Power dynamics within international development and global health are often hidden. This is particularly true in partnerships between organisations in high- middle- and low-income countries. Uncovering and analysing these relations is at the heart of much of our ethics work. In research, relationships between universities and communities face similar challenges.
Highlighting and challenging abuses in power can be uncomfortable and sometimes dangerous work.
Luckily many in the sector are working for change. Analysis and action aimed at decolonising development are increasingly popular. This aims to disrupt and destroy systemic and institutional relations of power that keep some people perpetually down and safeguard the security and stability of others. Also, tackling inequity in the wider world and within our own organisations and networks is the mainstay of feminist approaches to development. There’s a long history of participatory tools to act on asymmetries in relationships of knowledge generation and the creation of evidence.
Many of the projects that Pamoja supports are use research and communications to understand and act on injustice and inequity. For example, RinGs has done ground-breaking thinking and training on how gender pervades health systems. ARISE uses participatory methods to improve accountability mechanisms in informal urban areas.
The Power Awareness Tool
A few weeks ago I had the pleasure of doing some editing work for Partos – the Dutch membership body for organisations working in international development.
They have produced a new tool for looking at power in partnerships. Here’s their rationale:
There is widespread consensus that in partnerships for development, donors, and international NGOs have too much power, and local NGOs in the Global South too little. Despite this consensus, the power imbalances persist. Apparently, it is hard to put the principles into practice. Those with the most power, usually the donors, and to a lesser extent the INGOs, are not always the most knowledgeable about the local situation or about the change needed and how. While there is broad consensus on this, power imbalances persist. We believe this is partly because power is in many ways elusive. Therefore, the Lab decided to develop a tool to make power more visible, enabling partners to analyse and reflect on their power relations.
I think there are many people who will find this tool useful. Maybe you want to check the health of your partnerships but you’re not sure how. Are you entering into a new organisational relationship and you want to get off on the right foot? Or maybe you feel like your partnerships are not properly balanced but you can’t identify how. The tool is simple, easy to use and freely available. Why don’t you check it out?
ARISE will engage with communities in participatory method design, data collection and analysis to develop priorities and actions. To make this a reality we are debating the community based participatory approaches we will use. It’s a rich and challenging discussion! In this blog we outline some issues which are taxing us. How can we build on existing community strengths? How can we ensure that the most marginalised community members are included in our research? What safety challenges will we face in the research process? So, if you have experienced any of the same dilemmas, please comment below. It would be great to talk and share experiences!
How to build on existing community structures
ARISE wants to engage and work with existing community structures and processes. However, how to do this is not straightforward. We have had a lot of discussions about the best way to introduce the project and how to capitalise on the strong work that is already underway in relation to accountability and health.
Researchers and co-researchers (their community counterparts) recently met in Sierra Leone. There is a lot going on in the informal settlements of Freetown. Community members are actively collecting data contributing to local development and advocating for change. Because of this, co-researchers wanted to take advantage of these pre-existing structures in the ARISE research. They felt very strongly that setting up parallel ‘research specific’ systems was risky because they might not properly respond to the situation in informal settlements.
For example, representatives from the Federation for Urban and Rural Poor (FEDURP) believed members who are community mobilisers would be good at raising awareness and explaining the purpose of the research. However, communities didn’t always think these community mobilisers were ‘trustworthy’. As a result, other FEDURP members – who are passionate about accountability and health – might be better at data collection or facilitation. These passionate change makers need to be identified by community members as opposed to being handpicked by powerful community members. We discussed how incentives can compromise organic processes to identify change makers and should only be offered later in the research process. Therefore, the process of selecting co-researchers was systematic, trying to select the best from FEDURP, community representatives and community mobilizers. Selection was based on skills such as facilitation, mobilization, community activism and awareness raising skills, particularly on health.
Defining researchers, co-researchers and participants
FEDURP felt part of the ARISE research consortium, particularly as they had been part of the original consortium planning process. They were confused about whether this made them co-researchers or researchers. FEDURP is a representative organisation for people living in informal settlements. Does this immediately make all its members co-researchers? If FEDURP is a core-part of the ARISE family, should all co-researchers in Sierra Leone be members of FEDURP? Members of FEDURP, who also live in informal settlements, became further confused when they considered that they could also be ‘participants’ in the research process.
As we moved through our conversations it became clear that co-researchers should not be considered a uniform group with a ‘one-size fits all’ definition for their engagement, roles and responsibilities. Community members and organisations might move through different positions/spaces of participation in a fluid way. Co-researchers and researchers must develop trust with each other, the process cannot be forced or pre-designed, rather organically developed alongside the research.
How to facilitate the engagement of marginalised groups
Pre-existing community platforms for engaging co-researchers are unquestionably valuable to a new research project like ARISE. However, we want to ensure that marginalised or vulnerable community members are equitable participants in the process. These people may be less able to participate in pre-existing community development and advocacy. So, we will need to look for new ways of engaging to make the process inclusive.
We have been grappling with the dilemma of what to do when marginalised groups are disempowered and as a result unable to participate as co-researchers. Co-researchers – who have local knowledge on what is feasible and acceptable – could adapt participatory methods to better engage marginalised groups. Getting a better understanding of how marginalised groups like to communicate (e.g. through storytelling, drama, drawing pictures) and working with them to create outputs may help them feel more empowered. Informal discussions and ethnographic observation – interacting with marginalised groups in their own settings – might spark ideas. We also considered using ‘gatekeepers’ (or powerful people or institutions who provide an entry point to marginalised communities). For example, disabled persons organisations will usually know how to communicate with their constituency and support their participation.
Working with children and young people
Children and adolescents in urban informal spaces are often vulnerable to ill-health and have difficulty accessing accountability. However, we are concerned about how to ensure that we have a clear process of consent for their engagement in the research. Often children do not have a parent or guardian that can agree to their participation. We must strike a balance between the democratic principles of participation and empowerment and the ethical challenges of appropriate management, support and protection. Collaborative projects with young people are key to understanding their experiences of health and well being. But young people are often excluded from, or left out of, research projects.
