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Publications

Reflecting strategic and conforming gendered experiences of community health workers (CHWs) using photovoice in rural Wakiso district, Uganda

Future Health Systems

Musoke D, Ssemugabo C, Ndejjo R, Ekirapa-Kiracho E and George AS (2018) Reflecting strategic and conforming gendered experiences of community health workers (CHWs) using photovoice in rural Wakiso district, Uganda, Human Resources for Health, 16:41, DOI: 10.1186/s12960-018-0306-8

Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach.

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Gender dynamics in digital health: Overcoming blind spots and biases to seize opportunities and responsibilities for transformative health systems

Future Health Systems

George, A, Morgan, R, Larson, E and LeFevre, A (2018) Gender dynamics in digital health: Overcoming blind spots and biases to seize opportunities and responsibilities for transformative health systems, Journal of Public Health, fdy180, DOI: 10.1093/pubmed/fdy180

Much remains to ensure that digital health affirms rather than retrenches inequality, including for gender. Drawing from literature and from the SEARCH projects in this supplement, this commentary highlights key gender dynamics in digital health, including blind spots and biases, as well as transformative opportunities and responsibilities. Women face structural and social barriers that inhibit their participation in digital health, but are also frequently positioned as beneficiaries without opportunities to shape such projects to better fit their needs. Furthermore, overlooking gender relations and focussing on women in isolation can reinforce, rather than address, women’s exclusions in digital health, and worsen negative unanticipated consequences. While digital health provides opportunities to transform gender relations, gender is an intimate and deeply structural form of social inequality that rarely changes due to a single initiative or short-term project. Sustained support over time, across health system stakeholders and levels is required to ensure that transformative change with one set of actors is replicated and reinforced elsewhere in the health system. There is no one size prescriptive formula or checklist. Incremental learning and reflection is required to nurture ownership and respond to unanticipated reactions over time when transforming gender and its multiple intersections with inequality.

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Where girls are less likely to be fully vaccinated than boys: Evidence from a rural area in Bangladesh

Future Health Systems

Hanifi SM, Ravn H, Aaby P and Bhuiya A (2018) Where girls are less likely to be fully vaccinated than boys: Evidence from a rural area in Bangladesh, Vaccine, 36(23):3323-30, DOI: 10.1016/j.vaccine.2018.04.059

Immunization is one of the most successful and effective health intervention to reduce vaccine preventable diseases for children. Recently, Bangladesh has made huge progress in immunization coverage. In this study, we compared the recent immunization coverage between boys and girls in a rural area of Bangladesh.

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Evaluation and learning in complex, rapidly changing health systems

Future Health Systems

Xiao, Y, Husain, L and Bloom, G (2018) Evaluation and learning in complex, rapidly changing health systems, Globalization and Health, 14:112, DOI: 10.1186/s12992-018-0429-7

Healthcare systems are increasingly recognised as complex, in which a range of non-linear and emergent behaviours occur. China’s healthcare system is no exception. The hugeness of China, and the variation in conditions in different jurisdictions present very substantial challenges to reformers, and militate against adopting one-size-fits-all policy solutions. As a consequence, approaches to change management in China have frequently emphasised the importance of sub-national experimentation, innovation, and learning. Multiple mechanisms exist within the government structure to allow and encourage flexible implementation of policies, and tailoring of reforms to context. These limit the risk of large-scale policy failures and play a role in exploring new reform directions and potentially systemically-useful practices. They have helped in managing the huge transition that China has undergone from the 1970s onwards. China has historically made use of a number of mechanisms to encourage learning from innovative and emergent policy practices. Policy evaluation is increasingly becoming a tool used to probe emergent practices and inform iterative policy making/refining. This paper examines the case of a central policy research institute whose mandate includes evaluating reforms and providing feedback to the health ministry. Evaluation approaches being used are evolving as Chinese research agencies become increasingly professionalised, and in response to the increasing complexity of reforms. The paper argues that learning from widespread innovation and experimentation is challenging, but necessary for stewardship of large, and rapidly-changing systems.

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A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality

Future Health Systems

Huda TM, Rahman MM, Raihana S, Islam S, Tahsina T, Alam A, Agho K, Rasheed S, Hayes A, Karim MA and Rahman QS (2018) A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: the Shonjibon trial, BMC Public Health, 18(1):816, DOI: 10.1186/s12889-018-5713-1

Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes.

