Veloshnee Govender - Academia.edu (original) (raw)

Papers by Veloshnee Govender

Table of contents Executive summary................................................................. more Table of contents Executive summary................................................................................................................. 2 1. Background..................................................................................................................... 4 1.1 Background evidence on trends and issues in meeting the Abuja commitment in ESA... 5

Sexual and Reproductive Health Matters

Despite increasing calls to integrate and prioritise sexual and reproductive health (SRH) service... more Despite increasing calls to integrate and prioritise sexual and reproductive health (SRH) services in universal health coverage (UHC) processes, several SRH services have remained a low priority in countries' UHC plans. This study aims to understand the priority-setting process of SRH interventions in the context of UHC, drawing on the Malaysian experience. A realist evaluation framework was adopted to examine the priority-setting process for three SRH tracer interventions: pregnancy, safe delivery and post-natal care; gender-based violence (GBV) services; and abortion-related services. The study used a qualitative multimethod design, including a literature and document review, and 20 in-depth key informant interviews, to explore the context-mechanism-outcome configurations that influenced and explained the priority-setting process. Four key advocacy strategies were identified for the effective prioritisation of SRH services, namely: (1) generating public demand and social support, (2) linking SRH issues with public agendas or international commitments, (3) engaging champions that are internal and external to the public health sector, and (4) reframing SRH issues as public health issues. While these strategies successfully triggered mechanisms, such as mutual understanding and increased buy-in of policymakers to prioritise SRH services, the level and extent of prioritisation was affected by both inner and outer contextual factors, in particular the socio-cultural and political context. Priority-setting is a political decision-making process that reflects societal values and norms. Efforts to integrate SRH services in UHC processes need both to make technical arguments and to find strategies to overcome barriers related to societal values (including certain socio-cultural and religious norms). This is particularly important for sensitive SRH services, like GBV and safe abortion, and for certain populations.

Why it exists and how we can change it Report of the Women and Gender Equity Knowledge Network of... more Why it exists and how we can change it Report of the Women and Gender Equity Knowledge Network of the Commission on Social Determinants of Health Gender inequality damages the physical and mental health of millions of girls and women across the globe, and also of boys and men despite the many tangible benefits it gives men through resources, power, authority and control.

Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is am... more Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is among the three cities in the country with the highest TB burden. Despite implementation of Directly Observed Treatment Short-Course (DOTS), and improvements in the organisation and delivery of TB care, poor treatment adherence challenges treatment outcomes and the health system's ability to reach international targets. TB requires long-term care, where the relationship with healthcare providers is one of the important influences on decisions to seek care and adhere to treatment. This study sought to explore and deepen insight into how trust is built and experienced between patients and healthcare providers for TB treatment in primary care settings from a gender perspective. Methods: The research was located in three local government-managed clinics in the City of Cape Town's Metropole health district, similar in TB patient load and performance indicators, but differing in level of TB-HIV integrated services. A case study design employing qualitative data collection approaches (non-participant observations in clinics, focus group discussions and in-depth interviews with patients and providers) was applied. Findings: Trust plays a central role for both patients and providers in treatment for TB. On the part of patients, many expressed a deep desire and motivation to complete their treatment. However, patient vulnerability, a complex outcome of intersecting factors at all levels (personal, community and health service level), across which gender was an underlying influence, emerged as a critical influence over patient trust in providers and the health system, with consequences for a range of outcomes including treatment adherence. The ability of providers and the health system as an institution to recognise and respond to patient vulnerability and needs beyond the illness, including to access socioeconomic and psycho-social support for the patient, was critical for building trust and enabling adherence. On the part of healthcare providers, vulnerability was a consequence of a range of factors, including professional status and gender, with implications for how trust was built in patients and managers and its outcomes. Patient trustworthiness was based on judgements of competency, integrity and recognition. The ability of managers to mitigate the challenges healthcare providers faced, through providing a supportive and enabling work environment, had implications for providers' experiences and judgements of institutional trustworthiness. Conclusion: Reflecting on the findings within broader national, provincial and global health policy reforms, specific strategies for building patient and provider trust in each other, and in the health system, are proposed. Recommended strategies addressing both patient and provider vulnerabilities rooted in the personal, community and health facility environment are considered. While many of the recommendations are specific to the TB and TB/HIV model of care, they have wider relevance for building mutual trust between patients and providers and enhancing the responsiveness of the health system as a whole. This is important in the context of South Africa, where the vision espoused under proposed National Health Insurance reforms towards universal coverage is transformative, even revolutionary, but its implementation and ultimate achievements are likely to be dogged by challenges of patient and provider trust in the health system, unless themselves addressed. Globally, the study's conclusions also offer important insights about patient-provider trust relevant to health system development, as well as ideas for future, related research. Akin to taking a village to raise a child, it takes a community to write a thesis. This thesis would not have been possible without the support, encouragement and ultimately trust of many. I am grateful to: All research participants. Thank you for entrusting me with your stories. You have taught me that despair need not be companion to ill-health and our shared vulnerability is what makes us human. You have changed the way I see the world. I will not forget you. The City of Cape Town and managers at all levels of the system. Thank you for the opportunity to conduct the study and your commitment and belief that research and evidence are critical for strengthening the health system. My sincerest hope is that this study will contribute to improving the health systems for all. Professor Lucy Gilson, my supervisor. Lucy, it is not an exaggeration to say that you are a giant in the field of health policy and systems research and there were times when I was so intimidated by both topic and you, I considered changing both topic and supervisor! I'm glad I stayed the course. I hope you are too. Thank you for believing in me and encouraging me to stretch my intellectual muscle. You are an exceptional supervisor, not only because of your technical expertise, but more importantly, you care. Professor Di McIntyre, my academic mentor and long-time friend, Di, for more than 20 years, you have been my champion and I your greatest fan. Thank you for seeing the best in me and always "making a plan". Dr Anna Strebel, my mentor, counsellor and friend. Anna, it takes a special person to mentor and you are that. Your humour and takeaway line, "A PhD is just another brick in the wall!" got me through many low moments, alongside those wonderful coffees in Mango Ginger. Thank you. Dr Edina Sinanovic, my friend, colleague and director. Edina, thank you for your leadership, encouragement and friendship over the past 20 years. My research team and my gurus in the field. Amanda, Melinda, Ntobeko and Anna, working alongside you was an opportunity for unparalleled learning. I am in no small way indebted to you. This thesis is a reflection of your commitment to building a country, our country, which is just, equitable and home to all.

