By Laura Dean*, Kate Hawkins, Rachel Tolhurst, Eleanor Macpherson, Lee Haines, Daniela Ferreira, Angela Obasi and Sally Theobald
Zika is a disease exacerbated by poverty – risk is not spread uniformly – those who already face extreme social marginalisation are more vulnerable. If you live in a poor area, such as a Favela; Ghetto etc., with limited access to running water, sanitation, rubbish disposal, health facilities and education regarding how mosquitoes reproduce you are likely to be more at risk to vector-borne diseases. Over the next few weeks and months we are likely to witness the release of much more information that keeps Zika being discussed. This blog explores three key, inter-related issues in relation to Zika: gender and power; context and vulnerabilities; and stigma, disability and pregnancy. Zika particularly focuses a spotlight on gender and disability in low and middle income settings (LMICs). In the lead up to International Women’s Day, we believe that health systems researchers should grasp the opportunity to think about how they can ‘build back better’ health and social systems in the wake of this and other epidemics.
Delaying Pregnancy: Gender, power and sexual and reproductive rights
Richard Horton, the Editor-in-Chief of The Lancet, recently highlighted gender as the neglected area in global health, pointing out that it receives inadequate focus within the Sustainable Development Goals (SDG). Much of the messaging that has come in the wake of the Zika epidemic in the Americas seems similarly gender blind.
In her recent blog, Clementine Ford presents the predicament that governments face when associations are presented with potentially disabling congenital conditions (microcephaly), a virus epidemic (Zika), and pregnancy. A recommendation to delay pregnancy for two years, as is being suggested in countries like El Salvador, seems disconcerting to those of us familiar with contexts where abortion is illegal and/or stigmatised and there is a high unmet need for contraception. Sadly, challenges in realising sexual and reproductive rights for women in these contexts are not unique to the Zika epidemic.
There is a need for greater collaborative thinking between decision makers working within patriarchal systems, scientists, and those who these decisions are most likely to impact upon, particularly women of reproductive age. In responding to the growing evidence that suggests a causal link between Zika virus and microcephaly, there is a need to re-open, encourage and maintain focus on debates regarding sexual and reproductive health and rights within the Latin American region. Not only should it be a woman’s right to choose if and when to get pregnant, based on accurate information, but also she should be granted access to the services that enable her to make this informed choice.
Context Matters: Vulnerabilities and Social Marginalisation
Zika virus, and other insect-borne diseases like Dengue and Chikungunya, highlight the troubling health inequity that is based on deprived living conditions. Within Brazil’s favelas, there is a large proportion of single parent families, the majority of which are headed by women. These households are more likely to experience perpetual cycles of poverty as a result of the economic shock of disease. In addition, where children are born with potentially disabling impairments they are often further isolated by limited support or social protection from the government and become reliant on seeking support from the private non-governmental sector if and when it exists. For example, in their recent blog Reed Johnson and Rogeiro Jelmayer present the story of Alice, a baby born with microcephaly, whose parents now ‘spends one sixth of their income on a battery of medications and treatments for Alice’ in addition to the opportunity and travel costs associated with attending medical appointments. Families living in favelas are more vulnerable to arboviruses than those families living in apartment towers that are expensive, well built, screened and elevated well above primary mosquito habitats. This is inequitable.
Currently, Zika outbreak management is focused on mosquito control strategies aimed at reducing mosquito densities (larviciding and fogging) and bite prevention by female adult mosquitoes (repellents). Research into vaccine development and new diagnostic tools is also a global priority. Inequitable vulnerabilities also need to be considered alongside medical and technological advancements if we are to build better social and just systems and environments that reduce the risk of disease.
Disability related stigma: Reinforcement and creation
Since there has been such an increase in media coverage on Zika, several reports of disconcerting new stigmas in poor areas in Brazil have emerged, for example, pregnant women being made to feel stupid for being pregnant. In addition, men have been stigmatised for fathering a ‘Zika baby’ – further reinforcing stereotypical norms related to virility, fertility and machismo – and in some cases leading to the abandonment of their partners and children.
Abandonment of mother and baby due to a child being born with a disabling impairment is not a new phenomenon, nor is it unique to microcephaly in the context of Zika. However it provides another clear example of extreme social marginalisation and stigmatisation that disease outbreaks can create.
In part this is due to the portrayal of Zika and microcephaly within the media. Currently, there is no proven causal link between microcephaly and Zika, rather associations are hypothesised within the Brazilian context. Regardless of causal link or pathway, there is need to think critically about the portrayal of microcephaly and how this can label children ( in some instances before they are born), and (i) reinforce negative social constructs of disability and (ii) stigmatise pregnancy itself undermines one of the most fundamental reproductive rights that women have. The World Health Organisation describes microcephaly as a condition where a baby is born with a small head or the head stops growing after birth. Microcephaly can cause varying degrees of impairment and grouping all or indeed any babies born with microcephaly as ‘damaged’ is a dangerous branding. Nevertheless, babies born with microcephaly, particularly when located in the poorest regions, are likely to need additional access to medical services and social interventions. This cannot be forgotten as causality between microcephaly and Zika virus are further investigated, and focus should also be given to the provision of support and inclusive development for individuals living with microcephaly regardless of cause.
It is our role as health practitioners, researchers and policy makers, to think about what this means for people living with microcephaly and indeed other disabilities and what we can do to create more supportive, enabling and inclusive environments. This is likely to need multi-disciplinary approaches, with a need for social mobilisation. As an immediate priority we should reject the label ‘Zika baby’, just as the term ‘AIDS baby’ was consigned to the dustbin of medical history.
The way forward for gender and disability and the Zika epidemic
Responding appropriately to the Zika epidemic will require us to navigate the landscape of complex reproductive health messaging and service provision. It must be based on strong community engagement, adjustments within the health system to make service more equitable and accessible, and realistic and pragmatic thinking about policy implications, which may require a shift from ideology to evidence and rights. We would argue that this can only occur if new partnerships between epidemiologists, virologists, clinicians, gender specialists, disability rights activists, vector biologists, sociologists, psychologists, and health systems researchers are forged and inform policy. Multi-disciplinary approaches are essential. Furthermore, globally stakeholders who are most affected by disease epidemics need to have their voices heard and drive the questions on equity. It is critical to remember that as vaccines are developed, and scientific links are proven/disproven, human rights abuses related to disability and sexual and reproductive healthwill remain globally and are often felt most by those who are already socially marginalised. This is unacceptable and we must set aside resources to tackle these issues.
* Laura Dean is a research assistant and PhD candidate at theLiverpool School of Tropical Medicine. Her research focuses on equity andhealth systems, with specific interests in gender, disability and community ledinterventions. She currently works with the COUNTDOWN consortium on exploringways that control and elimination of Neglected Tropical Diseases can be moreinclusive and equitable.
By Kate Hawkins, Research in Gender and Ethics: Building stronger health systems (RinGs)
When you work on health there are many international days which crop up during the year. Sometimes it’s easy to disconnect from their origins and meaning. It is International Women’s Day in a month’s time. So I thought it might be useful to reflect on what they day has meant and how we might celebrate it as people who have a commitment to health systems.
Whilst we tend to think of International Women’s Day as an initiative of the United Nation its roots are in women’s labour organizing. “We’d rather starve quick than starve slow,” was one of the slogans used by the International Ladies’ Garment Workers’ Union (the ILGWU) during their strike of 1909 in America. The ILGWU were fighting for improvements in their working conditions, as the factories that employed them were essentially sweatshops.
