Gender

8 March 2016

Voting with your feet: Gender, power and positionality on international women’s day

In this blog post, we discuss different views on how gender dynamics play out in health systems.

“Voting with your feet” was an ice-breaker for our RinGS meeting in Kilifi, Kenya as a way to get discussions going and make views explicit in our ongoing meeting on gender. We read out the following statements and colleagues stood at one end of the room if they fully agreed, at the other if they disagreed, or alternatively somewhere in the middle.

Here are the statements: all of which triggered participants taking a range of places across the room (which by the way has amazing views over the Indian Ocean!)

Gender roles and relations are so context specific you cannot generalise learning across countries;
It is unfair and inappropriate to expect service providers to mitigate power dynamics between the couple seeing services;
Increasing men’s participation in family planning and reproductive health programmes will only further increase men’s power over women.

On question of context specificity many colleagues were right up against the “yes” wall – citing examples of the ways in which gender roles and relations are inextricably bound with context, down to the detail of Maasai hair styles. At the other end of the room were those who argued that we need to find ways to learn across contexts and that issues of power relations are systemic and apply and are felt by all of us shaping our everyday lives, whether we believe we have power or not. All too often we focus our attention on those we believe to have limited power, while neglecting subjecting the structures and systems that maintain privilege to the rigours of gender analysis and change. Sreytouch Vong from Cambodia stated that “gendered power shapes human resources for health and leadership“; with the depth and detail of context made explicit this is a nice example of the ways in which we can bring conceptual learning on gender across contexts, building spaces and coalitions for joint action on issues of mutual concern.

When discussing the role of service providers in intervening in power dynamics, many thought this is indeed both their role and responsibility. Health care workers within services focusing on family, planning, HIV and child health are better able to see and respond to negative power dynamics and outcomes such as gender based violence and coercion. Others were concerned that health care workers have limited resources, limited time and potentially limited skills to respond to issues like this. Depending on the issue, intervention may exacerbate problems or have negative unintended consequences.

Many thought increasing men’s participation in services which are traditionally considered the domain of women and girls would have positive outcomes such as greater support for women in accessing timely care, more shared and consensual decision making around contraception and sexual health. Others argued that family planning is one of the few areas where women have choices, options and more knowledge and there is danger of men co-opting this and using it to their advantage. Ultimately health care providers working in this area need to be appropriately skilled, supported and resourced.

Going back to question one, the generalisable learning is that health sector can and should be a part of the journey to transform gender power relations and foster people centred care. But this will only work if health workers, including community health workers, working at the front line of care and community health system intersection are appropriately supported. This is also part of a largely social, economic and political endeavour to overcome inequity and encourage change at an individual, social and structural level. The discussions highlighted the role of intersectionality because gender is not the only contour of analysis, but cautioned that we often focus on the disadvantaged who are also powerless and tend to forget the “powerful”. In the sum up of the discussions, we concluded that during gender analysis we have to ask how do key findings resonate with the literature. As a starting point the health sector needs to engage and with and learn from other sectors and be part of a joined up approach to a more gender equitable society. International women’s day is an appropriate day to begin thinking about the ‘how to’ of these challenges.

Participants included: Debjani Barman, Stephen Buzuzi, Asha George, Kate Hawkins, Dorcas Kamuya, Tani Kassimu, Richard Mangwi, Sassy Molyneux, Rosemary Morgan, Kelly Muraya, David Musoke, Ezumah Nkoli Nwakego, Tumaini Nyamhanga, Samuel Okaro, Sarah Ssali, Charles Ssemugabo, Sally Theobald, Sreytouch Vong

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4 March 2016

Community health workers and the gender agenda: answering your questions

by Rosalind Steege, Amuda Baba Dieu-Merci, Hana Rabadi, Asha George and Sally Theobald

As part of a month of events in the lead up to International Women’s day, Health Systems Global’s thematic working group on community health workers (CHWs), CHW Central, REACHOUT, and RinGs, held a webinar: “CHWs: the gender agenda”. There is a blog on the presentations and discussions. The purpose of this post is to answer some of the insightful questions our participants posed.

Chaired by Asha George, JHSPH, the webinar started with an overview from Sally Theobald, LSTM, of the issues and context surrounding gender and CHWs, highlighting their importance in addressing sustainable development. This was followed by case studies from conflict-affected settings, Amuda Baba Dieu-Merci, IPASC and Hana Rabadi, World Vision gave examples from DRC and Palestine respectively. There was a huge level of engagement from our participants from around the globe, who commented on parallels in the roles, challenges and contextual issues demonstrated by our case studies within their own diverse country contexts, from Uganda, Kenya, Nepal, India, Afghanistan to the US.

So, let’s start at the beginning:

What is the composition of CHWs by gender globally?

