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Webinar report – Practical Pathways for Change: Learning how to integrate a gender and equity lens in AMR research projects

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In this blog Hayley Stewart reports back on the recent Practical Pathways for Change webinar, introducing a new resource aiming to incorporate gender and equity considerations into Antimicrobial Resistance innovation, intervention, and implementation research.

Gender, among other social, cultural, and biological factors, can have an impact on susceptibility to antimicrobial resistance and adversely impact the effectiveness of mitigation strategies within a community. Earlier this month the International Centre for Antimicrobial Resistance Solutions (ICARS), in collaboration with the International Development Research Centre (IDRC), Human Sciences Research Council (HSRC), Mahidol Oxford Tropical Medicine Research Unit (MORU), and Jive Media Africa, released a new resource aiming to incorporate gender and equity considerations into AMR innovation, intervention, and implementation research. Here we tell you about what we learned at their recent webinar to introduce the tool.

Erica Westwood from ICARS opened the webinar talking about the importance of considering gender in the context of an emergency like AMR, taking lessons on the necessity of applying a gender lens in crises like COVID-19 and climate change. She outlined how ignoring social and contextual factors risked deepening inequalities. However, gender analysis still remains a weak point in AMR research, with a distinct lack of sex disaggregated data. She then went on to explain how women can be key to understanding AMR, particularly as in rural areas they frequently will be the ones tending to sick animals, collecting water, preparing food, and caring for the sick and the elderly. In this collaborative project, the partners worked together to create a tool that helps us find and create sustainable solutions to AMR that are gender sensitive. And these solutions need to be contextually relevant, locally driven, and enhance equity.

Bhensri Naemiratch from MORU talked though the development of the tool, beginning with a systematic scoping review, looking at journal articles from 2017 to 2022 that discussed gender and equity consideration in AMR, focussing on human and animal health in LIMCs. The team engaged with 17 researchers from Sub-Saharan Africa and South East Asia, undertaking a participatory process through online consultation workshops. They then went through a co-creation process with seven researchers to develop the toolkit.

Dr Ingrid Lynch from HSRC in South Africa then took participants through some of the key features of the tool:

Part one provides an overview of key concepts and the relevance of gender, equity and intersectional analysis in AMR. It synthesises research that does exist around the linkages between gender and AMR.

Part two is structured around the research cycle to illustrate how a gender and equity lens can be integrated into research. This is illustrated through the toolkit by two case studies. This section helps with problem identification and proposal development.

The guide includes a user-friendly tool, built on the vast array already available in this area, to guide researchers through a gender analysis at the beginning of their work, with a matrix to help them understand how gender considerations interact with their study topic. The authors see researchers coming back to the tool over and over again, helping them to build context and apply findings.

In stage one the guide helps with problem identification – including a checklist to prompt reflection and a systematic approach. Stage two cover proposal development and integrating gender and equity into study design, while stage three looks at implementation and data collection, including sampling and gender sensitive training for data collectors. Stage four examines data analysis, and outlines some of the common pitfalls when incorporating gender and equity considerations in data analysis. Stage five covers reporting and dissemination, including the use of gender sensitive and inclusive language and representation. Find out more about the resource and download it on the ICARS website.

10 Key Messages from the Webinar on Gendered Approaches to Monitoring and Evaluation in Health

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On the 19 October 2023 the MAGE project convened a stellar panel of experts to explore and advocate for gender-responsive monitoring and evaluation of health programmes. In this blog our Director, Kate Hawkins, has synthesised ten key points from the webinar for health systems researchers to consider.

  1. A gendered approach encompasses needs, rights, and preferences, as well as gender power relations and systems. It is crucial to recognise that gender extends beyond just biological differences and beyond the gender binary of men and women.
  2. Women, who often suffer from inequitable power relations and systemic disadvantages, are often a primary focus of gender-responsive monitoring and evaluation in health. An intersectional lens should be adopted to address issues like class, age, race, ethnicity, and geographical location, recognising that gender intersects with multiple aspects of identity.
  3. Indicators should be sex-specific, sex-disaggregated, and related to gendered power relations and systems, enabling a better understanding of gender dynamics.
  4. Power imbalances disproportionately disadvantage women and girls and affect their health outcomes, posing a threat to achieving universal health coverage. Sexual and reproductive health plays a significant role in empowering women and girls to make choices about their lives, and it is heavily influenced by gender norms. Controlling women’s bodies, sexuality, and reproductive choices is a significant contributor to gender inequality, making it crucial to understand these power dynamics to improve health outcomes in these areas. Health directly affects access to education, economic opportunities, and participation in social and political life, impacting women and girls’ ability to attain gender equity.
  5. Programmatic priorities should have a gender lens from the outset, enabling the creation of indicators to monitor progress on gender-related issues. Equitable participation and representation of diverse groups in interventions are essential for promoting gender equality.
  6. Gendered aspects of health in outcomes and determinants must be measured to prioritise these issues in the analysis and emphasise their importance. Striving for improvement in research and programs is vital while also being vigilant to prevent unintentional gendered harms.
  7. Gender-focused interventions often target women, men, and communities to change gender norms and roles in family planning, but the health systems supporting these communities are often overlooked. Identifying gaps and measuring inequalities within the health system is essential, requiring gender-responsive monitoring and evaluation.
  8. Addressing practical issues, such as inadequate facilities in health centers, lack of access to health insurance, and gender disparities in the health workforce, is crucial alongside normative processes.
  9. Progress should be tracked in real time, and responsive actions must address the specific challenges faced by women and girls.
  10. National health information systems may not capture all necessary gender-related data, and integrating information from other sources, like primary research, may be necessary to fill these gaps. Considerable capacity development may be needed at multiple levels of the health system to introduce and strengthen this approach, including improving political will in this area.

The workshop speakers emphasised that “We measure what we treasure, and we treasure what we measure.” The time for measuring gender in health is now.

MAGE is a partnership between Johns Hopkins University (JHU) and the Global Financing Facility for Women, Children and Adolescents (GFF), a multi-stakeholder partnership housed at the World Bank that is committed to ensuring women, adolescents, and children can survive and thrive. They do this through the advancement and strengthening of gender- and equity-intentional monitoring and evaluation.

