Introduction
Gender inequity is pervasive across many aspects of life, including educational attainment, financial independence, employment, and security or social protections. Healthcare is not exempt from the impact of such inequalities. Through an in-depth analysis of gender inequities facing both healthcare recipients and healthcare providers, we aim to determine what critical gender-related issues, challenges, and opportunities are most relevant to TIP Global Health’s innovation, E-Heza Data Solutions. We also seek to lay out clear priorities and an actionable implementation plan to achieve improvements toward gender equality.
The concept of E-Heza emerged from our desire to sustain and replicate the success of our quality improvement work with nurses and their patients in the Northern Province of Rwanda. This initiative resulted in nurses utilizing data trends to educate mothers, improve their workflows, address challenges, and celebrate improvements in health outcomes. By improving the efficiency of care, integrating critical tasks into care workflows, and optimizing opportunities for positive interactions between healthcare workers and pregnant women, E-Heza improves the quality of care, increases engagement in care among pregnant women, improves health outcomes and prevents burnout of healthcare workers, ultimately leading to sustained achievement of maternal child health outcome goals of the Sustainable Development Goals (SDGs). In its initial pilot, E-Heza focused on serving the needs of pregnant and postpartum women, as well as children under five years of age. Now, E-Heza is being expanded to include all primary care and acute illness needs of community members in resource-limited settings.
E-Heza supports both individual and group health assessments common in East Africa and promotes adherence to clinical care guidelines through positive feedback and experiential learning. For example, pregnant women can track the progress of their pregnancies through a personalized timeline that highlights pregnancy milestones such as the first documentation of fetal heart tones. Progressive web application technology allows healthcare workers at each level of care to easily access the longitudinal data they need to care for their patients without requiring the internet. When an internet connection is available, data entered by community health workers in their villages or by nurses at rural health centers will be immediately available to all users to allow for communication along the entire spectrum of care. Integration with national electronic medical record systems ensures access to timely and accurate data for effective and efficient decision-making at the local, regional, and national level.
E-Heza improves the lives of women and girls by strengthening the leadership positions of frontline health workers, who are primarily women, and by inspiring mothers to take active roles to improve their health and the health of their children. E-Heza provides an important platform for healthcare workers to share their expertise and inform user-centered digital health solutions. Health center nurses and Community Health Workers now sit alongside Ministry of Health officials in our steering committee, providing essential information on their unique requirements of health technology.
E-Heza facilitates positive reinforcement of healthy behavior change by allowing nurses to tailor health education to mothers and babies in a way that helps mothers to see the positive impact their behavior change is making on the health of their children. This enables mothers to be active participants in the health care decisions of their family. Many of these mothers have become community activists, advocating for healthy choices for the benefit of all children in their communities. Not only is E-Heza an effective tool to achieve improved health outcomes, but it is a catalyst that is inspiring women to become leaders in their communities and in the health technology sector.
Methodology
In order to develop this gender equality strategy, we first conducted a landscape analysis to better understand the context within which gender equities and inequities exist in Rwanda. We sourced from a variety of research articles and spoke directly with Rwandans working in the healthcare sector to gather personal experiences. Then, we analyzed E-Heza Data Solutions, looking at existing policies, staffing, marketing and distributions, and plans for scale to identify specific gaps or areas for improvement. The findings from the environmental scan and the business analysis resulted in the development of our four gender priorities. Once these priorities were set, we were able to develop an actionable work plan, timeline, and applicable metrics to support the implementation of each priority.
Gender Policy/Vision Statement
TIP Global Health, since its founding, has been concerned with gender equality in Rwanda. By focusing our efforts on the delivery of high-quality primary care to women and children for the past decade, we have been aware of various challenges women face in achieving positive health outcomes as well as the unique obstacles facing female frontline health workers. This analysis will serve as a tool to support the promotion of lasting change among frontline health workers and healthcare recipients to achieve a more equitable health system and improved health outcomes.
We envision is a world in which quality health care leads to inclusive, empowered, and healthy communities. TIP Global Health and our E-Heza team place gender equality at the center of our work because we recognize that we cannot achieve our vision until all people have equal voice and power to exercise their universal right to quality health care. Women are primarily responsible for the health care of their families. Women also comprise 70% of frontline health workers, yet only hold 25% of health leadership roles. Through this policy document, TIP Global Health aims to promote equal realization of good health for all genders and ages as the means to achieve our vision.
The purpose of this document is to clearly articulate our commitment to gender equality and establish guiding principles for all decisions within our organization. The following statements serve as our guiding principles related to gender equality.