Other marginalised groups
People with cognitive or intellectual disabilities may not be able to provide consent through conventional processes and we will need to account for this in the way we work. Sex workers and LGBT people may not want to be involved because they don’t want to be identified. These groups might be reached through community agents who have connections with them. We will continue to explore this ongoing dilemma during our research.
How to minimise risk and harm
We want to ensure our work is ethical and that people are safe. Community members and co-researchers might be put at risk if: tensions arise about the choice of co-researchers; communities are hostile to data collectors; or the findings of the research cause ructions.
Our discussions have thrown up a number of strategies to mitigate risk. We will involve communities in selection of co-researchers. That way they have ownership over the process and are more likely to support the research. We will try and be open and transparent in our working practices – communicating our intentions and the process. Research teams will keep an open dialogue going to keep abreast of emerging risks. It is important that ethics and safety are central to researcher training on participatory methods. They will be are aware of the boundaries of their role as researchers and put the safety and wellbeing of communities first.
Concluding reflections on participatory research
As ARISE is rolled out, we are thinking critically about power and participation. What does this mean in practice and in terms of generating equitable research partnerships? We are particularly keen to disrupt the balance of power between ‘researchers’ and the ‘researched’. Working through ethical dilemmas together and documenting this process will help us to learn and share with the wider research community.
There is no single blueprint for participatory research. It is a process rather than a set of uniform steps with predictable outcomes. Because we all come from different starting points, we have created an internal community of practice to exchange ideas.
We welcome, through the comments below this blog, insights from others who have experienced similar dilemmas.
This post was written by Kim Ozano, Abu Conteh, Laura Dean and Kate Hawkins and first appeared on the ARISE website.
It’s World Book Day in the UK! A more cheerful international day than many we tend to highlight.
A book is a precious, precious thing.
I love to read. It’s one of the ways I relax at the end of the day and I find novels, in particular, relieve stress and help me go to sleep. Sometimes they enable me to imagine an alternative, better world, full of hope. Alternatively I use them to immerse myself in post-apocalyptic hellscapes that help take my mind off things. According to my kindle I read 72 novels last year. I read fiction in a blur or a binge. It’s very satisfying.
But when it comes to non-fiction books I like a paper copy, and I am more discerning and more intentional and ponderous in my reading style. I tend to buy these books second hand and turn down the corner of pages, scribbling in margins, breaking spines. Sounds a bit brutal but I only buy hard copies of books that I know I am going to refer to time and time again. You should see the state of my cookery books.
For this post I wanted to highlight a handful of books that I return to often which focus on how to improve non-fiction writing. I most recently used them a couple of weeks ago when I gave a training to the folks at ARISE on storytelling. ‘Share a million stories’ is the theme of this year’s World Book Day and these books will help you do that. As you’d imagine, they are all incredibly well written which makes browsing them very far from a chore.
Storycraft: The Complete Guide to Writing Narrative Nonfiction
This book really takes you through the anatomy of a good story. It covers elements such as point of view, voice, dialogue, scene, action, and character. Examples of writing from award winning journalism means it grips your attention from the outset!
Narrative nonfiction has flowered across media, from newspapers and magazines, to books and documentary film, to radio, television, and new digital forms. Despite the diversity, narrative springs from a common theory of story and employs shared techniques. But surprisingly little help exists for writers who want to create the kind of nonfiction that dominates today’s real-world storytelling.
Writing tools: 55 essential strategies for every writer
This book is made up of tiny little chapters that are like a pop of enlightenment. I often get tied up by grammatical rules but this book demystifies the technicalities that slow me down. There are homework tasks where you can practice what you learn and lots of advice on how to build the habit of writing and planning a plot or a story.
On writing well: The classic guide to writing nonfiction
This book has an authoritative but chatty style. It’s really a beauty to read. The chapters are separated out into sections covering; principles, methods, forms and attitudes. I really liked this quote on the lead (or sometimes the lede) – or the need to construct a strong opening. I use it a lot:
“The most important sentence in any article is the first one. If it doesn’t induce the reader to proceed to the second sentence, your article is dead. And if the second sentence doesn’t induce him to continue to the third sentence, it’s equally dead. Of such a progression of sentences, each tugging the reader forward until … safely hooked, a writer constructs that fateful unit: the lead.”
The people I work with, in universities and NGOs, have been taught to write in a particular style – in journal articles and technical reports. There’s nothing at all wrong with that. But that style of writing is not always accessible or impactful. It’s good to experiment with different ways of capturing the reader’s attention, cutting out the clutter and reeling them in with some emotional content.
Learning to write well is an ongoing labour and none of us have cracked it – least of all me. I would love recommendations for other books on writing, especially from people outside the US (because these books draw heavily on writing from North America). Help broaden my horizons! Leave a comment below. And Happy World Book Day!
Kate Hawkins, Pamoja Communications Ltd./Research in Gender and Ethics: Building Stronger Health Systems
Just in time for International Women’s Day 2018 the Global Equity Hub (coordinated by Women in Global Health and The WHO Global Health Workforce Network) held a hard-hitting webinar on Gender Transformative Approaches in the Health and Social Sectors. Drawing on expert opinion from the Africa, Europe and the Caribbean the speakers described a sector in crisis, and one that needs urgent reform if we are to meet the Sustainable Development Goals and other international targets.
The health and social workforce needs gender-transformative reform
In introducing the webinar Tana Wuliji explained that the global economy is projected to create around 40 million new health and social sector jobs by 2030. However, there is a projected shortfall of 18 million health workers and the problem is particularly pronounced in low-income countries. Much of the global dialogue on women and health focuses on women’s health and does not recognise the significant contribution women make to global health. Women’s contribution to global health, where they perform about 70% of all jobs, is US$3 trillion. Half of all of this work is in unpaid care roles, which are finally beginning to be seen as legitimate work by international policy making bodies.