Speakers at the webinar included: Anju Malhotra, PhD, Professor of the Practice, International Health, Johns Hopkins Bloomberg School of Public Health, Senior Gender and M&E Advisor, GFF, The World Bank • Choolwe Jacobs, PhD, Head of Department of Epidemiology and Biostatistics at the School of Public Health, University of Zambia, Country Lead, Women in Global Health, Zambia • Rosemary Morgan, PhD, Associate Scientist, Johns Hopkins Bloomberg School of Public Health, USA • Asha George, PhD, South African Research Chair in Health Systems, Complexity and Social Change, School of Public Health, University of the Western Cape, South Africa

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None of us are safe until we are all safe

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Lynda Keeru reports back from the two-day summit, ‘Lives in the Balance: Equity in COVID-19 Response and Recovery’ organized by PMNCH, the Global Financing Facility for Women, Children and Adolescents (GFF), Gavi, the Vaccine Alliance, and CORE Group. This summit revealed the urgent needs of women, children and adolescents during COVID-19, and enabled coordinated action by partners and governments to help meet those needs. The summit sought to: 

  • Reflect on how well countries have been able to implement equity enhancing strategies to protect the health and wellbeing of women, children and adolescents, particularly those with the least access to social, economic and political power; 
  • Share lessons, tools, and resources on why focusing on women, children and adolescents in national COVID-19 responses is key; 
  • Collaborate by identifying ways to promote equity and realize the PMNCH Call to Action on COVID-19, including aligning partners for common action around the seven asks; and
  • Act by demonstrating how countries are improving women’s, children’s and adolescents’ health in the context of COVID-19, including making commitments to the COVID-19 Call to Action

“A year into the pandemic, the unique challenges faced by women, children and young people are no longer merely anecdotal. There is abundant evidence of impact and many lessons learned. A universal lesson is that social and economic recovery depends entirely upon our willingness to see inequalities, to seek evidence – and to act upon it. No one is safe until everyone is safe. Equity in vaccine delivery is a core example. How fast can we move from rhetoric to action? How can we turn this unexpected crisis into an opportunity for change?” Conference organizers

The summit sessions aimed to guide participants in reflecting on the lessons learnt and the shared progress made throughout the COVID-19 pandemic and use the opportunity to recommit to action. Elif Shafak, a celebrated Turkish novelist kicked off by saying:

“We can’t talk about equity without understanding the inequalities, the silences, the invisible barriers that keep us divided particularly gender inequality.”

She was raised by two women, her mother and grandmother, who were in their own right very different women. Her mother was more Westernized, while her grandmother was more ‘Easternized’ and more traditional. What stuck with her, irrespective of these differences, was the fact that they supported each other in a very patriarchal world. She learnt from them that when women support and empower each other, the impact goes beyond gender issues. 

Vaccines

Helen Clark reiterated the importance of saving lives and protecting hard earned progress. She talked of how the mass vaccination for COVID-19 is characterized by inequities. High-income countries accounting for only 18% of the world’s population; have bought 4.6 billion doses of vaccines which represents 60% of all confirmed orders. Unfortunately, only 2% of the total number of vaccinations have been administered in Africa. This geographic inequity puts a particular risk on populations in low- and middle-income countries where the greatest number of maternal, child and adolescent deaths occur. However, the very simple truth is: None of us will be safe from COVID-19 until we are all safe. It is therefore very urgent that the production and distribution of vaccines is accelerated so that everyone all over the world has access to them.  

Low- and middle-income countries and small island developing states

The pandemic has disproportionately affected low-income countries and small island developing states. It has also affected middle-income countries in which 70% of the world’s poorest people live. These countries are confronted with the realities of inequities with respect to access to medical technologies, laboratory services, essential medicines and vaccines. These disparities mostly affect women, children and adolescents; who don’t receive the same social services to weather the ravages of the pandemic. It is essential that national, regional and international strategies are developed to support the most vulnerable among us so that no one is left behind. For this to be achieved, it’ll require a societal approach, enhanced by the contributions of Civil Society Organizations, Non-Governmental Organizations, the private sector, religious groups and everyone coming together with a single mission. 

Mia Amor Mottley, the Prime Minister of Barbados explained that we are not living in normal times and that there is a need to develop tailored social interventions that will reach people and communities where they live. In keeping with the Sustainable Development Goals therefore, all countries should focus on extending health services to the most vulnerable populations in order to achieve Universal Health Coverage. Political will at an international level is required to address these existing disparities and the only path for completely mitigating this pandemic is through global leadership and global political goodwill and commitment. 

Global solidarity on gender equity

In support of the need for global leadership to alleviate the pandemic, Wendy Morton gave insight on how global leaders could ensure that equity is advanced and how the COVID-19 response can ensure that the progress made on women’s children’s and adolescents health can be preserved. 

The impact of COVID-19 on women, adolescents and children has been disproportionate. Global leaders must advocate in the strongest possible terms for gender equality and for the needs of women and children to be at the heart of the efforts to rebuild.  This does not mean going back to where we were because where we were had its own challenges; rather, there needs to be vision as well as leadership to rebuild in ways that challenge and overcome the systemic reasons for inequality. Success will only be achieved when the recovery leaves no one behind. When leaders unite, they can give a voice to those who have gone unheard. Women have been at the forefront of the pandemic response and we see more clearly than ever before that women are the backbone of the global health workforce. Their access to vaccines and essential services is critical for the health of the whole population.

Jennifer Klein followed immediately after to elaborate on how equity can be advanced to improve the health of women, children and adolescents and spoke on the strategies the United States was employing to address those inequalities. The first step to addressing the inequities is embedding gender in all that is done. She highlighted that America’s maternal mortality rates are among the highest in the developed world and they are especially high among black and native American women who often die from complications related to pregnancy at two to three times the rates of white or Hispanic women regardless of income or educational level.  She noted that the US government under the leadership of the new administration is particularly committed to addressing these unacceptable disparities and build health systems in the that deliver equity and dignity to black indigenous women and girls of color in the US and this principle is applicable in the country’s foreign assistance as well as far as equity in health is concerned. 

Awa Marie in closing shed light on the need for a gendered response to COVID-19 and the importance of recognizing the special needs of women and girls. She based her presentation on how Senegal has been handling the crisis, what recommendations she has for others including development partners on how to ensure that responses to COVID-19 are gender responsive. She also touched on the barriers that were slowing down these processes. 

Marie stated that the manner in which Senegal has handled the COVID-19 pandemic has been informed by lessons learnt from Senegal’s past epidemics and particularly Ebola. Countries and development partners need to elaborate the gender responsive frameworks and plans with clear indicators adapted to country specificity. These plans should highlight women’s participation in COVID-19 decision making processes as well as national policies particularly those addressing women’s economic and social security. Gender sensitivity should guide policy makers. These frameworks should be financed in country as well as by external partners outside the country. 

She also felt that countries and partners should invest in sex disaggregated data to ensure that impact of the epidemic is managed effectively. There exist huge gaps in data and these barriers have been identified in investments required to collect data statistics. Data collection on issues facing women and girls is often irregular with existing knowledge gaps for new and emerging issues. 

Finally, she felt that governments should engage actionable policy measures such as the expansion of social protection coverage, direct cash transfers and adaptation of existing services for survivors of gender-based violence. Intervention and prevention services for women and girls should be managed as essential services and be an integral part of the national and local response planning for COVID-19. Women are at the forefront of all public health crisis in their different capacities as nurses, doctors, midwives, community health workers but their roles are often overlooked and underpaid. Women and girls carry out most of the care in the house, take care of children and also work back at their professional levels. Authorities must provide adequate social, psychological and economical support. 