Primary health care delivery is overwhelmingly provided by women for women. Women must play key decision-making roles in how primary health care is delivered as both key providers and receivers of health care.
TIP Global Health is deeply committed to gender equality and will promote equality in our programming, hiring practices, and advocacy.
TIP Global Health promotes an environment of equality in which all staff members, regardless of gender, have a clear understanding of our position and practice of promoting gender equality.
Gender Analysis Findings- Environmental Scan
Although Rwanda is considered one of the global leaders in gender equality progress, great disparities remain within the healthcare system, affecting both healthcare recipients and frontline health workers. These challenges primarily affect the women we support, which directly impacts the health and well-being of their children. To combat these inequities, TIP collaborated with key stakeholders to listen and learn before co-designing our solution, E-Heza. The process consisted of consulting nurses, midwives, community health workers, and mothers from Ruli district to ensure the innovation would best serve frontline health workers and mothers and their children.
Healthcare recipients
Childcare and domestic responsibilities
Gender inequities create challenges for mothers in several ways. First, women are primarily responsible for the care of the household and for their children. To receive a healthcare assessment for one child, she must first consider the well-being of her other children. Often, this means the other children are left with an older sister, a female neighbor, or their grandmother. The mother must also cook for them before leaving the home. On average, women spend 21 hours/week on unpaid domestic work, while men spend 8 hours/week.1 Research shows that women in rural areas across Rwanda have said their life situation is unfavorable when compared with that of men.2 They report they are constantly tired from the hard work in which they have to engage and say that they feel and look old before their time while their husbands look young and are full of energy.
Men control finances
Men, particularly in rural areas, still maintain control of their family’s finances, even if the women work. Men have the power to refuse their wives the money they might need for transportation to access healthcare for themselves and their children. This may result in women not receiving proper antenatal care or not accessing care when needed, waiting until an illness has become advanced. Women might also struggle to implement the recommendation of their healthcare providers. On occasion, a community health worker (CHW) might advise the pregnant woman to eat a balanced diet, which includes fruits and meat, for example. However, her husband allocates the spending and may not allow her to purchase the recommended food.
Men control some health decisions
In the case of severe illness, where a woman requires hospitalization, she might refuse this service without first receiving permission from her husband. This imbalance of power creates situations where women do not make decisions in their own best interest for fear of how their husbands’ might react. Men also expect to make decisions related to family planning. Women often report they need permission from their husbands to receive birth control. Yet, less than 50% of married women report having their need for family planning satisfied with modern methods, resulting in conflicts within the family.1
Lack of buy-in halts behavior change
Despite the control men have over his wife’s health decisions, men rarely participate in healthcare visits. When a woman is presented with information from the healthcare provider that requires behavior change, she is often met with pushback from her husband, creating conflict within the family.
Women face violence or fear of violence
Gender-based violence remains widely prevalent, tolerant, and under-reported in Rwanda. It is estimated that at least two in five girls will have experienced physical violence by the age of 15. Twenty percent of women aged 15-49 have been subject to physical and/or sexual violence by a current or former intimate partner, in the last 12 months.3
The combination of these gender inequalities results in women not accessing care as often as they need. In fact, less than 50% of women, in both rural and urban settings, have at least four antenatal care visits, despite the WHO recommendation of eight antenatal care visits.1 Additionally, high illiteracy rates between both genders limit awareness of existing gender-sensitive laws and governmental priorities.3 Due to lack of knowledge and low partner support, may result in inaccurate or improper care received.
Frontline health workers
Lower wages and traditionally defined roles
Even though Rwanda’s women are as active as men in the labor market, their income and wages remain significantly lower. While this may partially be due to cultural biases, the skill differences between women and men currently in the labor force also play a role. As a result, less than 40% of Rwanda’s women are employed in skilled professions and only 14% are senior officials. While skills are not the only factors, the fact that women’s access to education has been limited in the past is still affecting the opportunities they need to compete in the workplace today.2 This is particularly evident in the healthcare sector. Although women make up the majority of CHWs, nurses, and midwives, only two of nine health centers where TIP Global Health works are run by a woman. Doctors are also primarily men. Moreover, women receive less access to credit and other income-supplementing sources, which contribute to women being boxed into more domestic roles, like secretaries, nurses, or teachers.1
Burnout related to double burden
Similar to the burden facing many women, frontline health workers not only hold jobs, but also are responsible for caring for their home and families. Two-thirds of community health workers are women, and they find it difficult to juggle the competing demands on their time. They have reported that it is difficult for them to farm the land, care for their own families, and carry out their duties as CHWs.2 High turnover also endangers the quality and continuity of the service, as retaining them is difficult due to the demands of making a living and looking after a family.
