Health Systems Development and Gender Equity · • Health systems research has tended to neglect...

Health Systems Developmentand Gender EquityDr Sally Theobald, Dr Esther Richards, Dr Kate Jehan

2© The Liverpool School of Tropical Medicine

Health Systems Development and Gender Equity

Part of International Health Research Group

• Academic staff - Tim Martineau, SallyTheobald, Rachel Tolhurst, Jo Raven, EstherRichards, Kate Jehan, Olivia Tulloch

• Management/support staff - Helen Carlin,Helen Macfarlane, Faye Moody, Lizzy Carline

• PhD Students – Rachel Anderson de Cuevas,Ireen Namakhoma, Eleanor Macpherson,Lignet Chepuka, Dorcas Kamuya (OU)


Key Questions

• To explore andrespond to

socialdeterminants

of ill-health

and

health seeking


Key Questions

• To analyse

and improve

the operation ofhealth systems

to improveequitable accessto health services


Key Questions

• Focus on:

capacitybuilding

researchengagement/uptake

equity analysis


HEALTH SYSTEMS, HR & EQUITY

Amount Grant Funding Agency, Period

£6,000,000 Research for building pro-poor health

systems during the recovery from conflict

(REBUILD) PI Tim Martineau & Barbara

Mcpake; Sally Theobald, co-PI.

DFID 2011-2016

Euros 2,995,323 Supporting decentralised management to

improve health workforce performance in

Ghana, Uganda and Tanzania (PERFORM) PI

Tim Martineau, Sally Theobald, co-PI,

EU FP7 2011-15

US$ 55,255 Supporting community health workers in

community case management programmes

in Africa: a preliminary investigation PI Tim

Martineau, Theobald, co-PI.

TDR 2012


W

Project

Timescale

Funder

To understand howto strengthen policy and

practice related tohealth financing

and human resourcesin countries

recovering fromconflict

Aim

6 year programmeFocussed on healthfinancing and humanresources

Start February 2011Ends February 2017

UK Department ofInternationalDevelopment (DFID)


How does the consortiumwork?

ReBUILD

RPC

Liverpool

Edinburgh

Uganda

SierraLeone

Zimbabwe

Cambodia

Liverpool Schoolof TropicalMedicine

Queen MargaretUniversity

CambodiaDevelopmentResource Institute

Biomedical &Training Institute

MakerereUniversity

College ofMedicine & AlliedHealth Sciences


Key messages

• Health systems research has tended to neglect post-conflict settings.

• Decisions made in the early post-conflict period can setthe direction of development for the health system.

• There are particular opportunities to set health systemsin a pro-poor, gender equitable direction in theimmediate post-conflict period.

• The partner countries enable us to look from distance(Cambodia and Sierra Leone) and up close (NorthernUganda and Zimbabwe) at the post-conflict period.

• Affiliates can link us to further countries that canenable us to explore relationships further


ReBUILD Consortium Partners Meeting,November 2011


Improving health workforce performance inGhana, Tanzania and Uganda


• The deficit in health professionals needs to be addressed bothby training more new health personnel and improving theperformance of the existing and future workforce.

• A number of complex factors affect workforce performance

• maldistribution of staff

• inappropriate task allocations

• poor working conditions.

• Understanding the nature of these factors and developingappropriate responses through action research with DHMTs atdistrict level


TUBERCULOSIS AND EQUITY

Amount Grant Funding Agency,Period

£ 249,725 Identifying barriers to TB diagnosis and

treatment under a new rapid diagnostic

scheme Theobald PI – Ethiopia & Yemen with

Luis Cuevas

ESRC/DFID 2008-

2012

US$689,163Wave 1US$ 636,410Wave 2

Innovative community-based approaches for

enhanced tuberculosis case finding and

treatment outcome in Southern Ethiopia (PI

Mohammed Yassin and Sally Theobald)

TB REACH, 2010-11

TB REACH 2011-12

US$ 287,621 Increased detection of children, women and

elderly individuals with smear-positive TB in

Yemen (PI Najla Al-Sonboli and Sally Theobald);

TB REACH, 2010-11


GENDER EQUITY & SRH

Amount Grant Funding Agency,Period

£19,260 Strengthening the research to policy andpractice interface: Exploring strategies usedby research organisations working onSexual and Reproductive Health and HIVand AIDS, Theobald PI Olivia Tulloch

DFID 2009-11


Impact and engagement

“Research that doesn’t just gather dust on libraryshelves...”