In these times, we need global solidarity and sisterhood. Gender equality should be put at the center of all efforts. 2021 is giving us many opportunities to step up our game and build resilient, responsive and inclusive health systems for the future. With smart, compassionate leadership and a will to work together, we can step into a brighter, healthier future for women, girls, children and adolescents everywhere. 

There was a consensus on the need for gendered responses especially for women who have been left in the lurch by insufficient access to essential services like sexual reproductive health services. Inequities must be addressed both domestically and internationally. We need feminism everywhere. We need gender awareness everywhere.

Sessions that were covered in this blog: 

Opening Session

Leadership dialogue: “Looking back, looking ahead: COVID-19 one year on-what does equality mean now?

Music by and Conversation with Neneh Cherry

Importance of health care workers in the COVID-19 response – investing in midwives

Equity enhancing strategies: what works to ensure that COVID- 19 responses do not leave anyone behind 

A conversation between Juliana Matinez and Michelle Bachelet: COVID-19, human rights, and women’s, children’s and adolescents health 

A word from Titilope Sinuga 

Building Partnerships Across Actors and Sectors for Better Health-Kenya 

“Dakar, Senegal” by BobbiLe Ba Photography is licensed under CC BY-ND 2.0

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Launch of The WHO Handbook on Social Participation in UHC

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In this blog Lynda Keeru reports back on the launch of the WHO Handbook on Social Participation in Universal Health Coverage. The webinar focused on educating participants about why social participation matters and presenting real life experiences of implementation. During the webinar, the tensions at play in the implementation processes also surfaced. 

Dr Tedros opened by saying that the COVID-19 pandemic had demonstrated that societies are only as protected as their most vulnerable, and that equally engaged and empowered communities are the best defence against health threats.

Dheepa Rajan gave a brief overview of what the handbook is about and ran the participants through the key messages in the chapters. She indicated that the handbook’s main target audience are member states and governments; with its engagement modalities directly engaging with populations through communities and civil society. The overall goal of social participation is to achieve Universal Health Coverage (UHC). The handbook acknowledges that civil society plays a key role in strengthening social participation in policy and decision-making.

For social participation for UHC to be achieved, an enabling environment for participation needs to be created by evening out the playing field with the aim of empowering those who are weaker and less powerful. A participatory space is a powerful tool as it minimizes power asymmetries when designed in a manner that counters formal and informal barriers for equal participation.  Social participation challenges societal conventions of whose voice should be heard, who should have agency over their own health and who should be empowered to meaningfully contribute to policy making.

The format and design of participatory processes influences the ability to effectively take on representation roles. Selection strategies should be balanced and transparent and formats should ensure that they lend legitimacy to participants. Some of the ways to make this happen include: having neutral facilitators, forming homogenous focus groups, having participants decide on meeting locations and trusting them with preparing the material that will be used.

In order to increase the capacities for meaningful government engagement with other stakeholders there is need to recalibrate the balance of power which is rooted in expertise, knowledge and speaking skills. Quality of exchange between these stakeholders is determined by the competency and capacity of the participants. A level playing field for all stakeholders gives everyone an equal footing and gives way for more honest and fruitful discussions that influence policy.

Recognition is the most fundamental dimension of capacities for equal interaction but the most difficult to build.

It is important to note that policy uptake is not always the priority in participatory governance processes. Value driven arguments and participation itself add value.

Fran Baum reiterated that real value must be accorded to the knowledge and experience of community members because they bring something that most public servants, international bureaucrats, technical people can’t bring. They know their community best – they live it, and they breathe it. The only way to make health services work, is by listening to the people whom it’s meant for and shaping the interventions around these needs, particularly those that are marginalized such as women, indigenous people, migrants and people living with disabilities.

WHO hopes to start working with a number of countries to implement the recommendations from the handbook. They will tie their efforts to UHC 2030 and CSO engagement mechanisms.

The handbook must be promoted widely to ensure that it influences change and especially ensure that it gets into the hands of governments as a practical tool for sustainable social participation. We are happy to be part of this promotion.

Event was organized by WHO, UHC2030, Health System Governance Collaborative, UHC-Partnership and PMNCH

Webinar speakers:

Dheepa Rajan – Health Systems Adviser, WHO

Stephanie Seydoux – French Ambassador for Global Health

Ravi Ram – People’s Health Movement and Special Advisor, COPASAH

Joy Phumaphi – Executive Secretary, African Leaders Malaria Alliance

Fran Baum – People’s Health Movement

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Solidarity and psychosocial support: Healthcare workers on World Mental Health Day

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By Joanna Raven, Sally Theobald, Kate Hawkins, Sophie Witter and Haja Wurie, members of the Fragile and Conflict Affected States TWG

“Healthcare workers are only human. We experience the same COVID-19-related fear and anxiety as anyone else. This might be fear that we or our friends and family will have to self-isolate or quarantine, or become ill. But there is also the fear of caring for people with COVID-19, some of whom will die. A survey of nearly 1,300 healthcare workers treating people with COVID-19 in hospitals in China showed high rates of depression, distress, anxiety and insomnia.” ~ Miriam Taegtmeyer and Tom Wingfield

‘Invest in mental health’ is the theme set for this year’s mental health day by the World Federation for Mental Health. The impact of COVID-19 has triggered real challenges for mental health and well-being around the world. Narratives of anxiety, fear and distress are commonplace as people struggle with sickness, stigma, loneliness, and isolation, and gender-based violence is on the rise too.

The rallying call of “mental health for all” must include action, support and solidarity for frontline health care workers who face these challenges day in, day out at work, at home and in their communities. In many contexts, health care workers do not have easy access to Personal Protective Equipment (PPE) or psychosocial or mental health support.

Research from the ReBUILD consortium used life histories and other methodologies to understand the challenges faced by health care workers in fragile and shock-prone settings. This includes pre-, during and post-war and other shocks, such as Ebola in Sierra Leone. You can learn more about this and research on psychosocial health of adolescents’ girls in ReBUILD for Resilience World Mental Health Day – resources. COVID-19 brings new challenges for health care workers at all levels that require solidarity and psychosocial support.