Yet when you invest in the care economy you can boost overall employment, particularly the employment of women. With the right investments we could make a step forward on gender equity. This is the aim of the Gender and Equity hub, it is trying to accelerate this change by bringing together evidence, advocacy and a community of change-makers which can be used to accelerate gender transformative policy and practice in the health and social sector.
Women health workers face violence and sexual harassment at work
Health care is dangerous work. Shockingly, in the presentation by Sandra Massiah we heard that 25% of all violence in the world of work occurs in the health sector. This occurs across all countries and occupations in the sector. Furthermore, there is a growing culture of violence and conflict in many settings and austerity measures are leading to increased inequality which in turn leads to violent acts from third-parties.
Often there is a lack of legislation specifically on workplace violence and when it exists it is not implemented or policed (by unions and civil society). Particularly vulnerable women, for example young women and single mothers, are more frightened of reporting harassment and bullying in case they lose their employment.
She described the work of Public Services International with Lady Health Workers in Pakistan which revealed widespread sexual harassment in the field, sexual harassment by co-workers/colleagues, domestic violence, humiliation by community members, and violence from extremist groups.
Sadly, these dangers are also found in health worker education. The presentation from Varwo Sitor-Gbassie (Maternal and Child Survival Program Human Resources for Health Project) focused on Liberia. Their 2017 research aimed to increase women’s matriculation rates and reduce drop outs in pre-service health education. They found that there was very limited access to gender training in schools, there was poor access to sexual and reproductive health services, female students were not kept safe and secure, and there was sexual harassment on campus. School policies were also discriminatory. Pregnant learners were also forced to leave their studies for two years.
Fragile and conflict affected states have particular problems
Presenting on the health workforce, gender and conflict-affected and fragile statesSally Theobaldreported that there are severe challenges recruiting health care workers (training institutions have been destroyed and staff have been killed or fled). In addition to the under-representation of women in leadership positions and the struggle to balance caring responsibilities in the home and work which are found in other settings women in conflict settings deploy various strategies to cope. They talked of blending in so that it wasn’t so apparent that they were health care workers:
‘…the rebels came, abducted the in-charge and killed a nursing aide. I managed to escape but … I ran among the community members… I would not treat my hair… they [rebels] would follow you because you look different from other people. … That is why they [rebels] did not focus on me particularly because I was exactly like the community. And I used to buy simple clothes for my baby like for the community, even this one’ (woman health care worker, Northern Uganda)
In Cambodia male health workers trained themselves to use weapons for protection, whereas female health workers found ways to escape. In Sierra Leone health workers were targeted for kidnapping to provide health services behind rebel lines; female health workers also faced the additional risk of sexual violence if kidnapped by the rebels. Despite this, women showed special resilience and courage, supported by links to families and communities.
Sandra Massiah reflected on their work in the Democratic Republic of Congo. Since 2011, nurses and other healthcare workers have faced increased violence as a result of the military conflict and because of suspicion and traditional views: rape, molestation as well as attacks and murder during vaccination campaigns. SOLSICO reports that between 2011 and the present, over 700 nurses were raped and 188 killed. Poor working conditions in hospitals result in illnesses and death due to infections.
Employers have a duty of care and states must enforce this: Sandra Massiah provided valuable insights on how the trade union movement is organising to tackle both gender inequity (for example on pay), gendered violence in the health workplace, and patriarchal norms. PSI are calling for national governments and employers to support an ILO convention and recommendation on this issue. Assisting affiliates in linking gender-based violence and harassment to the campaign for Gender Responsive Public Services (GRPS). Promoting and encouraging the attendance and participation of members of national women’s committees in International Labour Conference discussions on the issues. Public services unions have a critical role to play in discussions and policy formulation on violence in society. Furthermore, she argued that tax justice is a gender issue – as it contributes to the public sector and thus the achievement of the Sustainable Development Goals. Gendered reform in the sector is reliant on this source of funding.
“Collective action by organised workers has proved to be a crucial means to mount a challenge to addressing inequality in remuneration between men and women…These struggles contribute to challenging the gendered construction of the economic and social value of productive and reproductive work that these inequalities stem from.”
Gendered approaches to health systems: As Sally Theobald argued, health systems are part of, and reflect, the broader social structures they are situated within. They are shaped by gender and other relations of power. This means that we must pay attention to systems and structures that maintain in equity in our research and policy frameworks. We also need to look at norms in households and communities as this shapes the way health systems operate and how unpaid care roles are distributed.
Institutional monitoring and transformation: Emma Nofal, an Athena Swan NHS Fellow from the United Kingdom presented on how inequality is being tackled in the National Health Service. The Athena Swan Programme was developed in 2005 to encourage and recognise commitment to advancing the careers of women in science, technology, engineering, maths and medicine. Emma’s team are adapting this for use in the health sector through a pilot study in Sheffield teaching hospitals. Members who sign up to the charter apply for an award which is dependent on a focus on promoting and supporting gender equality for women. It has enabled them to develop a better understanding of the barriers there are for women in progressing, accessing training, accessing maternity leave, pay banding and how we can make the working lives of staff better.
Supporting women’s leadership: Participants suggested that we need to encourage women’s leadership in the health and social care sector and this includes men in managerial positions pushing for change, supporting training for women and removing the barriers that they currently face. In the union sector we need to engage brothers to make the necessary changes in their thinking and attitudes. This may mean initiatives to educate them about what is going wrong and how they can become allies in transformative change.
