowers the respondent, giving them a more prominent role to decide what is significant, why it is significant and to locate themselves within the experience. As part of this it helps people to evaluate their lives, clarifying what life would have been and why it was so. At the same time it provides a history beyond the personal, the analysis helps to show that lives are not free floating but occur in a social context, hence are socially constructed.
What life histories taught us about health
The method demonstrated to us that choices about health are determined by forces beyond the health sector, such as gender relations, livelihoods, conflict, etc. Consequently, strategies to rebuild post-conflict health systems cannot be reduced to health interventions, but also need to encompass a focus on people’s livelihoods and social relationships. While the post conflict effort emphasised building/renovating health facilities, our life history participants spoke more of income generation strategies because with money, they could navigate the new post conflict health context which is characterised by poorly functioning public facilities and expensive but well facilitated private facilities. The life histories highlighted the importance of mental health as a key component of post conflict health reconstruction. They made prominent how men and women had experienced sexual and gender based violence. There is need to ensure services respond to the realities of all groups: and both women and men’s health needs should be provided for. We need to address people’s physical and psychological needs, and subsequently end the cycle of violence. Life histories also challenged common assumptions about war and disease, showing opportunities that existed in the war, such as ease of delivery of health services due to encampment.
We would be very interested to link up with other health systems researchers who are using a life history approach in other contexts and to think further what this method – and others that are people-centred – can contribute to the body of knowledge that we have.
* Sarah Ssali is a Senior Lecturer at the School of women and Gender Studies, Makerere University and Co-Pincipal Investigator on ReBUILD. She is also part of Research in Gender and Ethics: Building Stronger Health Systems (RinGs).
Sally Theobald works at Liverpool School of Tropical Medicine and has wide ranging experience of designing and implementing gender sensitive qualitative research projects on HIV, TB, SRH and health systems in Africa and Asia.
Kate Hawkins is Director of Pamoja Communications. She likes writing about health, gender and sexuality.
By Laura Dean, Anthony Bettee, Kate Hawkins, Sally Theobald and Karsor Kollie
During the recent Ebola outbreak Liberia lost over 185 of its professional health workforce. Trust between health workers and communities broke down and resources were diverted from routine health system activities to control the outbreak. This resulted in the near collapse of the health system as well as changes in the disease landscape and increased vulnerabilities related to the social determinants of health for many people. As the health system is rebuilt, it is critical that the full impact of the outbreak at all levels of the health system is understood from the perspective of different stakeholders, in order to put forward strategies to strengthen the resilience of the health system.
Small grant
In collaboration with the Ministry of Health in Liberia, COUNTDOWN colleagues were recently awarded a small grant for research engagement from the Thematic Working Group on Health Systems Research in Fragile and Conflict Affected States. We will use this to convene two stakeholder meetings, one at the national and one at the county level that explore the impact of the Ebola outbreak on the health system with a specific focus on the Neglected Tropical Disease (NTD) control programme. We aim to highlight the opinions of people whose voices are often not heard at such meetings, for example community members and frontline health staff. We hope these meetings will provide a unique opportunity to gain deeper understanding of the impact of health system collapse on vertical programmes and explore how these programmes can help support the wider system.
The Neglected Tropical Disease Programme in Liberia
The NTD control programme in Liberia is an integrated programme established in 2012 that engages with the health system from central Ministry of Health to the community level. During the Ebola outbreak the NTD programme ceased activity in order to support Ebola control, however it is now slowly beginning to resume activity. However before it starts up fully there is a need to understand in more detail the challenges faced in NTD control both prior to and since the Ebola outbreak. The stakeholder meetings allow reflections on the operations of the NTD control programme prior to the Ebola outbreak, as well as assessing how the Ebola outbreak may allow for a revitalisation of the programme to achieve a scaled-up, equitable response to NTDs in Liberia.