Five key messages from our work on health workers in fragile and shock-prone settings

  1. Health workers are often targeted during shocks and conflict. They face fear of or actual attack, sexual violence, abduction and death. Health workers also witness traumatic events that happen to others, including colleagues, relatives and community members.
  2. The stigmatising nature of disease outbreaks create particular challenges for health workers. During the Ebola outbreak, they were frequently ostracized by their communities — a social isolation which was not only hard to bear but also a poor reward for their continued service. There was often increased suspicion between health workers. Health workers also experienced isolation from families for fear of passing on the infection, and pressure from relatives to discontinue working. These continue to affect health workers’ daily life.
  3. There are ongoing everyday stressors for health workers in these settings, which contribute to increased stress and burnout. These include limited supplies, long hours and overload of work, managing complex health issues with little support, and challenges with referrals, irregular payment, and limited support from the health system and community.
  4. Health workers adopted coping strategies. Self-protection mechanisms included not wearing uniform and changing sleeping places frequently (during conflict). Psychosocial support came from drawing on internalized value systems such as religion and a sense of fatalism and service to country, as well as from community, peer and organizational support.
  5. However, we found that there are important gaps in the support for health workers in fragile and shock-prone settings. Support strategies should be in place at local, national and international levels, rather than relying on personal sacrifices by staff to keep services functioning.

Interventions to support mental health and wellbeing

In fragile and shock-prone settings – where chronic stressors and crisis situations often collide – there have been a number of trial interventions by communities and health facilities to support health care workers to maintain good mental health. For example, a recent paper in BMJ Global Health describes a series of rapid and longer term strategies that were used during and after the Ebola outbreak in Liberia and Sierra Leone. These include ‘de-stressing zones’ in health facilities to aid the transition between work and home, mandatory rest-periods, Schwarz rounds and the use of trained mental health nurses to support their peers. Informal WhatsApp groups and more professional crisis lines offered the opportunity for dialogue and counselling. Community healing and support groups were developed to deal with the fall out of fear, stigma and discrimination.

Conclusion

In ReBUILD, three new projects will explore health workers’ experiences during COVID-19. In Myanmar, we will identify strategies to maintain routine service delivery during the COVID-19 pandemic in the Yangon region, and how these strategies are affecting health worker wellbeing. In Nepal, a study focuses on how health workforce policies and practices are adapted at the district level to manage and support health workers during the COVID-19 pandemic. In Sierra Leone, Lebanon, Nepal and Myanmar, our focus is on close to community providers, their gendered experiences and how they are supported to fulfil their critical roles in the COVID-19 response.

Health workers are at the epicentre of the COVID-19 pandemic, and yet their interests are often last on the list of priorities. Personal and professional coping strategies which were already stretched to their limits in fragile and shock-prone settings are being tested even further. Pressures from frightened and confused community members, from health staff and their families, and from systems which often fail to provide the necessary guidance, equipment and support for staff.
At the same time, the world has understood – more than ever before, perhaps – how critical their frontline and public health staff are. And the measures which are needed to support them and their mental health are often simple and affordable, such as better communication, more recognition, and protected time to rest. On mental health day, let us remember that there is no person-centred health care system without person-centred health worker support systems.

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Image: UN Women Asia and the Pacific/Flickr, CC BY-NC-ND 2.0

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Gender and COVID-19 evidence informs Europe-wide policy change

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The Gender and COVID-19 Project are delighted to welcome new measures from the European Parliament to protect women’s rights and enhance gender equality during and after the pandemic. We are proud that evidence published by our colleague Clare Wenham has had such a monumental influence on this decision. Kate Hawkins explains more.

A press statement reported that the new report on gender and COVID-19 was adopted in the European Parliament with 485 votes in favour, 86 against with 108 abstentions:

“MEPs stress the need for a gender-sensitive response to all aspects of the COVID-19 crisis in order to enhance gender equality and to protect women’s rights during the pandemic and post-pandemic period.”

Themes

The Report on the gender perspective in the COVID-19 crisis and post-crisis period is a comprehensive treatise on the gendered and intersectional harms created by the pandemic and offers recommendations on how these can be overcome. It covers:

  • Equity, “Including women and men, young people, older people, persons with disabilities, victims of gender-based and domestic violence, people from different socioeconomic backgrounds, children, single parents, and minority groups including Roma, LGBTQI+ people and refugee and migrant women.”
  • Barriers to health services, particularly those related to sexual and reproductive health.
  • Increased domestic and gender-based violence.
  • Women’s work and associated threats of infection, low wages, part time and precarious employment, lack of social protection, unemployment and the double burden of paid and unpaid care work.
  • The devastating impact of COVID-19 on low- and middle-income countries, particularly fragile and conflict-affected states.

To overcome current and future challenges will require, “a gender-sensitive approach, with gender mainstreaming and gender budgeting principles reflected in all aspects of the response to the COVID-19.” The report calls for an intersectional response. This includes a dedicated working group on this topic and country assessments to track progress towards gendered recovery plans.

The role of evidence

The European Parliament Report draws on evidence from a background paper commissioned by the European Parliament’s Committee on Women’s rights and Gender Equality. The gendered impact of the COVID-19 crisis and post-crisis period, outlines some of the key gendered effects thus far and suggestions for how these may extend into the post-crisis period based on currently available data on COVID and longer-term effects of previous outbreaks.

The report’s author, Clare Wenham from London School of Economics, responded:

“I’m thrilled that the European Parliament has adopted this text and is committed to not only recognising the gendered effects of COVID-19 but are trying to mitigate this gender inequality. Not only is this a great step for women, men and non-binary groups across Europe, but sets an excellent precedent for the rest of the world.”

We look forward to the next steps because of this report and are happy to support the process with relevant and timely evidence.

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

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Kate Hawkins, Pamoja Communications Ltd./Research in Gender and Ethics: Building Stronger Health Systems

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

 

The health and social workforce needs gender-transformative reform

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

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

Women health workers face violence and sexual harassment at work

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

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

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

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

Fragile and conflict affected states have particular problems

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

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

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

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

Promising practices

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

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

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

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

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

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

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

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A Community Health Worker gender action framework: Implications for decent work, rights, and responsibilities

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By Rosie Steege, Sally Theobald, Kate Hawkins

The health system is a growing employer of women and can help to contribute towards gender equality. Yet gender biases and discrimination are sadly alive and well within this sector. The need to promote gender transformational processes and decent work for health workers of all cadres was discussed at the WHO Human Resources for Health (HRH) Forum held in Dublin earlier this month.

A gender lens is often missing from analysis of the Community Health Worker (CHW) cadre of health workers who operate within communities serving as a vital link between them and the health sector. Although it varies by context, CHWs are predominantly women, often of lower socio-economic status, who have limited career opportunities. The HRH Forum provided an opportunity to highlight some of the gendered aspects of this cadre and showcase experiences and inspiring stories of action for CHW programmes. A panel chaired by Sally Theobald covered India, Brazil, South Africa and Malawi. She opened the session by highlighting the importance of gender and equity in human resources for health and “decent work” agendas, stressing that this lens needs to extend to CHWs who both experience gender inequities and also negotiate the ways in which gender and power play out within the households and communities they serve.