Gender Analysis Findings- Business Model Analysis
Product/Service
E-Heza is designed to support the needs of frontline health workers and the community members they serve by promoting effective primary health care delivery. The cornerstone of primary health care is the relationship between frontline health workers and the community members they serve. E-Heza was designed to support this relationship by decreasing workloads for health workers to allow them to focus on direct patient care and by providing meaningful opportunities to engage and retain women in care by providing individualized health education that reinforces and celebrates healthy behavior change. E-Heza was designed with the recognition that frontline health workers are primarily women and that the community members they serve are also primarily women. We engage both groups at each stage of the design and implementation phase to ensure that we are addressing the needs of our users (frontline health workers) and our ultimate beneficiaries (women and children).
E-Heza as a product currently serves the primary care needs for women and children. TIP Global Health set this priority because these populations are most likely to require and seek primary care services. As E-Heza gradually expands to serve all primary care services, it will be critical to ensure that the product remains meaningful for women and men. As the key drivers of health care and healthy behaviors for families, women will always play essential roles in the successful delivery of primary care services.
The primary users of E-Heza are frontline health workers. While E-Heza can be used in urban or rural settings, the product has been designed to address the challenges associated with rural settings. In LMICs, frontline health workers primarily include nurses and midwives at health centers and Community Health Workers (CHWs) in villages. Seventy percent of these providers are women, and most CHWs in LMICs are unpaid. TIP Global Health conducted a needs assessment among one hundred CHWs, and found that the main motivation for serving in their role was the feeling of helping their communities and being respected for their knowledge and skills. E-Heza builds upon this motivation by providing CHWs and nurses the ability to provide real-time tailored health education to their community members that celebrates successes and identifies emerging health challenges before they become emergencies.
Marketing/Distribution
TIP Global Health is keenly focused on the needs of frontline health workers and the community members they serve, we and recognize that these populations are primarily comprised of women. We are also aware that most decision-makers in global health are men who are less aware of these needs. It is critical that our marketing approach remain focused on gender equality and the needs of frontline health workers while also demonstrating that E-Heza meets the needs of high-level decision makers who may have different priorities. As such, our marketing practices focus on the benefits of effective primary healthcare delivery at the local level to serve the needs of national governments, large NGOs, and multinational organizations.
A critical aspect of our marketing strategy involves educating national and global decision-makers on the reality of primary health care delivery at the local level and the benefits associated with prioritizing the needs of frontline health workers and the communities they serve. Relationships between frontline health workers and the women they serve are critical to primary care delivery because success requires behavior change and investment in the future. Health workers need tools that build trust among their patients, and women need positive reinforcement that demonstrates their efforts are leading to improved health for themselves and their families. This will become even more important as Electronic Medical Records (EMRs) become more influential because of the dangers associated with user interfaces that are poorly designed for frontline health workers. In the United States, for example, EMRs led to decreased time for direct patient care, increased burnout, poor quality of care and worsened health outcomes. E-Heza solves this challenge for LMICs by proving them with the opportunity to benefit from their existing EMRs while improving the experience of frontline health workers and women.
Organizational Design
TIP Global Health and E-Heza prioritize equal gender representation in our organizational design. Our team reflects the demographics of our end-users and ultimate beneficiaries. Seventy-eight percent of E-Heza’s core team are women. TIP Global Health’s implementation and quality improvement teams support the E-Heza software team to establish a robust and holistic package of services that provide holistic support to frontline health workers. All team leaders- including E-Heza- are women. Our hiring practices prioritize highly qualified candidates who also bring lived experience as frontline health workers. We strive to hire women into leadership and technology roles. The skill set pool in Rwanda facilitates this. For example, 34% of graduates from ICT programs in Rwanda are women. While we do not anticipate challenges with ensuring equal opportunity for women and men as we grow, it is important that we continue to prioritize equality in all hiring practices. Additionally, human resource policies such as gender discrimination and sexual harassment policies are in place. Each team member receives these policies upon hiring.
Strategy to Scale
TIP Global Health and E-Heza prioritizes national and international strategies for primary health care delivery. Women and children comprise the majority of those who benefit from primary health care services across Sub Saharan Africa. As such, E-Heza’s strategy for scale will prioritize all primary care services for women and children. We will scale through partners who also prioritize primary health care for women and children, and then expand our services to include all aspects of primary health care delivery for women, men, girls and boys.
