Sexuality

27 October 2021

Supporting community health workers in fragile settings requires a gendered approach

Experts at the recent ‘Close-to-community providers in fragile settings and vulnerable communities during crisis: Gender and COVID-19’ webinar discussed evidence from Brazil, Lebanon and Nepal. Participants also got an overview of the global situation for these vital workers. Lynda Keeru of Pamoja Communications Ltd reports back.

Close-to-community health workers play a vital role in supporting their local health systems in providing care and support to their communities. They often reach the most marginalized of people. Their roles can be particularly critical in fragile and shock-prone settings and during times of crisis such as the current COVID-19 pandemic.

Health systems are not gender neutral and gender shapes every bit of our world. Rosemary Morgan explained that women health care workers really are the drivers of health as they make up 70% of the 200 million workers who contribute to the health and social sector. They also deliver care to about 5 billion people worldwide and contribute to $3 trillion annually, half in the form of unpaid work.

Who are close-to-community providers?

Health workers play different roles and have different designations in the communities they serve, with community health workers constituting a large group. Close-to-community providers often have a lower socioeconomic status, educational level and are often women. They occupy the bottom of the health system hierarchy and are subject to the structural power relations which shape the health sector and their societies.

They are usually the first point of contact to the health system for community members and provide promotional, preventive and/or curative health services. The direct contact with communities enables them to expand access to services and hence contribute to improved health outcomes. They play a central role in times like the COVID-19 pandemic, where health systems are overwhelmed and there are shortages in health workers and health supplies.

Brazil

Brunah Schall pointed out that Brazil is one of the epicenters of the pandemic. In her presentation, Brunah indicated that the President of Brazil is openly against gender-related discourse, and it is no wonder that 80% of all pregnant women who have died from COVID-19 around the world are from Brazil. The community health workers model in Brazil goes way back to the 1970s. Brazil’s community health workers face many challenges. Owing to the fact that CHWs in Brazil are not considered to be health professionals, access to personal protective equipment is a struggle. There were no COVID-19 standards rolled out to guide community health workers in their job and they have frequently faced threats and aggression in some territories during the pandemic. Community Health Workers in Brazil are most essential to the “Quilombolas” who are the remaining communities created by slave descendants. These communities face a host of challenges that have an impact on the Community Health Workers that serve them. These include: transport challenges, domestic violence issues, lack of training, water shortages that made the virus spread a lot faster.

Nepal

Abriti Arjyal explained that Nepal is in its early years of federalization. Owing to this, power has devolved to local governments, who are responsible for providing basic health services and other public health programmes. The close-to-community providers in Nepal are Female Community Health Volunteers (FCHVs); and they are about 52,000 of them at a ratio of (1: per 120HH). They bridge the gap between communities and government health services, consequently reaching the unreached. They engage in community-based preventive and educational activities which are very useful in the progress of many key health indicators. To this end, FCHVS form a critical linkage for prevention and control of COVID-19. Some of their roles include: raising awareness about the virus, distribution of hygiene kits, tracking, screening, registering, doing follow ups and referrals for people with COVID-19 among others. The experiences of this cadre of health workers during COVID-19 has been highly influenced by norms and values. These include fear and discrimination from the community because of concerns about infection, planning and decision-making processes that are not gender sensitive and inadequate supportive behavior, particularly from men. They also often had to deal with lack of support from both family members and their health systems.

Lebanon

As ably presented by Rouham Yamout – Lebanon, which was once a high middle-income country – has been in a multi-crisis since October 2019 and could be termed a failed state. This has had dreadful implications on the health system: there has been a tremendous decrease in income of health workers, a massive exodus of health workers and too much service demand on surviving facilities. The practice of outreach and employment of volunteer close-to-community providers in Lebanon developed with the influx of Syrian refugees starting from 2012. The refugees live in settlements far from population centers and transportation, with a lot of restriction imposed on their movement because of the illegality associated with their status. Many can’t afford the co-payment health services subsidized by UNHCR and so they do not go to healthcare facilities. Close-to-community providers in Lebanon comprise of auxiliary nurses employed in local civil sector health facilities, social workers, UN and NGO outreach workers, ambulances drivers, mental health workers and midwives. Many of these are women with the multi-crisis conditions pushing female refugees to enter the job market as voluntary close-to-community providers. These close-to-community providefrs took charge of most COVID-19 related tasks and were in some regions, the sole healthcare providers to Syrian refugees. They provided continuation of health services while the entire health sector was going through financial turmoil. Due to the desperate need for paid work, many close-to-community providers, particularly women, accepted deplorable working conditions.