Gender dimensions of the ASHA programme

The first panellist was Kerry Scott (on behalf of Rejani Ved and Asha George) presenting work on the ASHA programme from India. The all-female cadre of staff was developed order to meet the country’s maternal and child health goals. The programme is now made up of 850,000 ASHAs (one per village). In order to better meet the needs of ASHAs a number of policy changes have been made. ASHA’s training has become residential with a crèche facility to ensure the women can participate and also fulfil childcare duties. ASHAs are included as member secretaries of village health committees. This enables them to move beyond the all-female maternal health space and encourages their active leadership in traditionally male dominated realms. Although ASHAs are not formally employed by the government, there are increasing monthly economic incentives for ASHAs to help them meet their need for regular income and encourage the uptake of banking services. The creation of more government scholarships for higher education for ASHAs creates more opportunities for women to access a career pathway. Newly introduced social security measures help support ASHAs via life and accident insurance and pension opportunities. Finally, the creation of rest accommodation in health facilities helps to increase ASHA safety and comfort (as one of their main duties is to escort expectant mothers to facilities to deliver, often at night).

These policy changes demonstrate positive active steps towards securing the safety and wellbeing of the ASHA as a mobiliser, facilitator and as a care provider. However, there are still challenges. There have been shocking examples of ASHAs being sexually harassed and even raped by community members and other health service providers in the course of their work. The government response has been to ensure that all service providers undergo sensitisation training, but there is still work to be done to ensure ASHAs’ safety and rights are protected at the community level. Kerry concluded with the call for constant adaptation of policies to ensure appropriate response to the ASHAs gendered needs. She posed the question, how do we balance policy progress against social norms which are slower to change?

Power, gender relations and heteronormativity in Brazil

João Nunes presented on Brazil and highlighted that there is a need for a political economy in analysis of human resources for health and the ways in which international political economies intersect with gender. Since its inception in 1987, the Brazilian CHW programme has been shaped by gender norms. The programme developed against a backdrop of neo-liberalisation, privatisation and an increasing feminisation of labour, where women were seen as precarious workers to fulfil permanent job needs. The programme was initially conceptualised as a way to reduce infant mortality whilst at the same time provide employment opportunities for poor vulnerable women and a make-shift solution for the health of poor communities. Perceived as natural carers and providers for their communities, these women are often required to go beyond their job specification and working hours, providing informal work which is not remunerated such as support for single mothers, victims of domestic violence, and sexual health.

As is often seen CHW programmes that require CHWs to come from the communities they serve, CHWs work in systems that enable and reproduce gendered vulnerabilities. Informal care work is seen as a women’s domain – this work is downgraded and informalised within the socio-economic system. Similarly, primary health clinics are understood to be a feminine space and often men do not visit. This is compounded by the cultural understanding that men must play a bread-winning role, working during the hours that the primary health care clinic is open. An example of how CHWs internalise and reproduce the norms that they work within was given with regards to the family health strategy – which assumes a binary heteronormative family of man, women and child. In recent years there has been change to make this strategy more diverse and reflective of current households and communities but there has been conservative push back with many CHWs themselves sharing these views.

Finally, João described how there are many obstacles to the discussion about women’s sexuality which has an impact on what CHWs can do in their formal conversations and advice. Women are seen as mothers and daughters and activities to support women’s sexual health is perceived to be limited to vulnerable groups such as sex workers or trans women. Due to religious and cultural norms discussion about sexuality can be very difficult. For example, the use of condoms is not acceptable for married couples. In the same way that heteronormative gender norms limit women’s capacity to provide sexual and reproductive care, they also constrain men in becoming CHWs. Due to sexual politics men are unable to enter homes which prevents them from providing adequate care. This suspicion of men and reluctance for them to enter the household space, is not unique to Brazil and similar dynamics have been seen in Kenya and many other countries.

Gender roles and CHWs in Malawi

Kingsley Chikaphupha from REACH Trust (and co-chair of the Thematic Working Group) gave us examples from Malawi, where there are both male and female Health Surveillance Assistants (HSAs). He highlighted how recruitment of CHWs, is not considered from a gender perspective and because of this there is a large imbalance between the numbers of men and women performing the role. Across all districts there are 30% male HSAs to 70% female HSAs. However, when you look specifically at hard to reach areas within these districts, the numbers are flipped, with 70% male, 30% female.

In hard to reach areas the 30% that are female also appears to be diminishing – this may be due to pressure from husbands to leave the role, or often it is reported that female HSAs leave if they are married to men in who are posted to work in urban settings due to their jobs. In some cases, male HSAs had wives who were posted to urban settings however, they chose to remain in rural areas due to cultural norms that make it shameful for men to be seen to follow their wives.

We heard how this imbalance affects the health of the community as, although both male and female HSAs have the same responsibilities on paper, in reality the division of labour is quite gendered.  In most settings male CHWs are more privileged than women with greater access to supervisory roles and equipment such as motorcycles.

King called for: 1) More gender disaggregated data on CHWs; 2) Greater support for skills development; 3) Gender transformative approaches in CHW policy; 4) Work with broader coalitions to prompt societal transformation, a review of current gender strategies, and the creation of a gender frameworks for CHWs.

Working with CHWs to engage fathers in health, wellbeing, and care

Andre Lewaks of Sonke Gender Justice South Africa, talked us through the MenCare Project,  gender transformative training by CHWs to promote father’s involvement in Early Child Development (ECD).

In South Africa 64% of children don’t live with their biological fathers following patterns that reflect strong cultural and patriarchal norms that promote women as the natural caregiver for children. For every hour of unpaid care given by a man, a woman gives eight. The MenCare Project trained child and youth care workers (CYCWs), provided home visitation programmes and complimented this with onsite mentorship and support of CYCWs.

A mixed methods evaluation of 544 fathers who took part in the project found a positive transformative change in attitudes towards heteronormative care roles and women’s labour. For example, when asked whether they agree with the statement “a women’s most important role is to take care of her home and cook for her family” before the intervention 79% of men and 60% of women agreed. After the intervention, this dropped to 31% of men and 33% of women. Participants also realised father’s roles went beyond provision of financial support and some women also reported that they realised their own role in the entrenched patriarchal mind set of the community.

The project reported that CYCWs had an improved capacity to understand and engage men. Men had an improved ability to express themselves which in turn improved communication between partners and lead to improved sharing of household responsibilities. Importantly, in a context of a high prevalence of intimate partner violence, there was a reduction in men’s abusive behaviour.

Instilling a gender transformative approach to National CHW programmes

Sarah Crass (on behalf of Polly Walker) discussed the gender transformative approaches that World Vision International (WVI) are undertaking through their CHW programmes in Lesotho, Ghana, Sudan and Mauritania. This includes the Timed and Targeted Counselling (TTC) model.

Fathers’ have a huge impact on children’s cognitive outcomes and even the relationships that they will go on to have in later life. Negative father figures can result in early sexual debut and increased childhood pregnancies. WVI’s evaluations found that a key limitation of CHW programmes, is lack of male partner engagement. Through their TTC model men are included by default and indicators for their involvement are included. It uses positive role modelling and healthy family models to engage men in family activities including time to play with their children and take part in other household activities traditionally viewed as women’s work. The model also makes use of male and female CHW pairs in household visits which is beneficial to circumvent norms that may inhibit cross gender discussions.