There is a need for greater reporting here as the evidence base is very dependent on the definitions we use; while an older literature review found that among those studies that disaggregated data, programs were reported to be female dominated, subsequent studies focused on CHWs for sick children found that national programs in sub-Saharan Africa had mixed gender compositions.

What are the benefits/limitations of having male or female CHWs in terms of the specific health activities they can carry out?

A review of the literature shows the need for further context based evidence on how gender influences. In Uganda, CHWs in a RinGs and FHS photovoice project documented that male CHWs perform better, in certain roles such as responding to emergencies, mobilising the community for public health interventions and engaging in manual activities such as clearing drainage of water sources.

However, one of the key issues with having a male or female CHW is client preference for receiving services. One participant offered an example from a CHW programme in Zambia, which demonstrated that clients expressed a preference for receiving services, particularly for sexual and reproductive health services, from a provider of the same sex, and this is echoed throughout the literature. Research from Tanzania showed that male and female CHWs performed equally well in maternal, newborn and child health promotion, but women who were married and had had children of their own were more accepted by other mothers. In this way, it is pertinent to consider the gender in recruitment of CHWs – if the focus is on maternal health it probably is justified to have an all female by policy cadre of CHWs, but in doing this, are we neglecting the role of men in pregnancy and associated care seeking and more broadly the health of the men in the community? The same study in Tanzania found that male CHWs were more acceptable for addressing male health issues, particularly those related to sexual and reproductive health, a study in Brazil found that addressing STIs and domestic violence among pregnant women, could not be done without male engagement.

The next question is one we’re glad came up – are there any tools or policy guidelines to help countries make strategic decisions about CHW gender based on their expected roles and responsibilities and on the context?

The simple answer, to the best of our knowledge, is no. Whilst policies may acknowledge gender responsiveness to an extent in their guidelines, there are no hard or fast recommendations, simply because this is an emerging topic and not enough research has been done is this area yet.

However, it is important gender is considered in policy as the development of policies and guidelines addressing the gendered experience of the CHWs may also aid us in answering some of the other questions that arose regarding scale-up of using CHWs to address gender–related barriers in access to care and the successful integration of CHWs into the formal health sector.

CHW attrition rate and discontinuity in service provision has been a key concern within the industry; how do we ensure programme sustainability and continuity of service provision among CHWs?

Attrition and discontinuity has long been an issue, and whilst it is ultimately an individual’s decision to stop work as a CHW, some of the literature suggests that competing demands on a woman’s time, lack of spousal support and lack of proper remuneration have a role to play. Policies that promote payment of CHWs may also have unintended gendered consequences. In Mozambique, while the revitalized CHW policy had an explicit preference for women, communities selected men because they felt men were more deserving of ‘paid’ work. Similar dynamics were also found in Burkina Faso. Attrition rates among male CHWs in Mozambique are also high, as men tend to drop-out in favour of higher salaried positions to fulfill their ‘breadwinning’ role.

Additionally, supportive supervision is vital in solving this issue, however, when men occupy most supervisory positions, female CHWs often don’t see that they have room for progression, or an obvious career path and may become demotivated. Again, the need for guidelines and policies acknowledging these gender-related challenges would be incredibly beneficial.

Questions about the DRC

What sort of relationship do CHWs have with health facility health workers? Has their increased influence in the communities had any negative impact on their relationship with health workers?

In the DRC normally CHWs have a very good relationship with health facility health workers as the chief nurse is invested in the selection process of CHWs with staff from health district. They have regular meetings with health centre staff to see how they can improve their work. Their increased influence in the communities has very positive impact on their relationship with health facility workers as nurses consider that the population health indicators improve through the work of CHWs. CHWs and health facility workers meet regularly in health centre to discuss, plan, monitor and evaluate.

In DRC, to what extent do community health programmes engage other community stakeholders? Has this influenced community and government buy-in and commitment, and therefore sustainability?

For each different community health programme involving CHWs, different community stakeholders are associated from the planning phase. Delegates from community health committee, traditional institutions and social groups such as women’s groups from different health-centre catchment areas, discuss health problems and try to identify solutions. Then CHWs make a plan to address the problem. This level of ownership means there is a high commitment of different stakeholders, which facilitates the sustainability of the interventions.However, specific programmes, such as Expanded Programme of Immunisation may have greater sustainability issues than others.

Many community health programmes targeting mothers and newborn are donor-funded (and sometimes donor-driven). This raises the issue of sustainability when donors pull out. What are the lessons learnt from the Congo?

Yes, many community health programmes targeting mothers and new born are donor funded and there can be the issue of sustainability when they pull out. However, in DRC, CHWs are not programme-focused, they have a holistic role in the community and are involved in different community-based activities. Furthermore, the CHWs come from the communities they serve so they are willing and committed to helping their communities. Aside from CHWs there are also other measures in place, such as mothers’ groups, which have been highly successful in sustaining the programme.

