Snap shots from a photo competition: what does it reveal about close-to-community providers, gender and power in health systems?

In this commentary, we discuss a photography competition, launched during the summer of 2014, to explore the everyday stories of how gender plays out within health systems around the world. While no submission fees were charged nor financial awards involved, the winning entries were exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. Anyone who had an experience of, or interest in, gender and health systems was invited to participate. Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement and in venues where their perspectives are often missing. The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. In total, 54 photos were submitted by 29 participants from 15 different nationalities and country locations. We unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. Three themes emerged: women active on the frontlines of service delivery and as primary unpaid carers, the visibility of men in gender and health systems and the inter-sectoral nature and intra-household dynamics of community health that embed close-to-community health providers. The question of who has the right to take and display images, under what contexts and for what purpose also permeated the photo competition. We reflect on how photos can be valuable representations of the worlds that we, health workers and health systems are embedded in. Photographs broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways but also reflect the politics, values and subjectivities of the photographer. They represent stereotypes, but also showcase alternate realities of people and health systems, and thereby can engender further reflection and change. We conclude with thoughts about the place of photography in health systems research and practice in highlighting and potentially transforming how we look at and address close-to-community providers

Implementation research to assess a health workers performance-based management system in Nepal

Aim To test and refine a performance‐based management system to improve health worker performance in Nepal. Methods A mixed‐methods implementation research in three districts. The study assessed health workers’ job satisfaction at the start and end of the study. Qualitative techniques were used to document processes, and routine health service data were analysed to measure outcomes. Results Job satisfaction significantly increased in six of nine key areas, and the proportion of staff absenteeism significantly declined in the study districts. It demonstrated an increase in immunisation coverage, the proportion of women who had a first antenatal check‐up also having a fourth check‐up and the proportion of childbirth in a health facility. The greatest perceived strengths of the system were its robust approach to performance planning and evaluation, supportive supervision, outcome‐based job descriptions and a transparent reward system. A functional health facility environment, leadership and community engagement support successful implementation. Conclusion The performance‐based management system has the potential to increase health workers’ job satisfaction, and it offers a tool to link facility‐wide human resource management. A collaborative approach, ownership and commitment of the health system are critical to success. Considering the Nepal context, a management system that demonstrates a positive improvement has potential for improved health care delivery

Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries

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.Open Society Foundations, Vozes Desiguais/Unequal Voices, Future Health Systems consortium, the Impact Initiative and Health Systems Globa

Towards a socially just model: balancing hunger and response to the COVID-19 pandemic in Bangladesh

Summary box Responsive and timely research is needed to better understand the challenges faced by poor and vulnerable populations to inform immediate interventions and policies to address this unprecedented COVID-19 modern-day pandemic. There is a need to research changes through time to understand and address the continuous and long-term economic, mental and emotional impact of lockdown on the most marginalised. Many of the Bangladeshi population are vulnerable, yet the COVID-19 response focuses on individual behaviour with limited attention to the social, economic and contextual factors that prevent the most marginalised from following national recommendations. In the context of structural constraints, continuation of the lockdown has to be accompanied by strong political resolve to ensure that people do not go without basic meals and have basic health information and support. The experiences of people living and working in slums in Bangladesh needs to be captured and translated to context specific strategies for lockdown, as current measures risk starvation for many. In the context of COVID-19, the lockdown model is being imported from a different context (western or developed economies) with stronger economic bases and better social safety nets for those in need, but is there a better way forward for low resource contexts? Economic mortalities may overtake health mortalities for the poorest who survive on daily wage labour

Promoting vulnerability or resilience to HIV? A qualitative study on polygamy in Maiduguri, Nigeria

Literature on the links between polygamy and HIV and AIDS is limited and the findings inconclusive. Literature to date in Sub-Saharan Africa has relied mainly on case-control studies and surveys. This qualitative study aimed to explore different community members' perceptions of the links between the practice of polygamy and vulnerability or resilience to HIV and AIDS in Maiduguri, north-eastern Nigeria. The study used focus group discussions and in-depth interviews with religious and community leaders and different groups of women and men in the community. Participant views on the links between polygamy and HIV were varied. However, one clear emerging theme was that it is not the practice of polygamy per se that shapes vulnerability to HIV and AIDS but the dynamics of sexual relations and practices both within and beyond the marital union - whether monogamous or polygamous. The ways in which these social relationships are negotiated and experienced are in turn shaped by religious traditions, gender roles and relations, education and socio-economic status. Within the religious environment of north-eastern Nigeria, where asymmetrical gender roles and relations and connotations of morality shape experiences of sexual interactions, windows of opportunity to promote behaviour-change strategies to support women and men's resilience to HIV need to be carefully created. Health practitioners and planners should develop partnerships with religious and community leaders and women's groups to construct and deliver behaviour-changes strategies

Health systems and gender in post-conflict contexts: building back better?