The COVID-19 pandemic, besides magnifying and exacerbating existing inequalities, is a catastrophe in fragile and vulnerable settings. This translates to dreadful working conditions for the close-to-community providers who sit at the bottom of the health system. Ergo, it is important that the negative impacts of COVID-19 are addressed for the wellbeing and sustainability of the health workforce.

Presenters

Rosemary Morgan, Johns Hopkins School of Public Health, USA

Brunah Schall, Rene Rachou research Institute, Fiocruz Minus, Brazil

Rouham Yamout, American University of Beirut, Lebanon

Abriti Arjyal, HERD International, Nepal

Photo credit – A health professional from the Special Indigenous Health District (DSEI) prepares a dose of the Coronavac vaccine by International Monetary Fund is licensed under CC BY-NC-ND 2.0

1 July 2021

Working with research brokers: Power, positionality and ethics

Lynda Keeru reports back on a recent webinar, ‘Coloniality of research and spotlight on the research backstage.’ The speakers suggested ways that we can forge more ethical and transparent research collaborations that produce knowledge that is accessible, meaningful and transformatory in a world altered by COVID-19. This blog summarises the presentation given by Swati Parasha Director of the Gothenburg Centre for Globalisation and Development. To find out more please watch the recording of the lecture.

Researchers engage with many people on the ground, in field sites. These people make important decisions about what knowledge is made visible and what frame is used to tell the story of people involved in research. Knowledge or research brokers are the people who facilitate field research (also known as fixers, facilitators, managers, assistants, gate keepers, interpreters etc.) They assist researchers in the field and collect field data. Sometimes they work for local research partners to whom research has been outsourced. Field work practices thrive on the labour of racialized research subjects and brokers. Yet these workers are often not acknowledged and there are few discussions about their role. Brokers and research subjects are often diminished and erased when it comes to the authorship of research publications. This means that researchers (and brokers) in the Global South receive fewer citations than their colleagues in the Global North.

It is important to document the role of brokers, examine their positionality and reflect on the way that they shape research processes.

Many researchers from the Global South have documented their experiences of how they are treated differently to white researchers. There is an intersectional hierarchy based on gender, class, race that operates in the research backstage that people need to start paying attention to. Many Global South researchers and academics also inadvertently get roped into broker roles by researchers from the Global North and this too has its own dynamics.

Paradoxically brokers can be both powerful (and able to dictate how research unfolds and its outcomes) and vulnerable (as marginalized people who can be exploited or manipulated by researchers). When researchers in the Global North engage with brokers in the Global South power differentials can potentially be greater.

It is not uncommon for brokers to face challenging and potentially violent circumstances in the course of their work. But while safeguarding is becoming an increasingly hot topic in development, we rarely see discussions about the ways in which the relationship between researchers and brokers impacts the security of the brokers or that of their families both in the field and afterwards.

Swati reflected on the inequalities and exploitation present in the ‘use’ of research sites in the Global South – which are often positioned as ‘case studies’ on which Western and Eurocentric theories are applied. Swati described a vicarious expertise industry thriving on the intellectual labour of people of colour where the bounties are only available to white scholars with access to resources, funding and publication. She argued that there is need to do away with this model and recognize that all phenomena in the Global South have their own theoretical foundations, developments, and explanatory trajectories. White privilege often means that the analysis of scholars in the Global North is considered more credible and legitimate in comparison to work produced by local scholars despite the likelihood that they have a deeper and more nuanced analysis of research phenomena due to their embeddedness and potential lived experience.

To conclude Swati raised some ways in which the pandemic has altered the traditional research dynamic. For example, ‘access to the field’ has become more challenging and restrictive, governments have become more concerned about permissions to enter field sites and communities have become less trusting of outside researchers and their prying questions in the light of more pressing demands. This provides a useful moment to rethink and reshape research practices in more ethical and equitable ways.

