Gender, health systems resilience and equity

Kim Ozano: 00:00:03

Hello listeners, and welcome to Connecting Citizens to Science, a podcast where we hear about the ways that researchers connect with communities globally to solve challenges together.

Kim Ozano: 00:00:13

I'm very happy to bring you the second episode of a six part mini series brought to you by ReBUILD for Resilience.

Kim Ozano: 00:00:20

ReBUILD is a research consortium that examines health systems resilience in fragile settings that experience violence, conflict, pandemics, and other shocks.

Kim Ozano: 00:00:29

Many health systems projects have aimed to work on equity and justice, but today's episode is going to be focused on gender and health systems.

Kim Ozano: 00:00:38

The gendered nature of the health system is often overlooked or downplayed in practice.

Kim Ozano: 00:00:43

There is an increasing body of knowledge that demonstrates that gender plays a role in all aspects of health system function, and that health systems can both recreate or challenge norms in wider society.

Kim Ozano: 00:00:56

ReBUILD has been exploring how gender and health systems function in contexts where there is fragility and shocks, and they have been tracing and analysing the contextual ways in which the power relation can take us towards or away from human rights, improved health outcomes, and societal well being.

Kim Ozano: 00:01:17

Our co-host today, I'm very pleased to announce is Abriti Arjyal from HERD International in Nepal.

Kim Ozano: 00:01:23

Abriti is leading on the qualitative and participatory approaches in ReBUILD, and has experience in public health, health systems, service delivery research, social science, and gender and equity.

Kim Ozano: 00:01:35

I am also very excited to introduce our two guests today, Dr.

Kim Ozano: 00:01:39

Rouham Yamout, who works at the American University of Beirut.

Kim Ozano: 00:01:43

She was a medical doctor for 20 years before moving into public health, and now she focuses on health system research and strengthening access to quality health care.

Kim Ozano: 00:01:53

Our second guest is Dr.

Kim Ozano: 00:01:55

Val Percival, who is an associate professor at the Norman Patterson School of International Affairs at Carleton University, and is also a commissioner with the Lancet Site Commission on Peace, Justice and Gender Equality for Healthy Societies.

Kim Ozano: 00:02:08

Her current research focuses on three areas.

Kim Ozano: 00:02:11

The measurement and meaning of the suffering of civilians in violent conflict and humanitarian emergencies, the complexity of engagement in health systems, and the promise and perils of policy networks.

Kim Ozano: 00:02:24

So to start off this episode, let's say hello, welcome Rouham and Val to the podcast.

Kim Ozano: 00:02:29

Abriti, why do we need to consider gender in this time of shocks and polycrisis?

Abriti Arjyal: 00:02:35

Thank you Kim So, we know that we are in currently in the state of global polycrisis where we are facing multiple crisis that is ranging from COVID-19 pandemic to global conflicts, political and economic instability, and climate change.

Abriti Arjyal: 00:02:49

So this is in turn deepening the already existing gender disparities and health inequities in the communities as well as in the health system.

Abriti Arjyal: 00:02:59

In the current ReBUILD projects, we are looking into the dimensions of gender equality and health equity and how these have been influencing in the healthcare system, particularly at the local level for it to be more responsive and equitable to the needs of diverse communities.

Abriti Arjyal: 00:03:14

So Val and Rouham, I do understand you have been working in different contexts with the focus on equitable and resilient health system.

Abriti Arjyal: 00:03:22

So I would like to start today's discussion and conversation hearing more about how did you start getting engaged in this topic.

Abriti Arjyal: 00:03:29

so Val, maybe I could start with you.

Val Percival: 00:03:31

Thank you so much Abriti, it's a pleasure to be here and to discuss this really important topic of gender and health systems.

Val Percival: 00:03:40

One thing that I just like to reflect on when you talked about the polycrisis, I think one of the things that we see, when that concept is discussed.

Val Percival: 00:03:49

It's almost discussed in a way that is fatalistic, right?