As E-Heza grows and becomes more influential in the global health sector, it will be critical to increase our advocacy for female representation among global health decision-makers. While women comprise 70% of frontline health workers, women only comprise 25% of global health decision-makers. TIP Global Health and E-Heza embrace our role as educators regarding the positive and negative impact of primary care delivery on women and girls, as well as advocates for the elevation of the voices of women who are most impacted.
System Change
E-Heza was designed by and for frontline health workers and the community members they serve while remaining closely aligned with government priorities and national health systems. We strive to change all aspects of global health by elevating the voices and experience of women at the frontlines of health care, demonstrating that local innovation is not only scalable but essential for effective primary health care delivery, and by promoting female leadership within all aspects of global health.
Primary health care emphasizes ‘whole person care’ while prioritizing prevention, early diagnosis, early treatment, and continuity care. In reality, this requires frontline health workers- primarily women- to provide more care to more people more often. It also requires women- the primary caregivers in families- to access care, insist upon behavior change in their families, maintain behavior change, and continually return for ongoing care. It is critical to recognize that the shift to primary health care delivery could add unanticipated burdens to women who are providing and/or receiving care. This will require a fundamental shift in how health systems and health policies are designed and implemented in local health systems. To achieve the promise of primary health care, TIP Global Health and E-Heza are committed advocating to design local health systems and tools that mitigate the negative impact and promote the positive impact on women and girls.
Gender Equality Priorities
Based on the gender analysis findings, TIP Global Health has developed the following gender equality priorities:
Building a woman’s confidence and ability to educate other family members about health needs. In order to empower women to be decision makers in their homes, TIP will focus on behavior change, encouraging community members to attend trainings and equipping women with knowledge and confidence to bring home healthcare recommendations for their families.
Preventing burnout among women frontline health workers. While E-Heza is designed to specifically prevent burnout among healthcare professionals, the gender analysis identified the need to particularly focus on the double burden many women face of working while also being responsible for most of the housework and childcare.
Inform the global health community on the additional responsibilities that primary health care systems place on women. Successful primary health care delivery places an increased burden of responsibility on frontline health workers and those responsible for the health of their families. Women represent the overwhelming majority of those who are providing and receiving primary health care. As such, TIP Global Health and E-Heza are committed to shining a light on the role of women in primary health care delivery and the importance of providing opportunities to mitigate this additional burden.
Advocate for female representation at all policy-making levels within global health. Women must have an increased voice in the global health sector to ensure that the needs of women who provide and receive primary care services are well represented.
Implementation and Monitoring & Evaluation
Gender Priority 1: Building a woman’s confidence and ability to educate other family members about health needs.
Improving women’s access to health knowledge
TIP Global Health recognizes that effective primary health care depends upon effective delivery of health education. To support this concept, we established the TIP Education Model. This model, based upon key tenets of adult learning, is briefly summarized as: See It, Say It, Do It, Teach It, Talk About It. By using the model, women have the opportunity to talk together about ways to implement the health information that they have received. As part of this discussion, CHWs and nurses will be trained to incorporate questions regarding family dynamics into the “Talk About It” section of their training sessions. This allows the group to discuss challenges they may have when trying to convince their husbands of the benefits of behavior change. In this way, women not only increase their health knowledge, but also build confidence and strategies needed to advocate for change within their families.
Additionally, TIP’s model focuses on utilizing data to create behavior change. E-Heza enables mothers to take home data that supports the recommendations of the community health worker or nurse and contributes to their ability to advocate for change. TIP works to model a community of empowered women, building trust among frontline health workers and healthcare recipients.
Improving male support for women’s health decision-making power in families
To achieve Gender Priority 1, TIP Global Health will implement strategies to improve health education among both women and men. Women often face obstacles in convincing their husbands to adopt behavior change. One action to undertake is to incentivize men to attend trainings. TIP will identify men who are interested in participating and use their voices to convince other men in their communities. In this way, they will act as champions of change. These champions will be supported by male CHWs so that we work within the existing infrastructure of the healthcare system. If men have the necessary skills and knowledge, they can better understand the recommendations provided by frontline health workers. Key areas for health education include antenatal care, disease prevention, family planning, nutrition, family conflict, and money management.
Gender Priority 2: Preventing burnout among women frontline health workers, especially women.
The majority of community health workers, nurses, and midwives are women, most of whom are burdened by societal expectations that they maintain the home and take care of the children in addition to their job responsibilities. When developing E-Heza, frontline health workers expressed the need for a tool to streamline their work and save time. E-Heza has reduced the time taken for administrative tasks by 81% per patient, from 184 minutes to 34 minutes. Last year, E-Heza saved frontline health workers over 565 hours. By eliminating some of the workload, frontline health workers can accomplish tasks more efficiently and spend more time focusing on their needs at home.