The strike was led mainly by young, immigrant workers – Jewish women from Russia, Poles, and Italians who conducted their meetings in English, Yiddish and Italian. The call to strike was actually made by a 15-year-old Ukraine-born girl worker, Clara Lemlich. Factory workers were joined in their struggle by some middle class women who offered financialand practical support.
In striking they confounded the mainstream, male labour movement, who were skeptical about their ability to organize themselves, and they defied the state (they were unfairly arrested by the police and beaten by hired local thugs). The ILGWU accepted a settlement in 1910 that improved things like working hours but didn’t give their union recognition. In 1909 the Socialist Party of Americacelebrated International Women’s Day for the first time in remembrance of the strike.
To say that the women were striking for their lives is no exaggeration. In 1911, 146 women employed in a clothing factory died when a fire broke out in their workplace – the Triangle Shirtwaist Factory – the number of deaths was high because of the poor health and safety practices that were employed there.
Promotion of the concept of International Women’s Day beyond the United States was taken up by Clara Zetkin. Later to be adopted by the United Nations (in 1975) with a General Assembly Resolution. However, for many woman workers around the world occupational environments still constitute a hazard to health.
Thinking and acting together to make change
Whilst many people working in international development and global health may celebrate International Women’s Day we don’t often talk about its roots in collective organizing, intersectional struggle, and a radical redefinition of the possible. Thinking about the creation of the Day reminds us that gender equity is not just a nice idea, it can literally be lifesaving. Remembering this heritage is one way of sparking new ways of thinking and new partnerships to address the seemingly intractable issue of gender inequity. This is especially timely as one of the themes of the upcoming Global Symposium is Equity, Rights, Gender and Ethics.
The theme of this year’s International Women’s Day is “Planet 50-50 by 2030: Step It Up for Gender Equality”, with a focus on building momentum for the implementation of the new Sustainable Development Goals. This year we have asked Health Systems Global to celebrate International Women’s Day by running a month where they promote content on health systems and gender equality in the form of blogs, webinars, and a Twitter chat. You can find out more about the Twitter chat on this blog.
The blog series is open to all Health Systems Global members and it would be great to get inputs from a range of countries and perspectives. We hope that there will be active participation across all of the Thematic Working Groups. Please do get in touch and let us know how you would like to contribute.
If you can think of any other ways that we can share information on health systems and gender we are open to your ideas and we look forward to hearing from you.
Photo credits:
Two strikers during the 1909 “Uprising” courtesy of http://labormovement.blogs.brynmawr.edu/ a site dedicated to the International Ladies’ Garment Workers’ Union
At a rally by the International Ladies’ Garment Workers’ Union at the site of Triangle fire, placards in English and Spanish naming Domsey Fiber include “We shall not forget” and “Trabajadores uniodos hamas seran vencidos” pointing to the continuing struggles of immigrant workers.
Photographer: unknown, 1990, Kheel Center
by Kate Hawkins, Anthony Bettee, Karsor Kollie, Sally Theobald, and Laura Dean
Late last year – with funding from the Thematic Working Group on Fragile and Conflict-Affected States – we were able to run two workshops in Liberia to better understand the impact of the Ebola outbreak on the different levels of the Liberian health system, at national, county and community levels.
Our consultations took place in Monrovia and Buchanan in Grand Bassa County. Through these dialogues we captured the views of a variety of stakeholders: education and training institutes, implementing and funding partners; key ministries involved in the delivery of health interventions; county health officers; community health department directors; general community health volunteers (gCHVs); community drug distributors; community leaders; and women’s and youth group leaders. The meetings provided learning on each of the health systems building blocks.
Leadership and Governance
Stakeholders felt that inter-sectoral working, for example collaboration amongst the ministries of Education, Agriculture and the Ministry of Health, is important in moving the country forward and rebuilding systems post-Ebola. Involvement of the county and community levels of the health system in post-Ebola planning was considered crucial. Some stakeholders felt that there could have been better coordination at the county level during the outbreak. Many spoke about the crucial role of gCHVs who were described as overburdened and pulled in the direction of the many (competing) disease programmes. Moving forward some suggested that gCHVs should be seen as another cadre of the health workforce and/or frameworks for incentives should be developed.
Financing
There was concern amongst some participants that the Ebola outbreak had diverted donor attention and resources away from other diseases and health systems activities. Over-reliance on NGOs and external funding agencies to support activities associated with health programmes was considered problematic. Some felt that Ebola highlighted a lack of planning within county health team budgets and work plans for activities associated with vertical programmes which could be improved as we move forward.
Health Workforce
High turnover of personnel in the Ministry of Health was seen as a critical problem as it led to under staffing and overburdened workers. At the county level, participants felt that there was an ongoing overstretching of disease focal points and other health staff that was exacerbated during the Ebola outbreak. This is likely to continue given the high numbers of health staff lost to Ebola. This impacts on staff motivation and retention at the county level. Staff also left because they were not always paid on time. Participants felt that the Ebola outbreak exposed areas of weakness in health workforce training which emphasizes the need for continued professional development. However, it also led to rapid learning about hygiene and screening procedures, allowing staff to become more equipped to manage communicable disease in the future. gCHVs played a significant role in Ebola surveillance at the community level. As a result they received more focused, regular supervision from the county health teams than previously.
Medical products/technologies
The Ebola outbreak put a strain on resources and participants observed frequent stock-outs of essential medicines at the village health centre level. Participants thought this suggested a need for improved supply chain mechanisms that are more resilient in times of crisis. Stock-outs were thought to be gradually decreasing with the most common drugs now regularly being sent. Some participants felt that there was poor quality drug management at county and community levels and that there is a need to put in place transparent drug procurement, storage and monitoring processes. Participants felt the Ebola outbreak led to the provision of better equipment to manage communicable disease epidemics. Protective clothing and the development of triage and isolation points were referred to.
Information and Research
Many stakeholders felt that a key priority post-Ebola was to update facility catchment information as well as to have more detailed statistics regarding the population and disease profile within these catchment areas. Many felt that re-mapping of disease prevalence would be necessary post the Ebola epidemic as numerous diseases were likely to have faced set-backs in their control during the crisis. gCHVs explained that the data collection ledgers that they are required to record information in at the community level are over complicated and difficult to use. They felt that simpler, more streamlined, processes could help ensure consistency across the health system and programmes. Improved population statistics would make planning, monitoring and evaluation easier and more consisent.
Service Delivery
Stakeholders noted that there had been a decline in the uptake of services since Ebola. This was perceived to be due to a two way break down in trust between communities and the health system. At the community level, people were afraid to go to health facilities because they were afraid of contracting Ebola. When they did access services, there were insufficient medicines and personnel had been diverted to manage the crisis. When interventions were taken to the communities, community members thought that health personnel were ‘bringing Ebola’. Health workers, also lacked trust in the community. This has resulted in morbidity and mortality due to diseases such as Malaria, TB etc. It has also resulted in a reduction in the coverage of preventative activities such as immunization and Mass Drug Administration for NTDs.
Participants felt that the Ebola outbreak had emphasised the importance of disease dynamics between urban and rural settings suggesting that further thinking was needed about how to adapt service delivery for different contexts. Logistical challenges in accessing communities that are particularly remote and sprawling were identified. gCHVs found moving through these areas was timely and costly and felt that the provision of bikes or motorcycles would help in accessing these harder to reach areas. Meeting places such as schoools – where gCHVs could normally access large segments of the population to deliver interventions – were shut down during the outbreak or people were too afraid to attend. Participants felt that there were strong structures at the community level that they could work with to develop effective social mobilisation. This needs to happen before (and not at the same time as) the provision of medicine or other interventions. Participants felt that by re-establishing and evaluating strategies that were successful prior to the outbreak and making comparisons across disease programmes and the health sector, stronger creative approaches could be generated.