Citation

Parasha S (2021) Coloniality of research and spotlight on the research backstage, Webinar organized by The Danish Institute for International Studies, chaired by Ninna Nyberg Sørensen https://www.diis.dk/en/event/coloniality-of-research-and-spotlight-on-the-research-backstage

26 May 2021

Learning, acting and building for rehabilitation in health systems

By ReLAB-HS Consortium (Johns Hopkins Bloomberg School of Public Health’s International Injury Research Unit (JH-IIRU), Nossal Institute for Global Health at the University of Melbourne, Humanity and Inclusion, MiracleFeet, PhysioPedia, and UCP Wheels for Humanity)

We live in a time of rapid demographic and epidemiological change. Improvements in health care mean people live longer -the proportion of the population over 60 years of age will double in the next 30 years and they will live with the concurrent illnesses and disability that are part of the ageing process. Additionally, approximately 150 million children and adolescents experience disabilities. And COVID-19 – a disease that appears to manifest as long-term chronic ill-health in many – has demonstrated that we now live in a world where both communicable and non-communicable disease must be tackled simultaneously.

Rapid urbanization and concurrent increases in car ownership and use leave people vulnerable to injuries. In addition, we live in a world that faces political, economic and environmental flux and shock. Conflict and environmental disasters are common.

Already stretched health systems in low- and middle-income countries (LMICs) face challenges including poor infrastructure, insufficient specialized care-providers and trained professionals, and inadequate financial resources.

Rehabilitation and assistive technology

Rehabilitation is integral to overall health and wellbeing. According to recent estimates, one in three people across the globe will require rehabilitation at some point in their lives.

Yet many people do not have access to much needed assistive technology (AT) or rehabilitation services, which exacerbates their condition and may lead to further complications and lifelong consequences. Lack of access to rehabilitation and AT impacts not only on people’s functioning, quality-of-life, and well-being, but has implications for their family and community. Lack of rehabilitative support can trap people in a whirlpool of poverty due to lack of educational and work opportunities, as well as social isolation due to stigma and discrimination.

Building better health systems

In many LMICs, rehabilitation and AT are often offered as stand-alone services. However, there is need to rethink organization of rehabilitation services as an integral part of health systems to achieve better health and well-being of the population.
Solutions need to be contextualized, demand-driven, and be informed by principles of systems and implementation science; there’s unlikely to be a one-size-fits-all solution. This calls for a better understanding of local needs, how rehabilitation services and health systems are currently organized and operate, and barriers to integration that need to be addressed.
Potential patients need to understand the services that they require and where they can get them from. People are the center of the health system.
Engagement with non-governmental organizations, civil society organizations, and the private sector is key to ensure successful implementation and uptake of interventions.

Building such health systems will require collaboration across the primary, secondary and tertiary levels and between different sectors within and outside government. The road ahead is not easy, but it is necessary if we are to meet the needs of citizens and communities facing acute and long-term challenges.

26 May 2021

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

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

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

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

Themes

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

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

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

The role of evidence

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

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

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

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

19 February 2020

Adopting a gender lens in health systems policy

By Lynda Keeru

Momentum is building towards International Women’s Day marked and celebrated around the world on the 8 March. This indeed coincides with the general international interest among policy makers in knowing what practical steps to take to move towards a more gender-equitable and transformative health system.

This year will also mark 25 years since the Beijing Declaration and Platform for Action adopted at the Fourth World Conference on Women (Beijing, 1995). This conference sought to remove all the obstacles to women’s active participation in all spheres of public and private life through ensuring women a full and equal share in economic, social, cultural and political decision-making.

As the buzz around Universal Health Coverage continues to build, bringing on board the gender lens to policy deliberations cannot be more timely. In this common spirit, a number of advisors and researchers were brought together in Nairobi in February 2019 and developed this guide (Adopting a gender lens in health systems policy: A guide for policy makers) which does a few things:

Defines what a gender-equitable health system might look like
Provides a set of benchmarks that health policy makers can work towards
Features case studies from a range of countries, including Cambodia, Democratic Republic of Congo, Kenya, Liberia, Malawi, Sierra Leone, South Africa, Tanzania and Uganda. These illustrate how decision making that does not take gender into account leads to sub-optimal health systems and provide practical examples of strategies that have been effective in addressing gender barriers in health systems.
Lists further resources which are accessible online

Gender is everyone’s business

Adopting a gender lens in health systems policy

To start with, it is important to note that gender is everyone’s business and not only about women and girls and excluding others as is often misinterpreted. Owing to gender biases, norms, and power relations, some groups of people are often not factored in decision making processes and this means that their needs and rights are not identified, recognized or prioritized.

