Program Goal / Need:
The US Agency for International Development (USAID) funded the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project because evidence-based care is not reaching the people who most need it. Led by University Research Co., LLC, this five-year project aims to improve health care in USAID-assisted countries, strengthen their health systems, and advance the frontier of improvement science. The overall objective of ASSIST is to foster improvements in a range of health care processes through the application of modern improvement methods by host country providers and managers.

Addressing the different needs, behaviors, preferences, access to, and utilization of health services for men, women, girls and boys is critical to any quality improvement effort. Implementation of improvement interventions without consideration of gender dynamics risks failure to reach half of the population and may unintentionally exploit or harm one gender. From an implementation perspective, this is an inefficient use of resources; from a quality improvement standpoint, this jeopardizes patient-centeredness, safety and equality. Through strategic integration of gender into improvement planning, implementation, and documentation, we can avoid these harmful consequences and use gender as a driver for improvement.

Program Description:
As a partner on the global USAID ASSIST project, WI-HER LLC leads gender integration efforts in 20 countries so far. The gender integration approach that WI-HER developed was adopted by the USAID ASSIST Project. It aids health professionals to: 1) Build local capacity and foster local partnerships; 2) Integrate gender in planned improvement activities; 3) Document and share learning through knowledge management strategies and research; and 4) Scale up and institutionalize. To ensure a gender equality perspective is fully incorporated into all facets of patient care, we include gender analysis in the situational assessment during the development of each integrated country plan. The analysis explores gender norms and behaviors at the household, community, and facility levels; women’s legal rights and status, access to resources, and decision-making power; and men’s and women’s participation in health care and management. The practical, holistic, and patient-centered approach assures gender is addressed through contextualized and adaptable methods requiring little or no additional costs to the improvement effort while maximizing benefits.

We are implementing this strategy in all ASSIST countries, but share one successful example of our work here. In Uganda, some beliefs and practices after circumcision harbor negative health consequences for men and women or lead to strains in intimate partnerships which can dissuade men from getting circumcised or retroactively lead to violence or poor health outcomes. In collaboration with the ASSIST team in Uganda, we initiated a gender component in a Safe Male Circumcision (SMC) project to engage female partners as a means of improving post-operative care, adherence to follow up, and risk reduction behaviors in April 2013. This included training facility staff in gender integration in Voluntary Medical Male Circumcision (VMMC) at learning and coaching sessions, developing mobilization campaigns to encourage female involvement, and conducting research to measure the impact of female involvement in VMMC programs in Uganda.

Program Results:
Our gender integration approach to quality improvement in ASSIST results in locally-developed solutions, improved country leadership, an expanded partner base with links to other sectors, institutionalization of gender integration in quality improvement in all levels of care, and improved health outcomes. Health care providers have been able to successfully apply gender integration principles to their own improvement work, and the strategy has built the capacity of health workers to address gender issues in programming.

In the case of SMC in Uganda, from April 2013 to February 2014, the proportion of VMCC patients who attended educational sessions with female partners at 19 sites implementing SMC procedures in Uganda increased from 0% to 30%. Follow up after 48 hours reached 98% and after one week reached 94%. As the project matures in Uganda, we anticipate seeing an increase in post-operative follow-up visits after 6 weeks and a decrease in adverse events among patients as a result of the gender integration approach.

When gender is explicitly considered as a social determinant of health in improvement activities to achieve the goal of equitable and patient-centered care, it leads to improved program effectiveness and better outcomes among women, men, boys and girls.