Gender and equity in health sector reform programmes: a review

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China

Objectives

Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective.

Data and methods

This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes.

Results

Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents.

Conclusion

The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

Barreras de acceso a los servicios de salud para mujeres, niños y niñas en América Latina

Objetivo.

Determinar si existe una asociación entre las barreras de acceso informadas por mujeres de 15-49 años y la utilización de servicios esenciales de salud para mujeres, niños y niñas en América Latina.

Método.

Estudio transversal con base en modelos de regresión multivariada logística a partir de las Encuestas de Demografía y Salud de Bolivia, Haití, Honduras, Guatemala, Guyana, Nicaragua, Perú y República Dominicana.

Resultados.

Las barreras geográficas y financieras, la necesidad de obtener permiso para visitar al médico o no querer ir sola al establecimiento redujo significativamente la probabilidad de completar los controles prenatales y de tener un parto asistido. Las mujeres que notificaron dificultades para obtener permiso para visitar al médico redujeron su probabilidad de tener un examen de Papanicolau en los últimos 2 o 3 años, completar la vacunación de niños y niñas, y la probabilidad de buscar atención para sus hijos e hijas con cuadros de infección respiratoria aguda. No querer ir sola al centro de salud redujo la probabilidad de usar métodos anticonceptivos modernos.

Conclusiones.

La notificación de barreras de acceso por parte de las mujeres redujo de forma estadísticamente significativa la posibilidad de utilizar servicios esenciales de salud para ellas y para sus hijos e hijas. Las estrategias orientadas a eliminar barreras no solo deben enfocarse en mejorar la oferta de servicios, sino también abordar aspectos relacionados con las normas, los roles de género y el empoderamiento de las mujeres si se espera avanzar de manera sostenible hacia el acceso universal.

Informal mhealth at scale in Africa: Opportunities and challenges

The extraordinary global growth of digital connectivity has generated optimism that mobile technologies can help overcome infrastructural barriers to development, with 'mobile health' (mhealth) being a key component of this. However, while 'formal' (top-down) mhealth programmes continue to face challenges of scalability and sustainability, we know relatively little about how health-workers are using their own mobile phones informally in their work. Using data from Ghana, Ethiopia and Malawi, we document the reach, nature and perceived impacts of community health-workers' (CHWs') 'informal mhealth' practices, and ask how equitably these are distributed. We implemented a mixed-methods study, combining surveys of CHWs across the three countries, using multi-stage proportional-to-size sampling (N = 2197 total), with qualitative research (interviews and focus groups with CHWs, clients and higher-level stake-holders). Survey data were weighted to produce nationally- or regionally-representative samples for multivariate analysis; comparative thematic analysis was used for qualitative data. Our findings confirm the limited reach of 'formal' compared with 'informal' mhealth: while only 15% of CHWs surveyed were using formal mhealth applications, over 97% reported regularly using a personal mobile phone for work-related purposes in a range of innovative ways. CHWs and clients expressed unequivocally enthusiastic views about the perceived impacts of this 'informal health' usage. However, they also identified very real practical challenges, financial burdens and other threats to personal wellbeing; these appear to be borne disproportionately by the lowest-paid cadre of health-workers, especially those serving rural areas. Unlike previous small-scale, qualitative studies, our work has shown that informal mhealth is already happening at scale, far outstripping its formal equivalent. Policy-makers need to engage seriously with this emergent health system, and to work closely with those on the ground to address sources of inequity, without undermining existing good practice.

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.

Public health services use in a mountainous area, Vietnam: implications for health policy

Aims : The aim of this study is to describe the use of public health services in different social and ethnic groups and to explore the implementation of user fee exemption in a mountainous area in Vietnam. Methods: A cross-sectional household survey with a structured questionnaire and a four-week diary were used to collect information on illnesses, health seeking behaviour and socioeconomic factors. Three communes in a mountainous district in Northern Vietnam were selected and a random sample of 1,452 individuals in 300 households was drawn. Results: Self-medication was most common (57%) while 30% used public health services when suffering from a health problem. Persons living far from health services attended public health services less frequently than the others (adjusted OR=0.28; 95% CI 0.15-0.51). This was especially the case for ethnic minorities who were less likely to use public health services than the others were (adjusted OR=0.47; 95% CI 0.25-0.87). Persons with mild conditions tended to use public health services less than those with more severe conditions (OR=0.19; 95% CI 0.10-0.37). Health services use was similar among women and men, but the total expenditure per visit was higher for men. Almost no patients supposed to get free attendance had been exempted from user fees. Conclusions : It was found that there was a geographical inequity in use of public health services while there was relatively equal use of these services between social, gender, and ethnic groups. Long distance in combination with failure of the fee exemption may increase inequity in use of health services in remote and isolated areas. These observations contribute to the basis for implementation of the Vietnamese health policy, emphasizing efficiency and equity.

