Gendered health systems: evidence from low- and middle-income countries.

BACKGROUND: 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. METHODS: The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. RESULTS: Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. CONCLUSION: The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

Using a human resource management approach to support community health workers: experiences from five African countries.

BACKGROUND: Like any other health worker, community health workers (CHWs) need to be supported to ensure that they are able to contribute effectively to health programmes. Management challenges, similar to those of managing any other health worker, relate to improving attraction, retention and performance. METHODS: Exploratory case studies of CHW programmes in the Democratic Republic of Congo, Ghana, Senegal, Uganda and Zimbabwe were conducted to provide an understanding of the practices for supporting and managing CHWs from a multi-actor perspective. Document reviews (n = 43), in-depth interviews with programme managers, supervisors and community members involved in managing CHWs (n = 31) and focus group discussions with CHWs (n = 13) were conducted across the five countries. Data were transcribed, translated and analysed using the framework approach. RESULTS: CHWs had many expectations of their role in healthcare, including serving the community, enhancing skills, receiving financial benefits and their role as a CHW fitting in with their other responsibilities. Many human resource management (HRM) practices are employed, but how well they are implemented, the degree to which they meet the expectations of the CHWs and their effects on human resource (HR) outcomes vary across contexts. Front-line supervisors, such as health centre nurses and senior CHWs, play a major role in the management of CHWs and are central to the implementation of HRM practices. On the other hand, community members and programme managers have little involvement with managing the CHWs. CONCLUSIONS: This study highlighted that CHW expectations are not always met through HRM practices. This paper calls for a coordinated HRM approach to support CHWs, whereby HRM practices are designed to not only address expectations but also ensure that the CHW programme meets its goals. There is a need to work with all three groups of management actors (front-line supervisors, programme managers and community members) to ensure the use of an effective HRM approach. A larger multi-country study is needed to test an HRM approach that integrates context-appropriate strategies and coordinates relevant management actors. Ensuring that CHWs are adequately supported is vital if CHWs are to fulfil the critical role that they can play in improving the health of their communities.

Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe.

INTRODUCTION: Reaching men aged 20-35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT). METHODS: We conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT. RESULTS: We randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; <50% of IPC agents converted any men to VMMC, which undermined our ability to show an effect of demand creation and may reflect acceptability and feasibility of the interventions. CONCLUSION: This RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations. TRIAL REGISTRATION NUMBER: PACTR201804003064160.

The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts.

It is well known that the health workforce composition is influenced by gender relations. However, little research has been done which examines the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). We present mixed method research on HRH in four fragile and post-conflict contexts (Sierra Leone, Zimbabwe, northern Uganda and Cambodia) with different histories to understand how gender influences the health workforce. We apply a gender analysis framework to explore access to resources, occupations, values, decision-making and power. We draw largely on life histories with male and female health workers to explore their lived experiences, but complement the analysis with evidence from surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. Our findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level, affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences here shaped by gender, poverty and household structure. Most HRH regulatory frameworks did not sufficiently address gender concerns. Unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.

Experiences of using life histories with health workers in post-conflict and crisis settings: methodological reflections.

INTRODUCTION: Life history is a research tool which has been used primarily in sociology and anthropology to document experiences of marginalized individuals and communities. It has been less explored in relation to health system research. In this paper, we examine our experience of using life histories to explore health system trajectories coming out of conflict through the eyes of health workers. METHODS: Life histories were used in four inter-related projects looking at health worker incentives, the impact of Ebola on health workers, deployment policies, and gender and leadership in the health sector. In total 244 health workers of various cadres were interviewed in Uganda, Sierra Leone, Zimbabwe and Cambodia. The life histories were one element within mixed methods research. RESULTS: We examine the challenges faced and how these were managed. They arose in relation to gaining access, data gathering, and analysing and presenting findings from life histories. Access challenges included lack of familiarity with the method, reluctance to expose very personal information and sentiments, lack of trust in confidentiality, particularly given the traumatized contexts, and, in some cases, cynicism about research and its potential to improve working lives. In relation to data gathering, there was variable willingness to draw lifelines, and some reluctance to broach sensitive topics, particularly in contexts where policy-related issues and legitimacy are commonly still contested. Presentation of lifeline data without compromising confidentiality is also an ethical challenge. CONCLUSION: We discuss how these challenges were (to a large extent) surmounted and conclude that life histories with health staff can be a very powerful tool, particularly in contexts where routine data sources are absent or weak, and where health workers constitute a marginalized community (as is often the case for mid-level cadres, those serving in remote areas, and staff who have lived through conflict and crisis).

Validity of oral mucosal transudate specimens for HIV testing using enzyme-linked immunosorbent assay in children in Chimanimani district, Zimbabwe.

OBJECTIVE: To assess the validity of oral mucosal transudate (OMT) specimens for HIV testing in children using enzyme-linked immunosorbent assay (ELISA). METHODS: A cross-sectional descriptive study was conducted as part of a community-based behavioural and HIV sero-status survey of adults and children in the Chimanimani district of Zimbabwe. Dried blood spot (DBS) and OMT samples were collected from children aged between 2 and 14 years, inclusive. Both samples were tested for HIV using the Vironostika Uniform II plus O kits. The main study outcomes were the sensitivity and specificity of OMT samples, with DBS as the gold-standard specimen. RESULTS: Paired DBS and OMT specimens were available from 1 274 (94.4%) of the 1 350 children enrolled. Using the DBS, HIV prevalence was 3.2%. Overall sensitivity of OMT was 48.8% (95% confidence interval (CI) 33.3 - 64.5), and specificity was 98.5% (95% CI 97.7 - 99.1). CONCLUSION: The overall sensitivity of OMT specimens for HIV testing in children using ELISA was low. Stratifying the analysis by sector showed that OMT samples are good specimens for HIV testing. It is important to note that factors such as the low HIV prevalence in our study population, quality of the OMT, diet and oral hygiene could have influenced the results.