In the lead up to the Global Symposium on Health Systems Research in a few months’ time we’ve seen a renewed focus on health systems from the international development sector in the UK.
The International Development Select Committee has just run an enquiry into the Department for International Development's (DFID's) efforts to improve health systems in low- and middle-income countries. The Guardian recently hosted a web debate on how to make health systems work in poor countries.
As a health systems researcher who has focussed on equity and power issues I’ve been keeping an eye out for how women’s health and gender featured in these debates. Disappointingly parliamentarians asked few questions relating to gender in the enquiry - this seemed a strange oversight given that equity is a key focus in the post-2015 goals. The impact of gender roles and relations on health systems did emerge from the Guardian debate where I was one of 10 panellists.
So how did gender feature?
Intersectionality in action: Gender, power and access to health services
Gender and other social inequalities intersect to shape individual and community vulnerability to a wide range of health problems. In the debate there was a clear agreement that equity is important – whether people are talking about gender, poverty, disability, marginalised groups or sexuality; we need to seek opportunities to bring these perspectives together and build responsive health systems that are sensitive to these different needs. Some of the perspectives that were brought out during the debate are outlined below.
Sian Maseko (former Director of Sexual Rights Centre, Zimbabwe) talked about their research with LBT women and male, female and transgender sex workers. She pointed out that the main barrier that they faced in accessing healthcare was the attitudes of health care workers, particularly high levels of stigma and discrimination.
Elaine Ireland of Sight Savers pointed to the barriers in accessing health care that are experienced by people with disabilities, but she also elegantly brought intersectionality into the conversation. She explained that people with disabilities are often seen as asexual by service providers and as a result:
Information on priority health issues such as HIV, TB, malaria, sexual and reproductive health doesn't reach this marginalised population. Information is rarely produced in accessible formats, such as large-print or braille for people who are visually impaired or blind, or in the case of SRH and HIV, it is often assumed that people with disabilities are not sexually active and so therefore don't need access to this information.
Sian was able to speak to a particular example of these intersections from her work in Zimbabwe:
I absolutely agree that gender is a key issue and that inequalities are often deeply embedded or reflected within the healthcare systems. I think multiple discriminations is a key barrier to accessing healthcare. A case has just been taken against a state hospital in Bulawayo that turned a woman with a disability away four times while she was trying to have a Pap smear because they said the services were on the fourth floor and as she couldn't use the stairs then she would have to wait until the elevator was working. A simple example about physical access, but equally psychological access - how willing would she be to return for a critical SRH service?
Health systems: Challenges and opportunities for gender analysis?
There is a need for greater gender analysis within health systems research, however, this can only be effective through the collection of appropriate, high quality, and context-specific disaggregated data. During the debate, Elaine made the excellent point that:
[A] key challenge is data - how can a government know how to prioritise its limited resources for health if it doesn't know what its greatest health problems are and who in the population is at greatest need of those services - post-2015 offers a fantastic opportunity to emphasise the importance of quality data collection (including disaggregation by gender, age, disability, ethnic group) and continuing investments in health management information systems.
We need to showcase good examples of how gender disaggregated data has been used to improve health systems. For example, in Mozambique gender focal points meet with national and provincial health officers, health workers and community representatives on a monthly (at national level) or trimestral (at provincial level) basis to discuss the implications of their disaggregated data sets. This enables the team to embed the findings within the local context, to discuss important intersections such as how gender and cultural norms, literacy and age may be interacting to shape women’s and men’s health and service access for malaria, HIV, other diseases, and following violence. These discussions develop ownership over the data and enable the team to critically develop context embedded approaches to address the challenges and inequities uncovered.
Gender roles and relations vary across contexts. Contexts matter and some contexts pose particular challenges and opportunities for building gender equitable health systems. Drawing on her experiences of working and researching in Northern Uganda and elsewhere, Sarah Ssali of the ReBUILD consortium discussed the particular challenges and realities of health systems in reconstruction in post-conflict contexts. In post-conflict contexts we need to understand how health systems can best play a part in building recovery and peace and dealing with challenging issues such as strong and holistic services for survivors of sexual and gender based violence; whilst ensuring that gender is considered in all aspects of health systems and not only sexual and other forms of gender-based violence (SGBV).
Sara Bennett (Future Health Systems) suggested that sometimes issues get neglected because we don't know enough about them and how they play out in specific contexts. She went on to say:
It is easy to talk about cultural barriers in general terms, but it is the specifics that bring it home to us what the issues are. I was at a presentation yesterday where a speaker was talking about the cultural barriers that prevented Nepali widows from accessing reproductive health services - they were scared of being raped, or that their presence might be taken to indicate that they were sexually active. In the Sundarbans India, Future Health Systems has been examining the barriers to access among marginalized populations that live in the delta region. By providing some real illustrations of the nature of these barriers perhaps we can bring this issue "alive" for people.
How do we keep the momentum on health systems riding high?
Sara went on to pose an interesting question: What can we, as a community of people interested in health systems, do to make sure that they (health systems) don't drop off the radar again?
We need to look for opportunities to further strengthen partnerships. Keeping health systems on the agenda means taking these conversations outside the usual suspects, bringing in neglected voices (including women, men and people of other genders, marginalised because of social position, whether due to gender, sexuality, age, geography, literacy etc.), civil society, advocates and researchers working on gender, equity and social determinants. We also need to build stronger links between the health sector and other sectors and social movements such as worker’s rights groups, feminist movements and social justice actors more broadly.
There is also need to develop the evidence base on gender and health systems and make this responsive to the needs of key actors within health systems. This is the focus of Research in Gender and Ethics: Building Stronger Health Systems (RinGs) which brings together three health systems focused partnerships: Future Health Systems, ReBUILD and RESYST to galvanise gender and ethics analysis and evidence in health systems.
As our work develops we hope to engage more with feminist networks and academics and hope to stimulate a dialogue about these issues that moves us out of our usual siloes and stimulates some fresh thinking. We hope you will be part of the debate. To find out more email us on firstname.lastname@example.org
About the author
Sally has over 15 years’ experience of research on gender and health, gender training and designing and delivering gender mainstreaming approaches. She works at the Liverpool School of Tropical Medicine and works with REACHOUT and ReBUILD. She has wide ranging experience of designing and implementing gender sensitive qualitative research projects in health and have worked collaboratively on qualitative research projects on HIV, TB, SRH and health systems in Thailand, South Africa, Burkina Faso, Malawi , Ethiopia, Kenya, Yemen and Uganda. She is interested in building and extending understanding of gender, equity and health systems and has wide reaching research, policy and practice networks in this area.