sexuality

09 03 2018

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

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

By Sally Theobald, Valerie Percival and Kate Hawkins

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

Gender inequities neglected

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

Post-conflict opportunities

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

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

Supporting female health workers

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

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

Pressing for progress

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

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06 03 2017

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

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

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

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

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

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

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

Building trust is an evolving process

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

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

Policy making and implementation to build trust

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

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

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

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

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

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

CHW practices that maintain trust

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

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

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

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

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

Data handling and trust

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

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

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

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

Other health system practices to build trust

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

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

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

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

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

Gendered elements of trust

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

Conclusion

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

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18 01 2017

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

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

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

Event Date: 16 November 2016

Location: Vancouver, Canada

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

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

Power and Prejudice within Academic Institutions: from the literature

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

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

Conferences

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

Peer Review

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

Collaboration

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

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

Power and Prejudice within Academic Institutions: Participant concerns

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

‘Foreign’ Status

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

Academic Processes

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

Junior Status vs. Senior Status and Ageism

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

Validated Research

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

Understanding our own positions of power and privilege

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

Five “S”s emerged as a way forward:

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

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

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08 03 2016

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

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

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

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

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

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

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

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

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

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

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29 02 2016

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

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

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

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

Accessing Menstrual Regulation services: Opportunities and challenges

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

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

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

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

So what?

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

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

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20 12 2015

Sex and the Citadel: Shereen El Feki on the evolution of sexual rights in the Arab World

By Kate Hawkins

This week Sussex University’s Amnesty International society hosted a fascinating event on sexuality, the Middle East and North African regions where we were lucky enough to hear Shereen El Feki speak. Shereen was previously a journalist at the Economist. But she wears many hats, having been Vice-Chair of the Global Commission on HIV and the Law, a presenter at Al Jazeera, and a board member of AFE, an NGO based in Beirut which empowers human rights activists across the Arab region. Most recently, her book Sex and the Citadel has been causing quite a stir – focussing as it does on two explosive topics, sex and the Arab World – and is currently being translated into a range of languages, including Arabic.

Shereen’s background
Shereen explained that it was her personal and professional roots that led her to write Sex and the Citadel. Half Egyptian and half Welsh, she grew up in Canada as a Muslim but felt quite disconnected from her roots in the Arab World until September the 11^th 2001. Suddenly there was an outpouring of coverage in the West about the place her father heralded from, mostly from outsiders, and she felt it was time to ‘re-orient’ herself. Her professional training was in immunology and she then went on to become a journalist writing about health care, particularly HIV. Sex is the main route of transmission of HIV in the Arab World and that region has one of the fastest rates of new cases of HIV and AIDS-related deaths.

Shereen recounted how she had little trouble getting people to start talking about sex, in fact it was sometimes difficult to get them to stop! Poorer people were more free and frank, leading her to conclude that education doesn’t necessarily make you more open-minded. Perhaps it makes you more mindful of everything you have to lose. Because she looked Western, yet was a Muslim and spoke Arabic women were comfortable talking to her. Whilst people tend to avoid speaking to people outside their social circle for fear of being judged, the fact that Shereen was from the West – an area of the world where everything seemingly goes – meant people had little fear of shocking her.

‘What happens in the bedroom is reflective of what happens outside it’
Shereen’s study led her to believe that sexuality is a useful lens for viewing society as a whole. Whilst the Arab World is not homogenous, there are general themes and taboos that run across the region. How these came into being, how they are perpetuated and challenged provides useful insights into politics and the process of change,

‘The sexual and the political are intimate bedfellows. We can’t have freedom unless we think about our family, personal and intimate lives. Many women understood that immediately. That bodily autonomy is not my family’s business it is my own business.’

Her book uses the metaphor of ‘The Citadel’. The Citadel which is an impenetrable, imposing medieval fortress in Cairo which was constructed by Ṣalāḥ al-Dīn to protect the city from Crusaders. It has played an important political and religious role in Egyptian life since that time. The Citadel in contemporary Arab life is marriage – recognised by family and the state. Marriage is the only acceptable place for sex to occur and it is an institution many are desperate to be part of, yet a growing number of people no longer fit into this institution, or find it difficult to access.

The process of change
For all the uprisings in the region, Shereen cautioned the audience to expect evolution rather than revolution when it comes to sexual rights. She provided an anecdote about Aliaa Magda Elmahdy, an Egyptian woman who became infamous as the ‘Nude Photo Revolutionary’ for posting naked pictures of herself online. To some, her unveiling had a political spin that matched the spirit of the uprising. The response of religious conservatives was fire and brimstone. But many young liberals at the vanguard of the revolution disowned her actions, and some actually took her to court. Shereen cited this as evidence that even among the young and politically questioning sexual rights are seen as a Western invention, or imposition, which will lead to free love, prostitution, porn and homosexuality.