TIP Global Health provides capacity building for frontline health workers. CHWs who participate in our training provide better quality of care and can progress further than those who do not participate. Just two years ago, male CHWs were much more likely to attend a training offered by TIP. However, in recent E-Heza trainings, both men and women CHWs were equally likely to attend and actively participate. They also report performing equally in their villages and receiving similar performance-based financing.
Healthcare workers who excel in their roles have been hired by TIP or referred to partner organizations for employment related to E-Heza activities. TIP prioritizes the hiring of women at all levels of the organization. Our Board of Directors is 50% women and senior staff is 70% women. We have also theorized and are further researching the role of a positive relationship between the CHW and the mother in preventing burnout.
Additionally, TIP is conducting research on frontline health worker resilience. Phase One of the Hope Initiative research was published in BMC’s Health and Quality of Life Outcomes journal. This initial research is laying the groundwork for the development of an intervention to support mental health and resilience among healthcare workers. We recently completed in-depth interviews and focus groups among 45 HCWs and 141 HCR to understand the influences of hopefulness and hopelessness at an individual, interpersonal, and health system level. TIP Global Health is working with University of Global Health Equity (UGHE) to conduct a qualitative analysis of the information gathered. This information will inform Phase 3 of our research, which involves the identification of specific health system interventions designed to increase hopefulness among frontline health workers. Our ultimate goal is to demonstrate that health systems can be designed to increase hope and that this will lead to decreased burnout, higher quality care, and improved health outcomes.
Through the gender analysis, we have identified the need to better understand the double burden of family and household responsibilities on female frontline health workers. The insights gained from the Hope Initiative qualitative analysis will be used to build our strategies to address this challenge.
Gender Priority 3: Educate the global health community on the additional responsibilities that primary health care systems place on women.
Our work at TIP Global Health is built upon the foundation of our philosophy- that relationships are critical to successful primary health care delivery, and that these relationships are most effective when frontline health workers and the community members they serve are valued, capable and hopeful in the future. We built our approach for frontline health system innovation with this philosophy at the core. This has led to the successful development, implementation, and expansion of several effective innovations. TIP Global Health is now building our capacity to serve as advocates for the needs of frontline health workers and the community members they serve through the use of rigorous research methods that confirm key features of successful primary health care delivery systems. We are committed to conducting and publishing research findings that inform the design and implementation of effective health systems and policies.
Through this gender analysis, we have recognized the need to disaggregate our data to further demonstrate the gender effects- both positive and negative- of primary health care delivery on female frontline health workers and women as family caregivers. TIP Global Health will utilize our findings to educate the global health community on the hidden additional burden of primary health care on women, provide opportunities to effectively overcome these burdens, and demonstrate the health outcome benefits of designing primary care systems that support the needs of frontline health workers and the women they serve.
Gender Priority 4: Advocate for female representation at all policy-making levels within global health.
TIP Global Health advocates for female representation at all levels of leadership- in our organization, in communities where we work, and in the global health sector. TIP will participate in global networks that provide a platform to advocate for female representation at all policy-making levels within global health. We hope to contribute our perspective to these networks who are already doing excellent work in this realm. Additionally, by participating in these global networks, women leaders within our organization will be supported to become strong leaders in gender equality.
Monitoring and Evaluation
Our approach to gender equity is baked into the design and implementation strategies of E-Heza. In addition to the metrics described above, metrics used to track the effectiveness of E-Heza are disaggregated by gender and socioeconomic status. To assess the impact of E-Heza on hopefulness, the Herth Hope Index is tracked for both frontline health workers and those who engage in care with E-Heza. E-Heza is used to track engagement in care among pregnant women, as well as nutrition status for children disaggregated by socioeconomic status and primary care giver (father, mother, grandparent, sibling).
Notes
- National Gender Statistics Report 2016. https://www.statistics.gov.rw/publication/national-gender-statistics-report-2016
- The Promise and the Reality: Women’s Rights in Rwanda Pamela Abbott, Honorary Professor, School of Social Sciences, University of Aberdeen and Dixon Malunda, Senior Research Fellow, Institute of Policy Analysis and Research, Rwanda Working Paper No. 5 January 2015.
- UNDP. Gender Equality Strategy: UNDP Rwanda (2019-2022).
Last Modified: 1 January 0001