Moving ahead
The stakeholder mapping taught us a great deal that can be used to inform the roll out of the NTD programme over the coming months and provides Liberian stakeholders with some suggestions of areas of work that need to be strengthened. A full record of the meeting will shortly be made available for those of you who would like to learn more.
The Prince Mahidol Award Conference will take place in Thailand from the 26-31 January and is organized around the theme of decision making for Universal Health Coverage (UHC). They note:
“Universal health coverage (UHC) is high on the global agenda as a means to ensure population health, equity and social development. In most countries where current access to essential health care is limited, introducing UHC prompts serious concerns among government leaders on the growing expenditures and demands for public resources. As such, priority setting is indispensable and has been applied at various levels, to ensure that finite health resources can be used in the most cost-effective ways, to provide a high quality and appropriate package of healthcare for the population.”
The importance of CHWs**, and their contribution to health care and health promotion have garnered increasing attention from governments, donors, health systems researchers and planners within post-2015 and UHC agenda setting, and also as related to increasing focus on global health security. CHWs often work in the most underserved areas and serve as frontline health workers key for advancing services for maternal and child health and HIV/AIDS and in support of the control of other infectious diseases. In recent years, emphasis has been plac
ed on addressing identified evidence gaps for CHWs, implementing national programs and strengthening the fragmented CHW program landscape within countries. Simultaneously, across the globe, many country governments’ increased focus on CHWs has led to increased stakeholder engagement. Yet the extent to which evidence for CHWs has been used within this dialogue and the effectiveness of the participation and processes utilized by these decision making entities (e.g. national steering commitments, working groups) is unclear and have not been a focus to date.
The session will examine the extent of which evidence has been used to inform decision-making and the impact of diverse stakeholder participation in the dialogue around strengthening CHW programming for UHC and health goals in countries.
Panel
Dr. Jan-Walter De Neve, Harvard School of Public Health, USA
PEPFAR/USAID supported case studies conduct to inform decision-making to harmonize CHW investments for HIV programs in Swaziland, Mozambique, Lesotho, and South Africa
Lillian Otisio, LVCT Health, Kenya
Experience from the REACHOUT Consortium, a project working across six countries in Africa and Asia to strengthen the role of close-to-community providers of health care
Dr. Emma Sacks, Johns Hopkins University, USA
Experience in using the C3 Tool, an analytic decision-making tool, in Tanzania and Rwanda to help governments prioritize technical content for CHWs and refine strategies for investment, training and coverage
Department of Health Workforce, World Health Organization
The purpose and process of the development of WHO Guidelines on Community Based Practitioners for UHC
Find out more
The session is open to all conference participants and we hope that you will come along. If you would like to find out more please contact Diana Frymus, Health Science Specialist, USAID Washington, DC and Co-Chair.
* * See Campbell, J et all, “Maximizing the impact of community-based practitioners in the quest for Universal Health Coverage”, Editorial, Bulletin of the World Health Organization, 93:590-50A, 2015,.
Recently we both attended a RinGs webinar on how to do gender analysis. This is part of the capacity strengthening activities of the project. It is really nice to take some time to hear from colleagues working on health systems around the world and get some space to think through how we can work together to strengthen a gender analysis. RinGs is developing a great deal of detailed material on this topic so we thought we would keep this short and give you our ten things to bear in mind about gender and health systems research.
1.Gender is a key social stratifier: As a power relation it affects vulnerability to ill health and the decision making space and economic power that people have to tackle illness. Access to health services can be effected by gender, for example, women may have less money to pay for health care and find it difficult to travel to a health care centre. On the other hand, sometimes health care centres can be too tailored to women, which puts men off attending.
2.To strengthen health systems we need to pay attention to gender: It is important to understand how health systems components interact with each other, how gender plays a role in each of these, and how to address these gender issues in health systems strengthening activities in order to improve health and social outcomes. Including gender analysis in health systems research help maximise the effectiveness of programmes, lead to better research recommendations, more strategic interventions and programmes and more effective policies.
3. As health systems researchers we need to recognise gender: Expressions of gender inequity -whether in the relations between women and men or within organisations -need to be recognised and addressed in order to redress discrimination and ensure interventions in health involve and benefit the disadvantaged.
4. Sometimes gender issues are rendered invisible: For example, terms like Community Health Worker, village health committees, insurance policies appear gender neutral and yet they are gendered. When we disaggregate data and analyse context and relationships these gendered aspects can come to the fore.
5. There are still issues and confusion about separating gender and sex, especially in analysis: ‘Being’ female and ‘being’ a woman are two very different sort of being. Yet in data analysis, for example, gender disaggregation means separation into male and female. It is not uncommon to see such variables as ‘Sex/Gender’.
6.We need to look beyond the individual: It is important to think about gender relations between couples, families and households. But gender analysis is also about how society is structured, the norms and institutions that guide things and access to resources that flow from this.
7.We need to take account of gender-fluidity: Gender isn’t fixed, it changes across time and across contexts. Looking at gender in combination with race, class and other forms of inequality enhances the analysis.
8. Gender frameworks can help: RinGs has collated what they consider the top ten gender frameworks on their website. They can help us think through what constitutes power gendered relations and how power is negotiated and changed.
9.We should also think creatively about the methods that we use: For example, we could employ social networking analysis of gender issues in healthsystems research in addition to other available tools.
10. Building capacity goes beyond the individual: Ensuring that gender infuses questions about research design, data collection and analysis is important. Researchers need to think carefully about their own positionality. However, we also need to look to those political, social and economic structural barriers that prevent a focus on gender in the first place. What can we – as health systems researchers – do to overcome these?
We call upon our colleagues in RinGs to use the comments function below to add to the list of gender-related points to keep in mind when you are doing health systems research and to keep the conversation live!
*Prof BSC Uzochukwu is the deputy coordinator of the Health Policy Research Group, College of Medicine, University of Nigeria, Enugu-campus. He is a member of the Resilient and Responsive Health System Consortium (RESYST) and Board member of Health Systems Global (HSG).
Working with community health workers (CHWs) is seen as a good solution to the problem of a shortage of formal health workers and the push to scale up of programmes to meet universal health coverage.
But how do you attract, retain and support CHWs? Who manages CHWS and how do they support them in their vital role of serving their communities?
We set out to explore human resource management practices used for supporting and managing health workers, considering the views from CHWs, community members, and formal health workers in Ghana, Democratic Republic of Congo, Senegal, Uganda and Zimbabwe.
Who manages CHWs?
Frontline supervisors, such as health centre nurses, and senior CHWs play a major role in the management of CHWs and are central to the implementation of human resource management practices. Some support from the community is provided through health centre committees – such as helping select CHWs, discussion of health issues and planning CHW activities. However, in some contexts such as DRC, Uganda and Zimbabwe this support is minimal.
What do CHWs expect from their role in health care?
CHWs’ expectations from the role ranged from serving the community, enhancing their knowledge and skills, receiving financial benefits, being recognized in the community as a health worker, having social status and prestige in the community, and their role fitting in with other work such as family, home and other paid work.
How well do current human resource management practices meet these expectations?
CHW expectations are not always met through human resource management practices. For example help with farming to free up the time to carry out healthcare work did not materialise in Ghana. Incentives for carrying out health campaigns in DRC were too small and too late and therefore not sufficient to achieve the desired performance. Human resource management practice by managers had not sufficiently controlled the workload to enable CHWS to carry out their personal tasks such as farming, causing some CHWs wanting to leave.