Other changes include a growing awareness of, and backlash against, harassment and violence against women, particularly in the light of attacks that happened in Tahir Square. Whilst a UN report, published in 2013 a found that 99.3% of women and girls are subjected to sexual harassment in Egypt, due to rising conservatism and insecurity, young women and men are protecting each other in new ways. The hostile environment has also prompted women to speak out in ways which they wouldn’t have previously.

Shereen explained how patriarchy, or more precisely the mix of power and sex in an authoritarian and patriarchal system is to blame for rising tides of violence. Patriarchy affects young men too. There is a great burden of expectation on men around marriage and providing for their family, and yet due to the worsening economic and employment situation the age of marriage is rising because many cannot afford this commitment. In these circumstances how do you realise your masculinity and attain manhood? Many young men are in a suspended state of adolescence, still living at home with their parents. To assert themselves they lash out at those weaker than themselves, in this case often women.

Meanwhile dogmatic Islam has created entrenched ideas about the proper place of women. The policing of women’s mobility (and activities such as sport, using tampons or riding a bike), female genital mutilation, virginity testing, and hymen repair operations are all related to the need to preserve women’s virginity so that they can enter the Citadel of marriage. And it is an institution that the majority of people want to break into, given there are few, if any, other ‘legitimate’ sites for sexual activity.

Why this analysis is timely and important for the rest of the world
In many settings the ‘sexual rights as human rights’ approach to sexuality has been met with resistance by who see it as a foreign or ‘Western’ imposition which lies at odds with ‘traditional culture’. Indeed this debate has risen again in Uganda this week with the signing of the ‘Anti-Homosexuality Bill’ and President Museveni’s warning,

‘I advise friends from the West not to make this an issue because if they make it an issue the more they will lose,” he said. “This is social imperialism. To impose social values of one group on our society. “I would advise Western countries, this is a no-go area,” he said. “I don’t mind being in a collision course with the West. I am prepared.’

Whilst sexual rights are a vital framing for these issues there are other ways of approaching sexuality which might be fruitful too. Shereen’s entry points for the discussion of sexuality were more medically focussed, as a way of opening a wider conversation. Of course, HIV has often been a starting point for discussions of sexuality and this approach is not without its critics. But its utility is worth noting in this case.

She also is clear that the Arab World is evolving its own vision of sexual freedom which is unlikely to look anything like a Western model. Understanding how different models of freedom are evolving by listening closely to people experiencing this flux, rather than advocating for a blue-print approach to change tied to the Western model, is clearly important.

In addition, this politics of sexuality does not only focus on lesbian, gay, bisexual and trans identities (important as those are). Women’s desires, freedoms, challenges and triumphs are central to the analysis, which recognises that all people are effected by norms related to sexuality. I think this is enormously important for linking across social movements and interest groups and forging a wider coalition of people to press for change, which has been one of the underlying principles of the Sexuality and Development Programme at IDS since its inception. It is also important because a vision of a socially and sexually just world that doesn’t take account of gender inequality more broadly would fail to recognise and challenge law and policy that leads to women being married to the men who rape them; sterilised because they are HIV positive; arrested or harassed for wearing a mini skirt or trousers, left without a penny as widows, deprived of basic citizenship rights for selling sex. It is a world in which we would all be poorer.

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12 10 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kate Hawkins is Director of Pamoja Communications.

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25 09 2015

Close-to-community providers and menstrual regulation

Accessing Menstrual Regulation services: Opportunities and challenges

So what?

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17 08 2015

Intimacy, love, freedom, heartbreak, separation and migration

By Kate Hawkins

A conference participant views the ‘Queer Crossings’ poster

Sitting in front of a South African poster on ‘queer crossings’ was one of my highlights from the recent Migrating Out Of Poverty conference in Singapore. It made me happy that one of my pet subjects – sexuality – was being addressed by such a stellar line-up of researchers studying gender, poverty and migration linkages.

I find it difficult to think about gender without a corresponding focus on sexuality as the two things so often intersect in interesting and important ways. It is particularly pertinent when we look at issues of women’s empowerment:

If for example, you look at women’s empowerment through a sexuality lens, you see a more complete and realistic picture of a woman: not a victim, nor an end-product ‘empowered’ woman, but a woman with a complex and changing life. You see a woman whose well-being depends, among other things, on making choices about her own body, about pleasure and about her own sexuality. You also see a woman who lives within or perhaps challenges the confines of social pressure and expectations about her behaviour. A woman’s sexuality and identity can affect many aspects of her life including her work and her means to earn a living, her family relations, her ability to move around in public, her opportunities to participate in formal and informal politics, and her access to education.