Zero tolerance for sexual harassment and violence: On the webinar there was a call for a zero-tolerance approach to sexual harassment and violence, including in the health workplace. We need to centre the victims of violence and support them when they come forward (including with psycho-social interventions). Workplace policies need to be assessed and updated and workplaces need to become safe spaces for raising issues gendered and other forms of discrimination, this may also mean tackling bullying in the workplace more generally. Leaders in global health and in politics need to openly add their voices to calls against sexual harassment and set global standards to tackle violence in the world of health work.
Contactinfo@womeningh.org for more information about the Global Health Workforce Network Gender Equity Hub.
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.
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.
“We live in a rapidly changing world where it is difficult to keep up. Sexual and reproductive health needs, desires, expectations, and pressures are part of this.” –Sabina Faiz Rashid, Dean, BRAC JPGSPH
From the 30-31 January I was lucky to attend the BRAC James P Grant School of Public Health (JPGSPH) Gender and Sexual Reproductive Health Conference for Young Adults 2018. The first day had a focus on young people (and over 700 university students participated) and on the second day the dialogue was with practitioners. This was a fantastic opportunity to not only hear about cutting-edge research for Bangladesh but also engage in a dialogue with researchers and civil society leaders from the region. It is very rare that I get to hear the views of young people, unmediated by a scholar or a journalist and I very much appreciated their inputs, and their insights into the issues that matter most in sexual and reproductive health and rights (SRHR).
It is hard to do justice to a conference with such riches of ideas. Here are six of the conference themes that stood out for me.
1. We need to better acknowledge the agency and power of young people.
Maheen Sultan, who is leading the Centre for Gender and Social Transformation at BRAC Institute of Governance and Development (BIGD), pointed out that today’s adolescents increasingly see themselves as people with agency and a voice. It is beholden on public health practitioners to accept this and listen and learn from younger people in the organisation of services and interventions. As one speaker pointed out, young people talk about desire, emotion, sexual orientation, pornography, and drugs but we don’t engage with them on this. There is no space to talk about the issues that they find pertinent, there is just silence. Luckily the conference bucked this trend.
There was a fascinating insight into young people’s agency in the presentation by Seama Mowri, project coordinator at JPGSPH, on early and child marriage in Bangladesh and how it can be addressed. Early marriage is occurring in urban slums which are in a period of transition (with Dhaka on its way to becoming the sixth largest mega-city by 2030). Young people live with insecurity in the forms of the risk of eviction, fragmented families, and criminality. It is within this environment that they navigate narrow and difficult choices. Mowri’s interviews with 130 young people and other stakeholders found that the average age of marriage was 15-16 years and that love relationships were losing their taboo status. In a context where many young people had access to a mobile device, the older generation were increasingly concerned that this form of communication was leading to clandestine relationships and elopement. We heard that sometimes adolescents blackmailed other young people or their parents into agreeing to early marriage, threatening to run away or commit suicide if their desires weren’t fulfilled. Within marriages the majority of married girls wanted to delay pregnancy and took responsibility for contraception even if their husband did not (and sometimes kept it a secret from husband and in-laws). Furthermore, remaining single and entering the world of work was not necessarily considered empowering. Young working women talked of the need for protections against assault and harassment. This evidence was refreshing as it did not rely on stereotypes about young people’s lives. It demonstrated the agency of young women living in difficult situations. Interventions to halt or reduce early marriage are unlikely to succeed unless they take these women’s views and life experiences into account.
2. Intersectionality matters.
A strong message from the conference was that we need more discussions of intersectionality and we need to purposefully integrate this analysis into our research and programming. Commenting on a session on mainstreaming sexual and reproductive health education, disability rights activist Anita Ghai lamented the ways in which people with disabilities were excluded from the narrative and the interventions that follow from it. For example, when talking about menstruation how often do educators talk about the forced hysterectomies performed on disabled girls because their menstruation is too ‘difficult to manage’? Or their sterilisation because parents don’t want their daughters to get pregnant? Sabina Faiz Rashid suggested that ‘inclusion’ is often performed in a very tokenistic way, “We cut and paste and replicate, we borrow. If we get compliant and complacent and we don’t look at the heart level about who we are leaving out and what we are uncomfortable with we will lose out.” If sexuality education truly informs young people and empowers them to take control of their lives, as Chief of Health at UNFPA Bangladesh, Sathyanarayanan Doraiswamy argued, we need to ensure that it is sensitive and responsive to all young people not just some imagined norm.
Intersectionality analysis matters when it comes to tackling harmful conceptions of masculinity too. Speaking on masculinities as a social construct, Anand Pawar, Executive Director of SAMYAK, argued that it is not enough for men to simply learn the language of gender equality without embodying these principles. He asked, “What if a gender sensitive man is Islamophobic or racist? Is this enough, if they are not working on power more generally?” There was a strong theme within the conference which stressed the need for a holistic analysis of vulnerability and privilege in sexual and reproductive health education and the way that simultaneous structural power relations shape this.
3. Race and colourism should be part of the conversation.
“When I was I in ninth grade and relatives would visit they would ask if I was actually my parents daughter because my skin is not fair like my brothers and sisters.” –Audience member
“I am dark skinned, and I am obese and our society always wants to point it out and judge. But I have a supportive family and I am really happy how I am.” –Audience member
We heard a fascinating talk by Azra Mahmood, one of Bangladesh’s top models, who experienced discrimination on the grounds of her darker skin and overcame these notions of beauty to have a successful career and found her own modelling agency.
She encouraged us all to take personal action to end bullying and discrimination based on society’s beauty standards and to use social media to spread the message.
There sometimes appears to be a reluctance among public health practitioners to talk freely about race and its impact on health and wellbeing – despite the ever-broadening evidence base that racial discrimination leads to psychological and physical ill-health the results of which can pass through generations.
