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.
Waldman L, Theobald S and Morgan R (2018) Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.137
This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.
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.
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.
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.
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.
The use of mHealth interventions within health systems research is increasing, with few taking into account the connections between gender and mHealth.
This policy brief attempts to fill this gap by exploring key connections between mHealth and gender that need to be taken into account when conducting or implementing mHealth research and interventions.