What could be done?
Managing CHW programmes is complex if the aim is to foster ownership by the communities being served as well as delivering quality services. What is therefore needed is a coordinated human resource management approach which is designed to not only address CHW expectations but also to ensure that the programme meets its goals. There is a need to work with all management actors (programme managers, supervisors, community level managers and others involved) to put this in place and implement it.
This would include:
Getting a better understanding of the expectations of CHWs so that human resource practices meet their needs
Increasing clarity at the recruitment stage about which CHW expectations can and cannot be met
Joint use of human resource management practices by community and health sector representatives, monitoring the effects and making necessary adjustments to these practices for CHWs
Documenting what works, under what circumstances to increase learning about supporting CHWs to improve the health of their communities.
Are close-to-community providers and community health workers (CHW) part of the health workforce? If so, what can governments and international agencies like the World Health Organization do to support them and ensure that their work is integrated into and supported by the wider health system? What does a human resources for health strategy that includes CHWs actually look like? These are some of the questions that we have been grappling with in REACHOUT as we read and responded to the recent World Health Organisation consultation on this issue.
A focus on community
One of the many positive elements of the draft strategy that is under consideration is that one of the principles explicitly mentions the role of communities in realising the right to health and states that communities should be empowered in order to work on the social determinants of illness.
“Support governments to build optimal health workforce models for the provision of people-centred integrated health services, responsive to patients’ sociocultural expectations, and empowering and engaging communities to be active participants in the health care production process.”
We believe that various types of close-to-community health care workers are vital human resources for health and that these cadres provide a critical interface between the community and the formal health system. We are concerned that this cadre of staff are not explicitly mentioned in the Global Strategy and that as a result they will not be factored into this holistic approach.
While there are certainly challenges in scaling up, and making the most of, close-to-community health programmes CHWs should be valued and nurtured in a similar manner to their formally employed peers who they work alongside often at considerable material and emotional cost to themselves.
We would like to stress that we call for a greater emphasis in this area not to create special vertical programmes for CHWs, but rather to support the overall effectiveness and equity of national and sub-national health systems.
Political will
We note the focus in the draft strategy of the importance of political will in the scale up of well-functioning, appropriately supported health workforces. In recent months there has been a surge of support for close-to-community programmes. For example they have been being heralded as a ‘good buy’ for development in a high-level report released at the Financing for Development Conference. But how do we ensure that these programmes are effective and are run efficiently and equitably in ways that are owned by health care staff, CHWs and communities? From our REACHOUT analysis key areas of concern have emerged that have potential to undermine CHW programme effectiveness and equity: 1. supervision; 2. community engagement; 3. referrals; and 4. coordination between stakeholders. Scale-up of CHW programmes is seen as a way of reaching universal health coverage, but rapid scale-up that does not address these concerns poses a potential risk to service quality and equity.
Migration and health worker shortage
The overview of the draft strategy suggests that the out-migration of health workers from low- and middle-income countries and under-investment by governments in this area places a strain on the health system. We would also argue that it places more responsibility on under-supported close-to-community providers who are being expected to add new areas of work to their existing portfolios, despite limited capacity, barely any support and no complete picture of the quality of the services that are delivered. There is a danger that they are seen as a “magic bullet” which will ameliorate weaknesses in other areas of the system.
Improving the evidence base
We note that the draft strategy calls for stakeholders to draw on “evidence on what works in health workforce development across different aspects, ranging from assessment, planning and education, across management, retention, incentives and productivity, and refers to the tools and guidelines that can support policy development, implementation and evaluation in these various areas.” We feel that there should be mention of the local and community level in this paragraph. In REACHOUT we have been exploring quality improvement cycles in close-to-community programmes. We define quality improvement as a systematic approach to planning defining, monitoring, improving and evaluating community health programmes. Through our work we are embedding into CHW scale-up, tried and tested quality improvement methods that are easy to use, simple to do and where data are collected, analysed and used by communities and CHWs to improve things in their own contexts.
This is not without its challenges. Government standards and guidelines are not widely known or disseminated and few people in the health system and in the community are clear on what their roles in quality improvement for community health might be. There are far too many tools and documents that are not owned by communities and CHWs.
Furthermore, we note that there are few studies that capture or explicitly discuss the context in which CHW interventions take place. In our work contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were also prominent. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All these contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. Future health policy and systems research should better address the complexity of contextual influences on programmes.
Focus below the national level
Whilst increasing national and institutional capacity to govern programmes is a laudable aim we believe that attention should also be paid to the sub-national and community levels and management capacity. Our research has argued that a mix of financial and non-financial incentives, predictable for the CHWs, is an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
We also feel that capacity for conducting community health research deserves special attention as the voices and perspectives of communities are not adequately represented and this requires developing strategic partnerships and using innovative methods.
We look forward to the next steps in the policy development process and hope that some of our desires and concerns are reflected in the document moving forwards.
There are papers from a range countries about people working in quite different contexts and we also have articles which take an international or overarching approach. What seems clear is that CHW programme scale up is challenging in the face of health systems constraints and that there is no blue print approach. However, systematic and systemic interventions, for example related to human resource management or the governance of programmes is needed. Another key message is that it is important to, “put the human into human resources”, and that people-centred health systems need to understand community health workers as people with their own challenges, strengths and motivations. These can relate to incentives in the health system as well as the ways that they relate to community members and institutions. We also have a lot to learn about the costs of CHW programmes and how best to asses these.
The thematic series is not finished yet and will run for some time to come. So look out for new papers and the editorial which brings together learning on what has been published so far. We have also asked some of the authors to tell us a bit more about their work. So expect blogs and other communications from the Group over the coming months.
* Kate Hawkins is Director of Pamoja Communications. She also works for the REACHOUT Consortium and is the secretary of the Health Systems Global Thematic Working Group on Community Health Workers.
Sally Theobald, Rosemary Morgan, Kate Hawkins and Sassy Molyneux
Human Resources for Health: 57
In this commentary, we discuss a photography competition, launched during the summer of 2014, to explore the everyday stories of how gender plays out within health systems around the world. While no submission fees were charged nor financial awards involved, the winning entries were exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. Anyone who had an experience of, or interest in, gender and health systems was invited to participate. Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement and in venues where their perspectives are often missing. The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. In total, 54 photos were submitted by 29 participants from 15 different nationalities and country locations. We unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. Three themes emerged: women active on the frontlines of service delivery and as primary unpaid carers, the visibility of men in gender and health systems and the inter-sectoral nature and intra-household dynamics of community health that embed close-to-community health providers. The question of who has the right to take and display images, under what contexts and for what purpose also permeated the photo competition. We reflect on how photos can be valuable representations of the worlds that we, health workers and health systems are embedded in. Photographs broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways but also reflect the politics, values and subjectivities of the photographer. They represent stereotypes, but also showcase alternate realities of people and health systems, and thereby can engender further reflection and change. We conclude with thoughts about the place of photography in health systems research and practice in highlighting and potentially transforming how we look at and address close-to-community providers.