It is also a useful way of thinking about gender in terms of men and people who define themselves as something beyond/outside the binary of man and woman. (Even Facebook now has a list of over 58 gender options that people can choose from to describe themselves. Some of us scholars are lagging behind on this score!)

Sexuality came up in many of the sessions at the conference – even if it was rarely used as a frame of analysis.

Poverty, precarity and sexuality
Susie Jolly has written about the importance of housing to the realisation of sexual rights and desires and the constraining effects of poverty. This seemed relevant to some of the examples of migrant life spoken about at the conference. Trond Waage’s film, Les Mairuuwas, followed migrants from the Central African Republic in Northern Cameroon who were working as water carriers. One character didn’t see the point of a home, or felt that it was an unnecessary use of resources. But when he moved in to a room he realised that he had invested in the community and it also gave him the opportunity to have a sexual relationship. We heard from many presenters at the conference about the (inappropriate/inadequate) housing conditions of migrant workers. Some were living in their workplace with employers, particularly domestic workers. It would be interesting to better understand the effects of these living and working arrangements on migrants’ abilities to form intimate relationships and the wider effects on their lives.

‘Dangerous’ sexualities and the female migrant
There is a prevailing narrative about the sexual vulnerability of female migrants which was echoed in some of the discussions at the meeting and the presentation on employment brokers was particularly chilling in this regard. However speakers also pointed to the way that female migrants are often stigmatised on the grounds of their sexuality – which is imagined as undisciplined and unruly when far from home.

In a memorable talk about young women from Zimbabwe Stanford Mahati quoted one boy as saying ‘Good girls do not cross the border’. Mahati’s analysis of humanitarian workers’ formal and informal discourse around working migrant girls showed that they were often labelled as ‘promiscuous’, ‘lacking in morals’ and ‘far from innocent’. Meanwhile Ishred Binte Wahid spoke about notions of ‘purity’ in relation to Bangladeshi women migrants who travelled to work in the Gulf States. Female migrants found that religious piety (for example wearing the burkah) was a way of counteracting negative aspersions about what may have happened in their sexual lives whilst they were away from their families. She questioned the notion of female migration as inherently empowering and pointed to how it could sometimes reinforce patriarchal norms.

We heard from South African sex workers in the MOVE visual exhibition. Sex workers are arguably some of the most maligned ‘bad women’ in patriarchal societies’ bogus hierarchy of womanhood. Visual methods enabled them to take back control of the stories about their lives and express their humanity. Chantel, a participant from Johannesburg, wrote in her journal,

Telling my story is so powerful for me. Every day I look forward to writing or thinking about my story. I want to take images that show the way that sex workers are treated. That I am a person. This project let me do this. It helps me to take away stress and to know that I am not alone.

The conference was silent on the issue of the clients of sex workers, despite the fact that it is likely some of them are men characterised problematically in the HIV literature as ‘mobile men with money’. Migration researchers may have some interesting insights for their counterparts in health on this issue.

The pain and the liberation of separation
Some presentations at the conference explored the ways that prolonged separation due to migration could lead to challenges in maintaining ‘family unity’. One study from Indonesia showed how 18% of married migrants ended up getting divorced which was contrasted with a divorce rate on 7% in non-migrant families. This had particular impacts on the income of divorced women who also faced negativity from the wider community on account of their divorcee-status.

Deirdre McKay’s presentation of the lives of Philippine women working without documents in the UK explained how long separations with little chance of being reunited due to cost and visa restrictions created stress and a strain on family life. However, she also argued that living in chronic poverty can cause family tensions. She pointed to the potentially liberating aspects of separation in some circumstances and highlighted how when men are ‘dud’ husbands (i.e. they gamble, drink, or can’t look after money) there is often migration in lieu of divorce.

Future sexuality-migration exploration
As a newcomer to the field of migration studies it was fantastic to attend the recent conference. I hope that as work on gender continues there is critical reflection on the topic of sexuality and some cross learning with other programmes working on the poverty-sexuality links. In particular it would have been interesting to hear more about same sex desire and the migrant experience and to have a more explicit focus on heteronormativity. Interesting research from (my friends at) Galang in the Philippines described how lesbian women and trans men migrated because of homophobia and gendered discrimination. For these people migration (and the money earned) sometimes created opportunities for sexual freedom and improved status within the family but it could also leave people vulnerable to homophobic abuse. These are interesting insights which are ripe for further investigation in other contexts.
Kate Hawkins is the Director of Pamoja Communications. She works on communications and research uptake for projects looking at health, gender, sexuality, and more. Kate was the communications consultant on the Gendered Dimensions of Migration conference for the Migrating out of Poverty Research Programme Consortium.

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30 06 2014

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

By Kate Hawkins

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

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

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

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

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

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

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

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

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

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