Follow-up
As a result of the meeting we hope to develop a research agenda for health systems with specific focus on NTD control in Liberia that we can begin to address within COUNTDOWN. The engagement of international stakeholders from other Ebola affected countries such as Sierra Leone aims to increase the transferability of this research agenda and its findings, as well encouraging south-south collaboration and lesson learning as health systems are rebuilt. Watch this space for more information and outputs from COUNTDOWN’s first stakeholder meeting in Liberia!
This blog post first appeared on the Cross-Talk blog.
Photo: Two women in front of Ebola billboard in Monrovia, Liberia. Credit: UNMIL/Emmanuel Tobey
A conference participant views the ‘Queer Crossings’ poster
Sitting in front of a South African poster on ‘queer crossings’ was one of my highlights from the recent Migrating Out Of Poverty conference in Singapore. It made me happy that one of my pet subjects – sexuality – was being addressed by such a stellar line-up of researchers studying gender, poverty and migration linkages.
I find it difficult to think about gender without a corresponding focus on sexuality as the two things so often intersect in interesting and important ways. It is particularly pertinent when we look at issues of women’s empowerment:
If for example, you look at women’s empowerment through a sexuality lens, you see a more complete and realistic picture of a woman: not a victim, nor an end-product ‘empowered’ woman, but a woman with a complex and changing life. You see a woman whose well-being depends, among other things, on making choices about her own body, about pleasure and about her own sexuality. You also see a woman who lives within or perhaps challenges the confines of social pressure and expectations about her behaviour. A woman’s sexuality and identity can affect many aspects of her life including her work and her means to earn a living, her family relations, her ability to move around in public, her opportunities to participate in formal and informal politics, and her access to education.
It is also a useful way of thinking about gender in terms of men and people who define themselves as something beyond/outside the binary of man and woman. (Even Facebook now has a list of over 58 gender options that people can choose from to describe themselves. Some of us scholars are lagging behind on this score!)
Sexuality came up in many of the sessions at the conference – even if it was rarely used as a frame of analysis.
Poverty, precarity and sexuality
Susie Jolly has written about the importance of housing to the realisation of sexual rights and desires and the constraining effects of poverty. This seemed relevant to some of the examples of migrant life spoken about at the conference. Trond Waage’s film, Les Mairuuwas, followed migrants from the Central African Republic in Northern Cameroon who were working as water carriers. One character didn’t see the point of a home, or felt that it was an unnecessary use of resources. But when he moved in to a room he realised that he had invested in the community and it also gave him the opportunity to have a sexual relationship. We heard from many presenters at the conference about the (inappropriate/inadequate) housing conditions of migrant workers. Some were living in their workplace with employers, particularly domestic workers. It would be interesting to better understand the effects of these living and working arrangements on migrants’ abilities to form intimate relationships and the wider effects on their lives.
‘Dangerous’ sexualities and the female migrant
There is a prevailing narrative about the sexual vulnerability of female migrants which was echoed in some of the discussions at the meeting and the presentation on employment brokers was particularly chilling in this regard. However speakers also pointed to the way that female migrants are often stigmatised on the grounds of their sexuality – which is imagined as undisciplined and unruly when far from home.
In a memorable talk about young women from Zimbabwe Stanford Mahati quoted one boy as saying ‘Good girls do not cross the border’. Mahati’s analysis of humanitarian workers’ formal and informal discourse around working migrant girls showed that they were often labelled as ‘promiscuous’, ‘lacking in morals’ and ‘far from innocent’. Meanwhile Ishred Binte Wahid spoke about notions of ‘purity’ in relation to Bangladeshi women migrants who travelled to work in the Gulf States. Female migrants found that religious piety (for example wearing the burkah) was a way of counteracting negative aspersions about what may have happened in their sexual lives whilst they were away from their families. She questioned the notion of female migration as inherently empowering and pointed to how it could sometimes reinforce patriarchal norms.
We heard from South African sex workers in the MOVE visual exhibition. Sex workers are arguably some of the most maligned ‘bad women’ in patriarchal societies’ bogus hierarchy of womanhood. Visual methods enabled them to take back control of the stories about their lives and express their humanity. Chantel, a participant from Johannesburg, wrote in her journal,
Telling my story is so powerful for me. Every day I look forward to writing or thinking about my story. I want to take images that show the way that sex workers are treated. That I am a person. This project let me do this. It helps me to take away stress and to know that I am not alone.