Introduction
Research in Gender and Ethics (RinGs): Building Stronger Health Systems is a partnership across three health systems research consortia1, developing a platform for learning and research on gender, ethics and health systems. During the summer of 2014, RinGs launched a photography competition to explore the everyday stories of how gender plays out within health systems around the world. Given that gender is often not considered relevant to health systems or understood in simplistic ways 1], we hoped that the photography competition would generate visual stories that would inspire imagination and provoke contemplation among health system researchers and practitioners about what gender means for their work.Photos, like written outputs, are representations of the social and ideological worlds we, health workers and health systems are embedded in. As such, they are an important data source to communicate and understand complex issues and diverse contexts 2, 3], particularly in the increasingly visually saturated and globalized economy we are situated in. Photographs can broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways. However, they do not simply mirror reality but also reflect the politics, values and subjectivities of the photographer, through what they choose to highlight and how they frame their images. They can either represent stereotypes or provide an opportunity to showcase unique and vivid alternate realities of people and health systems, and thereby engender further reflection and change.In this commentary, we reflect on the photos submitted and the ensuing judging process and email dialogue with participants who reacted to the photo competition. We are a team of health systems researchers and a communications and research uptake manager. We have little experience in photography beyond personal use and no expertise in the various academic fields that engage with photography, beyond work with participatory photography as a research methodology. As researchers, our incentive structures may prioritize academic publications over other ways of supporting and documenting community voice and social change. Nonetheless, we strongly feel that photography is an important medium that health systems researchers and practitioners must critically engage in.Within this paper, we seek to unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. The latter include “health workers who carry out promotional, preventive and/or curative health services and who are often the first point of contact at community level…[and] are strategically placed as the interface between health systems and the communities they serve” 4]. In examining our experience of the photo competition, we discuss our interpretation of the narrative and politics underlying the images and the potential of photography to better understand and therefore inform more effective and equitable ways of supporting close-to-community provision of health services. We describe the photo competition, analyse the three main themes that emerged, consider the ethical issues that arose and conclude with thoughts about the place of photography in health systems research and practice.
The photo competition
The RinGs photography competition was advertised widely through twitter, email list serves and several websites between 22 July and 1 September 2014. The deadline for entries was 1 September 2014. The competition was particularly targeted at health systems researchers within our own networks and potential Global Symposium on Health Systems Research participants. The aim of the competition was to capture the everyday stories of the ways that gender plays out within health systems around the world. In particular, we were looking for images which challenged stereotypes, encouraged the viewer to learn more and act differently, and which respected the integrity of any people who may be photographed. We welcomed images of people of all genders from all areas of the health system and from all around the world 5]. While advertising the competition, links were included to discussions on the ethics of photography in international development, which dealt with issues of consent, motives, respect and portrayal of subjects. Participants were asked to describe the level of consent obtained for each submission, and photos which were taken without consent were not considered. Additional submission requirements and information required from participants is presented in Table 1.
Table 1: Submission requirements and information supplied by participants
Submission requirements
Information supplied by participants
1. Size: at least 1 MB
1. Name of participant
2. Print resolution: 300 dpi
2. Participant’s email
3. Format: JPEG or tiff only
3. Participant’s phone
4. Landscape and portrait images are acceptable
4. Title of photograph
5. Although some digital enhancement is acceptable, we cannot accept images that have been digitally altered to change what is portrayed
5. Location (country and city/town/village where the photograph was taken)
6. The date (if unknown, please provide the year) each photograph was taken
7. The level of consent provided from any people pictured in the photo (see informed consent guidelines for more information)
While no submission fees were charged nor financial awards involved, it was advertised that the winning entries would be exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. In addition, RinGs stated that it would use the images to illustrate our website and other published materials with credit to the photographers. Based on learning from the competition process, we removed this last condition, as discussed later.Up to three photos could be submitted via email to RinGs and were displayed online through a Flickr account. In total, 54 photos were submitted by 29 participants of 15 different nationalities and country locations (see Table 2). We were pleased to see the breadth of geographic participation and that so many of the participants were female. The repository of images was actively disseminated via social media by the RinGs steering committee to stimulate interest and discussion on the subject matter among health systems researchers and practitioners.
Table 2: Summary of photo competition participants’ profile
Gender
Nationality
Photo location
Female
17
United States
6
Nigeria
5
Male
11
Kenya
4
Uganda
4
Unknown
1
India
3
India
3
Total
29
Nigeria
2
United States
3
Indonesia
2
Indonesia
2
United Kingdom
2
Mozambique
2
Ireland
1
Kenya
2
Germany
1
Cambodia
2
Cameron
1
Bolivia
1
Uganda
1
Ethiopia
1
South Africa
1
Tanzania
1
Cambodia
1
Guinea Bissau
1
Myanmar (Burma)
1
Bangladesh
1
China
1
South Africa
1
Taiwan
1
Ghana
1
Unknown
1
Total
29
Total
30
Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement. We saw the competition as one way to increase their visibility at an international health systems research conference where the perspectives of communities, health workers and other non-academics are often missing. Anyone who had an experience of, or interest in, gender and health systems was invited to participate.The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. Two of the submissions that were given an honourable mention were photovoice entries, where community members themselves got behind the lens to document and narrate their stories; these photos where submitted by researchers who were involved with the photovoice projects. One highlighted women in street performance peer education activities for maternal health in Uganda, and another profiled a woman from a marginalized community learning how to use a camera to document community resilience in the Sundarbans, an ecologically vulnerable region in India.All photos were judged on the basis of their content (their relevance to the subject), their ability to tell the story of gender and health systems and the technical merit of the photo by five judges. The judges included academics working on gender and health systems drawn from the RinGs steering committee, and a research communications consultant independent of RinGs who has extensive experience in international research on women’s empowerment. Each judge scored the photos on a scale of 1 to 3 (from not meeting the criteria to fully meeting the criteria) in relation to the three criteria listed above. The scores were then totalled and averaged across the five judges. The photos were subsequently ranked according to their overall score. All photos that received a score of 2.3 and above were given an honourable mention.As stated above, photos often reflect the politics, values and subjectivities of the photographer, through what they choose to highlight and how they frame their images. How photos are interpreted by the viewer is also subjective, grounded in his/her own social and ideological world. The judges therefore interpreted the photographs in a way that was congruent with their own knowledge, backgrounds and interests, which may or may not have matched the intent of the photographer or resonate with other viewers. All the judges had expertise relevant to gender and community health systems; three were based in high-income countries (the United Kingdom and the United States) and two were based in a low- and middle-income country (Kenya).
One winner was unanimously selected 6], and 15 photographs were given an honourable mention by the judges 7]. The winning photo was submitted by AMREF Health Africa and is a professional portrait of an older woman who used to be a traditional birth attendant, who has retrained as a midwife in Uganda (Figure 1). The image resounds with the strength, dignity and confidence of a woman proud of her contributions despite the challenges faced. She shines like a ray of hope parting the stormy clouds of circumstance. As the photograph is taken from below, we look up to her with respect, which is in contrast to the many photos where we look down on women. She is wearing the gloves and a uniform of a female vocation and profession that is under negotiation and transformation. The photo was selected because it presents a strong, positive image that pushes boundaries. It takes a conventional role and presents it in an unconventional and affirming manner, while valuing women as wise and weathered agents, rather than objects of passive beauty.
Figure 1 Winning photo: The power of a midwife. Photo credit: this photo was taken during a collaboration between the Guardian UK and AMREF Health Africa. Caption: the traditional birth attendant, trained as a professional midwife, is leading the maternal and neonatal care revolution in Africa. What was once a neglected role of women has now taken the attention of international health NGOs and global policymakers working toward a healthier Africa. Photo location: Katine, Uganda. Images submitted and the themes they portray
Women active on the frontlines of service delivery and as primary unpaid carers
Women on the frontline of health service delivery was a theme portrayed by 17 photos. This is representative of global statistics that show that human resources for health are gendered. In many countries, women make up more than 75% of the health workforce, primarily at the lower tiers closest to communities 8]. Many of the 17 photos feature women working in communities as volunteers or community health workers, highlighting their roles in serving other women primarily through community or preventive services. This included being trained as peer educators in Nigeria, as Kaders registering women and children in Indonesia, weighing children in Uganda, or immunizing children in Ethiopia. Often, these tasks were undertaken with vigour and humour, as shown by the traditional birth attendants (TBAs) in Guinea Bissau who are pictured in a line seemingly staring down the photographer (Figure 2).