4. Re-writing the masculinity script.
There were a few sessions at the conference that addressed what it is to be a man and how we define masculinity. Adnan Hossain’s presentation was a good reminder that there are many forms of masculinity, but some are hegemonic and others subaltern and there is a tendency to make a hierarchy of them. In Bangladesh, as in all other settings, notions of masculinity are historically dependent underpinned by a governing logic which stems from framings formed in colonial times, the war of liberation and in recent years related to economic growth.
We heard how normative ideas of masculinity tends to begin by constructing men in relation to their biology and social rituals such as heterosexual marriage and being an economic provider. Deviating from these norms can come with health and other costs and vulnerabilities. These issues are compounded for people who are non-binary, gay, bisexual and transgender. Adherence to these norms can also be unhealthy leading to self-neglect, poor health care seeking and underpinning gender-based violence against women, children, weaker men and non-binary people.
Drawing on his research of risky sexual behaviour and masculinity in Dhaka slums, Arifur Rahman painted a picture of a community of young men who were mostly sexually active before the age of 18 and had easy access to various types of illegal drugs. While many were having sex with girlfriends and with sex workers about half said that they were not satisfied with their sexual life. For some it went against social and religious norms and was shameful. Others felt it was unsafe. While they understood that using a condom and other forms of contraception was desirable they didn’t like buying condoms from the local pharmacy for privacy reasons, felt uncomfortable using them or had a lack of knowledge about them. A lack of privacy to have sex was also cited as a source of discomfort and vulnerability in this crowded urban space. The research uncovered tensions around their masculinity with concerns about sexual function and performance, such as premature ejaculation, about their ability to live up to financial expectations. Despite having girlfriends, they had conservative ideas about women’s dress and a victim blaming attitude towards harassment and assault. The majority said that if a woman doesn’t obey her husband then she deserves a beating, others said we should talk, others said that if it is extreme they should file for divorce.
In terms of efforts to challenge harmful masculinities, Sharful Islam Khan provided a wonderful case study from his anthropological studies with icddr,b arguing that global norms around masculinity are tied to notions of money, power and politics and privilege physical strength and toughness. These norms are reinforced by popular messaging, such as in the media. Anand Pawar argued that we need to create intervention with politicians, religious leaders and other powerful people who are creating the notion of manhood rather than only focusing on poor men. And we need to talk about market constructed norms of masculinity and the influence that they have.
5. Mental and physical health go hand-in-hand.
“When I had my diagnosis, I was more afraid people would know my HIV status than my fear of dying. At the weekend I would go into nature and close my eyes and contemplate that we all share the same universal consciousness. We all go through sadness, happiness… Now I only think about HIV when I take my medication at night. At other times, I don’t [care] about HIV.” –Wangda Dorji
“It is ok to hurt, and it is ok not to be ok.” –Onaiza Owais
Some sessions at the conference highlighted the importance of mental health to young people’s wellbeing more generally. Ms Onaiza Owais reflected on her own experiences of depression during university, seeking psychological assistance and medication and how finding a peer group who she could talk with in a safe space led her to use her experiences in assisting others facing similar challenges. Shila Rashid presented on eating disorders and how these are gendered and shaped by family, society, religion and our own perceptions. The way that mental and physical health are intertwined came through in their presentations, and that of Wangda Dorji, reminding delegates of the importance of seeing sexual and reproductive health in a complete way.
6. A focus on disability
“In normative society there is a conspiracy of silence about the sexuality of people with disabilities. It is thought that you are either asexual or hypersexual and not prioritised even among advocates for disability rights.” –Anita Ghai
The conference had a strong focus on disability not just in terms of exclusion (how disabled people are infantilised and their needs, desires and inputs are considered unimportant) but also on disability as a knowledge systems which can provide vital insights for those working on sexual and reproductive health. We learned how disability is heterogenous – India has 21 different categories of disability – if we were to build our sexual and reproductive health education system around catering to all students regardless of (dis)ability it would provide a more imaginative starting point for our discussions of love, sex and romance.
At the conference we heard from a range of implementing organisations about how they were responding to some of the contemporary challenges raised above.
Debarati Halder gave an overview of the subject of cyber-bullying, a more common phenomenon as rates of internet use and connectivity are rising. This has implications for regulation of online spaces but also young people’s self-image and mental health. Others spoke of the rise in young people accessing information about sexual and reproductive health online in lieu of decent sex education. Pornography is readily available in Bangladesh and is one way that young people learn about their bodies and sexuality. In this there is a challenge in distinguishing accurate from inaccurate information. One young person explicitly asked how young people can navigate ‘fake news’ online.
To provide accurate information we heard that initiatives like Digital Sister for Urban Youth are creating platforms which seek to understand how urban youth access sexual and reproductive health information and develop communication tools to meet their needs. Interestingly, the Digital Sister project had feedback from young people that they should also spread messages through offline channels. Young people were concerned that their parents had insufficient access to information and inaccurate beliefs and that online sources would not meet their needs. This speaks to the need to integrate online and offline spaces in ways which are targeted to the needs of users.
Echoing Jeroen Steeghs’s speech at the conference, it is important that implementers take these issues on board and do not leave them to parents, many of whom are ill equipped and lack information, to deal with. Adolescents have sexual needs, fall in love and feel attraction, explore and develop their sexual identity. They often have to navigate incorrect and distorted sources of information in the process, including from censored or abstinence-based sexual and reproductive health education in schools. More guidance is becoming available on sexual and reproductive health programming and sexuality education such as the recent UNESCO publication on international best practices. However, despite overwhelming evidence that comprehensive sexuality education works there are barriers to its implementation such as the embarrassment of teachers and parents in taking this forward. Similarly, existing legal frameworks can simultaneously protect young people from abuse while constraining access to information and justice, and these need to be critically considered.