The conference was silent on the issue of the clients of sex workers, despite the fact that it is likely some of them are men characterised problematically in the HIV literature as ‘mobile men with money’. Migration researchers may have some interesting insights for their counterparts in health on this issue.
The pain and the liberation of separation
Some presentations at the conference explored the ways that prolonged separation due to migration could lead to challenges in maintaining ‘family unity’. One study from Indonesia showed how 18% of married migrants ended up getting divorced which was contrasted with a divorce rate on 7% in non-migrant families. This had particular impacts on the income of divorced women who also faced negativity from the wider community on account of their divorcee-status.
Deirdre McKay’s presentation of the lives of Philippine women working without documents in the UK explained how long separations with little chance of being reunited due to cost and visa restrictions created stress and a strain on family life. However, she also argued that living in chronic poverty can cause family tensions. She pointed to the potentially liberating aspects of separation in some circumstances and highlighted how when men are ‘dud’ husbands (i.e. they gamble, drink, or can’t look after money) there is often migration in lieu of divorce.
Future sexuality-migration exploration
As a newcomer to the field of migration studies it was fantastic to attend the recent conference. I hope that as work on gender continues there is critical reflection on the topic of sexuality and some cross learning with other programmes working on the poverty-sexuality links. In particular it would have been interesting to hear more about same sex desire and the migrant experience and to have a more explicit focus on heteronormativity. Interesting research from (my friends at) Galang in the Philippines described how lesbian women and trans men migrated because of homophobia and gendered discrimination. For these people migration (and the money earned) sometimes created opportunities for sexual freedom and improved status within the family but it could also leave people vulnerable to homophobic abuse. These are interesting insights which are ripe for further investigation in other contexts.
Kate Hawkins is the Director of Pamoja Communications. She works on communications and research uptake for projects looking at health, gender, sexuality, and more. Kate was the communications consultant on the Gendered Dimensions of Migration conference for the Migrating out of Poverty Research Programme Consortium.
PROJECT IDS DATE 7/29/2015 AUTHOR(S) Kate Hawkins, Saharah Nesbitt-Ahmed, Thea Shahrokh, Jenny Edwards
Streams of Influence tells the story of how the Gender, Power and Sexuality programme that sought to bring about positive changes on gender equality imagined and then experienced the process of influencing. Along the way there were the positives in terms of actions and outcomes going to plan, there were also some unintended but nonetheless welcome effects, but there were also a few activities that didn’t work as well as hoped. Programme partners also experienced periods of doubt, struggle and confusion.
PROJECT Migrating out of Poverty DATE 7/19/2015 AUTHOR(S) Dorte Thorsesn and Kate Hawkins
From the 30 June – 2 July 2015 a group of researchers, policy analysis and civil society representatives met in Singapore to debate and discuss how gender roles and expectations influence the factors leading to migration, male and female migrants’ different experiences of migration and its impact on migrants, their families and communities. Our analysis does not equate gender with women and girls but aims to unpack how changes to occupational niches and flows of female migrants shape relationships with employers, families and friends, how they shape society and change our notions of gender and age appropriate behaviour. This conference was also an important opportunity to see men and boys as gendered persons. This brief provides a summary of some of the ways that gender shapes and is shaped by contemporary migrant journeys. Our work focuses on migration within low- and middle-income countries as a strategy to overcome poverty and build a brighter future for migrants, their families and their communities.
For some months now our team within the Thematic Working Group on Health Systems in Fragile and Conflict Affected States has been involved in a process of canvassing opinions on key research needs. This has included face-to-face meetings, a survey, and online discussion. This has enabled us to reach out to over 500 people in 28 different countries (over half of which could be characterised as fragile). This week we added a webinar to the portfolio of tools we have used to try and build a consensus with a wide range of stakeholders.
