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.

Further information:

. Reply . Category: Social Sciences History and Philosophy . Tags: , ,

Guilt, pity and shame in humanitarian and human rights communications

This post was contributed by Dr Bruna Seu from Birkbeck’s Department of Psychosocial Studies

NGOs often use images designed to induce feelings of guilt in order to encourage donations

You have just sat down for lunch. You switch on the TV and you are confronted with the image of a malnourished child. Somebody is measuring their arm with a tape and the appeal asks you to donate £3. It’s simple: you have your lunch, they don’t. You feel guilty and you give.

This guilt-inducing formula raises much-needed revenue for NGOs and humanitarian organisations, so it is understandable why they return to it time and again. However, my research into the way the public responds to information about human rights violations and humanitarian crises suggests that using guilt as a fundraising tool is problematic.

The problem with guilt in humanitarian fundraising

The pain of guilt inspires in people a new capacity for reparation and the desire to right the wrong. While a monetary donation can momentarily alleviate the guilt inspired by humanitarian appeals, for many it does not constitute a sufficiently reparative action.

A more desirable aim than finding a way to momentarily alleviate guilt is to develop a feeling of connectedness with those suffering. Development of a meaningful understanding of the issues at play is hindered by narrow, racially-stereotyped portrayals of developing countries, which ignore the role of domestic actors in the global South and reinforce the perception that more charity is required rather than fundamental political and economic change.

A further problem is that the sheer volume of these guilt-inducing messages leads to a sense of hopelessness and helplessness that shuts down routes to improved understanding and connectedness, creating a vicious cycle where we feel guilty, donate to alleviate guilt, and then ignore the suffering other until we are bombarded by further guilt-inducing messages. This cycle leaves no room for alternative thinking that would increase awareness of development issues or behavioural engagement in the form of volunteering and campaigning.

Participants in my studies have shown awareness of guilt being part of their immediate reaction and that when ‘it wears off’, as they put it, they are left with nothing to hang onto. So we have a self-perpetuating cycle whereby people donate partly because they  feel pity, compassion, guilt and they want to help; partly because they don’t know what else to do; and partly, as a consequence of these two. Donating is a way of ‘switching off with a clear conscience’.

Shame vs guilt

My research is now beginning to consider the experience of shame as opposed to guilt, and whether this would lead to more meaningful engagement in the issues. There are many potential problems to invoking feelings of shame. However, while guilt is related to an action – something we did or didn’t do, shame is about the whole of ourselves. Yet, precisely because it is personal, rather than relating to a bad action, it rests on relationality – what needs repairing is the link with the other. Let’s say if guilt messages are of the kind ‘skip lunch – save a child’ and a child dies because you did not skip lunch, of course you give – you ‘did the right thing’. But what if messages prompted reactions such as: ‘I don’t want to be the kind of person who is informed of such horrors and doesn’t do anything.’?

Contrary to guilt, regulated by the world of norms and laws which is the territory of the superego – the self I ought to be, the referent in shame is the ego ideal – the self I wish I could be. It might seem a small difference, but one that shifts the terrain from the transactional to the relational. I am no longer saving the other, but on the contrary it is with the other that I can be saved. When the bond between self and other is intact we feel pride and harmony. Maybe such a relational mode could return dignity and power to the other and make us agents not of hand downs but of our own betterment as human beings.

This article is based on a talk that Dr Seu gave recently at the Dartington Centre for Social Research

Find out more:

. 1 comment . Category: Social Sciences History and Philosophy . Tags: , , , , , , , , , ,

‘All they want is my money’; a relationship in crisis

This post was written by Dr Bruna Seu, from Birkbeck’s Department of Psychosocial Studies and Dr Shani Orgad from the LSE.

Donating Money To Charity‘All they want is my money.’ This is the most common rejoinder from participants in a UK nationwide study carried out between 2011 and 2014 by Birkbeck and LSE on public attitudes towards humanitarian and international development issues and responses to humanitarian communications.

The study found that we, the UK public, are emotionally responsive to humanitarian problems but we are also fatigued and disillusioned. Although people give generously to one-off appeals in response to natural disasters, they struggle with maintaining an on-going and meaningful connectedness with humanitarian and international development issues. This is a big problem for NGOs long-term work. Part of the problem is how humanitarian and international development crises are communicated to the public by NGOs. Financial pressure and increased competition within the field means that NGOs’ communications have become increasingly geared towards raising funds from the public via methods derived from advertisers and commercial retailers. Yet data shows that as soon as humanitarian communications are perceived as advertising the public switches off.

This predominantly fundraising-driven approach is proving detrimental. With the exception of humanitarian emergencies, the public is expressing widespread fatigue and resentment to being targeted solely as monetary donors. They resist engaging with the communications because they believe that ‘all they want is my money’. The public expect to and accept feeling sad and upset by humanitarian communications but too often they believe that NGOs manipulate their emotions in order to make them donate. We become desensitised and resentful towards NGOs, which leads us to further distance ourselves from humanitarian issues.

In order to decide what action we should take when faced with a humanitarian crisis of almost incomprehensible scale, such as the Syrian civil war, floods in the Philippines or the earthquake in Haiti, we need to be able to understand and contextualise the human suffering that they cause. NGOs can help us to do this by providing concise information which clearly sets out how our support can improve the lives of others. Rather than evoking an extreme emotional reaction, this information can be processed, managed and then used to consider what social responsibility we have towards these distant sufferers , as well as the humanitarian imperative to help and care for them.

Although the UK public respond overwhelmingly with compassion and empathy to the suffering of those affected by humanitarian crises, several factors prevent this emotional responsiveness from turning into action. When talking about helping distant sufferers, people think and respond as if the world were a small village and apply principles and practices of care they are familiar with. They want a relationship with those they are helping that is more ‘human’, close and embodied. They believe that sufferers ‘need more than money’, and overall doubt that their monetary donation will make any difference, particularly in the long term.

However, there is a clear discrepancy between the model offered by NGOs, and the one wished for by the public. This increases a sense of alienation between the public and distant sufferers as well as between the public and NGOs.

NGO communications and fundraising professionals in humanitarian and international development believe that the UK public trust them and view their work as valuable, but the Birkbeck/LSE study found that the public overall distrust and resent NGOs for behaving as a business.

If NGOs want a more sustainable relationship with the public, it is essential that they revisit their view of the public, to one predicated on understanding of and respect for the psychosocial complexities of the public’s responses – how we understand, process and emotionally respond to humanitarian causes, and what moral principles govern our responses.

It is urgent that both governmental and non-governmental organisations reflect on their current practices and make a concerted effort to foster and sustain public’s connectedness with humanitarian issues if they wish to create a civil society, where the public feels connected to and globally responsible to others. NGOS need to invest in rebuilding trust with the UK public, by complementing the interest and efforts geared at making the public donate, with a better understanding of how to evoke and enable appropriate emotions, foster understanding by providing manageable information, and offer possible actions which correspond with practices of care the public is familiar with.

NGOs can support connectedness between the public and humanitarian causes which is sustainable over time but it will require a reassessment of how they conceive of, interact with, and communicate to the public.

The findings from the project were discussed at the ‘Caring in crisis?’ colloquium, held at Birkbeck on 7 June 2014. Listen to the podcasts of the colloquium.

. Reply . Category: Social Sciences History and Philosophy . Tags: , , , ,