Health Policy and Planning, 2019

Women comprise a significant proportion of the health workforce globally but remain under-represe... more Women comprise a significant proportion of the health workforce globally but remain under-represented in the higher professional categories. Concern about the under-representation of women in health leadership positions has resulted in increased research on the topic, although this research has focused primarily on high-income countries. An improved understanding of the career trajectories and experiences of healthcare leaders in low- and middle-income countries (LMICs), and the role of gender, is therefore needed. This qualitative case study was undertaken in two counties in coastal Kenya. Drawing on the life-history approach, 12 male and 13 female healthcare leaders were interviewed between August 2015 and July 2016 on their career progression and related experiences. Although gender was not spontaneously identified as a significant influence, closer exploration of responses revealed that gendered factors played an important role. Most fundamentally, women’s role as child bearers ...

Health Policy and Planning, 2017

In a webinar in 2015 on health financing and gender, the question was raised why we need to focus... more In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts. We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, femaleheaded households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority. We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized. We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the 'progressive universalism' advocated for by the 2013 Lancet Commission on Investing in Health.

International Journal for Equity in Health, 2017

Background: This paper uses the concepts of organisational culture and organisational trust to ex... more Background: This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policiesthe Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC)-in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low-and middle-income country health systems, and broader work on health systems' people-centeredness and "software". Methods: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patientprovider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. Results: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.

Sociology Mind, 2015

This paper examines elements of mistrust, blame and suspicion among patients and providers in the... more This paper examines elements of mistrust, blame and suspicion among patients and providers in the South African health system which affect practice and policy development. Using stories told by patients and providers in Cape Town, Johannesburg and Bushbuckridge, it examines how suspicion is constructed and how others are blamed for adverse outcomes. This paper sets a conceptual framework which examines the attribution of blame in contemporary social and political life, the narratives of 45 patients receiving HIV/AIDS, TB or maternal delivery services and those of 63 providers dealing with similar treatments and arranged across a series of facilities, clinics, hospitals and mobile vans were constructed and shared with participants. These narratives form the basis of the results sections which examines suspicions among both providers and patients with the former seeing the latter as having no respect and regard and providing poor care and access to grants. Providers saw themselves as highly stressed but diligent with service challenges being blamed on patient ignorance, unreasonable demands and failure to follow medical advice. The paper ends with a discussion on how to limit mistrust and reduce suspicion through more cooperative provider-patient relations and what this kind of evidence means for decisionmakers.

