Presentation given by Sassy Molyneux at the 2017 Oxford Global Health and Bioethics International Conference

1. Sassy Molyneux, University of Oxford, KEMRI-Wellcome Trust Research Programme
Freddy Kitutu, Bridget Pratt, Hayley McGregor, Sarah Saali and Dorcas Kamuya
Building the field: Developing networks to support
ethics research and practice for health policy and
systems research in sub-Saharan Africa

2. What is Health Policy
and Systems Research
(HPSR)?
Essential to strengthening health
systems, but boundaries, definitions
and characteristics debated.
Emerging consensus on foci:
• Health system/sub-component
performance
• How sub-component links shape
performance
• How to strengthen performance over
time.
Social science/qualitative research
essential
• ‘Where health systems are understood
as social and political constructs with
vital opportunities for tackling social
injustice (Sheikh et al., 2014)’.

3. What is ethics in practice: many approaches
• How do existing guidelines apply in practice for my
kind of study/project/work…
• What are the issues/realities in relation to those
concepts/requirements on the ground?
• What does that mean about how I should do my study, or
respond to a situation?
• What are the ethical issues I/we face from the ground
up?
• What situations in ‘the field’/in our work that make us
question whether we are doing the ‘right thing’?
• What do stakeholders and literature, including guidelines,
suggest we should do?

4. Governance of HPSR underdeveloped and contested
(Often) different issues, experiences
and implications from biomedical
research:
• Individual consent
• Individual burdens vs public gain
• Data ownership and sharing,
especially where the research-
practice distinction is blurred or
collapsed

5. RinGs is a partnership which brings together four research
networks encompassing 22 institutions across 39 countries to
galvanise priority for gender and ethics in health systems
research

6. RinGs galvanises the priority given to gender and ethics
in health systems research by:
Conducting new
empirical and
synthesis research on
gender, resilience,
and health systems
Expanding and
embedding
research uptake
at the national
and international
level
Building the
capacity of
health systems
researchers to
undertake gender
and intersectional
analysis

7. What is
intersectionality?
• Research ‘seeks to demonstrate the convergence of
different types of exclusion and marginalization’
(Hankivsky 2014).
• Moves beyond understanding social hierarchies in
isolation (e.g. gender as separate from race) or
additive (e.g. gender plus race equals greater
disadvantage)… highlights social categories as mutually
constituted and intersecting in dynamic and interactive
ways (Bowleg, 2012; Hankivsky 2012b).
• A broader philosophy underlying researcher and
activist engagement; ideally has transformational aims,
seeking to give voice to those most marginalized

8. How is intersectionality
relevant to us?
• Increasingly being applied to
public health
• Supports equity analysis
• Allows us to deepen our
understanding of
inequality through better
reflecting the complexity
of the real world
• Does not make a priori
assumptions regarding
the importance of any
one or multiple social
categories (e.g. gender,
race)
• Pushes us to understand the
drivers of inequality…to
examine power relations as
multi-level processes
• Links the social
circumstances of
marginalized groups to
forms of discrimination
and the structural factors
underpinning them

9. A person’s unique circumstances
Aspects of identity
Processes of discrimination
Systems and structures of power

10. Intersectionality and ethics are inter-twined
• Deal with power relations and
equity and how these are
transformed over time and
space
• Pay attention to fairness,
vulnerability and agency in
diverse contexts and at
multiple levels
• Consider how gender interacts
with other social stratifiers

11. Gender and power in the conduct of health policy and
systems research in the Global South: reflections from RinGs
funded researchers
• Last year, RinGs
brought together 9
grantees conducting
health systems
research on gender and
ethics in Kilifi, Kenya
• During meeting
discussed key
challenges we faced
related to gender and
power in HPSR

12. Ways in which gender and power shapes
interactions during research process
Resistance to
gender
perspective in
research
Misunderstanding
gender analysis
Questioning
relevance of gender
analysis
Power relations in
methods
Power relations
between
researchers and
respondents
Gender
&
Power

13. Questioning relevance of
gender analysis …
Power and gender abstract and difficult to
engage with, even for those with an interest
in equity.
Beyond maternal and child health, research
from a gender perspective questioned:
• What you need are health services for all
• Do diseases differentiate between males and
females?
• Do mosquitoes disaggregate by gender?
• If we are to study malaria, let us study malaria,
not gender because malaria catches all equally

14. Resistance to gender perspective
in research…
By those who feel criticised or challenged, or who
do not believe that gender discrimination is a
reality.
… by women who don’t want men encroaching in
their ‘space’
Specific concerns:
• ‘Is focusing on women a punishment for men?
And are all men guilty of women’s suffering?’
• ‘But some women oppress men!’ …. The focus
on women ignores men’s suffering! I.e. are we
talking about gender or women?

15. Misunderstanding of what
gender analysis is…
• Continued focus of women and girls within
gender analysis
• While important, it does not necessarily
address determinants of gender inequality that
can also undermine such a focus, and
underestimates ingrained power relations and
men’s roles
• Heteronormative nature of much international
development also means that people who
define their gender as neither man nor women
are often excluded

16. Power relations playing out in
methods and relationships…
• Power relations in mixed groups impact on
information shared
• Challenges to getting male participation on
topics considered “women’s issues”
• Difficultly interviewing opposite sex
• Inappropriate behavior of male respondents
towards female researchers
• Older women uncomfortable to be interviewed
by male research assistants, especially if they
are younger

17. What worked well – reflections from our workshop…
• Build our capacity for quality ethical research:
• Reflect on positionality and implications
• Co-learn with others
• Use methods that flatten power relations as much as
possible – participatory, narrative, visual
• Ask about gender and power without using the
words; draw on frameworks to probe
• Develop/agree/debate strategies and appropriate
approaches to respect local norms and
requirements, and challenge them
• Specific to study and socio-cultural and policy context
• At least do no harm
Photo credit: Robyne Hayze

19. Making ‘ethics’ everybody’s business at
HSR2016
Ethics featured in the titles and as core topics with several messages
standing out for us:
• Health systems research ethics should address the broad justice
questions that can be relatively neglected in biomedical ethics
• A critical examination of more obvious or common micro-level ethics
questions remains essential, e.g. how individual consent processes
unfold on the ground
• In practice, all HPSR researchers have to consider their obligations
and responsibilities in the face of multiple needs and inequities
• Recommendations and guidelines can be helpful in supporting ethical
practice, but are not enough in themselves
• What next for the Ethics of Health Systems Research TWG?
Watch the webinar:
https://www.dropbox.com/sh/dh89lifulaigfsh/AABHbAGa5Cobx_1jgxr9
CHkJa?dl=0

20. The discussions on rights, justice, inequity, gender and intersectionality, participation and voice, and resources and control
were heard throughout HSR2016, and are all fundamental ethical concerns. As a Thematic Working Group (TWG) for Health
Systems Global (HSG) we plan to take forward these discussions by adding a focus on power, politics, equity, and rights, and
continuing to promote a recognition that ethics is everybody’s business. With the Global Symposium in our sights, a key
priority is to broaden the voices contributing to ethics discussion and debate.

21. Contact us and stay in touch
• Website:
http://resyst.lshtm.ac.uk/rings
• E-mail: RinGs.RPC@gmail.com
• Twitter: @RinGsRPC
• Google+: RinGs
• Linked In:
https://www.linkedin.com/groups/Gender-
Health-Health-Systems-Group-8293050/about
• Website:
http://www.healthsystemsgloba
l.org/twg-group/9/Ethics-of-
Health-Systems-Research/
• E-mail: Hayley MacGregor
(h.macgregor@ids.ac.uk)