The post-conflict or post-crisis period provides the opportunity for wide-ranging public sector reforms: donors fund rebuilding and reform efforts, social norms are in a state of flux, and the political climate may be conducive to change. This reform period presents favourable circumstances for the promotion of gender equity in multiple social arenas, including the health system. As part of a larger research project that explores whether and how gender equity considerations are taken into account in the reconstruction and reform of health systems in conflict-affected and post conflict countries, we undertook a narrative literature review based on the questions “How gender sensitive is the reconstruction and reform of health systems in post conflict countries, and what factors need to be taken into consideration to build a gender equitable health system?” We used the World Health Organisation’s (WHO) six building blocks as a framework for our analysis; these six building blocks are: 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance

How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review

Background Community health workers (CHWs) are uniquely placed to link communities with the health system, playing a role in improving the reach of health systems and bringing health services closer to hard-to-reach and marginalised groups. A systematic review was conducted to determine the extent of equity of CHW programmes and to identify intervention design factors which influence equity of health outcomes. Methods In accordance with our published protocol, we systematically searched eight databases from 2004 - 2014 for quantitative and qualitative studies which assessed access, utilisation, quality or community empowerment following introduction of a CHW programme according to equity stratifiers (place of residence, gender, socio-economic position and disability). Thirty four papers met inclusion criteria. A thematic framework was applied and data extracted and managed, prior to charting and thematic analysis. Results To our knowledge this is the first systematic review that describes the extent of equity within CHW programmes and identifies CHW intervention design features which influence equity. CHW programmes were found to promote equity of access and utilisation for community health by reducing inequities relating to place of residence, gender, education and socio-economic position. CHWs can also contribute towards more equitable uptake of referrals at health facility level. There was no clear evidence for equitable quality of services provided by CHWs and limited information regarding the role of the CHW in generating community empowerment to respond to social determinants of health. Factors promoting greater equity of CHW services include recruitment of most poor community members as CHWs, close proximity of services to households, pre-existing social relationship with CHW, provision of home-based services, free service delivery, targeting of poor households, strengthened referral to facility, sensitisation and mobilisation of community. However, if CHW programmes are not well planned some of the barriers faced by clients at health facility level can replicate at community level. Conclusions CHWs promote equitable access to health promotion, disease prevention and use of curative services at household level. However, care must be taken by policymakers and implementers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes. Keywords Equity; inequity; community health worker; close-to-community provider; systematic review

Understanding the challenges to caring for low birthweight babies in rural southern Malawi: a qualitative study exploring caregiver and health worker perceptions and experiences

Low birthweight (LBW) babies account for >80% of neonatal mortality in sub-Saharan Africa and South Asia and those who survive the neonatal period are still at risk of detrimental outcomes. LBW is a major public health problem in Malawi and strongly contributes to the country's high neonatal mortality rate. We aimed to get a better understanding of the care of LBW babies in rural Malawi in order to inform action to improve their outcomes. Qualitative methods were used to identify challenges faced by caregivers and health workers within communities and at the rural facility level. We conducted 33 in-depth interviews (18 with caregivers; 15 with health workers) and 4 focus group discussions with caregivers. Interviews were recorded, transcribed and translated. Thematic analysis was used to index the data into themes and develop a robust analytical framework. Caregivers referred to LBW babies as weak, with poor health, stunted growth, developmental problems and lack of intelligence. Poor nutrition of the mother and illnesses during pregnancy were perceived to be important causes of LBW. Discrimination and stigma were described as a major challenge faced by carers of LBW babies. Problems related to feeding and the high burden of care were seen as another major challenge. Health workers described a lack of resources in health facilities, lack of adherence to counselling provided to carers and difficulties with continuity of care and follow-up in the community. This study highlights that care of LBW babies in rural Malawi is compromised both at community and rural facility level with poverty and existing community perceptions constituting the main challenges. To make progress in reducing neonatal mortality and promoting better outcomes, we must develop integrated community-based care packages, improve care at facility level and strengthen the links between them

What can volunteer co-providers contribute to health systems? The role of people living with HIV in the Thai paediatric HIV programme

In Thailand people living with HIV (PLHIV) have played a major role in shaping policy and practice. They have acted as volunteer co-providers, although their potential in terms of paediatric service provision has seldom been explored from a health systems perspective. We describe the Thai paediatric HIV care system and use both demand- and supply-side perspectives to explore the impact, opportunities and challenges of PLHIV acting as volunteer co-providers. We employed qualitative methods to assess experiences and perceptions and triangulate stakeholder perspectives. Data were collected in Khon Kaen province, in the poorest Northeastern region of Thailand: three focus group discussions and two workshops (total participants n = 31) with co-providers and hospital staff; interviews with ART service-users (n = 35). Nationally, key informant interviews were conducted with policy actors (n = 20). Volunteer co-providers were found to be ideally placed to broker the link between clinic and communities for HIV infected children and played an important part in the vital psychosocial support component of HIV care. As co-providers they were recognized as having multiple roles linking and delivering services in clinics and communities. Clear emerging needs include strengthened coordination and training as well as strategies to support funding. Using motivated volunteers with a shared HIV status as co-providers for specific clinical services can contribute to strengthening health systems in Asia; they are critical players in delivering care (supply side) and being responsive to service-users needs (demand side). Co-providers blur the boundaries between these two spheres. Sustaining and optimising co-providers' contribution to health systems strengthening requires a health systems approach. Our findings help to guide policy makers and service providers on how to balance clinical priorities with psycho-social responsiveness and on how best to integrate the views and experience of volunteers into a holistic model of care

Obtaining the perspective of the TB patient attending diagnostic services in Yemen: A qualitative study employing In Depth Interviews and Focus Group Discussions

In this entry, we present the qualitative phase of a multi-method, multi-country study exploring barriers and enablers to accessing TB diagnosis. We describe the implementation of the study in Yemen, of particular interest as little qualitative research has been undertaken in this country and, even less so, studies in the area of health that solicit the views of patients. The lack of a precedent and the distinct cultural context meant that implementing a generic protocol presented a range of practical, budgetary, logistical, sociocultural and ethical considerations. Of particular prominence were normative practices surrounding the freedom of women to work, travel and speak autonomously; religious sensitivities influencing the wording of interview questions; and the organisation of individual and group interviews and a cultural tendency to operate in groups. Reflecting on how these considerations were addressed illuminates the planning and problem solving entailed in managing a research project overseas