Health Systems Development
and Gender Equity
Dr Sally Theobald, Dr Esther Richards, Dr Kate Jehan
Health Systems Development and Gender Equity
Part of International Health Research Group
• Academic staff - Tim Martineau, Sally
Theobald, Rachel Tolhurst, Jo Raven, Esther
Richards, Kate Jehan, Olivia Tulloch
• Management/support staff - Helen Carlin,
Helen Macfarlane, Faye Moody, Lizzy Carline
• PhD Students – Rachel Anderson de Cuevas,
Ireen Namakhoma, Eleanor Macpherson,
Lignet Chepuka, Dorcas Kamuya (OU)
© The Liverpool School of Tropical Medicine
2
Key Questions
• To explore and
respond to
social
determinants
of ill-health
and
health seeking
© The Liverpool School of Tropical Medicine
3
Key Questions
• To analyse
and improve
the operation of
health systems
to improve
equitable access
to health services
© The Liverpool School of Tropical Medicine
4
Key Questions
• Focus on:
capacity
building
research
engagement/
uptake
equity analysis
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HEALTH SYSTEMS, HR & EQUITY
Amount
Grant
£6,000,000
Research for building pro-poor health
DFID 2011-2016
systems during the recovery from conflict
(REBUILD) PI Tim Martineau & Barbara
Mcpake; Sally Theobald, co-PI.
Supporting decentralised management to EU FP7 2011-15
improve health workforce performance in
Ghana, Uganda and Tanzania (PERFORM) PI
Tim Martineau, Sally Theobald, co-PI,
Supporting community health workers in
TDR 2012
community case management programmes
in Africa: a preliminary investigation PI Tim
Martineau, Theobald, co-PI.
Euros 2,995,323
US$ 55,255
© The Liverpool School of Tropical Medicine
Funding Agency, Period
6
W
Project
Aim
To understand how
to strengthen policy and
practice related to
health financing
and human resources
in countries
recovering from
conflict
Timescale
Funder
© The Liverpool School of Tropical Medicine
6 year programme
Focussed on health
financing and human
resources
Start February 2011
Ends February 2017
UK Department of
International
Development (DFID)
7
How does the consortium
work?
Liverpool School
of Tropical
Medicine
Liverpool
Cambodia
Development
Resource Institute
Cambodia
Edinburgh
ReBUILD
RPC
Biomedical &
Training Institute
Zimbabwe
Queen Margaret
University
Uganda
Sierra
Leone
College of
Medicine & Allied
Health Sciences
© The Liverpool School of Tropical Medicine
Makerere
University
8
Key messages
• Health systems research has tended to neglect postconflict settings.
• Decisions made in the early post-conflict period can set
the direction of development for the health system.
• There are particular opportunities to set health systems
in a pro-poor, gender equitable direction in the
immediate post-conflict period.
• The partner countries enable us to look from distance
(Cambodia and Sierra Leone) and up close (Northern
Uganda and Zimbabwe) at the post-conflict period.
• Affiliates can link us to further countries that can
enable us to explore relationships further
© The Liverpool School of Tropical Medicine
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ReBUILD Consortium Partners Meeting,
November 2011
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Improving health workforce performance in
Ghana, Tanzania and Uganda
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• The deficit in health professionals needs to be addressed both
by training more new health personnel and improving the
performance of the existing and future workforce.
• A number of complex factors affect workforce performance
• maldistribution of staff
• inappropriate task allocations
• poor working conditions.
• Understanding the nature of these factors and developing
appropriate responses through action research with DHMTs at
district level
© The Liverpool School of Tropical Medicine
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TUBERCULOSIS AND EQUITY
Amount
Grant
£ 249,725
Identifying barriers to TB diagnosis and
treatment under a new rapid diagnostic
scheme Theobald PI – Ethiopia & Yemen with
Luis Cuevas
Innovative community-based approaches for
enhanced tuberculosis case finding and
treatment outcome in Southern Ethiopia (PI
Mohammed Yassin and Sally Theobald)
US$689,163
Wave 1
US$ 636,410
Wave 2
US$ 287,621
Funding Agency,
Period
ESRC/DFID 20082012
TB REACH, 2010-11
TB REACH 2011-12
Increased detection of children, women and
TB REACH, 2010-11
elderly individuals with smear-positive TB in
Yemen (PI Najla Al-Sonboli and Sally Theobald);
© The Liverpool School of Tropical Medicine
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GENDER EQUITY & SRH
Amount
Grant
£19,260
Strengthening the research to policy and
DFID 2009-11
practice interface: Exploring strategies used
by research organisations working on
Sexual and Reproductive Health and HIV
and AIDS, Theobald PI Olivia Tulloch
© The Liverpool School of Tropical Medicine
Funding Agency,
Period
14
Impact and engagement
“Research that doesn’t just gather dust on library
shelves...”