Comprehensive sexuality and sexual and reproductive health education prepares and empowers young people to take control and make informed decisions. It can be transformative – and help to build a fair and equitable society by overcoming issues like colourism, sexism, homophobia, ableism, sizeism, marriage normativity and other forms of discriminatory practice. It is the responsibility of those working on policy and interventions to take the concerns of young people seriously and ensure that they are at the forefront of shaping the response.
This blog was written by Kate Hawkins, Pamoja Communications Ltd/REACHOUT Consortium.
The Gender and SRH Conference for Young Adults 2018 was funded by NUFFIC and implemented through a partnership between BRAC JPGSPH, RHSTEP and NIPORT.
By Aschenaki Z. Kea, Kate Hawkins, and Daniel G. Datiko
Though improvements have been achieved in maternal and child health related indicators, Ethiopia still experiences high maternal mortality due to challenges related to utilization of antenatal care, skilled delivery and postnatal care.
REACHOUT has been working to improve the performance of health extension workers (HEWs) in maternal health by strengthening services provided in primary health care units. Through the intervention we have seen remarkable improvements in the uptake of maternal health services.
What did we do?
The life cycle of the REACHOUT project can be broadly divided in three phases: a context analysis and two quality improvement cycles. The context analysis was carried out to understand the barriers to and facilitators of maternal health. This informed the introduction of the first quality improvement cycle in Shebedino woreda/district in Sidama zone. The key interventions of the first quality improvement cycle included group supervision of HEWs, community engagement and strengthening referral linkage, it was led by the research team.
The second quality improvement cycle, primarily led by the woreda health system, was started by establishing a Quality Improvement Team and a technical working group (TWG) at nine health centers and woreda health offices and scaled up to six districts of Sidama zone. The intervention has transitioned from being project led to district led as a result of embedment in the health system. The health center Quality Improvement Teams are made up of five members: the head of the health center (chair), the person responsible for the Health Management Information System, the maternal and child health coordinators, a HEWs’ supervisor and the Woreda Health Office focal person for that particular health centre.
A three-day training was provided to the Quality Improvement Teams in our first workshop, which included how to identify and prioritize quality problems in maternal health, how to develop a change plan, and how to measure and document changes. They identified the root cause of the problems using problem tree and fish bone analysis exercises based on service standards, from their practice and routine reports. Some of quality problems identified and being addressed include: inadequate routine lab services for pregnant mothers including testing for HIV and syphilis; poor data quality; low coverage of fourth ANC visit and facility delivery; lack of logistics; and shortages of supplies.
Priority problems were selected by the Quality Improvement Teams based on a prioritization matrix and developed detail change plan including monitoring and evaluation mechanisms. The TWG provided technical support and oversaw the Quality Improvement Team to ensure functionality and sustainability.
The Quality Improvement Teams held regular meeting on a monthly basis to discuss the progress of the implementation of the selected quality improvement indicators and develop the next action plans based on the identified gaps. The findings were shared with the HEWs and their supervisors during group supervision meetings.
Besides the Quality Improvement Team monthly meetings, three joint workshops were held including the initial training. The two subsequent workshops addressed the problems identified in previous workshops, and reviewed the change plans developed for the identified problems, activities undertaken, successes achieved, challenges encountered, and lessons learned.
What have we achieved?
Implementation of the multidisciplinary Quality Improvement Team team has improved the efficiency of the team, quality of group supervision, and the exchange of feedback within primary health care unit.
A focal person from the woreda health office shares information about the work of the Quality Improvement Team with the woreda health office to ensure district led sustained support and learning across the health centers. The tools developed by the project have been successfully decentralized and used in health facilities, contributing to the successful provision of maternal health services. The shift from project led to district led implementation has improved the coverage of facility delivery in Shebedino woreda from 28% in 2013 at the baseline to 78% by July 2017.
The health system is a growing employer of women and can help to contribute towards gender equality. Yet gender biases and discrimination are sadly alive and well within this sector. The need to promote gender transformational processes and decent work for health workers of all cadres was discussed at the WHO Human Resources for Health (HRH) Forum held in Dublin earlier this month.
A gender lens is often missing from analysis of the Community Health Worker (CHW) cadre of health workers who operate within communities serving as a vital link between them and the health sector. Although it varies by context, CHWs are predominantly women, often of lower socio-economic status, who have limited career opportunities. The HRH Forum provided an opportunity to highlight some of the gendered aspects of this cadre and showcase experiences and inspiring stories of action for CHW programmes. A panel chaired by Sally Theobald covered India, Brazil, South Africa and Malawi. She opened the session by highlighting the importance of gender and equity in human resources for health and “decent work” agendas, stressing that this lens needs to extend to CHWs who both experience gender inequities and also negotiate the ways in which gender and power play out within the households and communities they serve.
Gender dimensions of the ASHA programme
The first panellist was Kerry Scott (on behalf of Rejani Ved and Asha George) presenting work on the ASHA programme from India. The all-female cadre of staff was developed order to meet the country’s maternal and child health goals. The programme is now made up of 850,000 ASHAs (one per village). In order to better meet the needs of ASHAs a number of policy changes have been made. ASHA’s training has become residential with a crèche facility to ensure the women can participate and also fulfil childcare duties. ASHAs are included as member secretaries of village health committees. This enables them to move beyond the all-female maternal health space and encourages their active leadership in traditionally male dominated realms. Although ASHAs are not formally employed by the government, there are increasing monthly economic incentives for ASHAs to help them meet their need for regular income and encourage the uptake of banking services. The creation of more government scholarships for higher education for ASHAs creates more opportunities for women to access a career pathway. Newly introduced social security measures help support ASHAs via life and accident insurance and pension opportunities. Finally, the creation of rest accommodation in health facilities helps to increase ASHA safety and comfort (as one of their main duties is to escort expectant mothers to facilities to deliver, often at night).