Donor Agencies' Involvement in Reproductive Health: Saying One Thing and Doing Another?

The debates about what services constitute reproductive health, how these services should be organized, managed, and delivered, and what the role of donor agencies' support should be mirror the long-standing debates on how best to implement primary health care. After briefly reviewing the development of the discourse on primary health care and reproductive health, the authors present results of qualitative research in Ghana, Kenya, and Zambia that indicate a range of factors influencing and explaining the way donors operate in these countries and consider the implications of these results for the delivery of comprehensive reproductive health services. These findings are compared with South Africa, a country with limited donor activity. In the light of the complex interplay of factors, the authors suggest that donors' words and actions frequently do not correlate. Conclusions are drawn as to the potential for donor support for integrated reproductive health service delivery in sub-Saharan Africa, drawing on the research to provide lessons and a reappraisal of the role of donors in health sector aid.

How to do (or not to do)… gender analysis in health systems research

Gender-the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders-affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs and policies; and the inclusion of gender analysis into HSR is a core part of that endeavour. We outline what gender analysis is and how gender analysis can be incorporated into HSR content, process and outcomes Starting with HSR content, i.e. the substantive focus of HSR, we recommend exploring whether and how gender power relations affect females and males in health systems through the use of sex disaggregated data, gender frameworks and questions. Sex disaggregation flags female-male differences or similarities that warrant further analysis; and further analysis is guided by gender frameworks and questions to understand how gender power relations are constituted and negotiated in health systems. Critical aspects of understanding gender power relations include examining who has what (access to resources); who does what (the division of labour and everyday practices); how values are defined (social norms) and who decides (rules and decision-making). Secondly, we examine gender in HSR process by reflecting on how the research process itself is imbued with power relations. We focus on data collection and analysis by reviewing who participates as respondents; when data is collected and where; who is present; who collects data and who analyses data. Thirdly, we consider gender and HSR outcomes by considering who is empowered and disempowered as a result of HSR, including the extent to which HSR outcomes progressively transform gender power relations in health systems, or at least do not further exacerbate them.

Inequalities in access to healthcare services among people living with HIV/AIDS in Nigeria

The study investigated the magnitude of social inequities in access to subsidised healthcare services among people living with HIV and AIDS (PLWHA) in Nigeria. Structured interviews were conducted with 1 056 PLWHA selected from 60 community based support groups in 12 local government areas across 3 Nigerian states and the federal capital territory, using a multi-stage cluster sampling method. Data were collected on socio-economic characteristics of the respondents; awareness about location of health facilities; current health status; distance to facilities; and utilisation and expenditure on healthcare. The socio-economic characteristics of the respondents were used to compare their level of access to healthcare services from antiretroviral therapy (ART) sites and government hospitals. Awareness about location of health facilities was generally high (≥79%) among the respondents but higher among males, urban dwellers and those in highest wealth class (p < 0.05). About 60% of rural PLWHA and 55.2% of those in the lowest wealth class reported illness compared with 49.4% of urban residents and 47.4% of those in the highest wealth class. However, PLWHA in urban areas utilised government hospitals more than those in rural areas while rural PLWHA and those in the lowest wealth class travelled longer distances to ART sites (p < 0.05). PLWHA in lowest wealth class and females faced catastrophic health expenditure of 67.6% and 55.5% of their monthly income respectively. Social inequities were observed in the subsidised HIV-treatment programme in Nigeria. Expansion of ART sites in rural areas and decentralisation of HIV care at government hospitals will reduce travel distance and transport costs and ensure universal access to healthcare services among PLWHA.