Questions about Palestine

Relating to CHWs in Palestine’s health system participants were interested to know how CHWs address security challenges during home visits?

The presentation was mainly focussed on CHWs from West Bank, which is considered a less fragile context comparing to Gaza but measures to ensure security are that CHWs have been selected from the same communities they serve so they can easily and safely deliver their services. The CHWs programme in Gaza was only introduced few months ago so there are no clear details as yet however, due to the specific context, the CHWs have been trained on how to shift from normal interventions to crisis interventions and they have also been trained in first aid.

Given that CHWs are predominately women, who are particularly vulnerable in fragile and conflict affected states this is clearly an important area for lesson sharing across contexts.

Regarding the transformative role and empowerment of CHWs as demonstrated in West Bank, participants were interested to find out, whether the empowerment was an intended side effect and what the indicators for measuring change were in the CHWs themselves?

The main aim of this program was to improve and maternal child health outcomes so we didn’t have clear indicators for empowerment at the beginning. The personal changes were beyond our expectations but during the implementation we noticed huge changes regarding community norms, gender and empowerment and we started discussing these changes with the CHWs to learn more about the impact of this program from a different angle. Data was collected from the CHWs and their families through personal interviews only, in addition to our observations.

In Palestine CHWs are now officially registered with the directorates of health supporting government’s health teams in activities such as growth monitoring, vaccination and awareness raising. The transformation CHWs in West Bank experienced is not unique to Palestine with a participant from Uganda commenting that CHWs in East Central Uganda have recognised their role as a potential conduit into local politics. These unintended consequences of CHW programmes are fascinating and would benefit from further exploration.

Participants also recognised the importance of buy-in from other community stakeholders to address health and gender issues and asked: to what extent are other community stakeholders involved in the day-to day activities?

Hana Rabadi commented that in Palestine they have the following groups involved:

Community active groups (CAGs) who support the CHWs when needed
Disaster risk reduction groups (DRR) whose main role is to support and provide services during emergency situations they usually coordinate and work closely with the civil defense
Male and Female faith leaders support in delivering messages and organizing related activities

So there you have it.We hope that helps answer some of your questions, and inspires you to think about these gendered issues in your own research. In the meantime we look forward to welcoming you back for the next event in the lead up to International Women’s day 8^th March. Watch this space.

Supporting the health system to respond to the needs of women in bangladesh: close-to-community health service providers and menstrual regulation

By Ilias Mahmud, Sabina Faiz Rashid, Kate Hawkins, Sally Theobald, Rifat Mahfuza, Sadia Chowdhury, Malabika Sarker

The liberation war in Bangladesh ended in December 1971. It has left many legacies, one of which is the provision of Menstrual Regulation services. Some health systems researchers have described the post-conflict moment as a ‘window of opportunity’ when policy makers and practitioners have space within the flux of change to do things differently. In the aftermath of war in Bangladesh many women were pregnant due to rape by war perpetrators. Menstrual Regulation was a medically reliable, politically expedient, culturally acceptable, morally correct, and humane response to this. Menstrual Regulation is essentially the termination of pregnancy of up to 12 weeks gestation sometimes through Menstrual Regulation Medication (misoprostol) or manual vacuum aspiration.

Menstrual Regulation services continue in Bangladesh, providing legal pregnancy termination services, while abortion continues to remain illegal.Nowadays many different women access Menstrual Regulation services. However, younger, married women are more visible because of stigma related to non-normative sexualities (e.g. women who have extra-marital sex; sexually active single women, young working women, divorcees and widows; and older women who continue to have sex past an age deemed appropriate by mainstream society). While access to services is available, the care pathway to these services is by no means straightforward and is mediated by a number of formal and informal health systems actors. Within REACHOUT we have been exploring the role or close-to-community health service providers in improving access to Menstrual Regulation services and using quality improvement methods to see how they could be better supported in this role.

Accessing Menstrual Regulation services: Opportunities and challenges

Bangladesh has a famously complex and plural health system with a range of paid, unpaid, public, private, formal and informal providers – many of whom cross these categories from time to time. As in many other low- and middle-income countries there is also growing urbanisation in Bangladesh. Through acontext analysis in Sylhet and Dhaka and quality improvement process with Marie Stopes and RHSTEP clinics in Dhaka we have gathered useful insights into how access services could be improved.

Women’s choice of health provider is mediated by: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect, privacy and familiarity. In our study informal providers are usually the first point of contact even for those clients who subsequently access sexual and reproductive health services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding sexual and reproductive health services.