Through this intervention WVI found that TTC counselling is more productive and results in a greater number of concrete decisions being made if male partner is present. They also found that at the policy level male involvement is inadequately addressed and there is dearth of evidence here. They report that policy makers are aware of this gap and are keen to explore new methods for male involvement in community health as the non-participation of men inhibits early childhood development. Through a qualitative evaluation of the TTC model, they were able to report that male involvement leads to improved sharing of household chores with male partners. Male partners were also reported as more likely to take an interest in mothers’ nutrition during pregnancy and accompany mothers to give birth.

This panel helped to illuminate some of the issues facing CHWs and the communities they serve around gender. It was part of a larger call for greater gender analysis of challenges facing human resources for health which was heard throughout the conference.  For more information on gender and CHWs see our previous webinar on this topic and the REACHOUT blog. If you are interested in community health workers – join our thematic working group by emailing Faye.moody@lstmed.ac.uk.

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Emerging issues related to gender and community health workers

Emerging issues related to gender and community health workers

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By Kate Hawkins, Sally Theobald, Rosie Steege, Maryse Kok, Mohsin Sidat, Kingsley Chikaphupha, Ralalicia Limato, Hermen Ormel, Daniel Gemechu Datiko, Robinson Karuga

To celebrate International Women’s Day the REACHOUT Consortium held a symposium in Nairobi on “women in the changing world of work”. This symposium grew out of a recognition that the sex of the Community Health Worker (CHW) influences their interaction with the health system.

Gender norms also shape CHWs’ different experiences in the course of their work both with households and the health sector. We have argued that CHWs play a critical interface role – connecting the health sector with the community – and although an analysis of the ways that gender influences this was not explicitly built into our research design from the outset, it emerged as an important issue in our REACHOUT context analysis. To investigate further, a Liverpool based Masters student, Woedem Gomez, undertook a literature review on gender and close-to-community (CTC) providers.  REACHOUT PhD student, Rosie Steege is exploring this topic in international policy discourse, as well as conducting empirical case studies in Ethiopia and Mozambique investigating how the health system can best support both male and female CHWs, recognising their differing needs.  We also worked with the Health Systems Global Thematic Working Group on CHWs to hold a webinar to share learning on gender and CHWs in different settings, including Democratic Republic of Congo and Palestine; which triggered further debate and questions.

Based on this learning and the premise that we still have time in the last months of our research programme to further educate ourselves on this area (and at least encourage others to consider from our lessons learned, positive and negative) we decided to spark off the process with a dialogue that enabled our team to engage with other stakeholders in Kenya.

Gender norms and related attitudes and behaviours are not fixed

We heard that gender norms are contextually specific and subject to flux and change through time. Mohsin Sidat (Mozambique) pointed out that many years ago women were not allowed to learn and practice medicine and about 100 years ago female physicians were still exceptional in the medical world. Today the scenario is different and, for example, in Faculty of Medicine of University Eduardo Mondlane where he is Dean they have about 60% female students. This clearly indicates gender roles in medical study and practice have changed.  Nevertheless, for centuries, the role of midwifery has been reserved for women and it continues to be so in recruitment and training of midwives. The midwifery role attributed to women is acceptable in most countries and few men take it up (in Sub-Saharan Africa). However, men and women are trained as Gyneco-Obstetricians and both perform deliveries and the role of men at this level is not questioned. These gender ascribed roles within health sector are certainly historical and perhaps also consolidated by social and cultural norms.

Miriam Taegtmeyer (UK) made a strong case that it is the responsibility of health systems researchers to challenge gender inequities – it is an ethical issue – and one that enables us to contribute to tackling the social determinants of health, as well as harmful practices such as gender-based violence and female genital mutilation.

CHWs are leaders

There is increasing focus on women and leadership in the global community, although this often focuses on leadership within the UN, WHO, donors, national parliaments and universities and is not extended to the community level. Sally Theobald (UK) led us through the global literature in which it has been argued that women may make up 70% of the CHW cadre.

They are arguably leaders at the community level. Unfortunately, although training and salary differ across contexts, female CHWs are more likely to be unpaid than their male counterparts – which is a unacceptable example of gender inequity, with higher level positions often reserved for men. Drawing on research on leadership in the Kenyan system more generally Kui Muraya (Kemri, Kenya) explained that there are social and cultural factors which are a hindrance to women’s leadership. Women’s domestic responsibilities often mean that they do not have the same amount of time for this work which means that these barriers need to be tackled if quotas are to be met.

Kingsley Chikaphupha (Malawi) reflected on how at the recent Kampala conference a community health volunteer (CHV) articulated these issues very clearly. Framing his thinking via the Sustainable Development Goals (SDGs) and in particular SDG 8 relating to decent work, he posed the question: Are we providing enough decent work for women?  He felt that if one were talking about gender and CHWs and all of the unpaid volunteers were women and most of the paid positions were filled by men, then this is a serious problem. If the health system provides decent work to women, there will be no excuse for excluding women from decision making. However, others argued that women having paid jobs doesn’t automatically mean they are heard when it comes to decision-making; in many organizational setting men’s voices are more often heard (they are in higher positions etc.).

Daniel Gemechu Datiko (Ethiopia) explained how (all-female) Health Extension Workers (HEWs) in his setting are paid and that this is a deliberate move to recognise the work of women as part of the health system and empower them by expanding the role that they were already doing for free in the community. Wages cover the opportunity cost of the time that they spend doing this work. HEWs leadership is positioned and explicitly recognised through their role as the secretary for the village committee/leadership, this positon allows them to call meetings, share health related information and to influence their peers. Some HEWs have moved up the career ladder and obtained their diploma and Bachelors degree, and in some cases they have been assigned to health centres and district health programmes. In three years’ time all of the HEWs will complete their training diploma as a matter of national policy. However, there are still very few female supervisors – so although we are paying this cadre of women, there is still a ceiling for them to become leaders among HEWs and until we address wider issues of female education/ gender and culture norms then this will remain a barrier.

In a story from Kenya, Penina Ochollo, explained how she had observed female CHWs taking leadership when it was not offered. A group of female CHWs who had been working for ten years got tired of retired men from the big city dominating in the community councils and pocketing expenses. Through their lobbying one of the local women got elected to the council anddespite being in the minority, it changed the dynamic. She argued that initiatives like this need support and that gender mainstreaming needs to come from county leaders in line with the Kenyan gender mainstreaming strategy which was written in 2006 but has sadly yet to be fully implemented at County or community level. In her reflections, Penina stated that women took up leadership in delivering community health services whilst delivering on pressing household and societal duties – with no financial incentives.