Investigating the interface between health system reform and HIV/AIDS in sub-Saharan Africa: an approach for improving the fight against the epidemic

During the period in which the HIV/AIDS epidemic has taken hold in sub-Saharan Africa, health system reforms have and continue to be introduced throughout the region. In spite of the multidisciplinary research undertaken, it can be questioned whether the relationships between processes of reform and some of the critical issues of HIV/AIDS response have been fully appreciated. This is particularly worrying since many countries in sub-Saharan Africa have already embarked on reform whilst concurrently and independently attempting to develop and manage effective responses to the overwhelming challenges posed by the HIV/AIDS epidemic. This paper explores the relationship between health system reform and HIV/AIDS, and argues that an interface approach is crucial for understanding the complexity of combating the epidemic whilst reforming health systems. The interface refers to the interacting processes between reform and the effects of the disease and attempts to respond to it. It includes the ways in which reforms, and such features as decentralisation and user fees, affect the capacity to fight HIV/AIDS, and conversely how the implications of the disease affect the performance of reformed health systems. Two sets of constraints in the interface are defined: internal and delivery constraints. The former are illustrated by deteriorating levels of human resources, poor integration of HIV/AIDS activities and problems faced by tiered health systems. The latter are illustrated by issues of access to relevant health services and rural-urban disparities. Issues in the interface need to be addressed by researchers and implementers in order to move forward in containing the epidemic.

Leveraging Community-Based Financing for Women’s Nonmaternal Health Care

Given the increasing need for mainstreaming household financing for women’s nonmaternal health care and evidences on community-based financing’s contribution to women’s health care in general, this study explored their scope for nonmaternal health care in Orissa. A qualitative assessment conducted focus group discussions with rural women who met the eligibility criteria. Community-based financing provided financial access and risk protection for women’s nonmaternal health care during the previous 1 year, though not adequately. Schemes covering outpatient care (or mild illnesses) provided relatively more financial access. The major determinants of their restricted financial access were limited sum assured, noncomprehensive coverage of services, exclusion of elderly women, and the lower priority households gave to nonmaternal health care. Community-based financing requires relevant structural changes along with demand-side behavioral modifications to ensure optimal attention to women’s nonmaternal health care.

A literary analysis of global female identity, health, and equity

Females' experiences of identity, health, and equity share similar features around the world. This literary analysis describes the narratives of 4 female protagonists from popular fiction novels to identify similarities between their personal and contextualized experiences. The impact these private realities and public structures have on female health will be used to demonstrate the universal ecological threats to women's health. In conclusion, we offer suggestions on how to incorporate the shared female movement from domination and separation toward liberation and connection into modern health care practices that emphasize shared decision making, open communication, and social activism.

Strengthening health systems by health sector reforms

BACKGROUND

The rising burden of disease and weak health systems are being compounded by the persistent economic downturn, re-emerging diseases, and violent conflicts. There is a growing recognition that the global health agenda needs to shift from an emphasis on disease-specific approaches to strengthening of health systems, including dealing with social, environmental, and economic determinants through multisectoral responses.

METHODS

A review and analysis of data on strengthening health sector reform and health systems was conducted. Attention was paid to the goal of health and interactions between health sector reforms and the functions of health systems. Further, we explored how these interactions contribute toward delivery of health services, equity, financial protection, and improved health.

FINDINGS

Health sector reforms cannot be developed from a single global or regional policy formula. Any reform will depend on the country's history, values and culture, and the population's expectations. Some of the emerging ingredients that need to be explored are infusion of a health systems agenda; development of a comprehensive policy package for health sector reforms; improving alignment of planning and coordination; use of reliable data; engaging 'street level' policy implementers; strengthening governance and leadership; and allowing a holistic and developmental approach to reforms.

CONCLUSIONS

The process of reform needs a fundamental rather than merely an incremental and evolutionary change. Without radical structural and systemic changes, existing governance structures and management systems will continue to fail to address the existing health problems.

A gendered users' perspective on decentralized primary health services in rural Tanzania

Since the 1990s, Tanzania has been implementing health sector reforms including decentralization of primary healthcare services to districts and users. The impact of the reforms on the access, quality and appropriateness of primary healthcare services from the viewpoint of users is, however, not clearly documented. This article draws on a gendered users' perspective to address the question of whether the delivery of gender-sensitive primary health services has improved after the reforms. The article is based on empirical data collected through a household survey, interviews, focus group discussions, case studies and analysis of secondary data in two rural districts in Tanzania. The analysis shows that the reforms have generated mixed effects: they have contributed to improving the availability of health facilities in some villages but have also reinforced inter-village inequalities. Men and women hold similar views on the perceived changes and appropriateness to women on a number of services. Gender inequalities are, however, reflected in the significantly low membership of female-headed households in the community health fund and their inability to pay the user fees and in the fact that women's reproductive and maternal health needs are as yet insufficiently addressed. Although over half of users are satisfied with the services, more women than men are dissatisfied. The reforms appear to have put much emphasis on building health infrastructure and less on quality issues as perceived by users.