These policy changes demonstrate positive active steps towards securing the safety and wellbeing of the ASHA as a mobiliser, facilitator and as a care provider. However, there are still challenges. There have been shocking examples of ASHAs being sexually harassed and even raped by community members and other health service providers in the course of their work. The government response has been to ensure that all service providers undergo sensitisation training, but there is still work to be done to ensure ASHAs’ safety and rights are protected at the community level. Kerry concluded with the call for constant adaptation of policies to ensure appropriate response to the ASHAs gendered needs. She posed the question, how do we balance policy progress against social norms which are slower to change?
Power, gender relations and heteronormativity in Brazil
João Nunes presented on Brazil and highlighted that there is a need for a political economy in analysis of human resources for health and the ways in which international political economies intersect with gender. Since its inception in 1987, the Brazilian CHW programme has been shaped by gender norms. The programme developed against a backdrop of neo-liberalisation, privatisation and an increasing feminisation of labour, where women were seen as precarious workers to fulfil permanent job needs. The programme was initially conceptualised as a way to reduce infant mortality whilst at the same time provide employment opportunities for poor vulnerable women and a make-shift solution for the health of poor communities. Perceived as natural carers and providers for their communities, these women are often required to go beyond their job specification and working hours, providing informal work which is not remunerated such as support for single mothers, victims of domestic violence, and sexual health.
As is often seen CHW programmes that require CHWs to come from the communities they serve, CHWs work in systems that enable and reproduce gendered vulnerabilities. Informal care work is seen as a women’s domain – this work is downgraded and informalised within the socio-economic system. Similarly, primary health clinics are understood to be a feminine space and often men do not visit. This is compounded by the cultural understanding that men must play a bread-winning role, working during the hours that the primary health care clinic is open. An example of how CHWs internalise and reproduce the norms that they work within was given with regards to the family health strategy – which assumes a binary heteronormative family of man, women and child. In recent years there has been change to make this strategy more diverse and reflective of current households and communities but there has been conservative push back with many CHWs themselves sharing these views.
Finally, João described how there are many obstacles to the discussion about women’s sexuality which has an impact on what CHWs can do in their formal conversations and advice. Women are seen as mothers and daughters and activities to support women’s sexual health is perceived to be limited to vulnerable groups such as sex workers or trans women. Due to religious and cultural norms discussion about sexuality can be very difficult. For example, the use of condoms is not acceptable for married couples. In the same way that heteronormative gender norms limit women’s capacity to provide sexual and reproductive care, they also constrain men in becoming CHWs. Due to sexual politics men are unable to enter homes which prevents them from providing adequate care. This suspicion of men and reluctance for them to enter the household space, is not unique to Brazil and similar dynamics have been seen in Kenya and many other countries.
Gender roles and CHWs in Malawi
Kingsley Chikaphupha from REACH Trust (and co-chair of the Thematic Working Group) gave us examples from Malawi, where there are both male and female Health Surveillance Assistants (HSAs). He highlighted how recruitment of CHWs, is not considered from a gender perspective and because of this there is a large imbalance between the numbers of men and women performing the role. Across all districts there are 30% male HSAs to 70% female HSAs. However, when you look specifically at hard to reach areas within these districts, the numbers are flipped, with 70% male, 30% female.
In hard to reach areas the 30% that are female also appears to be diminishing – this may be due to pressure from husbands to leave the role, or often it is reported that female HSAs leave if they are married to men in who are posted to work in urban settings due to their jobs. In some cases, male HSAs had wives who were posted to urban settings however, they chose to remain in rural areas due to cultural norms that make it shameful for men to be seen to follow their wives.
We heard how this imbalance affects the health of the community as, although both male and female HSAs have the same responsibilities on paper, in reality the division of labour is quite gendered. In most settings male CHWs are more privileged than women with greater access to supervisory roles and equipment such as motorcycles.
King called for: 1) More gender disaggregated data on CHWs; 2) Greater support for skills development; 3) Gender transformative approaches in CHW policy; 4) Work with broader coalitions to prompt societal transformation, a review of current gender strategies, and the creation of a gender frameworks for CHWs.
Working with CHWs to engage fathers in health, wellbeing, and care
Andre Lewaks of Sonke Gender Justice South Africa, talked us through the MenCare Project, gender transformative training by CHWs to promote father’s involvement in Early Child Development (ECD).
In South Africa 64% of children don’t live with their biological fathers following patterns that reflect strong cultural and patriarchal norms that promote women as the natural caregiver for children. For every hour of unpaid care given by a man, a woman gives eight. The MenCare Project trained child and youth care workers (CYCWs), provided home visitation programmes and complimented this with onsite mentorship and support of CYCWs.
A mixed methods evaluation of 544 fathers who took part in the project found a positive transformative change in attitudes towards heteronormative care roles and women’s labour. For example, when asked whether they agree with the statement “a women’s most important role is to take care of her home and cook for her family” before the intervention 79% of men and 60% of women agreed. After the intervention, this dropped to 31% of men and 33% of women. Participants also realised father’s roles went beyond provision of financial support and some women also reported that they realised their own role in the entrenched patriarchal mind set of the community.
The project reported that CYCWs had an improved capacity to understand and engage men. Men had an improved ability to express themselves which in turn improved communication between partners and lead to improved sharing of household responsibilities. Importantly, in a context of a high prevalence of intimate partner violence, there was a reduction in men’s abusive behaviour.
Instilling a gender transformative approach to National CHW programmes
Sarah Crass (on behalf of Polly Walker) discussed the gender transformative approaches that World Vision International (WVI) are undertaking through their CHW programmes in Lesotho, Ghana, Sudan and Mauritania. This includes the Timed and Targeted Counselling (TTC) model.