Being a CHW can be empowering but there are gender-related challenges

Penina shared many insights about the trajectory of CHW programmes in Kenya. She explained how the trainings that CHWs receive create changes in their personal and family life. Becoming a CHW enables them to participate in exchange visits around Kenya, to network and attend training seminars which inspire them. They are no longer ‘poor ladies’. Whilst some husbands agreed that there had been positive changes in the home due to this, they were suspicious about home visits, that their wives might be involved in mpangowakando (having extra-marital sexual relationships). This led, in some cases, to gender based violence. The likelihood of suspicion and violence increased proportionately to the CHWs popularity in the community and influence with local leaders. She explained that male CHWs have the potential to influence other men in the community however they were not always received favourably by husbands who were suspicious of their presence in the house – another trigger for gender based violence. Penina argued that there was a need to work with the male partners of female CHWs to ‘sensitise’ them to what the job involves and include them in things like workshops so that they better understand the CHW role and its impact. Other countries, such as Ghana, have chosen for an explicit combination of male and female CHWs at the village level, which also needs special attention on how to address gender and optimize programme outcomes.

Rifat Mafuza explained how in Bangladesh the concept of women’s empowerment is explicitly linked to economic empowerment within the CHW policy. For this reason, CHWs are linked to micro-credit schemes to expand their economic potential and that their interactions with women in the home also cover access to education, legal services etc.

Gender-sensitive policy making and implementation is a gap that needs to be filled

Penina reminded us about the 1978 Alma Ata Declaration and the policy trajectory of primary health care and community health care. As the community health strategy was developed in Kenya they called upon the assistance of women, “they were the rock to move this mountain!” Women were the first choice of CHWs as they were directly affected by issues like nutrition and family planning. Initially women volunteered; it was not a paying job and had no career path. Men were not interested. There was too little attention to gender in the implementation of the strategy and its development over the years. She explained that male involvement has become more and more critical – particularly in terms of support for maternal, newborn and child health. Greater numbers of men are becoming CHVs but the ratio today is still around an 80/20 female to male.

We heard from Sally that CHWs can support change in the community– in terms of the social determinants of health and harmful gender norms – but we don’t always give them the tools or support to do this. This requires the support of the health system through policies related to supervision and community oversight bodies who need to be sensitised to gender-related. Summarising discussions, Maryse Kok (the Netherlands) explained how in community health committees in Kenya there are more males than females but that this is sometimes at odds with the constitutional requirement that no more than two-thirds of elected or appointed public bodies consist of one sex. Even when policies like this exist, their implementation may be slow. Kingsley suggested that when it comes to the selection criteria for CHWs we take our own biases into the process. If we say that women have more caring qualities, we influence the way that clients see male workers which makes it difficult for them to be employed as CHWs and carry out the role.

Salim Hussein (Kenya) returned to this point arguing that we need to mainstream gender inclusivity throughout the community health programme and that CHWs need to be trained in how they can improve gender equity and given messages that they can disseminate to the community. For this to be successful we need to sensitise formal health workers and to motivate and incentivise the leaders so that they have the capacity to advocate for gender equity. Simultaneously we need to assist communities in holding leaders to account. There was a strong plea for more leadership at all levels: from international to national and communities. Carol Ngunu (Kenya) explained that in Nairobi County they are ensuring that traditional birth attendants (TBAs) become CHVs because their experience in these roles means that they understand the challenges and norms in the community – and are an accepted support system that men feel comfortable with. She also outlined that Nairobi county is the first Kenyan county to roll out the gender mainstreaming guidelines in health facilities and the importance of these reaching the community level, including community leaders. She also stressed that there is a need for gender specific targets in health programmes.

The international literature outlined by Sally shows how the CHW role can bring personal harm and risk of sexual and gender based violence. This concern about safety was echoed by Penina and other participants, particularly the risk of sexual and gender based violence as they do this work, which needs to be a priority area to be addressed by the health system.

The contribution of CHWs to sexual and reproductive health and rights

We heard many examples of frontline, cutting edge sexual and reproductive health work by CHWs in diverse settings. For example, Licia Limato (Indonesia) explained how kader (community health volunteers) play a role to support unmarried, pregnant, teenage girls who are highly stigmatised and shamed. Usually, because of social disapproval and laws that prohibit service provision to unmarried women, the family hides the daughter in the house for the full pregnancy, with no ANC checks. Then at the time of delivery they are more likely to use the services of a TBA than the formal system. Because they are ‘of the community and for the community’ kader are more aware of when a young woman is pregnant and isolated. They often counsel parents about the importance of health checks with persistence. Sometimes they take the girls to formal services, mostly to the village midwife for delivery under the cover of darkness.

Rifat (Bangladesh) spoke about the ways in which maternal mortality has been reduced through the provision of safe abortion, or menstrual regulation (MR), services. There is a government regularised system of MR with trained providers. CHWs play a key role in referral of clients to MR services and REACHOUT has been supporting quality improvement to these systems and the supervision of CHWs.

Christine Sammy (Kenya) spoke about the improvements that have been made to family planning, HIV and maternal health services through the involvement of CHWs in Kitui county. The CHVs have been trained in recognising the danger signs and other elements of maternal health. They are becoming referral champions and are monitoring expectant mothers through house visits. By encouraging male involvement more households are saving money for transport costs so that women can go to the health facilities for birth. She emphasized the importance of collaborating with non-state actors, such as LVCT Health, in building the capacity of CHVs in maternal health.

Continuing the conversations

At the recent Kampala Conference we heard from CHWs in India and Uganda that some of their concerns relate to gender. In REACHOUT we believe that as researchers we have a moral obligation to let the voices of CHWs be heard ‘up there’ in national governments and in organisations like WHO. Given the increasing policy attention being given to this cadre of health worker, the coming years bring opportunities to gather and disseminate more information.

We will consider how we can communicate with a larger body of CHWs, policy makers, researchers and practitioners to keep conversations alive. In particular, the SDGs have a focus on unpaid care and there is more that we can do to make the links between this and volunteer labour in the health sector. We also need to look at the working conditions of CHWs as it relates to the concept of ‘decent work’.

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Photo: The image is of Mehret Lamiso at her health post in Becha Kabele, Ethiopia. It was taken by Rosie Steege.

power and prejudice

Power and prejudice: How does inequity play out in the institutions and processes of health systems research?

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This blog explores how power and privilege manifest within the institutions and processes of health systems research.

Co-facilitators Kate Hawkins (RinGS), Roopa Dhatt (Women in Global Health), Sreytouch Vong (RinGS), Rosemary Morgan (RinGS & John Hopkins), Kati Wilkins (Women in Global Health), and Sarah Ssali (RinGS)

Event Date: 16 November 2016

Location: Vancouver, Canada

The room was buzzing at the Global Symposium on Health Systems research with a new kind of energy as conference attendees found themselves in a rare engagement about power and prejudices, in relation to their own professional, political and personal lives. The participatory dialogue opened with a short presentation – with a clear goal – “To help us begin thinking about inequities within research systems, organisations and institutions. To shine a light on persistent weakness in our systems of knowledge generation and exchange.”

