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The cost-effectiveness of close-to-community health programmes: What do we know and where are the gaps?

Research shows that CHWs are effective in delivering health services in low- and middle-income countries. They can also improve equitable health care and extend access for populations who are difficult to reach. But data are often too patchy or project specific. Several assumptions are commonly made about CHWs including that they are less expensive than formal health care workers as a way of delivering key services. What is striking, however, is the lack of robust evidence on the cost-effectiveness of CHWs. In order to enhance understanding and inform policy dialogue on the role of CHWs in the health system, the international research consortium, REACHOUT, has recently supported research on this topic. T

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REACHOUT Consortium: Supporting community health workers

The REACHOUT programme is an international research project helping to understand and develop the role of close-to-community providers of health care in preventing, diagnosing, and treating major illnesses and health conditions in rural and urban areas in Africa and Asia. Using a quality improvement approach they have conducted research and communications in Bangladesh, Indonesia, Malawi, Mozambique, Ethiopia […]

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Evaluation of the Medicines Transparency Alliance

The Medicines Transparency Alliance (MeTA) brings together all stakeholders in the medicines market to improve access, availability and affordability of medicines for the one-third of the world’s population to whom access is currently denied. The project was externally evaluated and Pamoja Communications put together a communications strategy to disseminate and share the findings of the […]

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The importance of gender analysis in research for health systems strengthening

This editorial discusses a collection of papers examining gender across a range of health policy and systems contexts, from access to services, governance, health financing, and human resources for health. The papers interrogate differing health issues and core health systems functions using a gender lens. Together they produce new knowledge on the multiple impacts of gender on health experiences and demonstrate the importance of gender analyses and gender sensitive interventions for promoting well-being and health systems strengthening. The findings from these papers collectively show how gender intersects with other axes of inequity within specific contexts to shape experiences of health and health seeking within households, communities and health systems; illustrate how gender power relations affect access to important resources; and demonstrate that gender norms, poverty and patriarchy interplay to limit women’s choices and chances both within household interactions and within the health sector. Health systems researchers have a responsibility to promote the incorporation of gender analyses into their studies in order to inform more strategic, effective and equitable health systems interventions, programmes, and policies. Responding to gender inequitable systems, institutions, and services in this sector requires an ‘all hands-on deck’ approach. We cannot claim to take a ‘people-centred approach’ to health systems if the status quo continues.

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20 years of gender mainstreaming in health: lessons and reflections for the neglected tropical diseases community

Neglected tropical diseases (NTDs) affect the poorest of the poor. NTD programmes can and should rise to the challenge of playing a part in promoting more gender equitable societies. Gender equity shapes poverty and the experience of disease in multiple ways; yet to date, there has been little attention paid to gender equity in NTD control efforts. Drawing on a synthesis of relevant literature, the tacit knowledge and experience of the authors, and discussions at a meeting on women, girls and NTDs, this analysis paper distills five key lessons from over 20 years of gender mainstreaming in health. The paper links this learning to NTDs and Mass Drug Administration (MDA). Our first lesson is that tailored gender frameworks support gender analysis within research and programming. We present a gender review framework focusing on different MDA strategies. Second, gender interplays with other axes of inequality, such as disability and geographical location; hence, intersectionality is important for inclusive and responsive NTD programmes. Third, gender, power and positionality shape who is chosen as community drug distributors (CDDs). How CDDs interact with communities and how this interface role is valued and practised needs to be better understood. Fourth, we need to unpack the gender and power dynamics at household level to assess how this impacts MDA coverage and interactions with CDDs. Finally, we need to collect and use sex disaggregated data to support the development of more equitable and sustainable NTD programmes.

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Measuring quality in Malawi’s community health system: Barriers and challenges

As the drive for Universal Health Coverage and the Sustainable Development Goals (SDGs) has led to a push for greater health service access, the issue of sustaining and embedding quality in the ways in which these services are delivered has gained prominence. Measurement of quality and attribution of its effects in health is challenging at any level. But little is known about how quality is assessed within community health programmes, who are on the frontline of health service delivery in many low- and middle-income settings. The degree to which new initiatives like the Lancet Commission on Quality in Health Systems will include community health programming and the role of close-to-community health providers is currently unclear. Health systems are shaped around well analysed power asymmetries. Relatively less powerful staff who labour at the interface of the community and health sector are rarely canvassed on their opinions of quality nor are their voices prominent in the decision-making processes that effect their daily labour. At the more local level differences in the personal characteristics of community health workers and their supervisors (such as sex, educational level, class, experience of poverty etc.) also act to reinforce power asymmetries. This brief explores how close-tocommunity health providers in Malawi perceive quality as an aspect of their work and highlights some key challenges which may hinder the definition, measurement, and achievement of quality at the community level. It is based on research conducted by REACH Trust.

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The role of women’s leadership in health system strengthening

Equity is at the core of the Sustainable Development Goals (SDGs), including SDG 3: ‘ensure healthy lives and promote well-being for all at all ages’. Improving health requires accelerated efforts to address inequity, in particular, among marginalised populations who are most affected by the burden of disease. Increasingly, the importance of gender equity within global health leadership is being recognised, and SDG 5: ‘achieve gender equality and empower all women and girls’ is supported by a target on ensuring women’s equal opportunities for leadership. In many countries, more than 75% of people engaged and working in global health are women, but this proportion of women is not reflected at the top levels of leadership. Governance is a core pillar of health systems and greater parity and gender responsive, transformative leadership are essential in our efforts to strengthen health systems and meet the gender- and health-related SDGs Gender bias is apparent in personal, political, economic and public life. The health sector is no exception. Empirical research by Women in Global Health (WGH) and the Research in Gender and Ethics (RinGs) consortium draws on three data sources to explore the ways in which gender affects progression and leadership in global health at many levels. Researchers present a radical new agenda for change aimed at strengthening health systems, and making them more equitable and responsive. 

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The role of women’s leadership and gender equity in leadership and health system strengthening

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women’s leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women’s leadership in health as a means to promote the global goals of achieving gender equity.

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Galvanising gender analysis and practice in health systems Reflections from Research in Gender and Ethics: Building Stronger Health Systems (RinGs)

Despite the importance of incorporating gender analysis into existing research programmes, it is not without its challenges. This brief outlines some of these challenges, along with ways in which Research in Gender and Ethics (RinGs): Building Stronger Health Systems has responded to them. RinGs is a cross research programme consortium (RPC) bringing together three health systems RPCs – Future Health Systems, ReBUILD, and RESYST – to better understand gendered dynamics in health systems and to galvanise gender analysis in health systems research.

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