Organised into five themes

Themeone

Themetwo

Themethree

Themefour

Theoryand

practice ofresearch

engagement

Applyingpolicy

analysis toexplore roleof researchevidence

Strategiesand

methodologiesfor

engagement

Advocacyand

engagementto influence

attitudes

Themefive

Institutionalapproaches tointersectoral

engagement foraction and

strengtheningcommunications


GENDER EQUITY & SRH

Amount Grant Funding Agency, Period

LSTM share,368,415 Euros

Maternal health in India: Evaluatingdemand side financing to improve deliverycare access (MATIND), Tolhurst PI (HelenSmith, Kate Jehan)

EU FP7 2011-14

£22,533 Literature review on gender and childsurvival, Tolhurst PI, Theobald (EstherRichards)

UNICEF 2011

US$30,000 Exploring the role of structural drivers ofHIV among women and men over 50 inUganda: A gender analysis with PI JanetSeeley and Sally Theobald (Esther Richards)

UNAIDS 2011-12


COMMUNITY ENGAGEMENT AND ETHICS

Grant Funding Agency,Period

Consent to and Community Engagement in Health Research -Reviewing and Developing Research and Practice, meetingaward with, Susan Bull; Sally Theobald, Phaikyeong Cheah; KhinMaung Lwin; Vicki Marsh; Sassy Molyneux; Michael Parker;

WELLCOME TRUSTMEETING AWARD,2011

Strengthening community accountability in biomedicalresearch and health delivery (Kenya), Dr. Sassy Molyneux, SallyTheobald collaborator

Wellcome TrustFellowship

A programme to build capacity in global health researchethics and community engagement across the WellcomeTrust Major Overseas Programmes PI Prof Mike Parker,collabroators, Nicholas Day, Jeremy Farrar, Rob Hyderman, KevinMarsh, Sassy Molyneux, John Imrie, Mary-Louise Newell, VictoriaMarsh, Trudie Lang, Tinh Tran, Sam Kinyanjui, Dominic Kwiatkoski,Sally Theobald, Susan Bull

Wellcome Trust

Strategic Award


Maternal Healthin India:

an overview of theMATIND project

R D GardiMedicalCollege, UjjainMadhyaPradesh

2011-2015European Union funded FP7 project


MATIND project

• Maternal health context in India

• Demand-side finance for maternal healthcare

• Overview of MATIND

• Qualitative component of

MATIND


Maternal health care context

Improvements• Increased skilled birth attendance

in recent years

• Driving South Asian decline

in MMR (maternal mortality ratio)

Major problems• High numbers of maternal & neonatal deaths

(20% global maternal deaths; 31% neonatal deaths)

• Wide socioeconomic gap; inequitable access to care; high out-of-pocket costs to the user

• Lack of capacity & poor quality of care for majority

Source: Lim 2010


Demand-side finance for maternal health care

Rationale• Decades of supply-side intervention – little impact

• Demand-side barriers – as important in

determining utilisation of services as supply

• DSF designed to promote skilled attendance and

institutional deliveries by reducing cost barrier for poor women

Forms• Cash transfers – reimburse users for monies spent on maternal

health care services (can be conditional on uptake of services)

• Voucher or voucher-like schemes – partially or wholly subsidiseusers to purchase services from accredited providers.