Gender-based distributional skewness of the United Republic of Tanzania's health workforce cadres: a cross-sectional health facility survey

BACKGROUND

While severe shortages, inadequate skills and a geographical imbalance of health personnel have been consistently documented over the years as long term critical challenges in the health sector of the United Republic of Tanzania, there is limited evidence on the gender-based distribution of the health workforce and its likely implications. Extant evidence shows that some people may not seek healthcare unless they have access to a provider of their gender. This paper, therefore, assesses the gender-based distribution of the United Republic of Tanzania's health workforce cadres.

METHODS

This is a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening in the United Republic of Tanzania in 2008. During the survey, 88 health facilities, selected randomly from 8 regions, yielded 815 health workers (HWs) eligible for the current analysis. While Chi-square was used for testing associations in the bivariate analysis, multivariate analysis was conducted using logistic regression to assess the relationship between gender and each of the cadres involved in the analysis.

RESULTS

The mean age of the HWs was 39.7, ranging from 15 to 63 years. Overall, 75% of the HWs were women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. Multivariate analysis revealed that the odds ratio (OR) and 95% confidence interval (CI) that a HW was a female (baseline category is "male") for each cadre was: MCHA/MA, OR = 3.70, 95% CI 2.16-6.33; nurse, OR = 5.61, 95% CI 3.22-9.78; midwife, OR = 2.74, 95% CI 1.44-5.20; CO, OR = 0.08, 95% CI 0.04-0.17 and MD, OR = 0.04, 95% CI 0.02-0.09.

CONCLUSION

The distribution of the United Republic of Tanzania's health cadres is dramatically gender-skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, adequate representation of women in highly trained cadres is imperative to enhance responses to some gender-specific roles and needs.

Gender-stratified models to examine the relationship between financial hardship and self-reported oral health for older US men and women

OBJECTIVES

We evaluated the relationship between financial hardship and self-reported oral health for older men and women.

METHODS

We focused on adults in the 2008 Health and Retirement Study (n = 1,359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.

RESULTS

In the non-gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).

CONCLUSIONS

Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults' oral health should account for gender-based heterogeneity in financial hardship experiences.

Gender sensitivity in national health plans in Latin America and the European Union

OBJECTIVES

To evaluate the situation regarding gender sensitivity in national health plans in Latin America and the European Union for the decade 2000-2010.

METHODS

A systematic search and content analysis of national health plans were carried out within 37 countries. Gender sensitivity, defined as the extent to which a health plan considers gender as a central category and develops measures to reduce any gender-related inequalities, was analysed through an ad hoc checklist.

RESULTS

The description of health problems by sex was more frequent than intervention proposals aimed at reducing gender health disparities. The greatest number of specific intervention proposals targeted at overcoming gender-based health inequalities were associated with sexual and/or reproductive health, gender based violence, the working environment and human resources training. Compared to the European Union member states, Latin American health plans were found to be generally more gender sensitive.

CONCLUSIONS

National health plans are still generally lacking in gender sensitivity. Disparities exist in health policy formulation in favour of men, whilst women's health continues to be identified mainly with reproductive health. If gender sensitivity is not taken into account, efforts to improve the quality of clinical care will be insufficient as gender inequalities will persist.

The medicine that might kill the patient: Structural Adjustment and its impacts on health care in Bangladesh

Over the past decade, reforms of the health sector have evolved as a global phenomenon. There is, by now, a fair literature on the relationship between globalization and health. Within this literature, however, there is relatively little attention given to the Structural Adjustment Program (SAP), one aspect of globalization, and its impact on health. It can be observed that the SAP has had a dramatic impact on the status of education, health, the environment, and women and children in many developing countries. The restructuring of the health sector has led to the collapse of preventive and curative care due to the lack of medical equipment, supplies, poor working conditions, low pay of medical personnel, and the resulting low morale in Ghana, Philippines, and Zimbabwe. User fees in primary health care have led to the exclusion of a large section of the population from accessing health services as they are unable to pay. This article discusses the health specific impact of the SAP and the economic reforms initiated under it in Bangladesh. In particular, it will analyze how these policies affect the health care delivery system in Bangladesh in relation to geographic accessibility, affordability, quality of services, administrative efficiency, the rural urban service gap, public provision of health care, and donor influence on health policy.