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Organised into five themes
Theme
one
Theme
two
Theme
three
Theme
four
Theme
five
Theory
Applying
Strategies
Advocacy
Institutional
and
policy
and
and
approaches to
practice of analysis to methodologies engagement
intersectoral
research
explore role
for
to influence engagement for
engagement of research engagement
attitudes
action and
evidence
strengthening
communications
© The Liverpool School of Tropical Medicine
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GENDER EQUITY & SRH
Amount
Grant
Funding Agency, Period
LSTM share,
368,415 Euros
Maternal health in India: Evaluating
demand side financing to improve delivery
care access (MATIND), Tolhurst PI (Helen
Smith, Kate Jehan)
EU FP7 2011-14
£22,533
Literature review on gender and child
survival, Tolhurst PI, Theobald (Esther
Richards)
UNICEF 2011
US$30,000
Exploring the role of structural drivers of
HIV among women and men over 50 in
Uganda: A gender analysis with PI Janet
Seeley and Sally Theobald (Esther Richards)
UNAIDS 2011-12
© The Liverpool School of Tropical Medicine
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COMMUNITY ENGAGEMENT AND ETHICS
Grant
Funding Agency,
Period
Consent to and Community Engagement in Health Research - WELLCOME TRUST
Reviewing and Developing Research and Practice, meeting MEETING AWARD,
award with, Susan Bull; Sally Theobald, Phaikyeong Cheah; Khin 2011
Maung Lwin; Vicki Marsh; Sassy Molyneux; Michael Parker;
Strengthening community accountability in biomedical Wellcome Trust
research and health delivery (Kenya), Dr. Sassy Molyneux, Sally Fellowship
Theobald collaborator
A programme to build capacity in global health research
ethics and community engagement across the Wellcome
Trust Major Overseas Programmes PI Prof Mike Parker,
Wellcome Trust
Strategic Award
collabroators, Nicholas Day, Jeremy Farrar, Rob Hyderman, Kevin
Marsh, Sassy Molyneux, John Imrie, Mary-Louise Newell, Victoria
Marsh, Trudie Lang, Tinh Tran, Sam Kinyanjui, Dominic Kwiatkoski,
Sally Theobald, Susan Bull
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2011-2015
European Union funded FP7 project
Maternal Health
in India:
an overview of the
MATIND project
R D Gardi
Medical
College, Ujjain
Madhya
Pradesh
© The Liverpool School of Tropical Medicine
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MATIND project
• Maternal health context in India
• Demand-side finance for maternal health
care
• Overview of MATIND
• Qualitative component of
MATIND
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Maternal health care context
Improvements
• Increased skilled birth attendance
in recent years
• Driving South Asian decline
in MMR (maternal mortality ratio)
Major problems
• High numbers of maternal & neonatal deaths
(20% global maternal deaths; 31% neonatal deaths)
• Wide socioeconomic gap; inequitable access to care; high outof-pocket costs to the user
• Lack of capacity & poor quality of care for majority
© The Liverpool School of Tropical Medicine
Source: Lim 2010
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Demand-side finance for maternal health care
Rationale
• Decades of supply-side intervention – little impact
• Demand-side barriers – as important in
determining utilisation of services as supply
• DSF designed to promote skilled attendance and
institutional deliveries by reducing cost barrier for poor women
Forms
• Cash transfers – reimburse users for monies spent on maternal
health care services (can be conditional on uptake of services)
• Voucher or voucher-like schemes – partially or wholly subsidise
users to purchase services from accredited providers.
