Gender, rights, equity: Reflections from the Cape Town Health Systems Research Symposium

While ‘equity’ was a theme that was constant across previous symposium programs, mention of gender and rights increased from 6 times in Montreux and 10 times in Beijing to 53 times in Cape Town. While word counts are an imperfect measure, this is one sign among many that distinguished the Cape Town conference.

Who are the people in people-centred health systems?

‘People’ include women, men, and other genders, negotiating various social hierarchies, power relations and identities in diverse and dynamically changing social contexts. Symposium participants argued for deconstructing the term ‘community’ to understand how varied social determinants, such as gender, race, sexual orientation, (dis)ability, class, age, and migrant or refugee status, intersect to shape a person’s lived experiences, including their access to resources and services.

Facilitating engagement

In reviewing the terms by which diverse people are involved with health systems, participants noted that health systems must not only give people information about their rights, but also support an empowering environment that enables people to realise these rights.

Health workers can be agents of change or gatekeepers that perpetuate inequality; they are both creative and fallible. Discussions about patient-provider relations, as well as citizen and health system interfaces, emphasized engaging intimately with individuals and their attitudes, as well as systemically changing the conditions that frame such interactions.

Dialogue, listening, and the need to foster mutual respect percolated throughout the Symposium. At the opening, we watched videos from a broad array of stakeholders, and keynote speakers argued against silos between those who work on gender, sexuality, rights, equity, economics and health systems. Almost all plenary sessions facilitated informal conversations, inspiring many subsequent interactions and new relationships.

Politicising health systems

There was an appreciation of politics and its link to poverty and marginalisation. We were told, ‘Programs for the poor, are poor programs’, since they are often poorly resourced, poorly managed, segmented and often depoliticised. Revisiting the foundations of health systems, the importance of universality was affirmed, even if its translation into universal health coverage was not necessarily so. The People’s Health Movement charter was seen as an appropriate anchor mooring the health systems field, as were frameworks affirming sexual and reproductive rights and primary health care.

While many countries have agreements supporting the right to health, participants noted the potential for backlash if these are not supported or implemented adequately. The need for a rights perspective is all the more critical when witnessing – across the world –gross violations, large scale inequality, instability, threats to security and the rise of fundamentalist groups on the one hand, and the depoliticization of public health on the other.

Attendees reflected that when one raises politics or rights, one tends to get branded as ideological. Yet public health is a deeply political endeavour, and if our research is meant to advance the health of the public, frame entitlements, broaden resources, and include those often made invisible or left behind, then acknowledging and addressing politics is key.

Implications for research

Discussions frequently noted the value and credibility of qualitative research, particularly for understanding social exclusion and “hearing the voices of those marginalized”. The plenary presentation showcasing participatory research, the release of the Alliance reader on the same topic, and the multiple sessions discussing these approaches challenged conventional approaches to research. Participants questioned who undertakes research, who uses it and for what ends? The standards, practice and funding of research need revisiting if gender, rights and equity are to be central to health systems.

Research as a mediator of knowledge entails power and privilege, and therefore its misuse and failings are a central concern. Despite best intentions research can reflect global inequalities. Even with concerted organisation, several researchers were not able to attend the meeting due to discriminatory visa processes. Access to research funding and findings is also highly unequal. Many participants called for stronger efforts to ensure open access to research and fairer representation on journal editorial boards. The need to support research capacity and institutions in low and middle income countries, and to address inequities in institutional overheads and global research partnerships was strongly underscored.

A key part of research is challenging assumptions and altering perspectives. Work on gender, rights, and social exclusion is not just about intellectual understanding, but also about facilitating experiential empathy, solidarity, and action, via methodologies such as the ‘Theatre of the Oppressed’ and photovoice. In addition to films, posters, and cartoons, a photographic competition sponsored by RinGs was displayed to inspire imagination and provoke critical examination about what gender means for health systems.

Participants considered whether gender, rights, and equity researchers were sufficiently reflexive about their assumptions and values and able to communicate this to mainstream audiences, although those in power rarely worry about explaining their language or translating their terms. As distinctions between what is unacceptable and what is conventional in research vary from one person and discipline to another, we must all learn each other’s terms and step out of our comfort zones, pushing the boundaries of how we communicate, learn, and transform health systems.

Moving forward

Applying a gender, rights, and equity lens to health systems expands beyond thinking about the needs of ‘other’ people. It is also about how understanding infused by solidarity, combined with learning, reflection, movements, politics, and action serves as the foundation for people-centred health systems. Will the next Symposium sustain this attention to gender, rights, and equity?

To read the full Cape Town Statement (PDF) click here.

To find out more about RinGs visit our website or drop us an rings [dot] rpc [at] gmail [dot] com (email).