Overview of MATIND

Cash transfer scheme

Janani Suraksha Yojana(Safe Motherhood Scheme)

Nationwide

Public hospitals (state funded)

Study area: Madhya Pradesh

INR 1,400 ($35 to mother atdischarge)

MMR 359/100,00038.3% below poverty line

Voucher scheme

Chiranjeevi Yojana(Scheme for Long life)

State wide

Public private partnership

Study area: Gujarat

INR 1,745 ($44) paid to privateobstetrician per delivery

MMR 172/100,00016.8% below poverty line

Aim Evaluate impact of India’s major DSF schemes


MATIND study phases

• Transport study (Gujarat & MP)

• Private sector exclusion from JSY (MP)

• Use of a platform system - advantages anddisadvantages (Gujarat & MP)

Phase 1

Provinciallevel

• Private sector participation and provider choice(Gujarat)

• Task re-organisation (MP)

• Quality of care (Gujarat & MP)

Phase 2

Facility level

• Mothers’ experiences (programme & non-programme mothers) (Gujarat & MP)

• ASHA (Accredited Social Healthcare Activist)experiences (MP)

Phase 3

Communitylevel


Gender influences on child survival, healthand nutrition: review and guidance

LSTM team:Esther RichardsSally TheobaldRachel Tolhurst

With supportfrom:Asha GeorgeChristiane RudertJulia Kim


Gender influences on child survival, health andnutrition: a review of current evidence

Main aim: to review the available evidence and researchtools on the impact of gender on young child health andnutrition, in particular:

• How do women’s status, agency and access to resources affect thehealth and nutrition of young children?

• How do gender divisions of labour affect the health and nutrition ofyoung children?

• How do men’s roles and masculinities affect the health and nutritionof young children?

• Which methodologies and data sources have been used to assess theimpact of gender on the health and nutrition of young children andwhat are their strengths and weaknesses?

• Which approaches to addressing the impact of gender inequalities,roles and relations on young child survival have been assessed and withwhat results?


Search strategy

Studies cited: 117

Referencessaved toEndnote

Bibliography:1,170 (513

filed)

Reference lists,websites,

contacts &hand

searching: 325

Databasesearch: 845

(afterscreening)


Conceptual Framework

o Based on initial analyses of the studies we decided to adaptand use the gender analysis framework developed bygender and health experts from LSTM in the late 1990s.

We adapted the existing categories within the frameworkto focus on four main areas:

• Women’s status

• Intra-household bargaining power and process

• Gender divisions of labour

• Gender norms, values and identities


Selected findings: intra-householdbargaining and child health outcomes

Study Location Data source Gender index ofbargaining power

Key findings

Smith,Ramakrishnan,Ndiaye,Haddad &Martorell(2003)

“Theimportance ofwomen’sstatus for childnutrition indevelopingcountries”

36 countries

across

South Asia

(97% of

population

covered)

Latin America

& the

Caribbean

(55%)

&

Sub Saharan

Africa (61%)

National

Demographic and

Health Surveys

conducted

between 1990

and 1998

Data based on a

sample of 117,242

children across 36

countries

First index of women’s

decision-making power used

data on the difference

between partners’ education

levels, their age difference,

women’s age at first marriage

and finally whether she had

independent access to income.

Second index of “societal

gender equality”, was

constructed using the

difference in age-adjusted

weight-for-age Z-scores of girls

and boys under five years, the

difference in age-adjusted

vaccination score of girls and

boys under five, and the

difference in years of

education of adult women and

men.

The decision making powerindex was significantly correlatedwith child weight-for-age inSouth Asia; raising the decisionmaking index by 10 points overits current mean would increasethe region’s mean weight-for-agez-score (waz) by 0.156.

Raising the decision makingindex in Sub Saharan Africa by 10points over its current meanwould raise the region’s meanwaz by 0.046

Raising the decision makingindex in Latin America & theCaribbean would only have aneffect on weight-for-height (whz)to a certain point (53 on theindex) after which it would startto reduce.