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How can mobile phones be used to improve nutrition service delivery in rural Bangladesh?

Future Health Systems

Khan NU, Rasheed S, Sharmin T, Siddique AK, Dibley M and Alam A (2018) How can mobile phones be used to improve nutrition service delivery in rural Bangladesh?, BMC Health Services Research, 18(1):530, DOI: 10.1186/s12913-018-3351-z

Nutrition has been integrated within the health services in Bangladesh as it is an important issue for health and development. High penetration of mobile phones in the community and favourable policy and political commitment of the Government of Bangladesh has created possibilities of using Information Communication Technology such as mobile phones for nutrition programs. In this paper the implementation of nutrition services with a specific focus on infant and young child feeding was explored and the potential for using mobile phones to improve the quality and coverage of nutrition services was assessed.

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Health policy and systems research: the future of the field

Future Health Systems

Peters D (2018) Health policy and systems research: the future of the field, Health Research Policy and Systems, 16:84, DOI: 10.1186/s12961-018-0359-0

Health policy and systems research (HPSR) has changed considerably over the last 20 years, but its main purpose remains to inform and influence health policies and systems. Whereas goals that underpin health systems have endured – such as a focus on health equity – contexts and priorities change, research methods progress, and health organisations continue to learn and adapt, in part by using HPSR. For HPSR to remain relevant, its practitioners need to re-think how health systems are conceptualised, to keep up with rapid changes in how we diagnose and manage disease and use information, and consider factors affecting people’s health that go well beyond healthcare systems. The Sustainable Development Goals (SDGs) represent a shifting paradigm in human development by seeking convergence across sectors. They also offer an opportunity for HPSR to play a larger role, given its pioneering work on applying systems thinking to health, its focus on health equity, and the strength of its multi-disciplinary approaches that make it a good fit for the SDG era.

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Children of an Uncertain Climate

Future Health Systems

The FHS India team have produced a new film titled Children of an Uncertain Climate, based on an FHS study titled ‘Decoding Child Health Impact under Climate Crisis.’ This short film identifies the pathways by which Climate Change is impacting the child health in Indian Sundarbans – a climatically vulnerable setting.

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FHS Key Message Brief 5: Working with the media in pursuit of Health for All

Future Health Systems

This key message brief shares learning from Future Health Systems partners’ experiences of working with traditional, primarily mainstream, media outlets publishing in print and online, as well as some television and radio organisations over 12 years. We hope it offers some helpful reflections for those who are currently or considering working with the media.

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

Future Health Systems

Morgan R, Ayiasi RM, Barman D, Buzuzi S, Ssemugabo C, Ezumah N, George AS, Hawkins K, Hao X, King R, Liu T, Molyneux S, Muraya KW, Musoke D, Nyamhanga T, Ros B, Tani K, Theobald S, Vong S and Waldman L (2018) Gendered health systems: evidence from low- and middle-income countries, Health Research Policy and Systems, 16:58, DOI: 10.1186/s12961-018-0338-5

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.

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When Leadership Counts

Future Health Systems

FHS partner Makerere University School of Public Health is undertaking a Community Score Cards study, which is contributing to research on how leaders can work with the community and health workers to improve maternal and newborn health in Kibuku District. The use of the Community Score Card tool – a two-way and ongoing participatory tool for assessment, planning, monitoring and evaluation - aims to improve the performance of facilities and accountability by the different stakeholders who are responsible for improving the performance of facilities. This film provides an overview of the work and the use of community scorecards.

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What about us

Future Health Systems

This film, produced by FHS partner Makerere University School of Publich Health (MakSPH), highlights the challenges that women with disabilities face when seeking maternal health services in the Eastern Uganda district of Kibuku. To address some of these challenges, FHS partner MakSPH, in partnership with Research in Gender and Ethics (RinGs), is using the Community Scorecard methodology - a participatory tool for assessment, planning, monitoring and evaluation of services – with mothers living with disabilities, allowing their voices to be heard.

