Musoke D, Ssemugabo C, Ndejjo R, Ekirapa-Kiracho E and George AS (2018) Reflecting strategic and conforming gendered experiences of community health workers (CHWs) using photovoice in rural Wakiso district, Uganda, Human Resources for Health, 16:41, DOI: 10.1186/s12960-018-0306-8
Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach.
George, A, Morgan, R, Larson, E and LeFevre, A (2018) Gender dynamics in digital health: Overcoming blind spots and biases to seize opportunities and responsibilities for transformative health systems, Journal of Public Health, fdy180, DOI: 10.1093/pubmed/fdy180
Much remains to ensure that digital health affirms rather than retrenches inequality, including for gender. Drawing from literature and from the SEARCH projects in this supplement, this commentary highlights key gender dynamics in digital health, including blind spots and biases, as well as transformative opportunities and responsibilities. Women face structural and social barriers that inhibit their participation in digital health, but are also frequently positioned as beneficiaries without opportunities to shape such projects to better fit their needs. Furthermore, overlooking gender relations and focussing on women in isolation can reinforce, rather than address, women’s exclusions in digital health, and worsen negative unanticipated consequences. While digital health provides opportunities to transform gender relations, gender is an intimate and deeply structural form of social inequality that rarely changes due to a single initiative or short-term project. Sustained support over time, across health system stakeholders and levels is required to ensure that transformative change with one set of actors is replicated and reinforced elsewhere in the health system. There is no one size prescriptive formula or checklist. Incremental learning and reflection is required to nurture ownership and respond to unanticipated reactions over time when transforming gender and its multiple intersections with inequality.
Morgan R, Ayiasi RM, Barman D, Buzuzi S, Ssemugabo C, Ezumah N, George AS, Hawkins K, Hao X, King R, Liu T, Molyneux S, Muraya KW, Musoke D, Nyamhanga T, Ros B, Tani K, Theobald S, Vong S and Waldman L (2018) Gendered health systems: evidence from low- and middle-income countries, Health Research Policy and Systems, 16:58, DOI: 10.1186/s12961-018-0338-5
Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems.
Morgan R, Dhatt R, Muraya K, Buse K, and George AS (2017) Recognition Matters: Only One in Ten Awards given to Women, The Lancet, 389(10088):2469, DOI: 10.1016/S0140-6736(17)31592-1
Receiving an award is an accolade. Awards validate and bring visibility, help attract funding, hasten career advancement, and can consolidate career accomplishments. Yet, in the fields of public health and medicine, few women receive them. Between seven public health and medicine awards from diverse countries, the chances of a woman receiving a prize was nine out of 100 since their inception.
Kananura RM, Ekirapa-Kiracho E, Paina L, Bumba A, Mulekwa G, Nakiganda-Busiku D, Oo HNL, Kiwanuka SN, George A and Peters DH (2017) Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda, Health Research Policy and Systems, 15(Suppl 2):107, DOI: 10.1186/s12961-017-0274-9
The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders’ decision-making in eastern Uganda.
Tetui M, Coe A-B, Hurtig A-H, Bennett S, Kiwanuka SN, George A and Ekirapa Kiracho E (2017) A participatory action research approach to strengthening health managers’ capacity at district level in Eastern Uganda, Health Research Policy and Systems, 15(Suppl 2):110, DOI: 10.1186/s12961-017-0273-x
Many approaches to improving health managers’ capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers’ capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers’ capacity in Eastern Uganda.
Paina L, Wilkinson A, Tetui M, Ekirapa-Kiracho E, Barman D, Ahmed T, Mahmood SS, Bloom G, Knezovich J, George A and Bennett S (2017) Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda, Health Research Policy and Systems, 15(Suppl 2):109, DOI: 10.1186/s12961-017-0272-y
The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.
Morgan R, Tetui M, Kananura RM Ekirapa-Kiracho E and George AS (2017) Gender dynamics affecting maternal health and health care access and use in Uganda, Health Policy and Planning, Volume 32, Issue supplement 5, pp z13 - v21, doi: 10.1093/heapol/czx011
Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women’s access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women’s lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.
Ekirapa-Kiracho E, Kananura RM, Tetui M, Namazzi G, Mutebi A, George A, Paina L, Waiswa P, Bumba A, Mulekwa G, Nakiganda-Busiku D, Lyagoba M, Naiga H, Putan M, Kulwenza A, Ajeani J, Kakaire-Kirunda A, Makumbi F, Atuyambe L, Okui O and Kiwanuka SN (2017) Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts, Global Health Action, 10:sup4, 1363506, DOI: 10.1080/16549716.2017.1363506
The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services. This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices.
Ekirapa-Kiracho E, Tetui M, Bua J, Kananura RM, Waiswa P, Makumbi F, Atuyambe L, Ajeani J, George A, Mutebi A, Kakaire A, Namazzi G, Paina L and Kiwanuka SN (2017) Maternal and neonatal implementation for equitable systems: A study design paper, Global Health Action, 10:sup4, 1359924, DOI: 10.1080/16549716.2017.1346925
Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability. The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach.