Fathers’ have a huge impact on children’s cognitive outcomes and even the relationships that they will go on to have in later life. Negative father figures can result in early sexual debut and increased childhood pregnancies. WVI’s evaluations found that a key limitation of CHW programmes, is lack of male partner engagement. Through their TTC model men are included by default and indicators for their involvement are included. It uses positive role modelling and healthy family models to engage men in family activities including time to play with their children and take part in other household activities traditionally viewed as women’s work. The model also makes use of male and female CHW pairs in household visits which is beneficial to circumvent norms that may inhibit cross gender discussions.
Through this intervention WVI found that TTC counselling is more productive and results in a greater number of concrete decisions being made if male partner is present. They also found that at the policy level male involvement is inadequately addressed and there is dearth of evidence here. They report that policy makers are aware of this gap and are keen to explore new methods for male involvement in community health as the non-participation of men inhibits early childhood development. Through a qualitative evaluation of the TTC model, they were able to report that male involvement leads to improved sharing of household chores with male partners. Male partners were also reported as more likely to take an interest in mothers’ nutrition during pregnancy and accompany mothers to give birth.
This panel helped to illuminate some of the issues facing CHWs and the communities they serve around gender. It was part of a larger call for greater gender analysis of challenges facing human resources for health which was heard throughout the conference. For more information on gender and CHWs see our previous webinar on this topic and the REACHOUT blog. If you are interested in community health workers – join our thematic working group by emailing Faye.firstname.lastname@example.org.
By Kingsley Chikaphupha, Regeru Njoroge Regeru and Kate Hawkins
Data from community health programmes is essential in understanding their contribution to healthy lives and promotion of well-being of all. Unfortunately, the quality of data reported by Community Health Workers is often poor meaning – like community health programmes themselves – this information remains on the periphery of health systems and is not used by decision- and policy-makers at district and national levels.
Let us put ourselves in the shoes of a Community Health Volunteer (CHV) in urban Kenya:
Why should I worry about the quality of the data that I report to the Community Health Extension Worker (CHEW), a.k.a. my supervisor? Us CHVs are meant to meet with the CHEW monthly but she never calls us. I am still holding on to reports for the past two months because I don’t know where to take them.
And wait – what does data quality even mean? No one has ever told me. When I was recruited as a CHV two years ago, I was replacing another volunteer from my area who had suddenly dropped out from the programme. He had to go make money to feed his family. I was recruited after one of my friends who is also a CHV introduced me to the CHEW for our community unit. She told me that I was lucky because a non-governmental organisation would be conducting a training on water, sanitation and hygiene (WASH) in a few days and that I could join that training and then start working. The CHEW took me to our Chief and he gave his approval and that was that. I attended training on WASH the next week and the CHEW gave me photocopies of a form she said I should use to collect data when I make household visits. I began visiting households in our community unit with my friend and then eventually by myself. When I first started using that form I noticed there was so much we are meant to write about mother and child health. No one has ever taught me about mother and child health! My friend told me I should record data using ticks and crosses but this confused me so I just use 1s and 0s. Some of the terms also confuse me – what exactly does skilled delivery mean?
Anyway – I’ll just keep doing what I’m doing because whenever we meet the CHEW she just picks up our forms and we never get any feedback.
Now let us put ourselves of the shoes of a Community Health Volunteer in rural Malawi:
My Health Surveillance Assistant (HSA), a.k.a. my supervisor, has just called for me to come and help him with data collection about how many children under five in my catchment area are up to date with immunization. Now what am I going to write on? I just bought a new notebook for school for my child last week – I guess I must tear out some pages so I have data to give to my supervisor. I wish we had a tool from the government – after all we are collecting data that goes into government forms used by our supervisors.
Community health workers have the potential to be the ‘eyes and ears’ of the health system. They are our first point of contact with communities, collecting data that should be an essential underpinning to decisions about health service provision. Yet as these vignettes illustrate, the ways which they are treated run counter to the frequently repeated claim that decision making should be evidence based.
And we can do so much better. It is time that all community health programmes took steps to demonstrate how much they appreciate community-level data, and the people who collect it.
We put forward the following six recommendations for community health programmes:
Inform Community Health Workers why the data they collect and report is important.
Provide Community Health Workers with the tools that they need to do the job and ensure these are designed with their input.
Teach Community Health Workers how to complete their data collection and reporting tools and provide regular feedback and guidance on data management especially when new tools or processes are introduced.
Support supervisors of Community Health Workers in analysis of community-level data for identification of gaps and increased responsiveness to the challenges facing their communities.
Provide written guidelines and procedures for data management in community health information systems.
Inform Community Health Workers how the data they have reported has been used in decision- and policy-making so that they can see the impact of their labour.
There is a growing interest in women’s role in global health leadership. We know that women are the majority of people working to improve health outcomes in communities, health facilities, non-governmental organizations, and multilateral organizations. So why is it that when it comes to leadership positions we have a governance system that privileges men and what can we do to redress the balance?
We are delighted to announce that together with Women in Global Health, with the support of Springer, we will be publishing a book that explores women’s leadership in global health.
This ground-breaking collection will explore the leadership roles that women currently play in global health, teasing out the routes that women have taken to leadership, the challenges that they have faced, and what has facilitated their journey. It will bring to the fore the stories of women on the frontlines of this struggle from around the world, highlighting and complimenting these stories with theoretical and analytical explorations of the structures and systems that help or hinder the process. Empirical studies in this volume will demonstrate how women’s leadership is thwarted or supported from a range of different contexts, positions, and starting points.
The authors come from various academic and professional disciplines and have been purposefully selected to show the range of types of leadership in global health. The book will form a rallying call to arms to redress gender inequality and celebrate the many ways in which women are taking the lead in supporting the health of their communities internationally. This book will be a must read for those working in global health or studying the topic. It will also be a feminist primer that aims to support other women in their efforts to succeed in a highly unfair and unequal world.
The editors are Kate Hawkins, Rosemary Morgan, Roopa Dhatt, and Mehr Manzoor.
For more information watch this space! If you have any questions, just drop us a line.