Figure 2 Traditional birth attendants pose after newborn training in Guinea-Bissau.
Photo credit: Polly Walker. Photo location: Buba, Quinara Region, Guinea-Bissau.
Women’s role as unpaid carers for family members was also prominent 9, 10]. Caring for sick or elderly family members is often not recognized as work by the health sector. Many photos documented women waiting for service at health systems with babies and other family members. Sometimes, they were seemingly passive recipients, while others were in a more interactive role, for example, in dialogue with other women and different healthcare providers.
While many images came from rural contexts, one photo showed a female community health worker visiting an adolescent mother and her child in a low-income urban settlement in India 3, arguably portraying the trust that can enable positive patient–provider relations. Urban contexts provide different challenges for community-based work, given that populations are more mobile, settlements often illegal, and programmes non-existent in contrast to rural areas 1112.
Figure 3 Community health worker and stories of the urban poor.
Photo credit: Bhargav Shandilya. Photo location: Bangalore, India.
While demonstrating the importance of women as close-to-community providers, very few highlighted the working conditions of these frontline health workers. Women systematically are paid less than their male counterparts in the health workforce 1314, at times receive unequal non-pecuniary benefits 15 or work in contexts that are highly constrained and disempowering 16]. A photo of the Employment Equity Policy Guiding the Appointment of Staff in Health Facilities in South Africa quite explicitly raised concerns about employment terms. Only one photo showed an immunization officer and health committee member who were nursing mothers themselves. Strikingly, there were very few photos of women as facility-based health professionals, and only one photographer documented a woman in a managerial role: a nursing officer in Uganda resting on her motorcycle, self-assured while straddling a motorcycle typically associated with men. These images starkly reflect the multiple ways that hierarchy and gender intersect to stratify the health sector in inequitable ways 1718.
Where are the men in gender and health systems?
Men were also highlighted in gender transformative ways by the photo competition. Male peer educators provided HIV testing and counselling to couples from nomadic communities in rural Kenya (Figure 4). Another image showed a group of rural Indian men in a circle happily chatting, some leaning forward to engage, others listening, all seemingly relaxed. The photo captures them brainstorming on spousal communication and family planning decision-making. Another photo is of a young man in the library in Ghana attentively and quietly engrossed in a journal of obstetric nursing. From Cambodia, we received images of male nurses being trained alongside female nurses, caring for children in a Cambodian hospital that prides itself in promoting a more equitable work environment. And in the US, male and female public health students collaboratively engaged in a campaign to raise awareness of gender-based violence. These examples highlight the important role men play in working alongside women, engaging with women’s health concerns and advocating for gender equality. Given the social vulnerability of men to chronic diseases and injuries, attention to men’s gendered risks underpinning these imbalances is also critical 19.
Figure 4 Reaching the hard to reach, nomadic, young and old with HIV testing services in Kenya. Photo credit: LVCT Health. Photo location: Eremit Village, Kajiado, Kenya.
While these were good examples of the ways that men are supporting their communities and societies to combat ill health, there were very few submissions documenting the role of men as health providers, managers or politicians engaging in gender issues as a way of transforming health systems. Fewer still documented the role of men as frontline and close-to-community providers of healthcare. One image from Mozambique starkly depicted a male provider sitting at a desk out in the open facing a multitude of women waiting to see him. Given the influence of men in health systems – particularly the politics, policy and decision-making processes from the global to the household level – the relative absence of men photographed in these roles is interesting. This perhaps reflects the ways in which gender is so often equated with women but also how the visible face of frontline health and community systems is often female.
What issues arise being close to communities?
Many photos pictured women in active roles farming, buying, producing and processing food stuffs. For example, women in Nigeria were pictured processing forage powder using local stub to fry soya beans, groundnut and millet for weaning children. While these images were not immediately obvious “health systems” images to the staff judging the competition, they demonstrated the importance of nutrition to health in the minds of photographers and are a reminder of the importance of inter-sectoral action for health.For some of the women pictured, the livelihoods they relied on entailed extremely arduous working conditions and serious occupational risks. Female crab collectors from the Sundarbans, who were predominantly from households where men had out-migrated for formal sector employment, stood deep in mud and braved tiger attacks. Fisher women from the same community were pictured thigh high in water risking skin diseases and reproductive tract infections. One image was of women who journey approximately 10 hours from Cameroon to Nigeria carrying heavy loads of corn by foot to get it milled and then return to Cameroon with the flour. While all the photos of close-to-community health provision focussed on maternal and child health needs, these photos highlight the ways in which gender roles shape livelihoods and food production, which in turn shape health experiences and outcomes. Close-to-community health providers are embedded in communities and may therefore be strategically placed to understand intra-household gender and power dynamics and how social determinants, such as poverty and food security, shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood 20
Ethical considerations related to power
The question of who has the right to take and display images, under what contexts and for what purpose permeated the photo competition. Although we disseminated guidelines on the ethics of informed consent for photography, only one photographer made reference to a code of conduct with regard to use of images 21]. Most photographers reported verbal consent or written consent where possible. Nonetheless, several photo submissions did not detail consent or reported consent that was more casual in manner: photographers pointing at the camera and seeking consent non-verbally. However, this fails to distinguish between seeking consent for taking a photo, whether for personal memories or for professional imperatives, and seeking consent for disseminating the image publicly, whether for profit or non-profit motives (in this case, there were no direct financial gains from the competition). We cannot guarantee that all the photos submitted to the competition followed the recommended ethical principles with regard to consent. However, in the case of the photography competition, only photos that more clearly outlined consent for dissemination were considered for honourable mention and further publicity. Further follow-up with photographers was also undertaken before disseminating the images more broadly.Ethical principles in photography and use of images go beyond issues of consent 3, 22, 23]. They span issues of justice, autonomy, non-maleficence, beneficence and fidelity. Are we representing subjects respectfully, in ways that do not further marginalize, stigmatize or exploit them personally? Do the images raise questions about health workers, their health system realities and broader public health priorities to support constructive social change? It was striking that several photographs submitted did present traditional images of women as passive beneficiaries of maternal and child health services. Certain aspects of community health provision may be so normalized that they remain invisible. How does this influence policy and programme considerations for close-to-community providers? When reviewing lay health worker policy in South Africa, for example, policymakers failed to see the gendered origins of the working conditions that were acknowledged to be problematic 24].Who else benefits from the images being shared and in what ways? It is striking how photo credits are often for the photographer alone, without acknowledgement of the person or people photographed or the organization sponsoring the photographer. This may be to protect individual identities, but photos can be even more personal than research findings because they can be more irrefutably identifiable or contextually revealing. Feminist research ethics interrogate who has the right to be an author representing the realities of others and how; but how do we apply such principles to photography and photography competitions?Most of the photos submitted were by photographers who remained in control of shaping what was included in the images. The photos highlighted, while positive, do not necessarily express the active voice and perspective of close-to-community service providers themselves – their views, struggles and dilemmas. Large-scale participatory projects, such as the World