Val Percival: 00:03:54

We have so many crises that are multiplying and harming communities.

Val Percival: 00:03:58

So you have climate change.

Val Percival: 00:04:00

You have conflict in some settings, you have financial crisis, you have the impact of the COVID pandemic.

Val Percival: 00:04:05

And there's very little discussion about the things that you can do to change that.

Val Percival: 00:04:11

And one of the things that we know in the research that, that we did on the Lancet commission is that the polycrisis is caused by multiple systems interacting and harms in one system kind of cascading across, uh, social systems, economic systems and political systems.

Val Percival: 00:04:30

I think that there's a real opportunity of how you can work with communities through the health sector through building gender equality and I think it's really important that we work with communities of gender equality to tip those harmful cycles that contribute to the polycrisis into beneficial cycles, and this isn't easy, right?

Val Percival: 00:04:47

It requires consultation with communities.

Val Percival: 00:04:50

We talk about the importance of inside out approaches, working at the community level, getting communities to appreciate what the challenges of gender equality are.

Val Percival: 00:05:03

But I think in the long run, It's really the only way that we can kind of get out of the polycrisis and use the health system as that entry point.

Val Percival: 00:05:14

But I'm really interested to hear what Rouham says about her experience in Lebanon.

Rouham Yamout: 00:05:19

Okay.

Rouham Yamout: 00:05:20

I think that gender is one of dimensions of equity and justice.

Rouham Yamout: 00:05:24

According to the Lebanese experience, whenever the organisation wanted to pay less money to cut personnel costs, they started to employ women.

Rouham Yamout: 00:05:34

Why?

Rouham Yamout: 00:05:35

Because women were more prone to accept very low wages.

Rouham Yamout: 00:05:39

men wouldn't accept them.

Rouham Yamout: 00:05:41

So, uh, we saw that the health workforce got more and more feminised, uh, with the improvement of the resilience of the health system.

Rouham Yamout: 00:05:50

Now we are seeing more also, uh, women into, the non-physician health workers positions, as doctors, as managers, posts with more responsibilities in the health system.

Rouham Yamout: 00:06:03

This is, one of the ways, how gender interfered with the resilience of the health system.

Rouham Yamout: 00:06:10

Also, when they needed volunteers to do a work, they were women who were more volunteer maybe because they feel, uh, social responsibility more, and maybe because, they are interested in acquiring some experience and have ambitions for the future.

Rouham Yamout: 00:06:28

On the other hand, when institutions are in danger, and when there is a need to do task shifting, for example, asking a nurse to have more responsibility, women are more volunteer to do it.

Rouham Yamout: 00:06:40

They do it more easily.

Rouham Yamout: 00:06:41

They are faster to learn and to shift and they adapt better to their new roles.

Rouham Yamout: 00:06:48

This is why employers started to recruit more and more women.

Rouham Yamout: 00:06:53

So it is no surprise that 80 percent of the non-physician healthcare workforce in Lebanon are women.

Rouham Yamout: 00:07:01

And now we are starting to see a woman in such specialties that before were completely for men, like traumatology and neurosurgery.

Rouham Yamout: 00:07:11

And now women are going into those domains and they are starting to acquire more, uh, power and more responsibility into the health system.

Rouham Yamout: 00:07:21

So the resilience of the health system goes with the feminisation of the health system.

Abriti Arjyal: 00:07:26

So what is the impact of getting the health system or the workforce being more femininised?

Rouham Yamout: 00:07:33

The health system gives to women this opportunity to hold responsibility and to grow into the domain of healthcare provision.

Val Percival: 00:07:43

When we think about gender and health systems and resilience, one of the things that's important to remember is that health systems reflect their society, but they also can shape their society.

Val Percival: 00:07:55

So, if those gender inequalities exist, they're going to be reflected in the choices that health systems make, the kinds of financing decisions that they make, who gets paid what, what kind of services are prioritised, what is researched.

Val Percival: 00:08:11

And it's important that health systems recognise that they can also be instruments to promote gender equality.