Gender and care: access to HIV testing, care, and treatment

HIV transmission and occurrence of AIDS in the Middle East and North Africa region (MENA) is increasing, while access to ART in the region lags behind most low to middle-income countries. Like in other parts of the world, there is a growing feminization of the epidemic, and men and women each confront unique barriers to adequate HIV prevention and treatment services, while sharing some common obstacles as well. This paper focuses on important gender dimensions of access to HIV testing, care and treatment in the MENA region, including issues related to stigma, religion and morality, gender power imbalances, work status, and migration. Culturally specific policy and programmatic recommendations for improving HIV prevention and treatment in the MENA region are offered.

Strategies for gender-equitable HIV services in rural India

The emergence of HIV in rural India has the potential to heighten gender inequity in a context where women already suffer significant health disparities. Recent Indian health policies provide new opportunities to identify and implement gender-equitable rural HIV services. In this review, we adapt Mosley and Chen's conceptual framework of health to outline determinants for HIV health services utilization and outcomes. Examining the framework through a gender lens, we conduct a comprehensive literature review for gender-related gaps in HIV clinical services in rural India, focusing on patient access and outcomes, provider practices, and institutional partnerships. Contextualizing findings from rural India in the broader international literature, we describe potential strategies for gender-equitable HIV services in rural India, as responses to the following three questions: (1) What gender-specific patient needs should be addressed for gender-equitable HIV testing and care? (2) What do health care providers need to deliver HIV services with gender equity? (3) How should institutions enforce and sustain gender-equitable HIV services? Data at this early stage indicate substantial gender-related differences in HIV services in rural India, reflecting prevailing gender norms. Strategies including gender-specific HIV testing and care services would directly address current gender-specific patient needs. Rural care providers urgently need training in gender sensitivity and HIV-related communication and clinical skills. To enforce and sustain gender equity, multi-sectoral institutions must establish gender-equitable medical workplaces, interdisciplinary HIV services partnerships, and oversight methods, including analysis of gender-disaggregated data. A gender-equitable approach to rural India's rapidly evolving HIV services programmes could serve as a foundation for gender equity in the overall health care system.

"He will ask why the child gets sick so often": the gendered dynamics of intra-household bargaining over healthcare for children with fever in the Volta Region of Ghana

This paper explores the gendered dynamics of intra-household bargaining around treatment seeking for children with fever revealed through two qualitative research studies in the Volta Region of Ghana, and discusses the influence of different gender and health discourses on the likely policy implications drawn from such findings. Methods used included focus group discussions, in-depth and critical incidence interviews, and Participatory Learning and Action methods. We found that treatment seeking behaviour for children was influenced by norms of decision-making power and 'ownership' of children, access to and control over resources to pay for treatment, norms of responsibility for payment, marital status, household living arrangements, and the quality of relationships between mothers, fathers and elders. However, the implications of these findings may be interpreted from different perspectives. Most studies that have considered gender in relation to malaria have done so within a narrow biomedical approach to health that focuses only on the outcomes of gender relations in terms of the (non-)utilisation of allopathic healthcare. However, we argue that a 'gender transformatory' approach, which aims to promote women's empowerment, needs to include but go beyond this model, to consider broader potential outcomes of intra-household bargaining for women's and men's interests, including their livelihoods and 'bargaining positions'.

Poverty and access to health care in developing countries

People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.

Gender, pregnancy and the uptake of antenatal care services in Pakistan

An integrated analysis of detailed ethnography and large-scale survey data is presented to explore the gendered influences on women's uptake of antenatal care (ANC) services in Punjab, Pakistan. Pregnancy and its associated decisions were shown to be normatively the older women's domain, with pregnant women and their husbands being distanced from the decision-making process. Women who successfully claimed ANC did so not by overtly challenging the dominant construction of young femininity, but rather by using existing gendered structures and channels of communication to influence authority figures. The quality of a woman's inter-personal ties, particularly with her mother-in-law and husband, were found to be important in accessing resources, including ANC. Gendered influences were moderated by social class. Family finances were an important determinant of ANC use, as was women's education. Wealthier, higher status women also found it easier to circumvent gendered proscriptions against their mobility while pregnant. As well as illuminating the ways in which the sociocultural construction of gender acts to constrain women's access to ANC, the empirical findings are used to highlight significant inadequacies in the 'autonomy paradigm' that has dominated much of the research into women's reproductive health in South Asia.