Likening the health system to that of a computer, it has both the hardware and software system. The hardware components include the six building blocks identified by the World Health Organization (WHO). These building blocks include: health service delivery, governance, medical products and technology, health systems financing, human resources and health information systems. The software system on the other hand is hard to see but it is critical as it cements and informs the success of work on the building blocks and includes relationships, values, trust, and power. As the authors in this guide: state: “Both the hardware and software of the health system are affected by gender. Gender norms, roles, and relations are also shaped by the health system.”

The building blocks

On the second page of this very enlightening guide, the authors delve deeply and even graphically into what gender-equitable health systems look like, providing detailed information on the aforementioned six building blocks.

Take for example the importance of providing accessible, acceptable, affordable and available health services as a core function of a health system. Further down that page as you’ll see when you read, there is an illustration of how the divergent needs, rights, access, and experience of health services for men, women, and people of other genders affect the range of demand- (patient-led) and supply-side (health service-led) factors. For instance, a case study from Kibuku district in Uganda demonstrates how health facilities are making life more bearable for physically disabled women.

The second building block is very important as it focuses on health workers who are the backbone of the health system. The policy brief in this section outlines very fundamental recommendations for policy makers based on experience from the different implementers as reflected in the case studies and recommended resources like the WHO (2011) Gender mainstreaming for health managers: a practical approach.

An inclusive health system should, by definition, place fairness and equity at its core. However, many health systems’ governance structures and processes fall short of their potential when it comes to gender equity. There is a lack of goal setting for higher representation of women in leadership and policy spaces in the form of targets, quotas and affirmative action. The guide underscores the key issues in gender and accountability and also suggests ways in which these issues can be addressed by policy makers like ensuring gender balance and gender sensitivity of governance structures at all levels down to the facility and community level.

The brief also features a very well written and interesting case study on “Gender analysis of community health data in Kenya”. It documents the direct impacts of gender on the quality of data reported by Community Health Volunteers due to gendered barriers in data collection. Case in point, what many would regard as a “simple” issue – like the fact that some health issues are perceived to be the domains of men or women – consequently, inform trends like that of Community Health Volunteers collecting data from women. This leads to men’s perspectives missing from the data routinely reported. These gendered elements of data collection impact on dimensions of data quality such as accuracy, completeness, reliability and confidentiality. There’s a wealth of resources put together by the authors of the brief on the same. Check it out!!

‘The phone is my boss and my helper’ – A gender analysis of an mHealth intervention with Health Extension Workers in Southern Ethiopia, mHealth and Gender: Making the Connection and ‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information are some of the works in the brief that have been done by researchers in the area of medical products and technologies and are useful for actors in this field.

Finally, we turn to health financing. This is the accumulation and allocation of funding by and within the health system to ensure service quality and access. As quoted in the guide:

“The extent that financial protection is available to different groups needs to be considered, in addition to how out-of-pocket expenditure is experienced differently by men, women, and people of other genders. This affects policy makers’ ability to deliver Universal Health Coverage.”

Policy makers can give women their rights on International Women’s Day by taking up this recommendation to:

“Ensure that financial protection packages (i.e. prepaid health services under Universal Health Coverage schemes) include essential and routine sexual and reproductive health services, such as childbirth and emergency obstetric care, family planning, cancer care, such as for prostate cancer, and safe abortion.”

Gender mainstreaming is a challenging and ambitious process but we have no choice if we hope to achieve a gender equitable health system and this guide is a gift to all policy makers who are trusted to lead the process.

This guide was developed by Research in Gender and Ethics: Building Stronger Health Systems (RinGs).

28 January 2020

COPASAH launch Charter on Accountability and Health

READ THE CHARTER: https://www.copasah.net/uploads/1/2/6/4/12642634/copasah_sa_charter_and_call_to_action.pdf

We had the good fortune to attend a webinar where COPASAH launched their new Charter and Call to Action on Social Accountability for Health. This comes hot on the heels of the successful Symposium which was held in New Delhi in October.

The Charter is grounded in human rights, particularly the right to health. It recognises the commitments made at Alma Ata and within the Sustainable Development Goals. But the Charter is very future facing.

What’s going wrong?