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Overview of MATIND
Aim
Evaluate impact of India’s major DSF schemes
Cash transfer scheme
Voucher scheme
Janani Suraksha Yojana
Chiranjeevi Yojana
Nationwide
State wide
Public hospitals (state funded)
Public private partnership
Study area: Madhya Pradesh
Study area: Gujarat
INR 1,400 ($35 to mother at
discharge)
INR 1,745 ($44) paid to private
obstetrician per delivery
MMR 359/100,000
38.3% below poverty line
MMR 172/100,000
16.8% below poverty line
(Safe Motherhood Scheme)
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(Scheme for Long life)
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MATIND study phases
Phase 1
Provincial
level
Phase 2
Facility level
Phase 3
Community
level
© The Liverpool School of Tropical Medicine
• Transport study (Gujarat & MP)
• Private sector exclusion from JSY (MP)
• Use of a platform system - advantages and
disadvantages (Gujarat & MP)
• Private sector participation and provider choice
(Gujarat)
• Task re-organisation (MP)
• Quality of care (Gujarat & MP)
• Mothers’ experiences (programme & nonprogramme mothers) (Gujarat & MP)
• ASHA (Accredited Social Healthcare Activist)
experiences (MP)
24
Gender influences on child survival, health
and nutrition: review and guidance
LSTM team:
Esther Richards
Sally Theobald
Rachel Tolhurst
With support
from:
Asha George
Christiane Rudert
Julia Kim
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Gender influences on child survival, health and
nutrition: a review of current evidence
 Main aim: to review the available evidence and research
tools on the impact of gender on young child health and
nutrition, in particular:
• How do women’s status, agency and access to resources affect the
health and nutrition of young children?
• How do gender divisions of labour affect the health and nutrition of
young children?
• How do men’s roles and masculinities affect the health and nutrition
of young children?
• Which methodologies and data sources have been used to assess the
impact of gender on the health and nutrition of young children and
what are their strengths and weaknesses?
• Which approaches to addressing the impact of gender inequalities,
roles and relations on young child survival have been assessed and with
what results?
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Search strategy
Reference lists,
websites,
contacts &
hand
searching: 325
Database
search: 845
(after
screening)
References
saved to
Endnote
Bibliography:
1,170 (513
filed)
Studies cited: 117
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Conceptual Framework
o Based on initial analyses of the studies we decided to adapt
and use the gender analysis framework developed by
gender and health experts from LSTM in the late 1990s.
We adapted the existing categories within the framework
to focus on four main areas:
• Women’s status
• Intra-household bargaining power and process
• Gender divisions of labour
• Gender norms, values and identities
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Selected findings: intra-household
bargaining and child health outcomes
Study
Location
Data source
Gender index of
bargaining power
Key findings
Smith,
Ramakrishnan,
Ndiaye,
Haddad &
Martorell
(2003)
36 countries
across
National
Demographic and
Health Surveys
conducted
between 1990
and 1998
First index of women’s
decision-making power used
data on the difference
between partners’ education
levels, their age difference,
women’s age at first marriage
and finally whether she had
independent access to income.

“The
importance of
women’s
status for child
nutrition in
developing
countries”
South Asia
(97% of
population
covered)
Latin America
& the
Caribbean
(55%)
Data based on a
sample of 117,242 Second index of “societal
children across 36 gender equality”, was
constructed using the
countries
&
difference in age-adjusted
weight-for-age Z-scores of girls
Sub Saharan
Africa (61%)
and boys under five years, the
difference in age-adjusted
vaccination score of girls and
boys under five, and the
difference in years of
education of adult women and
men.
© The Liverpool School of Tropical Medicine


The decision making power
index was significantly correlated
with child weight-for-age in
South Asia; raising the decision
making index by 10 points over
its current mean would increase
the region’s mean weight-for-age
z-score (waz) by 0.156.
Raising the decision making
index in Sub Saharan Africa by 10
points over its current mean
would raise the region’s mean
waz by 0.046
Raising the decision making
index in Latin America & the
Caribbean would only have an
effect on weight-for-height (whz)
to a certain point (53 on the
index) after which it would start
to reduce.
