Gendered Health Systems: Evidence from Low- and Middle-Income Countries

"While gender power relations are highly context specific, the fact that we were able to identify core themes across nine studies conducted in diverse contexts demonstrates the permeability and perviousness of gender inequities globally."

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. Intersectionality offers an analysis of how gender and other social stratifiers are mutually constituted and intersect in interactive ways. This paper synthesises findings from 9 studies, providing examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income country (LMIC) settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria, and Tanzania) to issues across the health system.

The Research in Gender and Ethics (RinGs): Building Stronger Health Systems Consortium provided funding to researchers in Africa and Asia to explore the role of gender across health systems. 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). Care was also taken to think about multiple power relations that guide interactions within the particular communities of interest throughout the research process.

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 - These studies emphasise the need to analyse how gender intersects with other social identifiers, such as age and ethnic/migrant status, to influence health outcomes, access to services, and experience at health facilities, as well as how the salience of each particular stratifier depends on the context and should not be assumed a priori.
• The importance of male involvement - The studies highlight the importance of taking gendered power relations into account as a significant factor in relation to women's access to health services and progression within the health sector. An intersectional approach suggests that more attention now needs to be paid to understand men's positions and vulnerabilities, the potential benefits or harms caused by their involvement, and why their support is lacking. For example, research in Nigeria explored the extent of male involvement in prevention of mother-to-child transmission (PMTCT) and its effects on women's access to and use of PMTCT services. Factors that contributed to the limited participation of men in PMTCT occurred at the individual, community, and the health system levels - e.g., issues at the community level included: gendered norms and expectations, such as pregnancy being perceived as women's responsibility; male dominance in household decision-making, which makes some men feel that if they accompany their wives to PMTCT services they are being controlled by them; and the experience of men who accompanied women to antenatal care visits being ridiculed.
• The influence of gendered social norms on health system structures and processes - The studies in Zimbabwe and Uganda exploring human resources for health showed how gendered norms shaped the types of employment men and women had within the health system, and what roles were considered feasible and acceptable. In Cambodia, female managers felt that their voice was less respected; being younger women and having a lower level of technical skill compared with men was also seen to influence respect received.
• Reliance on (often female) unpaid carers within the health system - Two of the studies explored the issue of unpaid care, which forms the foundation of the health system and which is normally performed by women in the household and the community. The study in Wakiso District, Uganda, focused on community health workers (CHWs), a cadre of worker which is often lauded as a crucial force in expanding health service access whilst being notoriously underpaid or unpaid and under-supported by the health system.
• Gender in policy and practice - "Health systems policy development does not always pay adequate attention to gender....Gender relations and roles need to be considered when designing and implementing programmes within the health system..." A detailed study of Tanzania's PMTCT services shows the need to go beyond the inclusion of gender in policy to seek to promote gender-transformative approaches.

Reflecting on these themes, the researchers conclude: "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." They suggest that the core themes identified will be transferable to many LMIC contexts.