New social, political and economic forces are exacerbating pre-existing inequities, argues The Charter. This is eroding democracy and public systems. This includes unethical and exploitative private sector action. At the same time, multilateral systems – like the UN bodies that exist to protect our rights – are losing their teeth. Unfortunately, the research world is often a part of the problem:

Dominant practices of evidence-based policy making trivialise the lived experiences of ordinary people. Prevailing approaches favour aggregate data over more complex narratives that better represent the lived reality of marginalised people.

COPASAH vision for the future

Signatories to the Charter pledge to ensure that marginalised communities have access to accountability systems and to the promotion of solidarity, empowerment and leadership. Collective action is key to this, and the leadership of women and other disadvantaged people.

The Charter outlines a vision where adequately supported public services meet the needs of the marginalised. At the same time it argues that the private sector should be regulated, transparent and accountable. We should build a system where profit does not trump the rights of the people.

Both communities and health workers play a key role in providing health care. But they are often overstretched, working under pressure and blamed for weaknesses in the system. The Charter suggests that we must work together – taking our lead from the most marginalised – to monitor weaknesses in accountability systems and collectively press for change.

What next?

The Call to action in the Charter provides detailed guidance to researchers on their methods and more general engagement with communities. It urges research bodies to promote community participation and ensure the work is led by community priorities. As a result new knowledge should support communities in their struggles for accountability and the realisation of the right to health.

Many thanks to Ravi Ram (Kenya) and Aminu Magashi Garba (Nigeria) for their insightful presentations and for all COPASAH members for their inputs into the Charter and the Call for Action. This blog was written by Kate Hawkins and first appeared on the ARISE website.

9 March 2018

On International Women’s Day we need to shine a spotlight on women in fragile and conflict-affected settings

This blog post is part of a wider HSG blog series to celebrate International Women’s Day 2018. In this series, HSG members provide their perspectives on why gender should be a critical component of UHC, and what we can do about it.

By Sally Theobald, Valerie Percival and Kate Hawkins

Attention to fragile and conflict-affected states is critical to achieving universal health coverage, along with progress on other Sustainable Development Goals on gender equity and social justice. We need to ensure that women’s needs are met during crises and war, and that we join up action here with longer term, sustainable solutions.

Gender inequities neglected

In our work on gender and post-conflict health systems – Building Back Better – we explored the extent to which gender had been addressed in health systems rebuilding in several post-conflict states, including Mozambique, Sierra Leone, Northern Uganda, Timor Leste, Zimbabwe, Cambodia and Bangladesh. We found limited attention to gender equity in rebuilding efforts, and that conflict-related inequitable health outcomes linger in post-conflict health systems. These have wide-reaching implications for the health of communities, which need addressing urgently.

Post-conflict opportunities

To borrow the strapline for International Women’s Day 2018 we need to “#pressforprogress” against pernicious gender inequities in health systems in fragile and conflict-affected contexts. Health systems are key employers and respected institutions within society; they both reflect and shape the social, political and economic context that they are part of, and the lack of emphasis on gender equity within health systems is a significant missed opportunity. The health system could, and should, be an arena for building greater gender equity in all society.

Policymakers assume that if you build health systems they will be equitable; yet there is little guidance for people who may want to take a gendered approach to planning and implementation. To help address this, we developed bench marks for gender equity to be addressed within the health system, and produced case studies to highlight change and promising practice, including indigenous efforts towards embedding gender equity, such as in post-conflict Bangladesh.

Supporting female health workers

Health systems strengthening efforts require a strong and supported health workforce. There are challenges here in fragile and post-conflict contexts, where health workers are few, due to death or out-migration. In these settings there is a particular need to recognise and support the vital work of women health workers at all levels of the health system. This was an area of focus in a recent webinar jointly hosted by the World Health Organisation, the Global Health Workforce Network and Women in Global Health. Our research on the ‘gendered health workforce’, conducted through the ReBUILD and RinGs programmes, was presented, highlighting not only the multiple challenges women health workers face in Sierra Leone, Zimbabwe, Cambodia and northern Uganda, but also the incredible resilience they show in continuing to deliver vital services despite threats to their own lives, and risks of sexual and gender-based violence.

On International Women’s Day we call for women health workers working in contexts of ongoing crises and conflict, such as Yemen, to be recognised, celebrated, supported and kept safe.