BMC Health Services Research, 2015

Background: In South Africa, HIV/AIDS remains a major public health problem. In a context of chro... more Background: In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, we consider 1) inequalities in access to the DG for patients on ART and 2) implications of DG access for ongoing access to healthcare. Methods: Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. Results: Grant recipients were comparatively worse off than non-recipients in terms of employment (9.1 % vs. 29.9 %) and wealth (58.3 % in the poorest half vs. 45.8 %). After controlling for socioeconomic and demographic factors, site, treatment duration, adherence and concomitant TB treatment, the regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed (p < 0.001). Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG (significant at the 5 % level). The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. Conclusions: These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.

Global public health, 2015

Sexual and reproductive health and rights (SRHR) are centrally important to health. However, ther... more Sexual and reproductive health and rights (SRHR) are centrally important to health. However, there have been significant shortcomings in implementing SRHR to date. In the context of health systems reform and universal health coverage/care (UHC), this paper explores the following questions. What do these changes in health systems thinking mean for SRHR and gender equity in health in the context of renewed calls for increased investments in the health of women and girls? Can SRHR be integrated usefully into the call for UHC, and if so how? Can health systems reforms address the continuing sexual and reproductive ill health and violations of sexual and reproductive rights (SRR)? Conversely, can the attention to individual human rights that is intrinsic to the SRHR agenda and its continuing concerns about equality, quality and accountability provide impetus for strengthening the health system? The paper argues that achieving equity on the UHC path will require a combination of system im...

Global Health Action, 2013

Background: In 2005, the South African government introduced a voluntary, subsidised health insur... more Background: In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. Objectives: This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. Methods: Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. Results: Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socioeconomically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. Conclusion: Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.

Summary Abstract The purpose of the paper is to review the literature examining the resource cons... more Summary Abstract The purpose of the paper is to review the literature examining the resource consequences,of ill health at the household level. Policy been generally ineffective in reaching the poor who have substantial problems in

Tropical Medicine & International Health, 2012

objectives A mixed methods study exploring gender differences in patient profiles and experiences... more objectives A mixed methods study exploring gender differences in patient profiles and experiences of ART services, along the access dimensions of availability, affordability and acceptability, in two rural and two urban areas of South Africa. methods Structured exit interviews (n = 1266) combined with in-depth interviews (n = 20) of women and men enrolled in ART care. results Men attending ART services were more likely to be employed (29% vs. 20%, P = 0.001) and were twice as likely to be married ⁄ co-habiting as women (42% vs. 22% P = 0.001). Men had known their HIV status for a shorter time (mean 32 vs. 36 months, P = 0.021) and were also less likely to disclose their status to non-family members (17% vs. 26%, P = 0.001). From both forms of data collection, a key finding was the role of female partners in providing social support and facilitating use of services by men. The converse was true for women who relied more on extended families and friends than on partners for support. Young, unmarried and unemployed men faced the greatest social isolation and difficulty. There were no major gender differences in the health system (supply side) dimensions of access. conclusions Gender differences in experiences of HIV services relate more to social than health system factors. However, the health system could be more responsive by designing services in ways that enable earlier and easier use by men.

Journal of Public Health Policy, 2011

In South Africa, anticipated health sector reforms aim to achieve universal health coverage for a... more In South Africa, anticipated health sector reforms aim to achieve universal health coverage for all citizens. Success will depend on social solidarity and willingness to pay for health care according to means, while benefitting on the basis of their need. In this study, we interviewed 1330 health and education sector civil servants in four South African provinces, about potential income crosssubsidies and financing mechanisms for a National Health Insurance. One third was willing to cross-subsidize others and half favored a progressive financing system, with senior managers, black Africans, or those with tertiary education more likely to choose these options than lower-skilled staff, white, Indian or Asian respondents, or those with primary or less education. Insurance-and health-status were not associated with willingness to pay or preferred type of financing system. Understanding social relationships, identities, and shared meanings is important for any reform striving toward universal coverage.

BMC Health Services Research, 2015

Background: South Africa is at present undertaking a series of reforms to transform public health... more Background: South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. Methods: As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. Results: The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion-and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. Conclusions: Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.

The study assessed the perspectives of HIV-positive mothers and family members (grand-mothers and... more The study assessed the perspectives of HIV-positive mothers and family members (grand-mothers and fathers) of the infant feeding options recommended for HIV-infected mothers in Ghana. This entailed individual interviews with 40 HIV-positive mothers with infants aged 0 to 12 months and 6 focus group discussions with HIV-positive mothers, fathers and grandmothers of unknown status in two urban districts. All infants born to HIV-positive mothers in both districts had been breastfed. Breastfeeding was initiated between three hours and three days following birth. While some of the infants had been exclusively breast-fed, none had been exclusively formula fed. Early mixed feeding patterns were deeply entrenched. Barriers to exclusive replacement feeding by HIV-positive mothers included cultural and familial influences, socio-economic factors including cost of infant formula, lack of access to fridges, clean water and fuel. Interventions designed to promote safer infant feeding among HIVin...