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Climate change: a threat to child food security in the Indian Sundarbans

Future Health Systems

The Sundarbans, the mangrove forest delta shared both by India and Bangladesh, is among the worst hit regions of climate change in the world. Even though food insecurities due to climate change are felt across the region, the distribution of vulnerabilities is largely uneven depending upon existing climatic and social intersections.

Within the context of socio-cultural and political dynamics, and rapid globalization, efforts to respond to, mitigate, or adapt to climate change needs to address issues of equity and social justice, posing both challenges and opportunities.

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In from the cold: Shifting the discourse on informal providers in Bangladesh and India

Future Health Systems

In Bangladesh and India, informal healthcare providers (IHPs) have long been part of the countries’ health systems. However, formal recognition of their existence is sensitive, partly due to resistance and concern from professional health bodies. Research by Future Health Systems (FHS) partners ICDDR,B and IIHMR has been instrumental in bringing the issues to discussion tables. Consequently, stakeholders have begun to recognize and work with IHPs – something previously unheard of.

Integrating Actions to Tackle Antimicrobial Resistance into Strategies to Achieve Universal Health Coverage

Future Health Systems

It is critical that ensuring people’s access to effective treatment for common infections is aligned with efforts to reduce the risk of emerging antimicrobial resistance. The Institute of Development Studies, a Future Health Systems partner, is influencing policy agendas to give greater focus on the need for the just and sustainable use of antimicrobials.

Are Women of the Indian Sundarbans Living in the Dark?

Future Health Systems

World-wide, women experience a higher burden of visual impairments than men, and this increases with age. This short film from the FHS India team - based on research by IIHMR University, FHS and RinGs - highlights the gendered dimension of seeking eye health care in the Indian Sundarbans - a climatically vulnerable setting.

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

Future Health Systems

Waldman L, Theobald S and Morgan R (2018) Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.137

This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.

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Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage

Future Health Systems

Nelson E, Bloom G and Shankland A. (2018) Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.131

In July 2017, IDS hosted a workshop on ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity’, with the aim of generating dialogue and mutual learning among activists, researchers, policymakers, and funders working towards more equitable health systems and a commitment to Universal Health Coverage (UHC). This issue of the IDS Bulletin is based around three principal themes that emerged from the workshop as needing particular attention. First, the nature of accountability politics ‘in time’ and the cyclical aspects of efforts towards accountability for health equity. Second, the contested politics of ‘naming’ and measuring accountability, and the intersecting dimensions of marginalisation and exclusion that are missing from current debates. Third, the shifting nature of power in global health and new configurations of health actors, social contracts, and the role of technology.For the first time in IDS Bulletin history, themes are explored not only in text but also through a selection of online multimedia content, including a workshop video, a photo story and a documentary. This expansion into other forms of communication is explicitly aimed at galvanising larger numbers of people in a movement towards UHC and the linked agenda of accountability for health equity.The articles and multimedia in this IDS Bulletin reflect the fact that while the desired outcome might be the same – better health for all – accountability strategies are as diverse as the contexts in which they have developed.

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‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information

Future Health Systems

Waldman L, Ahmed T, Scott N, Akter S, Standing H and Rasheed S (2018) ‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information, Globalization and Health, 14:31, DOI: 10.1186/s12992-018-0349-6

Information and Communications Technologies (ICTs) which enable people to access, use and promote health information through digital technology, promise important health systems innovations which can challenge gatekeepers’ control of information, through processes of disintermediation. College students, in pursuit of sexual and reproductive health (SRH) information, are particularly affected by gatekeeping as strong social and cultural norms restrict their access to information and services. This paper examines mobile phone usage for obtaining health information in Mirzapur, Bangladesh. It contrasts college students’ usage with that of the general population, asks whether students are using digital technologies for health information in innovative ways, and examines how gender affects this.

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Health system innovations: adapting to rapid change

Future Health Systems

Bloom G, Wilkinson A and Bhuiya A  (2018) Health system innovations: adapting to rapid change, Globalization and Health, 14:29, DOI: 10.1186/s12992-018-0347-8

A fundamental challenge for health systems is the need to adapt to changes in the patterns of health service need, scientific and technological developments, and the economic and institutional contexts within which providers of health services are embedded. This is especially true of many low and middle-income countries, where the pace of multiple and interconnected changes is breath-taking. This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries. 

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