Pressing for progress

The recent launches of Canada’s Feminist International Assistance Policy and DFID’s Strategic Vision for Gender Equality (which has a specific focus on protecting and empowering girls and women in conflict, protracted crises and humanitarian emergencies) shows increasing focus on this issue, which is welcome. “Pressing for progress” means that all actors need to focus seriously on gender in their work. Strong, joined-up and gender transformative approaches to health systems strengthening are required.

Read the article

9 March 2018

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

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

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

The health and social workforce needs gender-transformative reform

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

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

Women health workers face violence and sexual harassment at work

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

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

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

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

Fragile and conflict affected states have particular problems

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

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

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

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

Promising practices

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

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

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

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

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

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

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

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6 March 2017

What does trust have to do with Community Health Workers and the Sustainable Development Goals?

By Kate Hawkins, Kingsley Chikaphupha, Rosalind Steege, Sushama Kanan, Aschenaki Z. Kea. Robinson Karuga, Ralalicia Limato, Nelly Muturi, Daniel Datiko, Maryse Kok

Trust: “The optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for the trustor’s interest”(Hall et al. 2001)

Trusting relationships:“Respectful, fair and cooperative interactions between individuals” (Gilson 2003; Okello and Gilson 2015)

The work of Dr Maryse Kok has brought to the attention that health systems are social institutions and community health worker programmes are part of this complex map. Besides the ‘hardware’ elements of health systems (often referred to as the WHO’s building blocks) we need to take account of the 1) ideas and interests, 2) relationships and power, and 3) values and norms that effect these programmes (the software elements of health systems). Looking at this ‘software’, every health worker is part of social interactions and environments, which, together with available resources, shape their performance.

Performance is a transactional social process and trust plays a part of this. Trust can be built by personal behaviours and organizational practices that provide space for engagement and open dialogue (Gilson 2006). Other factors that have been found to influence trust of health workers are: perceived organisational support, communication, procedural justice and feedback from upper levels (Albrecht and Travaglione 2003; Nyhan 2000). Understanding the factors that influence trust and CHWs interpersonal relationships with different actors in the community and health sector (such as supervisors and managers) is important in order to analyse and improve CHW performance.

In a refreshing fish bowl session at the first symposium on the Contribution of Community Health Workers (CHWs) in attainment of the Sustainable Development Goals (SDGs) we heard from colleagues from around the world about how CHWs can build trust, how we can strengthen the software components of the system and how to improve data quality and feedback loops. As well as hearing some warnings on how mistrust can negatively impact CHW programmes. We thank the participants whose interventions have helped us write this blog.

Building trust is an evolving process

Several participants pointed out that the process of building trust does not happen overnight.

We heard that trust starts with how CHWs are selected, their training, and the quality of their work. In Ethiopia, the community is part of the selection process for hiring CHWs. They choose community members that they trust to play the role of CHW and the CHW cements and builds this trust through their ongoing work. The more useful they are the more it grows. This can create demand for more services – which is evidence of their impact. From Uganda, we heard that CHWs’ integrity has at its foundation a clear terms of reference right from their first engagement with the community. One colleague pointed out that having adequate time to spend with the community can make the community feel trust in the CHW. Building rapport can be a long-term process.

Policy making and implementation to build trust

Policy making and implementation that favours CHWs can improve CHWs motivation. Suspicion from communities of CHWs’ involvement in politics also influence their trust of the CHWs.

In Ethiopia policy makers demonstrate their trust in CHWs when they construct policies, structures, and budgets (including monitoring and evaluation systems) that support and celebrate their work.

CHWs told us that whether or not the district level management is aware of them and is sensitised to their work motivates the CHWs. It is important that the health units know who the people are in the community.

We heard that policy makers need to take account of the plurality of health care providers within communities. In Bangladesh, informal for-profit providers such as pharmacists are more integrated into the community and accepted as almost family members. Because they are more trusted the community find them more credible than other health care providers and they are often the first point of call in the case of ill-health. So, good communication and rapport with informal providers helps CHWs in Bangladesh to build trust with community and refer clients to proper health facility. How can CHW programmes work with them and learn from them? In Uganda, we heard that Traditional Birth Attendants (TBAs) are part of the Village Health Teams (VHTs) and the communities trust them. However, policy makers do not trust them despite training them in the past. In Ethiopia, TBAs used to be very important in providing family health. But now they have been integrated into the CHW programme as health development army leaders working towards ensuring model household families.