George A, Tetui M, Pariyo GW and Peterson SS (2017) Maternal and newborn health implementation research: programme outcomes, pathways of change and partnerships for equitable health systems in Uganda, Global Health Action, 10:sup4, 1359924, DOI: 10.1080/16549716.2017.1359924
This editorial provides an overview of the Global Health Action MANIFEST special issue. The special issue covers 10 papers whose main purpose is to share findings from a maternal and neonatal health intervention in Uganda. The MANIFEST intervention used a participatory action research approach to engage different actors to improve maternal and neonatal health outcomes in the districts of
Pallisa, Kibuku and Kamuli, in eastern Uganda.
Ekirapa-Kiracho E, Namazzi G, Tetui M, Mutebi A, Waiswa P, Oo H, Peters DH and George AS (2016) Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda, BMC Health Services Research, 16:1864, DOI: 10.1186/s12913-016-1864-x
Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda.
George AS, Scott K, Mehra V and Sriram V (2016) Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review, BMC Health Services Research, 16:1860, DOI: 10.1186/s12913-016-1860-1
Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs).
George AS, Scott K, Sarriot E, Kanjilal B and Peters DH (2016) Unlocking community capabilities across health systems in low- and middle-income countries: lessons learned from research and reflective practice, BMC Health Services Research, 16:1859, DOI: 10.1186/s12913-016-1859-7
The right and responsibility of communities to participate in health service delivery was enshrined in the 1978 Alma Ata declaration and continues to feature centrally in health systems debates today. Communities are a vital part of people-centred health systems and their engagement is critical to realizing the diverse health targets prioritised by the Sustainable Development Goals and the commitments made to Universal Health Coverage. Community members’ intimate knowledge of local needs and adaptive capacities are essential in constructively harnessing global transformations related to epidemiological and demographic transitions, urbanization, migration, technological innovation and climate change. Effective community partnerships and governance processes that underpin community capability also strengthen local resilience, enabling communities to better manage shocks, sustain gains, and advocate for their needs through linkages to authorities and services. This is particularly important given how power relations mark broader contexts of resource scarcity and concentration, struggles related to social liberties and other types of ongoing conflicts.
This brief outlines some of the challenges of incorporating gender analysis into existing research programmes, along with ways in which Research in Gender and Ethics (RinGs): Building Stronger Health Systems has responded to them. RinGs is a cross research programme consortium (RPC) bringing together three health systems RPCs – Future Health Systems, ReBUILD, and RESYST – to better understand gendered dynamics in health systems and to galvanise gender analysis in HSR.
In Future Health Systems, we focused on communities as active service delivery participants across a wide variety of contexts. In this brief, we reflect on the process of unlocking community capabilities, the key actors involved, and the productive tensions within community partnerships forged to build more responsive, resilient and equitable health systems.
Musoke, D; Ndejjo, R; Ekirapa-Kiracho, E and George, AS (2016) Supporting youth and community capacity through photovoice: Reflections on participatory research on maternal health in Wakiso district, Uganda, Global Public Health, DOI:10.1080/17441692.2016.1168864
This paper reflects on the experiences of using photovoice to examine maternal health in Wakiso district, Uganda. The project involved 10 youth aged 18–29 years old, who were diverse in education, occupation, and marital status and identified by community leaders with researchers. By taking photos and sharing images and experiences in monthly meetings over five months, youth reported becoming more knowledgeable. They realised that they had common experiences but also reflected on and reinterpreted their circumstances.
Larson, E; George, A; Morgan, R and Poteat, T (2016) 10 Best resources on… intersectionality with an emphasis on low- and middle-income countries, Health Policy & Planning, doi: 10.1093/heapol/czw020
Intersectionality has emerged as an important framework for understanding and responding to health inequities by making visible the fluid and interconnected structures of power that create them. To orient readers to intersectionality theory and research, the authors first define intersectionality and describe its role in public health, and then we review resources on intersectionality. The first four resources explain intersectionality as a methodology. The subsequent six articles apply intersectionality to research in LMIC with quantitative and qualitative analysis. The authors provide examples from India, Swaziland, Uganda and Mexico. Topics for the studies range from HIV, violence and sexual abuse to immunization and the use of health entitlements. Through these 10 resources, the authors hope to spark interest and open a needed conversation on the importance and use of intersectional analysis in LMICs as part of understanding people-centred health systems.
Morgan, R; George, A; Ssali, S; Hawkins, K; Molyneux, S and Theobald, S (2016) How to do (or not to do)… gender analysis in health systems research, Health Policy & Planning, doi: 10.1093/heapol/czw037
Gender — the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders — affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs and policies; and the inclusion of gender analysis into HSR is a core part of that endeavour. The authors outline what gender analysis is and how gender analysis can be incorporated into HSR content, process and outcomes.
George AS, Mehra V, Scott K, Sriram V (2015) Community Participation in Health Systems Research: A Systematic Review Assessing the State of Research, the Nature of Interventions Involved and the Features of Engagement with Communities. PLoS ONE 10(10): e0141091. doi:10.1371/journal.pone.0141091
Community participation is a major principle of people centered health systems, with considerable research highlighting its intrinsic value and strategic importance. Existing reviews largely focus on the effectiveness of community participation with less attention to how community participation is supported in health systems intervention research.
This systematic review explores the extent, nature and quality of community participation in health systems intervention research in low- and middle-income countries.
It concludes that despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how much communities can participate and cognisant of who decides that.