Selected findings: women’s time poverty

• Studies have shown that women’s ‘triple roles’ leadto time poverty which in turn impacts on child healthoutcomes:

“They (husbands) should be helping us but unfortunatelythey are not doing it. What can one do when a man saysno!”

(women explaining why they don’t have time to practicewhat they know about child health in rural Gambia)

Source: Mwangome et al. 2010


Selected findings:strategies for intervention


Gender-sensitive interventions

Very few evaluations of gender-sensitive interventionswere identified

Those identified showed evidence for improvements inchild health and nutrition through different gender-sensitive approaches:

• Through seeking to increase women’s power throughparticipatory activities

• Through increasing women’s access to and control overresources for child health and nutrition

• Through seeking to address unequal gender relationsand norms to improve allocation of household resources


Exploring the role ofstructural drivers of HIV onwomen and men 50 andover in Uganda: A genderanalysis (study ongoing)

Co-PIs: Janet Seeley & SallyTheobald with Flavia Zalwango& Esther RichardsMRC/UVRI Uganda inassociation with LiverpoolSchool of Tropical Medicine(LSTM)


Study Background

Funded by UNAIDS

Building on recent work at MRC/UVRI funded byWHO/Cordaid

Main aim:

To explore the structural drivers shapingindividual risk of HIV infection and access to HIVservices (VCT/care and support) of women and menover 50 in Kalungu and Wakiso districts and Kampala,Uganda


Gender, age and structural drivers

Level

Distance

Distal factors Proximal factors

Superstructural Genderinequality

Structural Laws restrictingwomen’s ownershipof economic assets

Environmental Economicdependencyon men

Individual No money forfood and othernecessities

Use of two frameworks to analyse how a structural factor – in this case gender inequality – might lead womento risk behaviour (Adapted from Rao Gupta et al 2008)


Study design

Methods:

• Small, exploratory study of 6 months

• Sampling frame from the 510 people inWHO/Cordaid study

• Qualitative interviewing of women and men (IDIs -32 and FGDs - 8)

• Key informant interviews with 6 relevant NGOsand policy-makers


An older person workingin her garden in Malungudistrict

A research team membertalking to a participant in aprevious study


Drivers of vulnerability in older people

‘Invisibility’ of older people’s sexual experiences:

• The perception that older people should not be sexuallyactive means that older women and men feel their sexualexperiences are stigmatised by society.

• This may cause tensions for older people who feelunable to disclose their HIV+ status to their families andmeans they are less likely to access HIV services andcare.



Tensions in sexual relations:

• Women may experience sexual relations as forced andunwanted, which in many cases contributes to physicaland emotional distress.

• Men who wish to continue having sexual relations maycomplain that their wives are ‘unwilling’ and seek sexualalliances and encounters elsewhere.



Poverty

• Other important issues which shape men’s andwomen’s access to services are their lack of regularincome due to old age and ill-health

• Their ‘invisibility’ in terms of targeted services andmore broadly in society

• Perception that older people are a ‘drain’ on familyresources


Preliminary conclusions, based onongoing data collection

Age, gender and poverty interact to produce particularvulnerabilities and constraints for older women and men inUganda in terms of:

• HIV transmission

• HIV services and care

• Health care in general

HIV interventions need to go beyond conceptualising olderpeople simply as ‘carers’ of families living with HIV tobetter address their gendered vulnerabilities in relation toHIV.


Gender Equity: IMPACT

• Impact on policy & practice

• TB case finding – addressing opportunity costs of care seeking,Yemen & Ethiopia

• Partnership with policy makers on maternal health in India

• Impact on GLs

• Providing guidance to UNICEF field officers on gender sensitivemethodologies

• Impact on discourse

• Post conflict pro-poor/gender equity in health systems

• Older people & HIV beyond the carer discourse

• Impact on methods/approaches

• Gender equity and intersectionality

• Gender equity and methodological considerations - FGDs


THANK YOU - ANY QUESTIONS?

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Health Systems Development and Gender Equity · • Health systems research has tended to neglect...

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