From South Africa, we heard what happens when the trust breaks down. In this highly-politicised environment – which has moved from Apartheid to democracy – people may be reluctant to trust CHWs who they see as agents of the state as they think that they are visiting the home to try and canvas for votes or act as surveillance force. Fear of surveillance is heightened because of very real fears about HIV-related stigma. To counteract this there is a need to involve the communities in designing the intervention itself. Top down approaches to programme design often fail to take into accounts beliefs and norms and local context which is important to success. For example in South Africa, there is a belief in some communities that you should not allow visitors into your home 100 days after the birth of a child, which is at odds with the CHW policy. By ignoring cultural values, the relationship between the CHW and the community is at risk of further deterioration.

From Kenya, we heard how CHW programmes can be effected by political events and crises in the health system that go beyond the community sector. For example, the Kenyan doctors and nurses strikes can undermine trust in the health system which effects CHWs. However, CHWs may have an important role in re-establishing trust in systems that have been battered by instability and it would be good to understand better how this process can be supported.

CHW practices that maintain trust

To gain trust from the community, CHWs are expected to keep confidentiality and act in a responsble manner during interactions with the community, they should have a good knowledge on the health topics they deliver and be available whenever the community needs them.

A colleague from Kenya pointed out that when CHWs maintain confidentiality this supports the process of trust building. CHWs are in the unique position of not just handling sometimes stigmatising health issues but seeing vulnerabilities within the private space of the household. If they are successful communities have to believe that they will handle this information responsibly and sensitively. Commenting on Ethiopia a colleague pointed out that this becomes even more important when it comes to mhealth and new communication technologies. Communities may not fully understand who will see the information that is being entered into electronic devices and what it might be used for. So, they need to place a great deal of trust in the hands of the person that they are giving this data to. Conversely, just having access to an electronic device, like a phone or tablet, may make CHWs more trustworthy as it may make them seem more professional, or at least better equipped. The use of text messaging helps them to make prompt follow up of clients and improved adherence to care.

A colleague from Uganda felt that when CHWs treat themselves as professions for example, they don’t turn up to the household visits drunk, this can increase the respect and therefore trust that their clients have for them. However, another VHT colleague argued that you need to ‘live the professionalism’. A corporate manner when speaking with bad boys does not work. If you have a little drink with the alcoholics as it gains their trust. In addition, speaking the language of the community helps you to relate. You need to put yourself in the shoes of the people you are talking to – CHWs need to advise not supervise.

Colleagues from TASO in Uganda related that being experts in the subject that you are talking about, in this case HIV, helps build trust. This expert knowledge may mean you are living with HIV or have relatives or friends affected by HIV. In this way clients know that you are coming with a knowledge of the issues that are relevant to them.

We heard that trust is linked to availability. When the community knows the CHW is there for them they can trust then and in Zambia this has been shown to increase health service delivery. Availability isn’t just about the amount of time spent with the community. Particularly in emergency care settings it is about being there when a crisis occurs.

Data handling and trust

Trust between CHWs and the community can affect data collection and handling in terms of the aim of data collection, the existence of community dialogue/participation, and the availability of quality tools.

From Kenya, a participant felt that data quality was part of the process of trust building – in terms of what is collected and what is relayed to the community. Relationships effect the quality of data. If communities don’t trust that household visits are authentic and if they think the CHW got paid for collecting data it can affect the quality of the data provided and this is particularly true for vertical programmes. The reasons for collecting data need to be transparent. In addition, if CHWs are expected to ask the same questions of the same households month after month then households can fail to see the importance of answering them correctly. This effects the reliability of the information we are working with. A colleague pointed out that falsification of data sometimes occurs because of pressure to perform. To overcome this all CHWs need to meet together and frankly discuss the challenges that they have in data collection. From a disability organisation in Uganda we heard that an app for diagnosis and prescription improved the quality of the data collected by CHWs as they knew there were ramifications of not filing information correctly.