Kate Hawkins opened the session by deconstructing her own privileges and vulnerabilities, for example that she is a white, English, cis, heterosexual, middle-class, middle-aged woman, who probably had the fewest years of formal education of anyone in the room.  Her presentation used a combination of sources – news clippings, twitter, and research articles to bring attention to multiple layers of power – related to race, gender, sexuality, expertise etc. – that exist in our organization and institutions. It provided insights from the UK which aimed to prompt thinking from other settings. The presentation challenged the way that those raising questions about class, race, gender etc. in academia often get dismissed as playing ‘identity politics’. It questioned positions of ‘neutrality’ by suggesting that we all occupy political positions even if our positions appear to be the ‘norm’. In relation to health systems research two inter-related concerns rose to the top – researchers have mindset biases that result in them failing to sufficiently consider gender and other forms of intersecting inequity as social norms, and that analysis of the field of health systems research and its governance has failed to adequately take this into account.

Power and Prejudice within Academic Institutions: from the literature

The presentation highlighted the institutionalized sexism within UK academia and how this intersects with other forms of discrimination with regards to race, class etc. For example, a study by the National Union of Students in the UK found that sexual assault is significantly underreported, and “only 4% of women students experiencing serious sexual assault report to their universities” (source @alisonphipps).  Only 15% of scientists in the United Kingdom come from a working-class background (source @hcpearson). UK academia is also racist, in a study by Bhopal of 65 black and minority ethnic academics from the UK and the US a majority “said that they had experienced some form of racism or racist bullying – including all the UK-based interviewees.” Indeed there are only 18 Black women professors in Britain (source @AkwugoEmejulu).

It went on to look at the costs and the benefits of three significant institutions that support progression within academia: conferences, peer review, and collaboration.

Conferences

A lack of gender parity in conference spaces is hard to ignore and is one of the reasons for the protest hashtags that make visible and decry all male panels. But conferences also create exclusions due to unaffordable fees, a lack of childcare, advance payment, abusive border control practices, lack of disabled access, exclusionary communication styles etc.

Peer Review

In terms of citation one piece of research that looked at 1.5 million studies published between 1779 and 2011 found that men cited their own papers 56% more than women on average. Analysing a database containing 25 years of articles from the 12 leading International Relations journals, a study by Maliniak et al. found that over a period of several years, the average number of citations of articles authored by men alone was about 25 while it was about 20 for articles authored by women alone. “This may seem like a small difference, but the average article in the humanities and social sciences hardly gets cited at all — on average, less than once a year — so even these small numbers strongly impact the perceived quality of the work…Men cite men more (including citing themselves) and women cite women more. So, if a field is 80% men and 20% women, then of course the work of men is going to get a lot more citations than the work of women.”

Collaboration

Collaboration is often considered straightforwardly beneficial for all involved. However, we are increasingly seeing analysis that considers North-South collaboration in the context of movements to decolonize education, questioning its benefits to low-income countries. A recent study of collaboration on journal articles found that in economics women suffer a “coauthor penalty”. While women who solo-author everything have roughly the same chance of receiving tenure as a man, women who coauthor most of their work have a significantly lower probability of receiving tenure.  In addition, when women collaborate authorship with men, they get zero credit, because it is assumed that “the man” must have been the expert.

This presentation set the tone for a session about politics that was self-reflective and unveiled a conversation about the inequities that exist in our institutions and processes of health systems research.

Power and Prejudice within Academic Institutions: Participant concerns

Power, prejudices, privileges influence decision making, resources, role and responsibilities at all levels in research. Participants reflected on their own political, professional and personal lives to shift the prejudicial structures and institutional systems that work counter to research excellence, including identifying the weakness in our systems of knowledge generation and exchange. Some of the issues that arose included:

‘Foreign’ Status

We heard that international trainees only get partial experience on health systems courses as there are numerous reminders of how they are outsiders – from the structure of the course work to the low expectations set by being disqualified from post-doctoral positions, as many institutions do not offer positions to foreigners. Additionally, many echoed concerns that academic conferences are often held in countries that are inaccessible either due to regulatory challenges (i.e. borders, visas) or financial barriers (remote locations or costly destinations) becoming a barrier for researchers. Participants also felt that norm setting for academia is dominated by countries in the global north and this results in a system that places certain people at advantages and other at disadvantages.

Academic Processes

Standardized exams (GRE) become barriers to access higher study and promote people with certain privileges – i.e. those with greater financial resources, English as a primary language etc. We heard that in many settings gender discrimination means that women are less likely to be promoted to professorship positions, as it is perceived they will be care takers eventually. Rigidity of academic organizations was considered a problematic issue. Academic and research institutions are founded upon tradition and are resistant to change by design and therefore, certain groups continue to have more power and privileges. In addition, research agendas are set by economic and other interests, not necessarily for social good or interests of the researcher.

Junior Status vs. Senior Status and Ageism

Participants talked about the challenges of being a ‘junior’ member of a research team and being tasked with the greatest work load and then not receiving credit in publications or (first) authorship. We talked about the researcher ‘lifecycle’ whereby one is not valued at early or late stages, therefore, there is a short window of when one is valued within academia leading to discrimination and exclusion.

Validated Research

Given that qualitative research is less validated in certain settings it undermines certain researchers and becomes a form of discrimination on what is considered factual or evidence.

Understanding our own positions of power and privilege

It is common that those who inhabit spaces of power are the ones least likely to grapple with issues of power and privilege – the makeup of the room itself was testament to this. It is important to understand our own positions of power and privilege and how we might use these to dismantle inequity within academia. Questions that were raised include: What types of power does our gender, race, or age give us? How can we begin to shift power imbalances within our own institutions and use our own power to give space to those without it? Those who inhabit positions of power and privilege must not be afraid to unpack these, speak up about it, and use it to challenge the current power structures within our institutions.

Five “S”s emerged as a way forward: 

  1. Self – the individual power and the challenge to ourselves to challenge and deconstruct norms and biases that are discriminatory. We can bring greater visibility and credit to more people.
  2. Space and context – this is the power that emerges from one’s geographical, physical, or other spheres of influence and the ability to both leverage and transform these. This has particular power when it comes to making spaces more inclusive.
  3. Shifting power – it is important to remember the dynamic nature of power in order to work to counter its harmful discriminatory impact.
  4. Systems – power works within systems. Recognizing this is important in designing solutions, whether the barriers are gender, age, financial, policy etc.
  5. Solutions for social change – willingness to change itself is power.  In research settings, data and measurement itself becomes a source of power that we can use to make significant change.

In closing, we agreed, including the participants, to continue this dialogue and have future events to design a way forward.

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