Val Percival: 00:08:19

I think that health systems can be an important tool to increase not only the resilience of the health system, but also the resilience of the society.

Val Percival: 00:08:28

But it is a deliberative choice, and that's one of the reasons why it's so important that policymakers reflect on the fact that health systems can be gender unequal, but they can also be gender equal.

Val Percival: 00:08:42

One of the challenges, in the health sector and with human resources and with women is that the health sector itself it reflects those gender biases, and so, physicians are paid more, they have higher levels of responsibility, in part because they're male dominated.

Val Percival: 00:08:58

But if you think about the impact at the community level, community health workers are really critical, particularly in building resilient health systems, and helping the resilience of their community.

Val Percival: 00:09:12

And I think your experiences working in Nepal would really reflect that.

Abriti Arjyal: 00:09:17

Yeah, it's also building resilience, but then, like, it's also the broader gender dynamics that comes into play when we say we are bringing more women in the workforce.

Abriti Arjyal: 00:09:26

So, for instance, like, women do need to come across the double burden of work where they actually need to balance their household chores and also the responsibilities as a profession where they need to get engaged in the providing the health care services.

Abriti Arjyal: 00:09:42

So that is also something we need to further think about because, uh, in our context, gender norms are very strongly embedded, and although women work outside the chores, the family responsibilities is also their primary responsibility.

Kim Ozano: 00:09:58

I think that's really helpful.

Kim Ozano: 00:10:00

And, you know, we, we think a lot about terminology and the language we use, and I've heard a lot of bottom up approaches to tackling gender norms, but Val, you mentioned a new one for me, inside out approaches, and I would love to hear how that maybe is different and what that means when we're trying to challenge these gender norms.

Val Percival: 00:10:20

So we came up with this idea of inside out approaches through the research of the Lancet Commission.

Val Percival: 00:10:26

And one of the things that we noticed in a lot of the policies on gender is that they were kind of cookie cutter approaches.

Val Percival: 00:10:35

We know that there are universal principles that we need to aspire to.

Val Percival: 00:10:40

So, you know, things like autonomy, agency, et cetera, but the way that societies and particular communities move towards those goals is really, it needs to be something generated from within, maybe inspired from other experiences, but those kinds of conversations and drivers of change need to happen at the community level.

Rouham Yamout: 00:11:04

Yes, I wanted to just illustrate what Val was talking about.

Rouham Yamout: 00:11:10

We will be taking the refugee community in Lebanon, the Syrian refugee community in Lebanon.

Rouham Yamout: 00:11:15

And at the beginning, the society was very much alert about keeping gender norms very strongly.

Rouham Yamout: 00:11:22

But little by little, the society got into the necessity of the work of women.

Rouham Yamout: 00:11:29

Why?

Rouham Yamout: 00:11:29

Because men did not register as refugees.

Rouham Yamout: 00:11:33

They couldn't get their residency permit.

Rouham Yamout: 00:11:36

And when we had COVID, men lost the opportunity of working in daily work.

Rouham Yamout: 00:11:41

So women started to work and here, this is how we got this quantity of refugees, uh, women who worked as health workers.

Rouham Yamout: 00:11:51

And little by little, all the society started to change its sight towards working women.

Rouham Yamout: 00:11:59

They stopped talking 'ah, where she's, uh, doing at the night alone'.

Rouham Yamout: 00:12:04

They started to say, 'ah, she must be coming back from her work'.

Rouham Yamout: 00:12:08

The society, little by little started to accept the work of women and those women started to acquire more and more self-confidence because they were taking the responsibility of breadwinning for their family.

Rouham Yamout: 00:12:22

They were proud of this additional tasks they were taking on their shoulders and the society became much more clement towards working women and towards women in general, the family dynamics changed.

Rouham Yamout: 00:12:38

Now we can hear husband saying it's okay if I help my wife in domestic chores, before it was something not acceptable at all that a man do dishes or, or helps in something.