In Kenya, the governance of community health programmes can effect trust. CHWs collect data and submit it upwards but if they don’t know what happens to it they can stop feeling incentivised. In this case why not make it up – after all they do not know what they are contributing to. We heard that in Cote D’Ivoire the Ministry of Health wanted data accountability. To facilitate this data was made available at the clinic and CHWs and community members could talk directly to the nurses about it. In this way they could verify that they were being heard and that the community and the health system were connected. In Kenya, community dialogue days enable people to view the data collected by CHWs on a chalk boards and prioritise community action days. However, for these to be successful more support from development partners is required. A colleague in Uganda suggested that parallel systems of data collection for CHW data are being created and this can erode trust.

A participant from Uganda pointed out that to get quality data CHWs need quality tools. Whilst in Kenya it was argued that there are too many tools, as NGO working with specific community units and programmes often introduce their own tools creating parallel reporting systems with the standard Ministry of Health system thus leaving CHWs over-burdened and as a result cannot clearly see the impact of their work. In addition, we heard from South Africa that tools tend to measure how much work a CHW has done but whether or not this work was appropriate is not captured. This calls for a focus on quality not just coverage. In Malawi, We learnt that conducting regular and supportive supervision was key to getting quality data. Irregular supervision or lack of it led to CHWs testing the system in search of being supervised by submitting poor data that led to serious effects on decision making and interventions.

Other health system practices to build trust

Feedback to the community, approaches from CHWs’ supervisors, and financial incentives also can influence trust between CHWs and the health system.

We heard that in Malawi feedback loops for information help to build trust. For example, being able to tell communities what has happened to the information that has been collected is helpful for the relationship with the CHW.

Another participant felt that it was important that CHWs provide correct and accurate information in their messages, but also that they accept when they are defeated and don’t know. They pointed out that if community members suspect a CHW is pretending to know something that they don’t their clients may provoke them to see how much they know, with potentially negative results.

We heard that in terms of the supervision of CHWs trust is important. The approach and aim of supervision affect the relationship between supervisor and the CHWs. Fault finding can cause mistrust in the CHW relationships with their supervisors which can have knock on effects in the service that they provide. We heard from Ethiopia that the language of supervision is important. CHWs feel sense of belongingness and freely share their ideas when the supervisors able to speak local languages spoken by the CHWs. Using phrases like, ‘Let’s do this together’ and ‘We both want to achieve this’, can be motivating. From Uganda, we heard that the delegation of responsibility to CHWs – as long as it is manageable – can build trust, and it boosts confidence.

From Malawi, we heard that financial incentives can be motivating and build trust between the health system and CHWs. However, they can also have a negative effect. They can move CHWs to the programmes that pay the most, cause attrition, particularly allowances linked to training and workshops. This can affect trust across a range of other stakeholders, and the community. In many cases, community members expect basic care from CHWs. When the CHW supply kits are not sufficiently stocked over prolonged periods of time, apathy develops towards CHWs and this affects the trust that community members have in CHWs.

Gendered elements of trust

We heard that in Kenya the sex of the CHW matters as young men coming to visit the house is seen as a security concern by many. In addition, women do not want to have personal conversations with male CHWs about family planning as they fear that confidential information may be relayed to their husbands or others. Conversely, the trust built between a CHW and the community can also help women to overcome harmful gender norms. In Bangladesh, female CHWs are more able to freely move around the community and are less at risk from provocation by local thugs as they have earnt a position of respect within the community. In Ethiopia, all CHWs are women and are better positioned to make household visits and address maternal and child health issues.

Conclusion

From the above experiences and literature it is evident that most challenges affecting health systems are behaviour and relationships related. Trust has a lot to offer in health care delivery and policy analysis and by exploring it further, we are able to capture its relevance to health systems and the need to harness it. Trust plays a very important role for both health care providers and institutions and is a fundamental human norm. As such, it demands consideration as a key ‘software’ element of the health system. Further, the implications of ‘hardware’ interventions on trust, and how these play out in the community provide important lessons for CHW programmes across contexts.

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18 January 2017

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

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

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

Event Date: 16 November 2016

Location: Vancouver, Canada

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

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

Power and Prejudice within Academic Institutions: from the literature

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

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

Conferences

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

Peer Review

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

Collaboration

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

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

Power and Prejudice within Academic Institutions: Participant concerns

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

‘Foreign’ Status

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

Academic Processes

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

Junior Status vs. Senior Status and Ageism

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

Validated Research

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

Understanding our own positions of power and privilege

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

Five “S”s emerged as a way forward:

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

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

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