WOMEN IN DEVELOPING COUNTRIES AND BENEFIT SHARING

The aim of this paper is to show that any process of benefit sharing that does not guarantee the representation and participation of women in the decision-making process, as well as in the distribution of benefits, contravenes a central demand of social justice. It is argued that women, particularly in developing countries, can be excluded from benefits derived from genetic research because of existing social structures that promote and maintain discrimination. The paper describes how the structural problem of gender-based inequity can impact on benefit sharing processes. At the same time, examples are given of poor women's ability to organise themselves and to achieve social benefits for entire communities. Relevant international guidelines (e.g. the Convention on Biodiversity) recognise the importance of women's contributions to the protection of biodiversity and thereby, implicitly, their right to a share of the benefits, but no mechanism is outlined on how to bring this about. The authors make a clear recommendation to ensure women's participation in benefit sharing negotiations by demanding seats at the negotiation table.

HEALTH DISPARITIES AND HEALTH EQUITY: Concepts and Measurement

There is little consensus about the meaning of the terms "health disparities," "health inequalities," or "health equity." The definitions can have important practical consequences, determining the measurements that are monitored by governments and international agencies and the activities that will be supported by resources earmarked to address health disparities/inequalities or health equity. This paper aims to clarify the concepts of health disparities/inequalities (used interchangeably here) and health equity, focusing on the implications of different definitions for measurement and hence for accountability. Health disparities/inequalities do not refer to all differences in health. A health disparity/inequality is a particular type of difference in health (or in the most important influences on health that could potentially be shaped by policies); it is a difference in which disadvantaged social groups-such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination-systematically experience worse health or greater health risks than more advantaged social groups. ("Social advantage" refers to one's relative position in a social hierarchy determined by wealth, power, and/or prestige.) Health disparities/inequalities include differences between the most advantaged group in a given category-e.g., the wealthiest, the most powerful racial/ethnic group-and all others, not only between the best- and worst-off groups. Pursuing health equity means pursuing the elimination of such health disparities/inequalities.

The role of the media in public participation: framing and leading

This article focuses on the framing of women's health services in the context of restructuring dictated by health system regionalization. By examining the archives of a local newspaper and the minutes and documents of one of the key organizations involved in restructuring after regionalization, it was possible to examine the public discourse of the time and subsequently the journalists' and the readerships' understandings of women's health. The evidence suggests that the Salvation Army was instrumental in setting the tone that was taken by the media in framing the issues around the closure and move of its Grace Women's Health Centre. While the Calgary Health Region was successful in bringing the Grace under its mandate and organizational control, it was the Salvation Army, with its highly visible and powerful fundraising arm and its advocacy for holistic women's health that caught the public's attention. The internal discourse tracked some of the emerging issues, known only to those involved at managerial levels within the health system, but the public discourse kept women centered in decisions regarding the partnership. Women from many constituencies must continue to participate in the public policy realm to ensure that women's health remains an issue in health reform.

Gender differences in older patient populations: a case linkage study of community health, mental health, and social services in the United Kingdom

We identify gender differences in older health and social care populations by comparing the total population of older people with the total population of women and the total population of older women, respectively. We combine anonymised data across community health (CH; N = 82,751), mental health (MH; N = 19,029), and social care service (SC; N = 19,461) populations in one UK county (N = 496,863) over 3 years. Approximately two thirds of older care populations were female. In both single- and dual-agency care populations a profile emerged of older patients, female patients and older female patients, this profile varied across different diagnostic and care groups.

Gender equity and trichiasis surgery in the Vietnam and Tanzania national trachoma control programmes

AIMS

To calculate the gender distribution of trichiasis cases in trachoma communities in Vietnam and Tanzania, and the gender distribution of surgical cases, to determine if women are using surgical services proportional to their needs.

METHODS

Population based data from surveys done in Tanzania and Vietnam as part of the national trachoma control programmes were used to determine the rate of trichiasis by gender in the population. Surgical records provided data on the gender ratio of surgical cases.

RESULTS

The rates of trichiasis in both countries are from 1.4-fold to sixfold higher in females compared to males. In both countries, the female to male rate of surgery was the same or even higher than the female to male rate of trichiasis in the population.

CONCLUSIONS

These data provide assurance of gender equity in the provision and use of trichiasis surgery services in the national programmes of these two countries. Such simple analyses should be used by other programmes to assure gender equity in provision and use of trichiasis surgery services.