Bank’s “Voices of the Poor”, even with their limitations, demonstrate that policymakers can be moved by participatory methods 25]. Participatory approaches are increasingly recognized as a vital part of health systems research 26]. For example, photovoice offers important opportunities for community members and health workers to contextualize photos in relation to the individual and institutional realities that they experience.But there are tensions within participatory approaches, and politics and power play out in multiple ways. The two photovoice submissions were not initially selected by the judges as they were not as well composed as those submitted by professional photographers. Without understanding the transformative process behind those images, photovoice submissions can be dismissed as being of poor quality and can fail to present a compelling argument in an increasingly crowded communications environment characterized by large marketing budgets, high-specification technology and vastly more professional outputs. Within this environment, it may be difficult for the messages conveyed through participatory photography projects to gain traction.In response to this, some researchers have explored how partnerships between creative professionals and poor and marginalized groups can generate more compelling products for a general audience with no particular interest in alleviating poverty. For example, the Pathways of Women’s Empowerment Consortium has reimagined old fairy tales in Egypt and pop music in Ghana in order to challenge established narratives about women 27]. This kind of storytelling is a powerful medium for changing critical consciousness. Can such avenues also be explored to celebrate the heroes that hold up community health systems the world over? Close-to-community providers are critical foundations for communities and health systems but rarely are given opportunity to decide on the images that portray them or their perspectives.Finally, while we purposefully framed the terms of the competition to encourage lay and amateur photographers to get involved, particularly supporting further creativity and visibility among health systems researchers, this had the unintended consequence of further marginalizing some professional photographers. In a world of skewed financial resources, some professional photographers struggling to maintain their livelihoods found the non-financial terms of our photo competition an affront to their expertise, skills and profession 28]. This raises questions about the nature of photography competitions and participation in general, something which development organizations have been criticized for in the past. Photography competitions are sometimes used as a way to solicit unpaid work. As a result, they can create false incentives among the photographers who enter and can be unfair for those who look to make their living from photography.One response to our photo competition suggested that if the aim of the competition is to generate discussion, provide a voice to the otherwise voiceless or help researchers better communicate their research, then not offering a monetary prize or financial incentive may not be problematic. However, if the aim of the competition is to obtain professional photographs to use within publicity campaigns, then prizes should be offered which recognize the costs of producing the images and help contribute to the livelihood of the photographer 29]. Based on this feedback, we agreed to not use the photos for publicity purposes beyond the confines of the photography competition. Greater transparency is needed within photography competitions regarding the aim and purpose of the competition, and participants should be made aware of what the intended use of the photographs is. This would help to ensure that competitions do not add to the exploitation and maltreatment of photographers.
Conclusion
Photos can capture nuances or startle us and communicate issues powerfully and symbolically in ways that are sometimes more enticing, convincing and memorable than in tomes of written evidence that may or may not be read or remembered. Writing on the importance of creative communication in the uptake of research on women’s empowerment, Lewin 30: 223] has argued that, “good empirical research; intellectual work and compelling arguments are not enough to provoke change. People need to see alternative realities; utopian visioning is a political project. We need to see the world presented in different ways – our emotional and visceral responses are very important in shaping how we think, and more importantly, how we feel”. This is particularly important in relation to gender and health systems where the generation of political will to develop and act on an evidence base is necessary. It is also particularly relevant to close-to-community providers, who are too often treated as “resources for human health” rather than as people with needs and rights themselves 17, 24].The health system research field has begun to wake up to the potential of online social media in research communication (as exemplified by the recent Social Media awards at the 2014 Global Symposium on Health Systems Research). Looking to the future, the role of social media – such as Instagram and snap chat – which encourages the rapid exchange of photos and video images in unmediated ways will increase rapidly 31]. Key opportunities of this include activism, challenging stereotypes and breaking news of abuses. At the same time, issues of consent, agency and justice are of critical importance to ensure that photos are not taken out of context and do not objectify or disempower health workers and other health system actors who are at times on the margins of health systems. This is a fast changing world posing challenges to health systems researchers to stay with the curve, let alone get ahead of it to shape future trends. The opportunities and challenges of evolving media and mobile technologies for democratizing photography to highlight gender, human resources for health and health systems in transformative ways need further attention, analysis and action. Endnotes 1RESYST: Resilient and Responsive Health Systems, REBUILD Consortium, Future Health Systems: Innovations for Equity
tion id=”Declarations” class=”Section1 RenderAsSection1″ data-test=”declarations-section”>Declarations Acknowledgements
The authors would like to acknowledge everyone who took part in the photo competition. We would also like to acknowledge the Global Symposium on Health Systems Research for allowing us to showcase the photos during the conference in Cape Town. All authors are members of Research in Gender and Ethics (RinGs): Building Stronger Health Systems, funded by the UK Department for International Development (DFID) for the benefit of low and middle income countries. The views expressed are not necessarily those of DFID. We would also like to thank Future Health Systems (FHS), ReBUILD and RESYST for contributing to photo printing costs so that the photos could be displayed at the symposium. In addition we would like to thank FHS, RESYST, and REACHOUT for supporting open access publication costs. Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAG made substantial contributions to the conception and drafting of the manuscript; ST and KH have been involved in drafting the manuscript or revising it critically for important intellectual content; RM and SM have been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.
RinGs Steering Committee. Snapshot of needs assessment findings [Internet]. Research in Gender and Ethics (RinGs): building stronger health systems; 2014. Available from:
Devakumar D, Brotherton H, Halbert J, Clarke A, Prost A, Hall J. Taking ethical photos of children for medical and research purposes in low-resource settings: an exploratory qualitative study. BMC Med Ethics. 2013;14(1):1–27.View ArticleGoogle Scholar
Riley RG, Manias E. The uses of photography in clinical nursing practice and research: a literature review. J Adv Nurs. 2004;48(4):397–405.View ArticlePubMedGoogle Scholar
Human Resources for Health. Supporting and strengthening the role of close-to-community (CTC) providers for health system development [Internet]. 2015 [cited 2015 May 13]. Available from: http://www.human-resources-health.com/about/update/CTC
Ogden J, Esim S, Grown C. Expanding the care continuum for HIV/AIDS: bringing carers into focus. Health Policy Plan. 2006;21(5):333–42.View ArticlePubMedGoogle Scholar
Tijdens K, de Vries DH, Steinmetz S. Health workforce remuneration: comparing wage levels, ranking, and dispersion of 16 occupational groups in 20 countries. Hum Resour Health. 2013;11(11): doi:10.1186/1478-4491-11-11.
Vecchio N, Scuffham PA, Hilton MF, Whiteford HA. Differences in wage rates for males and females in the health sector: a consideration of unpaid overtime to decompose the gender wage gap. Hum Resour Health. 2013;11(9): doi:10.1186/1478-4491-11-9.
Gupta N, Alfano M. Access to non-pecuniary benefits: does gender matter? Evidence from six low- and middle-income countries. Hum Resour Health. 2011;9(25): doi:10.1186/1478-4491-9-25.
Maputle SM, Hiss DC. Midwives’ experiences of managing women in labour in the Limpopo Province of South Africa. Curationis. 2010;33(3):5–14.View ArticleGoogle Scholar
George A. Nurses, community health workers, and home carers: gendered human resources compensating for skewed health systems. Glob Public Health. 2008;3(S1):75–89.View ArticlePubMedGoogle Scholar
Newman C. Time to address gender discrimination and inequality in the health workforce. Hum Resour Health. 2014;12(25): doi:10.1186/1478-4491-12-25.