Abriti Arjyal: 00:12:52

That's a very interesting point to note, like how the context or the crisis could actually change the gender norms and make people start thinking differently than what they used to be thinking about women and their responsibilities or what they should be doing.

Kim Ozano: 00:13:09

Val, I would like to hear your perspectives as someone who works across context.

Kim Ozano: 00:13:15

Rouham has talked a little bit about, you know, how it starts to shift those norms, but what's the experience globally across contexts on how the norms either go back to how they were previously or remain sustainable?

Val Percival: 00:13:27

That's an excellent question, and I think one of the things that we always have to remember with gender norms is that it can open things can become more equitable for women, but they can also close as well.

Val Percival: 00:13:38

I think one of the things that we see in, in context is, is a big backlash against gender equality, and we need to be very cognizant of, of why that backlash is happening and how to mitigate against it.

Val Percival: 00:13:52

So I think, um, in conflicts in other fragile settings, there's both the challenge of that context for gender norms, but there's opportunities to shift it, and that's what makes policy so important.

Val Percival: 00:14:06

So, if the government's local communities supported by donors and multilateral organisations recognise the importance of of gender and integrating gender, and opportunities for women and understanding barriers to access for health care and addressing those, then you can see that more sustainable push these things become entrenched.

Val Percival: 00:14:32

But they can also revert back, and I think that's it's important for us to recognise both of those things.

Kim Ozano: 00:14:39

A lot of the context that you're discussing, there's quite often shifts in politics and power, and what happens to those policies?

Kim Ozano: 00:14:47

Do they become fragile themselves?

Val Percival: 00:14:49

Policies are important.

Val Percival: 00:14:50

Who's in power is very important.

Val Percival: 00:14:52

And I think we've seen in multiple contexts where gender has become a flashpoint, women's health tend to suffer as a result.

Val Percival: 00:15:02

I think that to build a consensus for social consensus for gender equality and to also provide an enabling environment for women who are in those positions within the health sector and in government to be able to push forward their initiatives.

Val Percival: 00:15:21

Just one more quick point.

Val Percival: 00:15:22

I think we also forget and, Rouham talked about the experience of men, Syrian refugees and male Syrian refugees and lacking opportunities.

Val Percival: 00:15:32

I think when we think about gender, we only tend to think about women and it's really important to understand the pressures that are facing men, how they, their whole world has shifted.

Val Percival: 00:15:44

Their whole purpose has shifted and be aware of that as we're working with communities as we're

Val Percival: 00:15:51

developing

Val Percival: 00:15:52

health policies to ensure that men aren't left behind because when they are, that's one of the forces that drive backlash against gender equality.

Kim Ozano: 00:16:02

I love that because again, that 'insider out' is really, really important because it can transcend policies and politics and power when the communities have some sort of influence.

Kim Ozano: 00:16:12

Abriti, this leads me very nicely onto your role in ReBUILD as very much participatory approaches.

Kim Ozano: 00:16:18

I would love to hear a little bit more about that and how it relates to this insider out approach.

Abriti Arjyal: 00:16:23

We are taking like participatory action research as an approach which evolves around identification of the issues by engaging the vulnerable communities,

Abriti Arjyal: 00:16:33

and then co-creating the intervention, engaging them and trying to prioritise the issues and developing an interventions that best suits the context and also the need based on the local health system.

Abriti Arjyal: 00:16:46

In one of the project, we engaged with female company health volunteers where we try to understand the gender experiences of being engaged during COVID-19 and also in normal time so we applied participatory action research process there.

Abriti Arjyal: 00:17:01

So we discussed with them.

Abriti Arjyal: 00:17:02

What are the issues?

Abriti Arjyal: 00:17:03

And then, like, we prioritise the issues using problem tree analysis.

Abriti Arjyal: 00:17:07

What could be the solution?

Abriti Arjyal: 00:17:09

Or how do you think we could address the gender issues that they have been facing?