Blinding trachoma: prevention with the safe strategy

Trachoma, the second leading cause of blindness worldwide, differentially affects the poorest communities, which may have the least access to resources. With the establishment of the Global Elimination of Blinding Trachoma by 2020 (GET 2020) goal, the World Health Organization has set an ambitious target for country programs. The currently recommended surgery for trichiasis/entropion, antibiotics for active disease, facial cleanliness, and environmental change to reduce transmission (SAFE) strategy targets all key elements believed to be necessary for a short- and long-term intervention program. This report reviews the need for a multi-faceted strategy, and the evidence supporting the elements of SAFE. Concerns about the implementation are discussed. Additional research is suggested that will enhance the implementation of the SAFE strategy. In the current climate of significant political and social momentum for trachoma control, the SAFE strategy is a safe bet to accomplish the elimination of blinding trachoma.

Defining equity in health

STUDY OBJECTIVE

To propose a definition of health equity to guide operationalisation and measurement, and to discuss the practical importance of clarity in defining this concept.

DESIGN

Conceptual discussion. Setting, Patients/Participants, and Main results: not applicable.

CONCLUSIONS

For the purposes of measurement and operationalisation, equity in health is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage-that is, wealth, power, or prestige. Inequities in health systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health; health is essential to wellbeing and to overcoming other effects of social disadvantage. Equity is an ethical principle; it also is consonant with and closely related to human rights principles. The proposed definition of equity supports operationalisation of the right to the highest attainable standard of health as indicated by the health status of the most socially advantaged group. Assessing health equity requires comparing health and its social determinants between more and less advantaged social groups. These comparisons are essential to assess whether national and international policies are leading toward or away from greater social justice in health.

Between intent and achievement in sector-wide approaches: staking a claim for reproductive health

Since 1995, sector-wide approaches (SWAps) to health development have significantly influenced health aid to developing countries. SWAps offer guidelines for new partnerships with international donors led by government, new relationships between donors and shared financing, development and implementation of agreed packages of health sector reforms. These structural and funding changes have significant implications for reproductive health. The early experience of SWAps suggests that the extent of donor commitment is constrained for administrative, philosophical and political reasons, with vertical programmes (including those relevant to reproductive health) protecting their 'core' business, and reproductive health, as an integrative concept, lacking strong advocates. Defining the sector in terms of government health systems focuses resources on building effective district health systems, but with uncertain outcomes for elements of reproductive health that depend on multi-sectoral strategies, e.g. safe motherhood. The context of the reforms remains a determining factor in their success, but despite savings available through increased efficiencies and coordinated services, the total per capita expenditure on health to ensure minimum clinical and public health services often remains beyond the budget available to least developed nations. Despite this, many of the elements of SWAps--government leadership, new donor relationships, better coordination, sectoral reform and service integration--offer the potential for more effective and efficient health services, including those for reproductive health.

Gender dimensions of user fees: implications for women's utilization of health care

This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care. Such studies need to collect gender-disaggregated data in relation to women's health service utilization and in relation to the range of reproductive health services, taking into account not only out-of-pocket fees charged by public health providers but also by private and traditional providers.

The role of oversight in the health sector: the example of sexual and reproductive health services in India

This paper examines the role of oversight in influencing the health sector, using examples from sexual and reproductive health services in India. Rather than simply trying to provide services through traditional bureaucratic mechanisms, governments can make use of oversight tools to influence how health care is delivered through the public and private sectors. Three main oversight functions are described: understanding health system performance, deciding when to intervene in the health system and strategizing and implementing change. Governments also need to understand the ethical basis for decisions. The potential for administering oversight through policy-making, disclosing and informing, regulating, collaborating, and strategically subsidising and contracting services in sexual and reproductive health is described. This approach implies an engagement with a broader set of stakeholders in the health sector than is often the case. It requires a set of skills for public officials beyond managing public programmes, and relies on a larger role for other stakeholders and the general public. When applied to reproductive and sexual health, implementation of the full range of oversight functions offers new opportunities to provide more effective, equitable, accountable and affordable services.