Motivating close-to-community providers, most of whom work for low or no pay, is a perennial problem in many settings. In our study close-to-community providers related that they were motivated by acknowledgement from the community and appreciation from within their organization, their supervisors and bosses. Of course, salary was also a motivating factor. Some said that they felt like ‘invisible men and women’ and there is a perception that if they weren’t there the client would still come to the clinic. This is very hurtful. One of the interventions that we are trialing on our quality improvement cycle is a referral card which ensures that there is documentary proof that someone has been referred and supervisors can see the effort that has been expended on encouraging take up. We are currently analyzing the impact of this.

Close-to-community providers also benefit from supportive supervision in the workplace – as most of us do. We have been working through our quality improvement approach to improve this management relationship and build the skills of supervisors.

So what?

The research that we have done so far has shown that training informal close-to-community providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality sexual and reproductive health (and other) care at the community level.

Building these links and better coordination requires evidence – which health systems researchers are ideally placed to gather. We are working with neglected health workers within the system who are laboring on an issue which is profit based, blurred between private and public, contested and tricky. These close-to-community providers require your support. So, as we head towards International Women’s Day we would like to invite further enquiry into this area and that sexual and reproductive health experts and their counterparts in health systems better collaborate for women’s health.

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26 February 2016

Zika virus, human rights, gender and disability: opportunities to ‘build back better’ health and social systems

By Laura Dean*, Kate Hawkins, Rachel Tolhurst, Eleanor Macpherson, Lee Haines, Daniela Ferreira, Angela Obasi and Sally Theobald

Zika is a disease exacerbated by poverty – risk is not spread uniformly – those who already face extreme social marginalisation are more vulnerable. If you live in a poor area, such as a Favela; Ghetto etc., with limited access to running water, sanitation, rubbish disposal, health facilities and education regarding how mosquitoes reproduce you are likely to be more at risk to vector-borne diseases. Over the next few weeks and months we are likely to witness the release of much more information that keeps Zika being discussed. This blog explores three key, inter-related issues in relation to Zika: gender and power; context and vulnerabilities; and stigma, disability and pregnancy. Zika particularly focuses a spotlight on gender and disability in low and middle income settings (LMICs). In the lead up to International Women’s Day, we believe that health systems researchers should grasp the opportunity to think about how they can ‘build back better’ health and social systems in the wake of this and other epidemics.

Delaying Pregnancy: Gender, power and sexual and reproductive rights

Richard Horton, the Editor-in-Chief of The Lancet, recently highlighted gender as the neglected area in global health, pointing out that it receives inadequate focus within the Sustainable Development Goals (SDG). Much of the messaging that has come in the wake of the Zika epidemic in the Americas seems similarly gender blind.

In her recent blog, Clementine Ford presents the predicament that governments face when associations are presented with potentially disabling congenital conditions (microcephaly), a virus epidemic (Zika), and pregnancy. A recommendation to delay pregnancy for two years, as is being suggested in countries like El Salvador, seems disconcerting to those of us familiar with contexts where abortion is illegal and/or stigmatised and there is a high unmet need for contraception. Sadly, challenges in realising sexual and reproductive rights for women in these contexts are not unique to the Zika epidemic.

There is a need for greater collaborative thinking between decision makers working within patriarchal systems, scientists, and those who these decisions are most likely to impact upon, particularly women of reproductive age. In responding to the growing evidence that suggests a causal link between Zika virus and microcephaly, there is a need to re-open, encourage and maintain focus on debates regarding sexual and reproductive health and rights within the Latin American region. Not only should it be a woman’s right to choose if and when to get pregnant, based on accurate information, but also she should be granted access to the services that enable her to make this informed choice.

Context Matters: Vulnerabilities and Social Marginalisation

Zika virus, and other insect-borne diseases like Dengue and Chikungunya, highlight the troubling health inequity that is based on deprived living conditions. Within Brazil’s favelas, there is a large proportion of single parent families, the majority of which are headed by women. These households are more likely to experience perpetual cycles of poverty as a result of the economic shock of disease. In addition, where children are born with potentially disabling impairments they are often further isolated by limited support or social protection from the government and become reliant on seeking support from the private non-governmental sector if and when it exists. For example, in their recent blog Reed Johnson and Rogeiro Jelmayer present the story of Alice, a baby born with microcephaly, whose parents now ‘spends one sixth of their income on a battery of medications and treatments for Alice’ in addition to the opportunity and travel costs associated with attending medical appointments. Families living in favelas are more vulnerable to arboviruses than those families living in apartment towers that are expensive, well built, screened and elevated well above primary mosquito habitats. This is inequitable.

Currently, Zika outbreak management is focused on mosquito control strategies aimed at reducing mosquito densities (larviciding and fogging) and bite prevention by female adult mosquitoes (repellents). Research into vaccine development and new diagnostic tools is also a global priority. Inequitable vulnerabilities also need to be considered alongside medical and technological advancements if we are to build better social and just systems and environments that reduce the risk of disease.

Disability related stigma: Reinforcement and creation

Since there has been such an increase in media coverage on Zika, several reports of disconcerting new stigmas in poor areas in Brazil have emerged, for example, pregnant women being made to feel stupid for being pregnant. In addition, men have been stigmatised for fathering a ‘Zika baby’ – further reinforcing stereotypical norms related to virility, fertility and machismo – and in some cases leading to the abandonment of their partners and children.

Abandonment of mother and baby due to a child being born with a disabling impairment is not a new phenomenon, nor is it unique to microcephaly in the context of Zika. However it provides another clear example of extreme social marginalisation and stigmatisation that disease outbreaks can create.

In part this is due to the portrayal of Zika and microcephaly within the media. Currently, there is no proven causal link between microcephaly and Zika, rather associations are hypothesised within the Brazilian context. Regardless of causal link or pathway, there is need to think critically about the portrayal of microcephaly and how this can label children ( in some instances before they are born), and (i) reinforce negative social constructs of disability and (ii) stigmatise pregnancy itself undermines one of the most fundamental reproductive rights that women have. The World Health Organisation describes microcephaly as a condition where a baby is born with a small head or the head stops growing after birth. Microcephaly can cause varying degrees of impairment and grouping all or indeed any babies born with microcephaly as ‘damaged’ is a dangerous branding. Nevertheless, babies born with microcephaly, particularly when located in the poorest regions, are likely to need additional access to medical services and social interventions. This cannot be forgotten as causality between microcephaly and Zika virus are further investigated, and focus should also be given to the provision of support and inclusive development for individuals living with microcephaly regardless of cause.

It is our role as health practitioners, researchers and policy makers, to think about what this means for people living with microcephaly and indeed other disabilities and what we can do to create more supportive, enabling and inclusive environments. This is likely to need multi-disciplinary approaches, with a need for social mobilisation. As an immediate priority we should reject the label ‘Zika baby’, just as the term ‘AIDS baby’ was consigned to the dustbin of medical history.

The way forward for gender and disability and the Zika epidemic

Responding appropriately to the Zika epidemic will require us to navigate the landscape of complex reproductive health messaging and service provision. It must be based on strong community engagement, adjustments within the health system to make service more equitable and accessible, and realistic and pragmatic thinking about policy implications, which may require a shift from ideology to evidence and rights. We would argue that this can only occur if new partnerships between epidemiologists, virologists, clinicians, gender specialists, disability rights activists, vector biologists, sociologists, psychologists, and health systems researchers are forged and inform policy. Multi-disciplinary approaches are essential. Furthermore, globally stakeholders who are most affected by disease epidemics need to have their voices heard and drive the questions on equity. It is critical to remember that as vaccines are developed, and scientific links are proven/disproven, human rights abuses related to disability and sexual and reproductive healthwill remain globally and are often felt most by those who are already socially marginalised. This is unacceptable and we must set aside resources to tackle these issues.

* Laura Dean is a research assistant and PhD candidate at theLiverpool School of Tropical Medicine. Her research focuses on equity andhealth systems, with specific interests in gender, disability and community ledinterventions. She currently works with the COUNTDOWN consortium on exploringways that control and elimination of Neglected Tropical Diseases can be moreinclusive and equitable.

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15 February 2016

Why we’re celebrating international women’s day and we invite you to too

By Kate Hawkins, Research in Gender and Ethics: Building stronger health systems (RinGs)

When you work on health there are many international days which crop up during the year. Sometimes it’s easy to disconnect from their origins and meaning. It is International Women’s Day in a month’s time. So I thought it might be useful to reflect on what they day has meant and how we might celebrate it as people who have a commitment to health systems.

Whilst we tend to think of International Women’s Day as an initiative of the United Nation its roots are in women’s labour organizing. “We’d rather starve quick than starve slow,” was one of the slogans used by the International Ladies’ Garment Workers’ Union (the ILGWU) during their strike of 1909 in America. The ILGWU were fighting for improvements in their working conditions, as the factories that employed them were essentially sweatshops.

The strike was led mainly by young, immigrant workers – Jewish women from Russia, Poles, and Italians who conducted their meetings in English, Yiddish and Italian. The call to strike was actually made by a 15-year-old Ukraine-born girl worker, Clara Lemlich. Factory workers were joined in their struggle by some middle class women who offered financialand practical support.

In striking they confounded the mainstream, male labour movement, who were skeptical about their ability to organize themselves, and they defied the state (they were unfairly arrested by the police and beaten by hired local thugs). The ILGWU accepted a settlement in 1910 that improved things like working hours but didn’t give their union recognition. In 1909 the Socialist Party of Americacelebrated International Women’s Day for the first time in remembrance of the strike.

To say that the women were striking for their lives is no exaggeration. In 1911, 146 women employed in a clothing factory died when a fire broke out in their workplace – the Triangle Shirtwaist Factory – the number of deaths was high because of the poor health and safety practices that were employed there.

Promotion of the concept of International Women’s Day beyond the United States was taken up by Clara Zetkin. Later to be adopted by the United Nations (in 1975) with a General Assembly Resolution. However, for many woman workers around the world occupational environments still constitute a hazard to health.

Thinking and acting together to make change

Whilst many people working in international development and global health may celebrate International Women’s Day we don’t often talk about its roots in collective organizing, intersectional struggle, and a radical redefinition of the possible. Thinking about the creation of the Day reminds us that gender equity is not just a nice idea, it can literally be lifesaving. Remembering this heritage is one way of sparking new ways of thinking and new partnerships to address the seemingly intractable issue of gender inequity. This is especially timely as one of the themes of the upcoming Global Symposium is Equity, Rights, Gender and Ethics.

The theme of this year’s International Women’s Day is “Planet 50-50 by 2030: Step It Up for Gender Equality”, with a focus on building momentum for the implementation of the new Sustainable Development Goals. This year we have asked Health Systems Global to celebrate International Women’s Day by running a month where they promote content on health systems and gender equality in the form of blogs, webinars, and a Twitter chat. You can find out more about the Twitter chat on this blog.

The blog series is open to all Health Systems Global members and it would be great to get inputs from a range of countries and perspectives. We hope that there will be active participation across all of the Thematic Working Groups. Please do get in touch and let us know how you would like to contribute.

If you can think of any other ways that we can share information on health systems and gender we are open to your ideas and we look forward to hearing from you.

Photo credits:

Two strikers during the 1909 “Uprising” courtesy of http://labormovement.blogs.brynmawr.edu/ a site dedicated to the International Ladies’ Garment Workers’ Union

At a rally by the International Ladies’ Garment Workers’ Union at the site of Triangle fire, placards in English and Spanish naming Domsey Fiber include “We shall not forget” and “Trabajadores uniodos hamas seran vencidos” pointing to the continuing struggles of immigrant workers.
Photographer: unknown, 1990, Kheel Center

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12 October 2015

Ten gender-related points to keep in mind when you are doing health systems research. This post explores 10 gender-related points to consider in health systems research.

Following RinGs webinar on how to do gender analysis in health systems research, Benjamin Uzochukwu and Kate Hawkins published a blog on Health Systems Global titled Ten gender-related points to keep in mind when you are doing health systems research.

For information visit Health Systems Global or read the 10 points below!

Recently we both attended a RinGs webinar on how to do gender analysis. This is part of the capacity strengthening activities of the project. It is really nice to take some time to hear from colleagues working on health systems around the world and get some space to think through how we can work together to strengthen a gender analysis. RinGs is developing a great deal of detailed material on this topic so we thought we would keep this short and give you our ten things to bear in mind about gender and health systems research.

1. Gender is a key social stratifier: As a power relation it affects vulnerability to ill health and the decision making space and economic power that people have to tackle illness. Access to health services can be effected by gender, for example, women may have less money to pay for health care and find it difficult to travel to a health care centre. On the other hand, sometimes health care centres can be too tailored to women, which puts men off attending.

2. To strengthen health systems we need to pay attention to gender: It is important to understand how health systems components interact with each other, how gender plays a role in each of these, and how to address these gender issues in health systems strengthening activities in order to improve health and social outcomes. Including gender analysis in health systems research help maximise the effectiveness of programmes, lead to better research recommendations, more strategic interventions and programmes and more effective policies.

3. As health systems researchers we need to recognise gender: Expressions of gender inequity -whether in the relations between women and men or within organisations -need to be recognised and addressed in order to redress discrimination and ensure interventions in health involve and benefit the disadvantaged.

4. Sometimes gender issues are rendered invisible: For example, terms like Community Health Worker, village health committees, insurance policies appear gender neutral and yet they are gendered. When we disaggregate data and analyse context and relationships these gendered aspects can come to the fore.

5. There are still issues and confusion about separating gender and sex, especially in analysis: ‘Being’ female and ‘being’ a woman are two very different sort of being. Yet in data analysis, for example, gender disaggregation means separation into male and female. It is not uncommon to see such variables as ‘Sex/Gender’.

6. We need to look beyond the individual: It is important to think about gender relations between couples, families and households. But gender analysis is also about how society is structured, the norms and institutions that guide things and access to resources that flow from this.

7. We need to take account of gender-fluidity: Gender isn’t fixed, it changes across time and across contexts. Looking at gender in combination with race, class and other forms of inequality enhances the analysis.

8. Gender frameworks can help: RinGs has collated what they consider the top ten gender frameworks on their website. They can help us think through what constitutes power gendered relations and how power is negotiated and changed.

9. We should also think creatively about the methods that we use: For example, we could employ social networking analysis of gender issues in healthsystems research in addition to other available tools.

10. Building capacity goes beyond the individual: Ensuring that gender infuses questions about research design, data collection and analysis is important. Researchers need to think carefully about their own positionality. However, we also need to look to those political, social and economic structural barriers that prevent a focus on gender in the first place. What can we – as health systems researchers – do to overcome these?

We call upon our colleagues in RinGs to use the comments function below to add to the list of gender-related points to keep in mind when you are doing health systems research and to keep the conversation live!

*Prof BSC Uzochukwu is the deputy coordinator of the Health Policy Research Group, College of Medicine, University of Nigeria, Enugu-campus. He is a member of the Resilient and Responsive Health System Consortium (RESYST) and Board member of Health Systems Global (HSG).

Kate Hawkins is Director of Pamoja Communications.

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6 October 2015

Ten gender-related points to keep in mind when you are doing health systems research

By Benjamin Uzochukwu and Kate Hawkins*

3.As health systems researchers we need to recognise gender: Expressions of gender inequity -whether in the relations between women and men or within organisations -need to be recognised and addressed in order to redress discrimination and ensure interventions in health involve and benefit the disadvantaged.

Kate Hawkins is Director of Pamoja Communications.

Photo credit: AUSAID / CC BY 2.0

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1 September 2015

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

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 11 12.

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 13 14, 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 17 18.

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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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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30 June 2014

5 take home messages from Pathways of Women’s Empowerment: Beyond 2015

By Kate Hawkins

The life of a meeting report writer is a lonely one. It is easy to get caught up in the energy and excitement of an issue when surrounded by fascinating and challenging speakers. But once everyone has flown home and you are wading through 50 pages of meeting notes, trying to decipher acronyms and cryptic quotes you sometimes feel like you are drowning in a mass of information you will never make legible to those who didn’t have the privilege of attending. So to give myself a bit of impetus and help order my thoughts I have come up with a list of what I consider the top 5 take home messages from the recent Pathways of Women’s Empowerment meeting.

To add to the complexity of synthesising simple messages, the meeting made it clear that there is no single feminist nor a single development actor. Those involved in this field inhabit very different worlds, subject positions, politics, and positionalities. When we sit outside the places that people live and look in on them, we can fail to make sense of, listen to, and resonate with women’s lives. Those caveats aside, here are the messages:

1. That there is a gulf between policy advocates engaged in post-2015 agenda setting and the fears, dreams and demands of many women organising in disparate settings. The skills required to track and influence advocacy at the global level are very technical and a particular cadre of feminists occupies this space doing vital and necessary work. But somehow, post-Beijing, the parallel structures which enable these staff to adequately network with women at the grass roots have been lost. (Re)building this dynamic and organic network of links and entry-points for dialogue is a key priority.

2. There is a translational issue. Women’s movements have been just as good as any other advocacy group in developing clear messages for policy. However, what is understood by the term ‘women’s empowerment’ differs between large development institutions and social movements struggling for justice. All too often empowerment is instrumentalised – as exemplified by catchphrases like ‘gender equality is smart economics’. The reductionism and sloganeering of the development sector sometimes strips the politics out of the work.

3. Feminist networks and monitoring, learning and evaluation experts need to work together. Participants at the meeting decried the difficulty of generating indicators and systems which would allow them to trace the impact of strategies like collective organising and consciousness raising. They also rightly pushed back against a value for money and results agenda which inadequately traces the types of change in women’s lives which women believe are important. More could be done to foster partnerships between feminist activists and progressive evaluation experts who are trialling methodologies such as process tracing and realist evaluation to strengthen this area of work.

4. Research has failed to adequately deal with the implications of global capitalism for women’s empowerment. The global financial crisis has had a very debilitating effect on global policy spaces. At first people with a progressive slant to their politics thought that it would highlight the failure of capitalism and provide an opportunity to create a new world. But the opposite has happened and neo-patriarchialism has been enforced. Moving forward this needs to be central to research agendas.

5.Forging new alliances and intersectionality will be central to the future of feminist activism. The importance of partnering and working together with men, sexual rights activists, the creative industries, workers movements, revolutionaries and legal and religious scholars with an interest in social justice all came through strongly in the meeting. As did the idea that women have complex identities which encompass a number of interests and issues beyond women’s rights. There is a need to be strategic about these alliances and understand that there will be instances where interests do not necessarily collide. Furthermore, women’s movements need to guard against instrumentalising others in the push for women’s empowerment.

I hope that this blog gives a flavor of some of the issues that we discussed. I am relying on my co-author Jenny Edwards to add a bit of oomph to the text I have come up with. And we are planning to bring together some of the multi-media content from the meeting which will make it all the more engaging. Join the Pathways of Women’s Empowerment mailing list to get a notification of when the report and the multi-media contents go live and watch this space for details of how to learn more…

Kate Hawkins is a member of the Sexuality and Development Programme International Advisory Group and the Director of Pamoja Communications.

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21 February 2014

Myth and Reality: New Alliances to Challenge Stereotypes and Build Gender Equality Beyond 2015 – join us for this event

By Kate Hawkins

All over the world women’s rights activists, gender experts, donors, government representatives, and UN staffers are gearing up for this year’s Commission on the Status of Women (CSW) which will take place from the 10 to 21 March in New York. This year’s theme is ‘Challenges and achievements in the implementation of the Millennium Development Goals for women and girls‘: A timely topic that suggests there is still a little time for some reflection and learning, in the midst of the clamour of advocacy to shape the post-2015 agenda.

Where we’ve gone wrong
Whilst there are a multiplicity of opinions about how the MDGs may have supported or undermined the push for gender equality, some central strands of argument stand out:

They failed to build on the progressive thinking and consensus building that occurred in order to construct the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), the Programme of Action of the International Conference on Population and Development (ICPD) 1994 and the Beijing Platform for Action at the Fourth World Conference on Women, 1995. This progress took us from the abstract instrumentalism of ‘women in development’ to seeing ‘gender and development’ as social relations of power and (in/) justice.
At their creation the MDGs did not include a goal or target that explicitly dealt with sexual and reproductive health and rights, but mainly saw women in their stereotypical role as mothers and carers of children. Whilst the World Summit in 2005 recommended the integration of the goals from the ICPD into the MDG monitoring framework their initial omission probably set back action on maternal health over the longer term and meant some issues like sexual rights and access to safe abortion were side-lined.
Within the Goals women were framed as individual agents of economic growth and development, hence the focus on improving access to education, literacy rates and employment. Yet, they did not tackle the potentially negative aspects of fiscal policy, the discrimination and abuse that can be experienced within waged work, nor did they tackle the incredible, soul-sapping, back-breaking burden of unpaid care which women throughout the world shoulder disproportionately.
The framework said nothing about how the world should tackle underlying systems which shape and perpetuate intersecting inequalities in different settings. How human rights might be part of the solution and how we go beyond improving average outcomes to a focus on the most neglected and marginalised amongst us. They say little about power and its workings or paint a picture of a world which is transformed through a new approach to gender.
The MDGs fail to acknowledge the importance of women’s participation (beyond in parliaments), their social movements and their organisations in furthering gender equality and broader social change, let alone what role men might play in the struggle for gender equality.

Working together for change
Calls for a stand-alone goal and the integration of gender throughout the post-2015 consensus are growing in strength. Many are thinking about how these might be operationalised. As part of this process colleagues from IDS will be holding a roundtable at the CSW which will explore the steps we need to take to create strong and sustainable alliances to influence global policy processes, to challenge the myths and expose the reality of gender inequality worldwide. The meeting is part of the Gender, Power and Sexuality Programme, funded by Sida, and is a follow-up event to a multi-stakeholder roundtable held by IDS and SDC at CSW in 2013 on the need to put gender at the heart of the post 2015 agenda. It promises to be a lively and cutting-edge event which will highlight thinking which doesn’t normally find expression in mainstream CSW debates.

Join us in New York – or online
Attend and hear how patriarchy and its relation to intersecting forms of oppression – linked to sexuality, (dis)ability, race, class, ethnicity and nationality – hinder progress on social justice. Debate with panellists what role men’s movements have in gender equality; particularly in tackling gender-based violence and equalising the distribution of care responsibilities. Explore how attitudes, behaviours, and stereotypes about women – both conscious and unconscious – prevent wider social movements from taking gender equality seriously.

This is an event which responds to a desire for change and new ways of looking at the world and how we come together, in partnership and dialogue to build something better. In the words of my colleague Jerker Edstrom,

’We need to think outside the box, to link across social movements to highlight these issues. Many of us recognise the underlying structures of constraint which hold us back, but there is a need to create alliances to make changes in policy and practice which have real resonance.’

Event details
Speakers: Hazel Reeves (writer and women’s rights activist), Gary Barker (Promundo), Jerker Edström (IDS), Zahrah Nesbitt-Ahmed (IDS) and Mariz Tadros (IDS)
Chair: Andrea Cornwall (University of Sussex)
Date: Wednesday 12 March, 12:30 pm
Venue: The Guild Hall of the Armenian Convention Center, 630 2nd Ave (at 35th Street), NY

If you can’t attend in person, follow us on Twitter #CSW58GPS or follow the proceedings online after the event.

Kate Hawkins is a member of the Sexuality and Development Programme International Advisory Group. She is the Director of Pamoja Communications and recently co-edited Women, Sexuality and the Political Power of Pleasure.