Public-Private Partnerships viewed through a gender lens

In a new paper, published in the Journal of International and Comparative Social Policy, Dr Jasmine Gideon argues that despite their current popularity, Public-Private Partnerships need to be reviewed through a gender lens in order to establish whether they are really enabling the health sector to address wider social determinants of health and to ensure the longer-term success of any pro-women healthcare interventions.

Credit: Russell Watkins/Department for International Development.

Credit: Russell Watkins/Department for International Development.

Good health and sustainable development are widely acknowledged to be inextricably linked, and the promotion of health and well-being is an essential element in the Sustainable Development Goals (SDGs).  Within SDG3, ‘Ensure healthy lives and promote wellbeing for all at all ages’, governments have pledged to ensure universal access to sexual and reproductive health (SRH) care services by 2030.

One of the approaches often cited as necessary to provide universal access is through Public-Private Partnerships (PPPs) in health. The term PPP has been used in a variety of different contexts, but in the case of delivery of SRH services, PPPs have been used to fund and implement social franchising and health care voucher programmes in the Global South. They typically tie the recipient to a specified good or service package, such as medical consultations during pregnancy, provided by specified service providers who are often private practitioners or private sector facilities.  The approaches have grown in popularity since 2000 because:

  • they have been promoted by a range of aid donors including DFID and USAID
  • they are relatively easy to administer and to measure and monitor,
  • they are considered to be a way of encouraging poor households to use services e.g. family planning that they would not otherwise access.

However, there is criticism about the lack of evidence to sustain the claims made about the effectiveness of PPPs in improving access to health care services, and a recent paper by Benjamin M. Hunter, Susan F. Murray and I has argued that such PPPs may do little to address gender inequalities in health. We highlight the need to apply a ‘gender lens’ to the debate around the effectiveness of PPPs in SRH. We propose three key questions that should be asked of all PPP programmes to determine whether issues of gender inequality have been considered:

  1. What are the assumptions underpinning agendas in SRH-PPP interventions?
  2. How are SRH-PPP programmes framed and judged?
  3. To what extent do the SRH-PPP interventions take into account, reinforce or confront the existing realities of gendered social and economic life?

Applying these questions to a case study of a voucher scheme in India, we found that the design of the voucher programme was based on an assumed relationship between use of formal healthcare and decreased mortality and fertility, and the assumed superior effectiveness of private healthcare ‘markets’. The programme was framed as ‘innovative’ yet programme documents indicate the emphasis was on demonstrating rather than testing vouchers as a healthcare delivery model, and claims of success were made based on changes in healthcare use that were not adjusted for government programmes running concurrently.

The scheme in India did little to confront gender norms and values that are deeply embedded within health systems as well as the households that interact with them. For example despite the claims in programme documents to give pregnant women a choice of facility where they wish to give birth, in reality the decision was made by a husband, mother-in-law, female community health worker or the worker’s male supervisor.

The case study also shows that while PPPs claim to address gender-based inequalities, they do so within a limited framework whose simplistic focus on the gaps in women’s health fails to consider the socially constructed relations between men and women. Such PPPs therefore become part of a wider trend of interventions that have contributed to the depoliticization of women’s health and instead maintain a simplistic focus on maternal health that ignores the gendered power relations.

We argue that despite their adoption as the buzzwords of the moment it is not clear that PPP arrangements move us closer towards the ability of the health sector to address the wider social determinants of health that are critical to ensuring the longer-term success of any pro-women healthcare intervention. Applying a gender lens to review the evidence is one way that we can move closer to this goal.

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Handbook on Gender and Health

This post was contributed by Dr Jasmine Gideon, senior lecturer in Development Studies at Birkbeck’s Department of Geography, Environment and Development Studies. Here, Dr Gideon offers an insight into her new book: The Handbook on Gender and Health

My monograph ‘Gender, Globalization and Health in a Latin American Context’ develops the idea of a gendered political economy of health and uses this framework to consider health reform in Chile. Compiling the Handbook on Gender and Health offered me an opportunity to develop my ideas further through directly engaging with a wide range of

Dr Gideon's book cover features an piece by Gambian artist Suelle Nachif titled 'Faj' ('heal')

Dr Gideon’s book cover features a piece by Gambian artist Suelle Nachif titled ‘Faj’ (‘heal’)

academics and policy makers working in this area.

The Handbook offered an opportunity to highlight empirical examples from across the globe and draw attention to case study analysis of specific issues that I was not able to include in my own book. Working on the Handbook was also a chance to think about what my ‘dream team’ of authors would look like and bring together a wide range of writers working on a variety of health-related issues, ranging from the historical development of health systems and how women and men are located within this to more ‘contemporary’ debates around migration, climate change and low paid labour which all have critical implications for health, particularly when viewed through a gender lens.

The Handbook brings together a wide range of disciplinary perspectives to consider four overarching themes, all constituting distinct but over-lapping elements of a broader gendered political economy of health. These are:

Gender equity vs gender equality

The first theme is the tension between ideas of gender equity and gender equality and how these translate in practice when applied to the health sector. Chapters explore the difference between ‘reductionist’ approaches where categories of women and men are not sufficiently explored, for example by failing to address how other axes of inequality (e.g. race/age/ class) can affect people’s ability to engage with health systems. In contrast a gender equality approach seeks to promote gender justice.

According to UN Women (2010), this entails ending the inequalities between women and men that are produced and reproduced in the family, the community, the market and the state. However, at the same time it requires that mainstream institutions are more accountable and transparent and points to the second theme discussed in the book.

Dr Jasmine Gideon

Dr Jasmine Gideon

The gendered nature of health systems

Several of the chapters reflect on the need to uncover the gendered nature of the health system itself and shed light on the diverse ways in which women’s interests are frequently marginalised or health policies work to reinforce women’s gendered roles and responsibilities.

Including marginalised voices

The third theme that is examined is the importance of incorporating the voices of excluded groups in policy processes as several chapters highlight the health costs of failing to engage with marginalised sectors of society.

Challenging ‘one size fits all’

Finally the fourth theme that emerges from a number of the chapters is the importance of appropriate policy responses and a move away from the ‘one size fits all’ approach, often espoused by international donors and global health discourses.

Within the Handbook authors from the Global North and South highlight how many of these challenges have wider relevance to all of our lives and that ‘gender’ remains central to any analysis of health, regardless of the level of development within the health system or wider economy.

Find out more

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