An overview of changing agendas in health sector reforms

This paper discusses health sector reforms and what they have meant for sexual and reproductive health advocacy in low-income countries. Beginning in the late 1980s, it outlines the main macro-economic shifts and policy trends which affect countries dependent on external aid and the main health sector reforms taking place. It then considers the implications of successive macro-economic and reform agendas for reproductive and sexual health advocacy. International debate today is focused on the conditions necessary for socio-economic development and the role of governments in these, and how to improve the performance of health sector bureaucracies and delivery systems. A critical challenge is how to re-negotiate the policy and financial space for sexual and reproductive health services within national health systems and at international level. Advocacy for sexual and reproductive health has to tread the line between a vision of reproductive health for all and action on priority conditions, which means articulating an informed view on needs and priorities. In pressing for greater funding for reproductive health, advocates need to find an appropriate balance between concern with health systems strengthening and service delivery and programmes, and create alliances with progressive health sector reformers.

Social inequalities in health within countries: not only an issue for affluent nations

While interest in social disparities in health within affluent nations has been growing, discussion of equity in health with regard to low- and middle-income countries has generally focused on north-south and between-country differences, rather than on gaps between social groups within the countries where most of the world's population lives. This paper aims to articulate a rationale for focusing on within- as well as between-country health disparities in nations of all per capita income levels, and to suggest relevant reference material, particularly for developing country researchers. Routine health information can obscure large inter-group disparities within a country. While appropriately disaggregated routine information is lacking, evidence from special studies reveals significant and in many cases widening disparities in health among more and less privileged social groups within low- and middle- as well as high-income countries: avoidable disparities are observed not only across socioeconomic groups but also by gender, ethnicity, and other markers of underlying social disadvantage. Globally, economic inequalities are widening and, where relevant information is available, generally accompanied by widening or stagnant health inequalities. Related global economic trends, including pressures to cut social spending and compete in global markets, are making it especially difficult for lower-income countries to implement and sustain equitable policies. For all of these reasons, explicit concerns about equity in health and its determinants need to be placed higher on the policy and research agendas of both international and national organizations in low-, middle-, and high-income countries. International agencies can strengthen or undermine national efforts to achieve greater equity. The Primary Health Care strategy is at least as relevant today as it was two decades ago: but equity needs to move from being largely implicit to becoming an explicit component of the strategy, and progress toward greater equity must be carefully monitored in countries of all per capita income levels. Particularly in the context of an increasingly globalized world, improvements in health for privileged groups should suggest what could, with political will, be possible for all.

Annotated Bibliography on Equity in Health, 1980-2001

The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.

Decentralization and central and regional coordination of health services: the case of Switzerland

As part of reforms in the health care delivery sector, decentralization is currently promoted in many countries as a means to improve performance and outcomes of national health care systems. Switzerland is an example of a country with a long-standing tradition of decentralized organization for many purposes, including health care delivery. Apart from the few aspects where the responsibility is at the federal level, it is the task of the 26 cantons to organize the provision of health services for the population of around 7 million people. This permits the system to be responsive to local priorities and interest as well as to new developments in medical and public health know-how. However, the increasing and complex difficulties of most health care delivery systems raise questions about the need for mechanisms for coordination at federal level, as well as about the equity and the effectiveness of the decentralized approach. The Swiss case shows that in a strongly decentralized system, health policy and strategy elaboration, as well as coordination mechanisms among the regional components of the system, are very hard to establish. This situation may lead to strong regional inequities in the financing of health care as well as to differences in the distribution of financial, human and material inputs into the health system. The study of the Swiss health system reveals also that, within a decentralized framework, the promotion of cost-effective interventions through a well-balanced approach towards promotional, preventive and curative services, or towards ambulatory and hospital care, is difficult to achieve, as agreements between relatively autonomous regions are difficult to obtain. Therefore, a decentralized system is not necessarily the most equitable and cost-effective way to deliver health care.

Skirting the issue: women and international health in historical perspective

Over the last decades women have become central to international health efforts, but most international health agencies continue to focus narrowly on the maternal and reproductive aspects of women's health. This article explores the origins of this paradigm as demonstrated in the emergence of women's health in the Rockefeller Foundation's public health programs in Mexico in the 1920s and 1930s. These efforts bore a significant reproductive imprint; women dispensed and received services oriented to maternal and childbearing roles. Women's health and social advocacy movements in Mexico and the United States partially shaped this interest. Even more important, the emphasis on women in the Rockefeller programs proved an expedient approach to the Foundation's underlying goals: promoting bacteriologically based public health to the government, medical personnel, business interests, and peasants; helping legitimize the Mexican state; and transforming Mexico into a good political and commercial neighbor. The article concludes by showing the limits to the maternal and reproductive health model currently advocated by most donor agencies, which continue to skirt--or sidestep--major concerns that are integral to the health of women.