29
Selected findings: women’s time poverty
• Studies have shown that women’s ‘triple roles’ lead
to time poverty which in turn impacts on child health
outcomes:
“They (husbands) should be helping us but unfortunately
they are not doing it. What can one do when a man says
no!”
(women explaining why they don’t have time to practice
what they know about child health in rural Gambia)
Source: Mwangome et al. 2010
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Selected findings:
strategies for intervention
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Gender-sensitive interventions
 Very few evaluations of gender-sensitive interventions
were identified
 Those identified showed evidence for improvements in
child health and nutrition through different gendersensitive approaches:
• Through seeking to increase women’s power through
participatory activities
• Through increasing women’s access to and control over
resources for child health and nutrition
• Through seeking to address unequal gender relations
and norms to improve allocation of household resources
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Exploring the role of
structural drivers of HIV on
women and men 50 and
over in Uganda: A gender
analysis (study ongoing)
Co-PIs: Janet Seeley & Sally
Theobald with Flavia Zalwango
& Esther Richards
MRC/UVRI Uganda in
association with Liverpool
School of Tropical Medicine
(LSTM)
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Study Background
 Funded by UNAIDS
 Building on recent work at MRC/UVRI funded by
WHO/Cordaid
 Main aim:
To explore the structural drivers shaping
individual risk of HIV infection and access to HIV
services (VCT/care and support) of women and men
over 50 in Kalungu and Wakiso districts and Kampala,
Uganda
© The Liverpool School of Tropical Medicine
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Gender, age and structural drivers
Distance
Level
Distal factors
Superstructural
Gender
inequality
Structural
Environmental
Individual
Proximal factors
Laws restricting
women’s ownership
of economic assets
Economic
dependency
on men
No money for
food and other
necessities
Use of two frameworks to analyse how a structural factor – in this case gender inequality – might lead women
to risk behaviour (Adapted from Rao Gupta et al 2008)
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Study design
 Methods:
• Small, exploratory study of 6 months
• Sampling frame from the 510 people in
WHO/Cordaid study
• Qualitative interviewing of women and men (IDIs 32 and FGDs - 8)
• Key informant interviews with 6 relevant NGOs
and policy-makers
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A research team member
talking to a participant in a
previous study
An older person working
in her garden in Malungu
district
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Drivers of vulnerability in older people
 ‘Invisibility’ of older people’s sexual experiences:
• The perception that older people should not be sexually
active means that older women and men feel their sexual
experiences are stigmatised by society.
• This may cause tensions for older people who feel
unable to disclose their HIV+ status to their families and
means they are less likely to access HIV services and
care.
© The Liverpool School of Tropical Medicine
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Drivers of vulnerability in older people
 Tensions in sexual relations:
• Women may experience sexual relations as forced and
unwanted, which in many cases contributes to physical
and emotional distress.
• Men who wish to continue having sexual relations may
complain that their wives are ‘unwilling’ and seek sexual
alliances and encounters elsewhere.
© The Liverpool School of Tropical Medicine
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Drivers of vulnerability in older people
 Poverty
• Other important issues which shape men’s and
women’s access to services are their lack of regular
income due to old age and ill-health
• Their ‘invisibility’ in terms of targeted services and
more broadly in society
• Perception that older people are a ‘drain’ on family
resources
© The Liverpool School of Tropical Medicine
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Preliminary conclusions, based on
ongoing data collection
 Age, gender and poverty interact to produce particular
vulnerabilities and constraints for older women and men in
Uganda in terms of:
• HIV transmission
• HIV services and care
• Health care in general
 HIV interventions need to go beyond conceptualising older
people simply as ‘carers’ of families living with HIV to
better address their gendered vulnerabilities in relation to
HIV.
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Gender Equity: IMPACT
• Impact on policy & practice
• TB case finding – addressing opportunity costs of care seeking,
Yemen & Ethiopia
• Partnership with policy makers on maternal health in India
• Impact on GLs
• Providing guidance to UNICEF field officers on gender sensitive
methodologies
• Impact on discourse
• Post conflict pro-poor/gender equity in health systems
• Older people & HIV beyond the carer discourse
• Impact on methods/approaches
• Gender equity and intersectionality
• Gender equity and methodological considerations - FGDs
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THANK YOU - ANY QUESTIONS?
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