By Ruth Young (Johns Hopkins Bloomberg School of Public Health), Richard Mangwi (Makerere University), Maylene Shung-King (University of Cape Town) and Rosemary Morgan (Johns Hopkins Bloomberg School of Public Health).
Health system functioning, operation, design and governance can reflect and perpetuate broader power structures in multiple ways. This dynamic of advantage/disadvantage may contribute to health disparities that reflect broader power structures. The aim of this blog post and associated commentary is to start a conversation around how and why we can use an intersectional lens to understand the power dynamics within health systems and the resulting health inequities in our communities.
Drawing on our previous work, we highlight the following ways health systems operate within and perpetuate systems of oppression:
- Health systems are based within existing societal systems
- Health service delivery excludes marginalized groups
- Health information systems reflect and perpetuate existing systems of oppression
Health systems are based within existing societal systems
Health systems and the ways we govern, finance and deliver health are rooted in historical and contemporary systems of oppression and power. For example, South Africa’s history of oppression of Black people during the apartheid era, coupled with a patriarchal society, restricted access to education and work opportunities especially for Black women. During apartheid, the career advancement and training for Black men, and even more so for Black women, were limited, contributing to poor representation in management positions, especially in senior positions. We see the repercussions of this history today, where the confluence of gender, race, and professional hierarchy still influence the nature of leadership and management in today’s health system. Historical barriers to advancement, coupled with gender norms, result in fewer Black women holding health management (and even fewer senior) positions. Understanding the intersectional drivers of leadership and representation in health systems can show how health systems reflect and perpetuate existing systems of oppression and power.
Health service delivery excludes marginalized groups
Different groups experience different barriers to accessing and utilizing health services. For example, in Masindi, Uganda, one of the authors of the commentary found that immigrant women perceived or experienced additional barriers to accessing maternal and newborn care compared to non-immigrant women. Immigrant women were likely to delay maternal care during delivery due to potential discrimination by health workers, cultural norms that perceive women as ‘strong’ if they did not complain during labor pains, and belief that delivery is a woman-only issue. Given the unique needs of immigrant women seeking maternal and newborn health care, services could be redesigned to be more user-friendly and as a result, make health delivery more equitable.
Health information systems reflect and perpetuate existing systems of oppression
What is measured reflects what is valued in a health system. In Uganda, for example, the sexual and reproductive health needs of women with physical disabilities were left unaddressed. Women with physical disabilities were perceived as not having the same reproductive and sexual needs as women without walking disabilities as they were often perceived to be asexual and/or unable to look after offspring. Without data describing the sexual and reproductive health needs of women with physical disabilities, preconceptions of their health needs prevail and services are not designed to meet their needs.
Applying an intersectional lens to help understand and dismantle systems of oppression within health systems
Applying an intersectional lens is a fundamental step to dismantling systems of oppression both in the health sector and beyond. Intersectionality shows how overlaying social stratifiers (gender, ableness, sexual orientation and identity etc.) can intersect making some groups at an advantage and others at a disadvantage. Intersectionality was first coined by Kimberlé Crenshaw to describe how the experience of Black women is not wholly captured by being Black or a woman alone. Rather, the intersection of being both Black and a woman interact in ways that result in a unique experience unable to be explained by either single identity.
Applying an intersectional lens to health systems helps us comprehensively examine health inequities. If we don’t, we run the risk of a superficial analysis of inequity in health outcomes, focused on the outcomes rather than the entrenched and root causes of the inequity. Policymakers, researchers and planners can take appropriate steps to help reduce the impact of entrenched inequity by examining power structures, describing health inequities, recognizing that health systems are set within historical and contemporary legacies of oppression. Applying an intersectional lens is key dismantling systems of oppression both in the health sector and beyond.
This blog and commentary is designed to start a discussion on ways to understand how health systems can perpetuate and challenge systems of oppression – can you think of other ways from your own work or experience that highlight how health systems operate within and perpetuate systems of oppression and/or how an intersectional lens can be used to dismantle systems of oppression both in the health sector and beyond?
- 10 Best Resources on Intersectionality with an emphases on LMICs
- TEDTALK from Kimberle Crenshaw: The urgency of intersectionality
- Providers’ perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya