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.
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.
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.
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.
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.
Indicators should be sex-specific, sex-disaggregated, and related to gendered power relations and systems, enabling a better understanding of gender dynamics.
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.
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.
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.
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.
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.
Progress should be tracked in real time, and responsive actions must address the specific challenges faced by women and girls.
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
In this blog post by Kate Hawkins, Saugat Pratap KC, Shreeman Sharma, Sophie Witter, Karen Miller, Jo Raven and Shophika Regmi, we report from the HERDi learning site in Kapilvastu, Nepal where ReBUILD for Resilience is implementing embedded health systems research.
“Nobody could have imagined the impact that COVID-19 created. I have been working as a paramedic for 25 years – I have seen floods and outbreaks. We did have small disaster management plans, but we were not prepared for the pandemic.” Siddhartha Kaji Bajracharya, Health Post in-charge
A recent visit to Kapilvastu, one of the districts in Lumbini Province of Nepal was an opportunity to hear from municipal elected officials of Kapilvastu Municipality (including mayor, deputy mayor and ward chairs) and health workers on their experiences during the early months of the COVID-19 outbreak in 2020. Their stories demonstrate the resilience of a local health system under strain, as well as the challenges of emergency planning, especially in a decentralised context, and important recommendations for institutional and structural changes.
The REBUILD team hear from those in the municipality involved in the COVID-19 response
When the pandemic hit, Kapilvastu, along with many local government authorities all over the world, found itself unprepared – in terms of human resources, medicines and supplies, infrastructure and information systems, with no obvious mechanism to generate the types of evidence that could help guide the emergency response.
Initially there was little federal guidance on how to respond. In this liminal space, local people had to make quick decisions about how to manage the crisis – innovating and adapting as COVID-19 unfolded.
Governance and communication
At the start of the pandemic there were no official updates through the usual federal government channels. In the absence of formal guidance, health workers and managers found information online, through Facebook and other global sites. While there is the potential for this type of source to broadcast dis- and misinformation, health workers were struggling with how to respond and counsel their constituencies. It was through online sources that they learned about aerosol transmission and isolating people suspected of having COVID-19.
They described chaos in their decision making in a context of rapid threat and information and resource gaps. To overcome this, local-level decisions had to be made by elected representatives as the situation evolved. Some of these decisions may not have been strictly compliant with the federal level but local actors were trying to avoid ‘unmanageable human catastrophe’, and this was made more challenging by the open border with India.
Kapilvastu Municipality formed two Rapid Response Teams that each comprise five team members. One was led by a health facility in-charge having a large catchment area, and another was led by a municipal health coordinator. The other team members included a nurse, a lab technician, a health assistant and an auxiliary nurse midwife who worked closely with the ward chair. Kapilvastu Municipality has 12 wards. The ward chair is the chair of the Health Facility Operation and Management Committee (HFOMC) in each health facility at ward level, and the Health facility in-charge is the member secretary of HFOMC, and together they quickly mobilized the Female Community Health Volunteers (FCHV). Municipality and ward offices, in coordination with local health facilities, enforced COVID-19 strategies at the local level. For health communication, FCHVs were mobilized, having the support of their communities and particularly close relationships with women and children given their work on maternal health and immunization.
Female Community Health Volunteers (FCHVs) and ReBUILD staff at Jahadi Health Post, Lumbini Province, Nepal
Medicine and supplies
Sourcing test kits and PPE during the initial stages of the pandemic was challenging. Local stakeholders didn’t even have masks at first, and were conducting house visits while frightened of potential infection and the possibility of harming their own families. They described attending patients without even a thermometer to assist with diagnosis. When test kits finally did come through, the PCR results were processed in Kathmandu and took 30 days to come through and this long timeframe hindered planning and action. When PPE did arrive it wasn’t fit for purpose. Health workers described taking 300-400 swabs a day in 35 degree heat inside stifling PPE that couldn’t be removed until the day was over.
Infrastructure
Local-level decision-makers were tasked with opening quarantine centres for people who they suspected were infected with COVID-19. But this was easier said than done as they had no existing infrastructure to use and they were unsure how to isolate people. In the end, they used the school buildings that were closed due to lockdown and quarantined more than 5,000 people in 12 wards. When the weather allowed, people from the isolation centre could stay in the fields outside, but when the heat and rains came there was a serious lack of space inside the building. They also had to run toilet facilities where none had previously existed plus the schools were not accessible for people with disabilities. Caring for Nepali migrant returnees from India was also a challenge as they didn’t have family members to bring them food every day, or had care takers who lived far from Kapilvastu. This problem was compounded by food shortages at that time. The health workers were also impacted by this and had to work throughout the day fuelled just by fruit, with most shops closed during the lockdown.
Health information at Krishnagar border health facility
On the Nepali-Indian border the arrival of people from India was also an issue. Potentially infected Nepali people were returning home and needed to be tested and cared for, so a new border health check was created at Krishnagar border. At the peak of the pandemic, staff (who themselves fell ill) tested around 300 returnees each day, issuing each infected person with care information. Unfortunately, the majority probably got straight on to public transport, spreading the infection further. This testing facility continues to run, supported by international NGOs, the EU and Kapilvastu Kids, however the nearby new quarantine facility remains unopened due to a lack of funds. (Another problem was migrant returnees entering Nepal via unofficial, unregulated transit points and not being tested.) The border health desks still test for COVID-19, TB, malaria and HIV but on a purely self-referral basis, and samples still need to be sent to Kapilvastu for screening, raising questions over patient and contact tracing and treatment.
Human resources for health
The COVID-19 response relied heavily on the health workforce; a workforce already understaffed and under strain. When these health workers themselves got infected with COVID-19 this was a significant challenge. In one of the health posts all of the staff were infected and it had to be shut down altogether. The Nepal Police helped with the response, managing the food provided in the quarantine centre and how funds were allocated for this. There was adaptation in the absence of guidance to try and ensure that the poorest were targeted, but because of the lockdown it wasn’t possible to launch a multi-sectoral approach and NGO staff stayed at home until much later in the pandemic.
Local health facilities struggle to provide routine health services on a good day and this was further aggravated when there is an emergency. For instance, Kapilvastu Municipality has five primary health centers, but not all sanctioned positions have been filled. Also, around 40% of the municipality’s population live in just four of twelve wards, and with just two health workers to deal with around 9,000 people in each ward the situation is very challenging. Furthermore, Kapilvastu is prone to disease outbreaks due to several socio-economic and geographic issues. During shocks like COVID-19, local health systems have trouble meeting routine health demands with such emergencies exacerbating the issue. Therefore, the resilience of the local health system is a pressing issue in Kapilvastu Municipality.
Looking to the future
The health system was heavily impacted by the pandemic. Immunisation, family planning and nutrition services – the foundations of primary health care – were all put on hold for more than three months. Data collection ceased. When services did resume they took time to get up to speed. In rebuilding the health system, lessons from the outbreak have been incorporated into practice and longer term aspirations:
Communication during the pandemic cemented the importance of mobile phones. Now the health posts have access to the internet which was not a priority before. Better communications are a key priority for the future.
In terms of infrastructure and medical supplies, the first stage of the emergency highlighted the need for greater testing and lab capacity, and the scarcity of oxygen in the second phase taught the importance of strengthening hospital care.
The pandemic highlighted how health emergency decisions by federal governments, such as the decision to impose a lockdown, may have hampered local level coordination and action. Stay-at-home orders prevented a truly multi-sectoral approach and led to a reliance on the police and army where other sectors might have been more appropriate. Restrictive measures based on the local context may be more appropriate.
During the emergency, the mayors had informal conversations and there was a formal inter- and intra-municipal sharing process. However, there were no mechanisms for sharing lessons learned across municipalities and communicating these stories of adaptation from one local level to another local level and from local level up to the provincial and federal governments. This is still lacking.
Most of the local level health budget is conditional and this potentially restricts decision making space which is vital in emergencies (although there was a pot of flexible emergency funding that could be used in emergencies). Progressive flexibility could be considered in times of extreme hardship.
ReBUILD with HERD International will continue to document the lessons from the COVID-19 experience, working with municipal partners to identify ways to strengthen the resilience of the local health system, building on the capacities identified and the gaps (for example, around communication), and to share those lessons with other areas and with the district, provincial and national authorities.
This book could not have been launched on a more befitting day, International Women’s day 2022. The authors and editors of the book are a bunch of brilliant, erudite women, well versed in global health matters. The book is a rallying call to arms to redress gender inequality and celebrate the many ways in which women are taking the lead in supporting the health in their communities. The launch was a very timely, as it presented an opportunity to celebrate women taking lead in supporting the health in their communities and their historic contribution.
This book is a first of its kind as it fills the gap in the literature. At a time when women are experts in global health but their professional experience and diverse perspectives are not valued sufficiently to guarantee them an equal place in leadership, the launch of this book is incredibly apt. Women held only 25% of leadership roles in health before the pandemic and women from the global south are further under-represented yet they make up 70% of the workforce. The frontline response of the pandemic was 90% women.
The establishment of root drivers of inequality and driving systems’ change are some of the key themes in the book. The book is inspired by partners, movements, organizations and communities that have been working to advance gender equality and spotlight women’s leadership.
A lot of ground has been lost with the onset of the pandemic and since this book went into production. A look at WHO’S Executive Board, the percentage of number of women that hold these seats went from 30% in early 2020, to 6% in January 2022. This is a reflection of where power is being shifted. This book highlights the many forms of leadership and demystifies social norms that reinforce the myths that men are natural leaders and women are destined to be followers.
Women in Global Health propose a four-point framework for change to support women’s leadership. First, governments must build the foundation for equality. Secondly, addressing social norms and stereotypes that drive gendered segregation. Third, is the need to address systemic inequalities and bias in work places and culture that favors men for leadership roles. Finally, enabling women to apply for leadership positions equally and on merit.
The book compiles research evidence examining barriers and facilitators to women’s global health leadership. It showcases personal, professional and political journeys to leadership of women across global health sectors. It additionally offers pragmatic solutions to increasing women’s representation in global health at different levels. It is a labor of love consisting of contributors and interviewees from 17 countries and six regions; hence providing a diversity of voices globally.
The book was inspired by a question that sought to find out:
“Why despite women representing the majority of people working to improve health outcomes in communities, non-governmental and multilateral organizations both as paid and unpaid health and social care workers, the existing governance system privileges men and what can be done to redress the imbalance?”
It takes its readers on an exploration of leadership roles that women currently play in global health and teases out the routes that women have taken to leadership. It also explores the challenges that these women have faced and things that have facilitated their journeys.
It brings to the fore stories of women on the frontlines of this struggle from around the world highlighting and complimenting these stories. It buttresses this with theoretical and analytical explorations of the structures and systems that help or hinder the process. The authors engaged ministers of health, policy makers, practitioners, academicians, students, researchers, healthcare workers, health service managers and members of multilateral organizations.
By highlighting key barriers and facilitators to women and global health leadership, the writers hope that organizations will use this book to help inform the development of institutional policies and procedures to support women in leadership positions across academic, health workforce and global health governance systems.
The editors too had a heartfelt word for their readers:
“We hope that within the pages of this book you will find information, inspiration and hope for how you can play a part in changing systems that no longer serve us well: information about women’s leadership experiences, inspiration from women leaders themselves, and hope for leadership systems and structures which are more equitable and just-leadership which places the most marginalized at the center and purposefully works towards positive change.”
The International Conference on COVID-19 2022 was hosted by BRAC James P Grant School of Public Health (JPGSPH) and the Bangladesh Health Watch (BHW). This was an opportunity to discuss, debate and document experiences of the COVID-19 pandemic across low-and middle-income countries. Lynda Keeru and Kate Hawkins report back.
The conference covered:
Evidence and lessons learned from the pandemic, which populations were impacted the most, livelihood and health vulnerabilities
The response of governments and health systems to containment and vaccine delivery
The effects of risk communication and the efficacy of local and national level data systems to aid and guide government decision-making
In the opening speech, Matshidiso Moeti, WHO Regional Director for Africa painted a very clear picture of the current situation:
“There have now been more than 10.4 million, that is almost 10 and a half million cases, of COVID-19 and over 234 000 lives sadly lost in Africa due to the pandemic. Vaccination remains our best defense against severe illness, death and overwhelmed health systems, along with other WHO-approved prevention measures, such as wearing masks consistently and correctly, as well as handwashing. So long as the virus continues to circulate, further pandemic waves are inevitable. Africa must not only broaden vaccinations, but also gain increased and equitable access to critical COVID-19 therapeutics to save lives and effectively combat this pandemic. African countries face major impediments in accessing a full range of COVID-19 treatment, due to limited availability and high costs. The deep inequity that left Africa at the back of the queue for vaccines must not be repeated with these life-saving treatments. Universal access to diagnostics, vaccines and therapeutics will pave the shortest path to the end of this pandemic.”
Speakers captured the situation in different contexts and offered recommendations from their divergent experiences. A selection of these presentations are highlighted below.
Caroline Kabaria: COVID-19, A driver of marginality in Nairobi’s informal settlements
Caroline presented work under the ARISE project. In Kenya research is being conducted in Korogocho, Viwandani and Mathare informal settlements. Slum statistics are often invisible/usually hidden in usual statistical sources such as the census. They are often lumped together with the general urban population in the data. This makes it hard to understand the actual situation of the urban poor who live within communities in the city. This can imply that slum communities are doing better than they really are.
There is a lot of danger in misrepresenting slum statistics by averaging with the regular urban statistics. For example, coverage of vaccination of children can appear as very high within urban areas, but within the same city in the slums, it is quite low. Providing municipalities, city managers, countries, NGOS, donors and policymakers with more granular data, helps them to prioritize interventions and investments.
Slum dwellers really depend on pharmacists and private providers with less utilization of public facilities. Most of the population spends out of pocket for consultation, medicines and other medical expenses. COVID-19 had a big impact on this population because majority of residents rely on the informal economy and staying at home meant losing their jobs and sources of livelihood. The pandemic disrupted this community’s access to healthcare and the lack of appropriate information on COVID-19 only made the situation worse. Many of the slum dwellers are illiterate and they reported difficulties in interpreting the COVID-19 messaging.
Recommendations:
There is a need for financial and risk protection innovations due to high out-of-pocket expenditure. It is also necessary for health systems and practitioners to collaborate with other sectors. More bottom up leadership approaches are needed. It is very important to empower communities to demand accountability from their leaders and service providers. The quality of primary health care and its linkages with allied and tertiary services is of utmost importance. Disaggregation of the deprivation of slum residents makes it easier to highlight issues of importance for people who live in slums and focus attention on these issues for policy makers. Caroline reiterated that investments in policies, programs and research requires slum-specific data systems.
Brunah Schall: Sexual and reproductive health during the COVID-19 pandemic in Brazil
Brunah’s presentation focused on sexual and reproductive health during the pandemic in Brazil. The neoliberal reforms introduced in 2016 reduced investments in the national public healthcare system. There was an uncoordinated response with the federal government pursuing heard immunity as a strategy and invested in an ‘early treatment kit’ that has no scientific basis. Preliminary results of research indicate reduced and closed sexual and reproductive health services, high attrition of sexual and reproductive health professionals, interruption of (infertility, breast and cervical cancer) treatment and investigation and difficulty in accessing pre-natal services among others.
Recommendations:
The study illuminates the importance of real-time data in order for policy makers to act. Circulation of correct information is key to avoid misinformation and the damage it causes.
Lilian Otiso: How Kenya’s health system adapted to COVID-19
The Kenyan government response, like many other countries, included national curfews, restricted movement in some counties, closure of (schools, bars and restaurants), fewer people on public transport, compulsory wearing of masks and people being asked to stay at home. Albeit with a few challenges, the health system’s response to the pandemic was quite efficient. It took a multisectoral approach with the coordination led by the government. There was a lot of community involvement, particularly by bringing on board community health workers who bridged the gap between communities and the health system.
The country ran major information campaigns with centralized real time data that recognized the needs of the vulnerable. The pandemic provided an opportunity and many innovations were coined such as digital technology (e-learning, remote working, online meetings, tele-consultations, tele-counseling), local manufacturing (PPE, beds, ventilators), courier services to deliver drugs and multi-month prescription for chronic diseases.
Even with the many impressive innovations, there were challenges. The poor, vulnerable and marginalized were left worse off. There was limited access to other health services, misinformation about the pandemic that spread, mistrust of the government by the citizens, increase in gender based violence and teenage pregnancies and a rise in mental health challenges. Noteworthy, most of these challenges were addressed by involving community members in the response.
Recommendations:
Successful efficient health systems responses to pandemics require public health responses with government coordination and multi-sectoral engagement. Community engagement is critical to address trust and misinformation in order to reach the vulnerable and encourage accountability. Health systems must encourage and nurture innovation as a means to remaining adaptive and resilient.
Sushil Baral: Rethinking primary healthcare after the pandemic
Health is a fundamental human right and Universal Health Coverage (UHC) is critical to achieving this right. Strong primary health care is the foundation of quality health systems that lead to UHC. UHC aspires to achieve good quality healthcare for everyone without them incurring financial hardship. Primary health care is important in bringing this goal to life because it is the first level of contact for individuals, families and communities with healthcare. It is an integral part of a country’s health system as it focusses on the health and wellbeing of its people including their social and economic development. It is important for quality healthcare to be available and at a cost that the community and country can afford to maintain at every stage. It should be practical, scientifically and technologically sound, socially acceptable and accessible to individuals and families.
Strengthening primary health care is a ‘hard grind’ task that involves multiple sectors and requires strong leadership. Adaptations that were made in health systems during the pandemic are unlikely to last if basics are not addressed. Continuity should remain a priority. Finally, the health workforce and community are the most fundamental elements to primary health care robustness and a lot of investment must be pumped into them.
If a paradigm shift is not taken, there is a real danger that COVID-19 will increase inequalities.
Recommendations:
The pandemic’s response to this crisis must be designed to mitigate this by taking account of the ways in which some people bear the brunt of multiple impacts. Those hardest hit by the pandemic tend to be those already most disadvantaged. In order to recover, policy must also take a long-term view and consider the long-standing impacts of the pandemic.
To mark UHC Day 2021, THET joined forces with Action for Global Health and Students for Global Health to call for Health Equity for All on this webinar ‘HEAL: Together for UHC’. Lynda Keeru and Kate Hawkins from Pamoja Communications reflect on what was said.
Ben Simms kicked off the webinar by reflecting on 2021, the second year of the pandemic. He said that COVID-19 exposed many existing inequalities, such as the harrowing ongoing vaccine inequality. There is a silver lining to this as it brings to light some of the inequalities people were not aware of, which he said was a useful thing, because by naming it, the journey to address it can begin. The pandemic has torn apart the world in so many ways, threatening decades of development progress. He challenged the webinar participants to think about how to find optimism that is so necessary in order to move forward. The greatest ray of hope is health workers and their commitment; as seen in how much they have stretched and worked so hard; not just in their day jobs but reaching across borders to express solidarity with each other.
The pandemic has forced people to have a much broader notion of who a health worker is, as people came to the realization that a huge coalition of people is needed to advance Universal Health Coverage (UHC). The HEAL Campaign brings together health workers prepared to speak out and make their views heard.
Power in partnership: Sonia Akrimi noted that the lessons learned are opportunities for progress; and that it is important to make sure that these lessons lead the actions taken and help develop strategies going forward. There’s need for a united response for this; all governments, policy makers and all healthcare systems and workers must be working together internationally to move the global situation forward. There is a lot of power in partnerships and how they can adapt and enforce meaningful change.
Overcoming inequality: The inequalities revealed and brought about by the pandemic have seriously hampered progress made towards achieving UHC as highlighted by Jose Manuel Barroso. About 8 billion doses of vaccines have been administered so far worldwide; enough to protect everyone in the planet, yet that’s not what has transpired. The vast majority of those vaccines have been administered in the world’s wealthiest nations. So while 70% of the population have been vaccinated, only 6-7% of the population in low-and middle-income countries have received their first shot. This inequality is not only morally wrong, but it is also preventing effective management of the pandemic. Ensuring that people all over the world have equitable access to vaccines and that countries have the capacity to distribute them, is the fastest way to end the crisis and set our economies on the road to recovery.
A focus on gender: Roopa Dhatt argued that gender equality must be hard wired into UHC. UHC will only be universal when it reaches everyone. Women face multiple barriers to accessing health services and for this reason, health services under UHC should be allocated according to health needs to address the distinct needs of women, adolescents and girls. UHC must be gender responsive and address gendered determinants of health and the root drivers of gender inequities. This includes ensuring gender equality in the health workforce.
Dealing with fragility: Sally Theobald reiterated that UHC would not be achieved unless there’s a focus on fragility. Fragile contexts are critical and are growing and we must concentrate our efforts there if we are serious about gender, equity and justice.
As we begin 2022, the priority has to be on redoubling efforts to make up for lost ground and building back better. This will bring the world closer to achieving the Sustainable Development Goals.
The President’s Lecture 2021 webinar hosted by RSTMH brought about some thought provoking conversation and presentations from Professor Sally Theobald and her colleagues, Abriti Arjyal, Bachera Aktar and Zeela Zaizay.
The webinar was a great opportunity to share learning on analysing and addressing intersecting inequities in global health across different contexts, projects and health issues. The presentations demonstrated the power and the potential of social science, participatory process and co-production processes for change.
The event highlighted three different projects that focus on three different types of neglected areas. These are neglected countries: particularly fragile and shock prone contexts, neglected communities in urban informal settlements and neglected health issues or conditions like neglected tropical diseases and stigmatising skin conditions.
Metaphors exert a powerful influence on our daily lives and Sally used a very significant one as she launched her speech. We are all in the same storm, but we are not all in the same boat. COVID-19 has demonstrated that we live in an interconnected but unequal world. We are differentially positioned in terms of our vulnerabilities to the pandemic. COVID-19 has been seen as a spotlight that amplifies the existing inequalities; exposing and often exacerbating these inequities.
In the UK, black and minority ethnic groups and people living in cramped conditions have been particularly adversely affected. The pandemic has also impacted and exacerbated how inequalities play out on a global stage.
Engagement with a community health volunteer (CHV) in the photovoice process in Foyah District, Liberia. Photo: REDRESS
Neglected Countries
ReBUILD for resilience research consortium works in partnerships in Sierra Leone, Lebanon, Nepal and Myanmar. They focus on fragility in health systems because 2 billion people around the world live in fragile and conflict affected settings (FCAS). The number of poor people living in FCAS is expected to rise 60% from the current 17% according to projections from the World Bank and other organisations. These settings experience multiple health challenges that emanate from severe resource constrains, multiple shocks and stressors to the health systems like the COVID-19 pandemic, weak and contested institutions, as well as the absence of reliable routine data.
The ReBUILD consortium has a resilience framework which focuses and grounds health systems; and views them as complex adaptive systems with gender, equity and human rights also being central. Sally explained the intricacies of how all this works together to underpin ReBUILD’s work and focus on health systems strengthening and access to better health.
Human resources is a key area of focus and particularly, community health workers (CHWs). CHWs are critical bridges between often neglected marginalised rural communities and health systems. They have proved to be essential, trusted and first-line responders providing health services in settings affected by conflict; often juggling many different programmes. It is the cadre every vertical programme wants to link and work with; resulting in a host of responsibilities. COVID-19 has brought new challenged and layered additional responsibilities for them.
Abriti Arjyal presented findings from the consortium’s study; the gendered experiences of community (CTC) providers in Fragile and Shock Prone Settings: Implications for Policy and Practice during and Post COVID-19. The most vital information she shared is the fact that these cadres play an important role in the COVID-19 response. Their experiences and challenges are shaped by existing gender norms and challenges. Thus, understanding these and incorporating these in design and implementation of community health programmes would not only ensure effective roles of female CHW but also broadly serve to amend existing gender inequities among community providers.
Female Community Health Volunteers (FCHVs) gathered to plan for a community health campaign. Photo: HERD International
Neglected communities
Countries are urbanising fast and in cities one in three people live in urban settlements. Speaking about the ARISE consortium work, Sally mentioned that cities face innumerable challenges. Some of these include housing, food insecurity, water and sanitation, pollution, access to healthcare among others. Most of these are caused by long-standing neglect from states as well as residents’ limited voice and power.
Cities illustrate some of the world’s darkest disparities in income, health and wellbeing. The presentation spelt out the consortium’s vision and how they carry out their work; referencing Bangladesh.
Bachera Aktar, who presented on the Bangladesh ARISE work, indicated that new vulnerabilities and vulnerable groups emerged during the pandemic with anticipated impacts into the post-pandemic era.
COVID-19 has generated new challenges impacting the broader social determinants of health and wellbeing. Bachera summarised the diversity of methods and approaches they have used to support the co-production of research with peer researchers and communities living and working in informal settlements. She highlighted the importance of ongoing community engagement to support translating research into action.
Neglected conditions and diseases
The aim of the REDRESS project is to use a person-centered approach to evaluate existing health system interventions for the management of severe stigmatising skin diseases in Liberia. People centered approaches are at the heart of REDRESS; meaning consciously adopting the perspectives of individuals, families and communities; seeing them as participants as well as beneficiaries and responding to their needs and preferences in humane and holistic ways.
Zeela Zaizay spoke about the community engagement, involvement and participation that they have been using in REDRESS in Liberia. Community engagement in this setting facilitates problem identification, design, planning and implementation of programmes.
He outlined key priority areas in REDRESS including establishing community advisory boards and a Ministry of Health technical advisory board; involving people affected by severe stigmatising skin diseases and other community actors as peer researchers, using participatory methods to elevate and listen to community voices and ongoing sharing of learning.
Lessons learned
The pandemic has indeed illustrated that no one is safe until we are all safe. There is a need to understand disparate voices, perceptions and knowledge hierarchies in making decisions. Combined efforts are called for to promote key issues such as vaccine inequity and reviewing existing structures and systems around key issues like funding and vaccination politics.
Teamwork and partnership are essential for strengthening and supporting health systems that are inclusive, people centred and built on the diverse views, perspectives and experiences illustrated in the presentations.
There is a need for continuous discussions on challenging knowledge hierarchies and applying the use of innovative research methods including social science and participatory knowledge to build partnerships and action and equity.
This blog by Lynda Keeru reports on the launch of the Alliance flagship report on learning health systems. During the webinar, participants heard an overview of the report, comments from a people who put together the report, as well as the thoughts of an esteemed panel on the report.
Reflections of the flagship report
During his introductory remarks, David Peters said that the report pushes forward the field of health systems strengthening and health policy research. He noted that it focused on the core ideas of cognition, action and learning. The report emphasizes the underlying role of learning at individual, organizational, cross-organizational levels within systems and explains how critical it is. It highlights learning in its multiplicity of meanings, and it helps its audience to understand what is needed for health systems to be effective, pursue goals of equity and to be sustainable.
There is greater appreciation for the need to strengthen health systems, including those in crisis situations. However, there is still a lot to learn about how to strengthen them and there are no magic bullets. Over the decades, descriptive frameworks have been developed culminating in complex adaptive systems approaches. This is coupled with a focus on resilience and how health systems can bounce back from stressors such as pandemics and disasters (both economic and social). However, for many health systems, bouncing back to an equilibrium is not good enough. Many are low performing; which means that they are either inequitable, of poor quality or they are unaccountable.
This report is therefore vital as it provides lessons on how to improve the performance, growth and sustainability of health systems. It places emphasis on continued learning and actions as a means of developing stronger, more effective, equitable and accountable systems that continue evolving.
Soumya Swaminathan explained that the report comes at a critical time for health systems all over the world because of the impact of the pandemic. The emergency response has given birth to many innovations. The reason this report is crucial is that it explains how a learning health system should use data from the field and the skills of epidemiologists, clinicians, public health experts and data scientists. A learning health system also listens to voices of people from the community and takes all those inputs into constantly trying to improve and deliver programs in a more impactful way.
COVID-19, the modern world’s first pandemic has wrought many negative effects. Everyone around the world has been dealt a bad hand. However, some people have had their circumstances profoundly aggravated by COVID-19. Lynda Keeru and Kate Hawkins explore how COVID-19 and subsequent vaccine rollout has affected persons with disability. This is a summary of a workshop (Vaccine Distribution and Disability Inclusion) organized by the CORE Group’s Disability Inclusive Health TAG.
There’s estimated one billion people in the world that live with disabilities; 80% of whom live in low- and middle-income countries. The speakers in this webinar, gave insight into how to build an inclusive COVID-19 response particularly when it comes to the distribution of vaccines.
Disability and health services
Mohammad Iqbal from Pakistan explained that persons with disabilities are a very vulnerable group when it comes to COVID-19. He cited a study that revealed that the COVID-19 mortality rate is six times higher for people living with disabilities. Persons with disability are often ‘invisible’ in big government programmes and initiatives which impedes their ability to access services. Stigma associated with disability is also a contributory component of their vulnerability.
The COVID-19 response has obstructed and disrupted routine health services in hospitals making it especially difficult for persons with disabilities that require regular medical checkups or attention. Women and girls face even greater challenges in trying to access sexual and reproductive health services.
There’s need to not only include persons with disabilities in planning processes, but to also include people with the lived experience of disabilities in leadership positions such as in the medical professions, research, public health planning and policy-making.
Disability and vaccination
Juliet Ajok explained that shortages of vaccines means that in many settings they are being allotted on a first come first served basis. This causes challenges to persons with disability because they may struggle with issues such as poor transportation which renders them automatically back of the queue.
Speaking from her experiences of leading the COVID-19 Vaccine Dashboard for People with Disabilities, Bonnielin Swenor explained that persons with disability should be included in all stages of developing policies and in the public health response of the vaccine rollout particularly in leadership roles.
Disability data must be collected as there cannot be accountability without the right information. This should be done in a standardized way in order to be able to report up and track vaccine allocation for people with disabilities; and prioritize them in public health information systems.
Finally, there’s need to think about how to balance lack of evidence with equity. It is important to realize that there is never going to be a time when there will be ‘enough evidence’ to make classic public health decisions for the disability community. This is because this group includes many other smaller groups including people with rare diseases. To reach a level of evidence that is considered ‘robust’ particular sample sizes are required, and so some people will always be left behind. Data and evidence only will never lead to the inclusion of all.
Using Uganda as an example, Juliet Ajok explained that persons with disability we to some extent a priority and disability inclusion efforts had started and were gaining momentum. Uganda has made certain commitments on the rights of persons with disabilities and supported affirmative action in legislation and political representation at all levels. However the the good intentions reflected in the legislation and policies need reinforcement; particularly in the monitoring of activities and ensuring compliance at the lower levels of the health system.
In order to ensure prioritization at the national level, the Ministry of Health should be tasked with ensuring inclusivity for persons with disability in health services. Disaggregated data is central to this. In Uganda, most of the data available is donor driven and not circulated widely to local health planners and the various departments at the national level.
Work at the facility level is required to reduce barriers to services and to educate health workers on the rights of persons with disabilities. Where there are shortages of health workers quality services become more difficult as patient numbers mean that there is little time to attend to people with more particular or complex requirements. Health care workers are mirrors of their societies and therefore can have stigmatizing and prejudiced attitudes.
Recommendations
Vaccination locations should be accessible. Accessibility includes easy-to-read formats, sign language interpretation and more patience from health workers. People with disabilities can’t queue in the long lines for the vaccines and therefore, there’s need to strategize how to reach them. Social mobilization should target people with disabilities and persons with disabilities should be included in the digital vaccination drive so that they are more inclusive and conducive. Society needs to provide a more inclusive environment for persons with disabilities and this is instrumental in enabling people with disabilities to transcend COVID-19.
Contributors:
Mohammad Iqbal | Disability, Gender and Age Specialist, Federation Handicap International Pakistan
Dr Bonnielin Swenor | Founder and Director, Johns Hopkins Disability Health Research Center
Dr Juliet Ajok | Child Health Technical Advisor, USAID RHITES-EC
In this blog Lynda Keeru reports back on some of the best moments from the Generation Equality Forum. Get up to date on what was said and pledged!
In his key address at the inception of the Generation Equality Forum 2021, French President, Emmanuel Macron remarked that ‘no country in the world has yet achieved complete equality between men and women.’ This statement illuminated the poor state of gender equality across the world; many years after the Fourth World Conference on Women in Beijing and the adoption of the landmark Beijing Declaration and Platform for Action.
The 1995 Declaration, highlighted 12 areas of focus where high-priority actions were identified for gender equality, development and peace for all women. Unfortunately, 26 years later, little has been done to fulfill these commitments. The COVID-19 pandemic has undone a lot of the little progress made over the years and exacerbated gender inequities. There is an increase in reports delineating rising violence against women, teen pregnancies, higher rates of job losses for women among others. Women have without a doubt borne the brunt of the pandemic.
The Generation Equality Forum held in Paris brought together governments, corporations, leaders, donors and change makers from around the world to define and announce ambitious investments and policies. It was a vital moment for feminists to outline transformative change for future generations. At the event, a series of concrete, ambitious, and transformative actions to achieve prompt and irreversible progress towards gender equality were launched.
Making her remarks, the Executive Director of UN Women said:
“The Generation Equality Forum marks a positive, historic shift in power and perspective. Together we have mobilized across different sectors of society, from south to north, to become a formidable force, ready to open a new chapter in gender equality. The Forum’s ecosystem of partners – and the investments, commitments, and energy they are bringing to confront the greatest barriers to gender equality – will ensure faster progress for the world’s women and girls than we have seen before.”
The Global Acceleration Plan for Gender Equality was launched during the Forum. The plan is driven by six Action Coalitions. The aim of the plan is to accelerate gender equality in the next five years and to face the growing risks of a decline on women’s rights caused by COVID-19.
Over the course of the event, a wide range of commitments were unearthed from every sector. Some of these include:
The United States Government’s commitment to a range of significant policies and investments including an investment of USD 1 billion to support programmes to end violence against women, and USD 175 million to prevent and respond to gender-based violence globally
The expansion of the Global Alliance for Care, initiated by the Government of Mexico and UN Women. This now includes over 39 countries. The Government of Canada made a commitment of USD 100 million to address inequalities in the care economy globally, as a parallel to significant investment in its own care system
The Government of Bangladesh’s pledge to increase women’s participation in the ICT sector, including the tech start-up and e-commerce sector, to 25 per cent by 2026 and 50 per cent by 2041
Raise Your Voice Saint Lucia’s commitment to collaborate with Caribbean NGOs to advocate for the recognition of the LGBTQI+ community and to undertake region-wide legislative reform to minimize discrimination and victimization
Open Society Foundation’s commitment of at least USD 100 million over five years to fund feminist political mobilization and leadership
The Government of Burkina Faso’s work with Benin, Guinea, Mali, Niger, and Togo to develop shared commitments related to family life education, free care for pregnant women and children under five years and legal and social change to end gender-based violence, including female genital mutilation and child marriage
The Malala Fund’s commitment to provide at least USD 20 million in feminist funding to girls education activists
The Gates Foundation commitment to USD 2.1 billion to women’s empowerment over the next five years. They characterize their priorities as cash, care and data
In addition to the range of financial commitments, many world leaders shared their thoughts commitments and sentiments as documented below:
“It is precisely when we confront how broken things are that we have the most power to reimagine them and lay a foundation for a more resilient society…The only way we can deliver an equal world is to be in the rooms where pivotal decisions get made. The beauty of our fight for gender equality is that every human being will gain from it. We are not playing a zero-sum game where one group’s success is another’s failure. In our world, when you are encouraged and supported to become whoever you want to be, the horizon expands. In our world, equal is greater. Let’s build that more equal world together.” Melinda Gates, the Bill and Melinda Gates Foundation
“They will stand on your shoulders and my shoulders. They will look much further than we can look, and they are a new generation. What was born in Beijing, these young people are going to take forward for us, who are older now. This is the new birth of a new generation and new leadership for women, and we thank them for everything that they have done in these last few days.” Under Secretary General of the United Nations and UN Women Executive Director, Phumzile Mlambo-Ngcuka
The conversations, investments and commitments made in Paris revolved around a common theme; the need to empower women. Time has come to get the power into the hands of the women themselves, including those in fragile settings and the global South. We must pay attention to who is not in the room and ensure that they are represented. We will only make progress if we work together.