Sexual and Reproductive Health Matters, 2020

Introduction Universal health coverage (UHC) is a monumental idea that gained prominence in the t... more Introduction Universal health coverage (UHC) is a monumental idea that gained prominence in the twentieth century, following earlier historical antecedents. Particularly, since the end of the Second World War, the adoption of measures by some governments to ensure – to varying degrees – needed health services without financial hardship has transformed the health and lives of billions of people. However, demonstrated through growing evidence, we know that the “universal” in UHC remains aspirational. The World Health Organization (WHO) estimates that at least half of the world’s population still does not have full coverage for essential health services and that 100 million people are pushed into extreme poverty because of healthcare costs. These figures predate the tremendous and expanding impact of COVID-19: a crisis which has put enormous strain on, in many instances, under-resourced, poorly functioning and inequitable health systems in high-, middleand low-income settings, and whic...

16 3.3 Creation of deprivation indices 16 3.3.1 General Index of Deprivation (GID) 16 3.3.2 Healt... more 16 3.3 Creation of deprivation indices 16 3.3.1 General Index of Deprivation (GID) 16 3.3.2 Health-related Index of Deprivation (HID) 17 3.3.3 Policy-perspective Index of Deprivation (PID) 18 3.3.4 Use of a single variable 18 3.3.5 Comparison of the alternative indices 18 3.4 Exploring the relationship between health and deprivation (Rural/Urban analysis) 19 3.5 Analysing the implications for inter-provincial resource allocation 19 3.6 Problems and limitations 19 3.6.1 Socioeconomic characteristics 19 3.6.2 Measures of health need 19 3.6.3 Small areas used 20 4. RESULTS 20 4.1 General Index of Deprivation: all areas 20 4.1.1 Selecting the variables for analysis 20 4.1.2 Constructing the General Index of Deprivation 22 4.2 Policy-perspective Index of Deprivation 23 4.3 Use of a single variable Index of Deprivation 24 4.4 Health-related Index of Deprivation 25 4.5 Comparison of the indices with each other and with ill-health indicators 26 4.6 Deprivation and ill-health in urban areas 28 4.7 Deprivation and health service provision 29 5 DISCUSSION 32 5.1 Review of alternative deprivation indices 32 5.1.1 Key issues in relation to the deprivation indices 32 5.1.2 Using perceptional information to critique the indices 33 5.2 Comparison of deprivation, mortality and health service distribution 34 5.3 Implications for planning and resource allocation 35 5.3.1 Inter-provincial resource allocation issues 35 5.3.2 Intra-provincial resource allocation and service planning issues 38 6. CONCLUSIONS 39 REFERENCES 43 We are also extremely grateful for the financial support which made this research possible: • This investigation received financial support from the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. • This research was supported and conducted under the auspices of the Southern African regional network on equity in health (EQUINET) with support from the International Development Research Centre (Canada). IMPORTANT NOTE This report is a summarised version of the original research report. If readers would like more extensive information on the literature review, research methodology and research results, please contact Di McIntyre

Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, 2004

South Asian nations are at the crossroads of economic and political progress but still face sever... more South Asian nations are at the crossroads of economic and political progress but still face severe problems of under-development. Available data illustrates that while some macroeconomic indicators have improved over the years, disparities between rich and poor have increased manifold. Although infectious diseases remain a formidable enemy, noncommunicable diseases and injuries are increasing the health challenges facing the countries of the region. While it is widely recognized and accepted that infectious diseases predominantly affect the poor, there is insufficient evidence documenting the burden of RTI on the lower socioeconomic groups in developing countries. Low educational level, poorly paid occupations and poverty have all been found to be risk factors for road traffic injuries. This paper reviews available data from South Asia to show that RTI disproportionately affect the poor in terms of mortality, morbidity and disability, and presents a persuasive argument to policy mak...

Sexual and Reproductive Health Matters

Health Policy and Planning, 2019

Health Policy and Planning, 2017

International Journal for Equity in Health, 2017

Sociology Mind, 2015

BMC Health Services Research, 2015

Global public health, 2015

Global Health Action, 2013

Tropical Medicine & International Health, 2012

Journal of Public Health Policy, 2011

BMC Health Services Research, 2015

Sexual and Reproductive Health Matters, 2020

Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, 2004