Abriti Arjyal: 00:17:13

So they came up with an idea of developing a film that actually talked about their experiences and how they manage their household chores and also the responsibility as a female community health volunteers.

Abriti Arjyal: 00:17:27

So this was then later showcased to the community and to the stakeholders.

Abriti Arjyal: 00:17:32

And they did feel that this has developed confidence in them.

Abriti Arjyal: 00:17:36

And then also has changed the lens of how other family members looked at their work and how the community people looked at their work and started receiving better support from them.

Kim Ozano: 00:17:48

I think that's really an important example and, and quite amazing that through the process of participatory action research, you're raising awareness of some of the issues that maybe, you know, haven't been thought about before, and also starting the discussions around gender, and we talk a lot about co-creation and, co-production on this podcast.

Kim Ozano: 00:18:08

So it's great to hear that that's a part your experience on the ground, but also right up to the policy level and advocating for that.

Kim Ozano: 00:18:15

So I'm going to end the podcast now by asking for your advice for someone who's looking to address gender in health systems within the settings that you work in.

Rouham Yamout: 00:18:25

I think that there is something that Val said and that Abriti also illustrated, that it should come, uh, from within.

Rouham Yamout: 00:18:33

This is the most important.

Rouham Yamout: 00:18:35

Women understand gender.

Rouham Yamout: 00:18:37

They understand also equity.

Rouham Yamout: 00:18:40

They understand all this and they understand the place of men and they give them the space needed.

Rouham Yamout: 00:18:47

They are not challenging the gender norm.

Rouham Yamout: 00:18:50

They are adhered to those gender norms and they consider that their rights will be fulfilled whenever the society will become more just and more equitable.

Rouham Yamout: 00:19:01

We shouldn't over emphasise the gender.

Rouham Yamout: 00:19:04

Gender will come by itself whenever the society will become more just and more equitable.

Abriti Arjyal: 00:19:09

So gender and health inequities are actually context driven and they differ in every small context.

Abriti Arjyal: 00:19:17

So it is very important that we understand the local context and try and inform our health system or health interventions to address their issues.

Abriti Arjyal: 00:19:28

Using a blanket approach might not actually address the inequities or the disparities that exist in the community and yes, as well Val also previously mentioned, it is also important that the policy actually understands and mainstreams these concepts and these dynamics into the actions and policies.

Kim Ozano: 00:19:49

Val, if you would like to take us home with a final piece of advice.

Val Percival: 00:19:52

I think that the critical thing to reflect on when it comes to gender and this echoes comments that have been made by Rouham and Abriti is that we need to really go beyond just the rhetoric of gender equality and really focus on concrete actions.

Val Percival: 00:20:07

What are the mechanisms?

Val Percival: 00:20:08

How do we ensure that health services are delivered?

Val Percival: 00:20:11

We need to, to focus on those kinds of concrete tools for gender equality to really move the needle and move it in a sustainable way.

Val Percival: 00:20:21

And I think one of the really special things about ReBUILD in terms of its research approach is that it's focusing on this research at the community level and really illustrating how this community led health system resilience is one important approach and critical approach to not just transform health systems, but also transform societies.

Rouham Yamout: 00:20:47

Yes.

Kim Ozano: 00:20:47

So a real call for practical tools and action that is community led from the inside out.

Kim Ozano: 00:20:54

So thank you so much for our co host and to our guests.

Kim Ozano: 00:20:57

That was a really insightful conversation.

Kim Ozano: 00:20:59

And also thanks for our listeners for joining us.

Kim Ozano: 00:21:02

If you haven't already had a chance, check out episode one of this mini series, where there's conversation with Sophie Witter, Seye Abimbola and Sushil Baral, who explore the balance between self reliance and demanding accountability from government systems.

Kim Ozano: 00:21:16

If you want to know more about ReBUILD or, any of the our guests and our co hosts today, have a look in the show notes.

Kim Ozano: 00:21:21

And finally, have a nice day to all our listeners and to our guests.

Kim Ozano: 00:21:25

Bye for now.