The challenges of conducting research
Our colleague Egbert Sondorp explained that as the work has developed the sheer magnitude of research needs has become apparent. We have also become aware of some of the barriers to high quality work in this area. These include infrastructural issues such as insecurity which can lead to the risk of ‘convenience sampling’. Travel bans imposed by donors can sometimes mean that bureaucracy trumps the need for good data. In many settings there is a shortage of researchers and data collectors and disruption of research infrastructures hinders health system research and can make processes like ethical clearance more challenging. Among donors there can be a lack of political will to provide ongoing, flexible financial support and so it is difficult to maintain continuity to manage the research process in a sustainable manner. There are real difficulties when it comes to research uptake. Too often research agendas are concocted by outsiders and therefore don’t necessarily tackle the issues that decision makers on the ground feel are most pressing. The plurality of stakeholders involved in the health sector post-conflict make it difficult to know who to target. Lack of state leadership and ownership of research can make it less likely that findings get used.
What have we learnt so far?
Aniek Woodward ably gave us a taste of some of the research issues that have been prominent in our discussions so far. These included the transition from emergency support to long term health system building. The importance of resilience – particularly in settings where populations experience recurrent shocks. She also raised the issue of non-state actors and how to ensure accountability in settings where the state is weak.
We were lucky to be joined by two great discussants Khalifa Elmusharaf and Nigel Pearson who interrogated some of the findings of our work. Khalifa pointed out that wars destroy trust, identity and social ties – community cohesion – and this has implications for health systems. What is needed in these settings are methods that bring the voice of marginalised citizens (women, refugees, disabled people etc.) into decisions about health systems. He made the great point:
‘If we don’t listen to people how will we plan accessible people-centered health services in post conflict settings?’
Nigel reiterated the point that we don’t just need enthusiastic outsiders to conduct this type of research. What is required are people with a deep knowledge of the context and environment – this calls for research into the type of research partnership models we employ and how funding is delivered. He stressed that too often shortcuts are taken in the research process – either in terms cherry picking the geographical areas covered or the methods that are used. In addition research can be hampered by problems of government legitimacy and sensitivity about questioning government decision making. He also made interesting points about gender and the employment of women in research and health care delivery its potential impact on equity and the amelioration of conflict.
Ethics, community engagement, local ownership and more!
Are webinars like, ‘talking to an invisible public’, as one of our panellists put it? Not in this case. With 32 audience questions in an hour we had great participation and a lot of important inputs to the research process to mull over. It is impossible to do justice to them all here but questions and issues raised included:
The importance of governance and leadership
How to conduct research in areas controlled by those who are hostile to outside interference – such as Al-Shabab in Somalia
The perception is of research not being a priority, particularly during first stages of emergency when there are pressing humanitarian needs
The need to build capacity in local research institutions
The ethics of research in these settings (risks to informants and ethical clearance, for example)
Is it right to sacrifice the highest quality of the research in order to get some insights?
What can we do in fragile settings in order to achieve community cohesion?
The need to focus not only on volume of aid but also how it is implemented/disbursed
Research on different service implementation strategies and models of care at the ground – health outcomes
How to ensure cross-sharing of evidence-based best practices and fragile state comparison
One particularly perplexing question related to whether this agenda applies to countries in an economic crisis such as Greece? So we certainly have a lot to consider as we move forward!
We will be contacting people who joined the webinar and following up on the issues raised. If you would like to join our group and be part of the discussion you can find us on LinkedIn. We hope to continue a discussion of these issues online. Be part of the conversation. Read our Storify of the event. Alternatively please contact Jan Randles Jan.Randles@lstmed.ac.uk.
PERFORM researched human resources for health in Ghana, Uganda and Tanzania. Through action research they provide new knowledge on how district managers can effectively intervene within their current constraints to improve the performance of their staff. We supported the PERFORM team by providing capacity development on how to write policy briefs, attending their planning meetings in order to support strategic communications planning. We managed and updated their website including writing, editing and publishing a toolkit of resources and tools that others can use to implement similar projects.