Hawkes S, Buse K. Gender and global health: evidence, policy, and inconvenient truths. Lancet. 2013;381(9879):1783–7.View ArticlePubMedGoogle Scholar
Theobald S, MacPherson E, McCollum R, Tolhurst R, in collaboration with REACHOUT. Close-to-community health providers post 2015: realising their role in responsive health systems and addressing gendered social determinants of health. Liverpool, UK: Background paper, Centre for Applied Health Research and Delivery (CAHRD); 2014.Google Scholar
>Dochas. Code of conduct on images and messages. Dublin, Ireland: The Irish Association on Non Governmental Development Organizisations; 2006.Google Scholar
Teti M, Murray C, Johnson L, Binson D. Photovoice as a community-based participatory research method among women living with HIV/AIDS: ethical opportunities and challenges. J Empir Res Hum Res Ethics. 2012;7(4):34–43.View ArticlePubMedGoogle Scholar
Wiles R, Prosser J, Bagnoli A, Clark A, Davies K, Holland S, Renold, E. Visual Ethics: Ethical Issues in Visual Research. Southampton: ESRC National Centre for Research Methods. 2008.Google Scholar
Daniels K, Clarke M, Ringsberg KC. Developing lay health worker policy in South Africa: a qualitative study. Heal Res Policy Syst. 2012;10(1):8.View ArticleGoogle Scholar
This blog post is part of a series on people-centred research methods for health systems development published in conjunction with a Twitter chat on the same topic. Please see below for links to other blog posts in this series.
The ReBUILD Consortium is conducting health systems research in post-conflict contexts. This brings with it several challenges, including: lack of data, recall and memory lapses, ensuring confidentiality and the changing contexts of conflict and displacement. Often people have experienced multiple traumatic events which many may want to forget, although these memories could be of importance to the reconstruction process. Both conflict and post-conflict rebuilding are political processes. So, attempts to rebuild a health system will be influenced by power relations, which in turn are shaped by historical, regional and social inequalities, and there is need to ensure that the experiences and realities of affected populations feed into the rebuilding process: life histories bring particular opportunities here.
What are life histories?
Life history interviewing is a qualitative method of data collection where people are asked to document their life over a period of time. It is a personal account of their life, in their own words and using their own personal time lines. Accordingly, they tend to be selective, contingent upon remembered events that are amenable to being told, be they fact or fiction.
Our study involved 47 heads of poor households (aged 45 years and above) in Gulu District, northern Uganda. Of these, 26 were women and 21 were men. Each life history was conducted by a pair of researchers, one interviewing and the other recording both manually and electronically. The heads of households were asked to narrate the story of their life as far back as they could remember, from whichever year, as long as it was before the war. They were asked to mark significant life events on a timeline covering the three key phases: before the war, during the war and after the war. The aim was to document changes in their households’ ability to cope with household health care costs over the three time periods. For each phase, they identified their major life event, why they considered it significant, and what memories they attached to it. For illnesses, they named the illness, the treatment sought, where treatment was sought from, how much was paid and the treatment outcome. As they narrated their life story, the researcher in charge of recording drew the timeline, matching the events with the years (if the respondent could remember it) and the outcomes.
The choice of determining what was a significant life event and why, health, health events, treatment sought, cost, what was paid and what was foregone to pay the cost of health care was left to the respondent to define and articulate. This was considered more empowering than choosing for them. Having told us their life experiences, they went on to give us their expectations of what good health care meant and recommendations for reconstruction. That way, we ceded some of our power as researchers, to participants to tell their own story other than just reproducing knowledge as part of the post war research industry. In addition to the lifelines drawn, the results of these life history in-depth interviews were transcribed, translated from Acholi into English, and analyzed thematically using Atlas ti software.
Examples of extracts from life histories
“…just only two things stick out for me: the sodomy I endured and how we left home going to the camp. We were chased from our homes in a very bad way, we only survived by God’s grace, it was not a good experience at all. Also there was a time we were abducted by the government army and they tied us with ropes and they were pouring on us red peppers [red chilli powder] just direct on our faces. We just escaped death narrowly”. (70 year old man).
“… we were on the run. … Sometimes they seriously fought and killed people. Here in my home, I was captured three times [by the rebels]. That was the year when the Kony war was severe; it was in the middle years. It was very bad. I cannot recall the year very well. … If you slept in the house, they could come and knock the door…if you opened, they ordered you to take them where people are, you see. There they would go and kill people in that home. I stayed badly here. We really faced problems here. The year?…I was captured three times…They captured my boy and went with him. They went with him. We started sleeping in the mission for the three years. Then it ended we are now here.” (72 year old woman)
Challenges
Like any other method there are challenges and advantages to this method. It’s a lengthy process and given the traumatic nature of the events experienced including death, abduction, torture and rape of women, men, girls and boys, developing rapport and trusting relationships is critical. Conversations need to be carefully and sensitively carried out.
The transcripts created a lot of data which takes time to record and analyse. The ability of one person to textualise the life of another for unknown readers is a challenge the researcher has to be cognizant of as they translate the life story into research reports or participate in research engagement activities, deciding which aspects to highlight and which to omit. Furthermore, decisions have to be made on re-representing the private/intimate details on people’s lives. This can create ethical dilemmas. Ensuring the confidentiality of vulnerable groups discussing their experiences of conflict, including for example male rape, within a homophobic context is critical.
Advantages
But for all the challenges outlined above we found life histories to be useful. They helped us explore and identify the dominant narratives of people’s lives within particular events and situations. These narratives were contextualised – they described how a particular event came to be significant, and how opinions and decisions change over time.
Life histories are good at enabling people to recollect the past and document change, especially where some events could have been missed out through other methods requiring simple recall of facts. People may not remember the actual details but remember the significant events.
Furthermore it is participatory and gives the respondent more voice than other deductive methods. We found that it empowers the respondent, giving them a more prominent role to decide what is significant, why it is significant and to locate themselves within the experience. As part of this it helps people to evaluate their lives, clarifying what life would have been and why it was so. At the same time it provides a history beyond the personal, the analysis helps to show that lives are not free floating but occur in a social context, hence are socially constructed.
What life histories taught us about health
The method demonstrated to us that choices about health are determined by forces beyond the health sector, such as gender relations, livelihoods, conflict, etc. Consequently, strategies to rebuild post-conflict health systems cannot be reduced to health interventions, but also need to encompass a focus on people’s livelihoods and social relationships. While the post conflict effort emphasised building/renovating health facilities, our life history participants spoke more of income generation strategies because with money, they could navigate the new post conflict health context which is characterised by poorly functioning public facilities and expensive but well facilitated private facilities. The life histories highlighted the importance of mental health as a key component of post conflict health reconstruction. They made prominent how men and women had experienced sexual and gender based violence. There is need to ensure services respond to the realities of all groups: and both women and men’s health needs should be provided for. We need to address people’s physical and psychological needs, and subsequently end the cycle of violence. Life histories also challenged common assumptions about war and disease, showing opportunities that existed in the war, such as ease of delivery of health services due to encampment.
We would be very interested to link up with other health systems researchers who are using a life history approach in other contexts and to think further what this method – and others that are people-centred – can contribute to the body of knowledge that we have.
* Sarah Ssali is a Senior Lecturer at the School of women and Gender Studies, Makerere University and Co-Pincipal Investigator on ReBUILD. She is also part of Research in Gender and Ethics: Building Stronger Health Systems (RinGs).
Sally Theobald works at Liverpool School of Tropical Medicine and has wide ranging experience of designing and implementing gender sensitive qualitative research projects on HIV, TB, SRH and health systems in Africa and Asia.
Kate Hawkins is Director of Pamoja Communications. She likes writing about health, gender and sexuality.
