Ssali Sarah

ABSTRACT Neo-liberal reformers of health care assume that accessing health care in a privatised health care system is a matter of choice. However, choices are mediated through an array of social relationships, which are in turn determined by culture. Culture, in many settings, is often the blueprint for social relations, determining appropriate masculine and feminine roles and identities. Simply introducing user fees to expand health care options is not enough to change the gender roles and identities pertaining to health care access and provision. Using gender roles and identities in the context of user fees, this focus highlights the extent to which health care processes are gendered. It demonstrates that culture interacts with, mediates and even modifies what would appear as a market process of ‘free’ choice of health care. It shows that, while women are able to identify openings within culture, which they can use to further their own agenda, culture is also capable of permeating new policies and strategies to the disadvantage of women.

Background: The AIDS Support Organization (TASO) Antiretroviral Program was rolled out in November 2004. The study aimed to assess adherence status of adult patients surviving for 60 months after HAART initiation in a resource-poor setting. Methodology: Retrospective cohort study of adult patients who initiated HAART 60 months prior to the date of data abstraction at TASO Soroti, Eastern Uganda. Participants included in the study were male and female adult (≥14 years) patients who initiated HAART at TASO Soroti (between 1st August 2005 to 31st March 2012). Among the 5317 HIV-infected patients who initiated HAART through 31 March 2012, 4827 adults who started HAART prior to data abstraction were included in the analysis. Since 2005 TASO Soroti has been providing HAART free of charge to patients either at World Health Organization (WHO) stage III or IV irrespective of CD4 cell count, or at any WHO stage with CD4 cell counts ≤350 cells/μl. HAART initiation began with pre-HAART counseling visits for psychosocial assessment. Follow-up visits were performed for the first 2 weeks and 1 month at the facility and thereafter patients were attached to community drug distribution points (CDDPs). At CDDPs patients were given two-monthly refills and thereafter with CD4 counts review at 6-month intervals and adherence support counseling at each visit. The primary outcomes were survival, continuation of HAART, and adherence at 60 months. Results: Of the 4827 adult patients included in the analysis, 32.1% were male and the median age was 43 years. 67.9% were female and the median age was 41 years. 94.9% of patient were HAART-naive, 5.1% were transfer-in. 3913 (81.1%) of 4827 patients were still on HAART after 5 years of follow-up. 18.9% difference is attributed to lost to follow-up, patient transferred out and reported deaths. Among the patients with adherence assessment reported, 96.6% of patients had adherence level >95%, 1.5% had adherence level of 85%-95% and 1% had adherence <85%. 74.5% patients received their HAART refills at the CDDP, 23.8% received refills at the facility, and 1.4% received refills at their homes. Conclusions: These positive results after 5 years of initiating HAART in patients with advanced HIV disease demonstrate efficacy of HAART in resource-limited settings. Additional support is required to ensure timely HAART among adults.

Circumcision is a cultural practice that has been documented in several ethnic groups in East Africa for both males and females. While it is considered a right by those that practice it, for others it has generated mixed reactions, with many condemning female genital cutting. A lot has been written linking female circumcision and its negative effects on women’s reproductive health. However, rarely have these studies focused on how circumcision constructs gendered identities and what implications this has for sexual behaviour. Using qualitative research methods based in a grounded theory design, this study provides a more nuanced understanding of the triad relationship between law, circumcision and sexuality. It shows that circumcision engendered a certain kind of sexuality that is stoical for both males and females. Nonetheless, males occasionally violate the norm by engaging in pleasurable sex whereas women cannot. Moreover, male rule-bending did not attract any penalties, while the consequences for females were quite dire. Furthermore, the social status of males that emerge from circumcision is superior to that of females.

The post-conflict trajectory presents an opportunity to rebuild health systems to better meet the needs of all citizens. However, there is limited literature or analysis on gender equity in health system reconstruction. Northern Uganda experienced multiple conflicts which ended with tentative peace and post-conflict reconstruction starting in 2007. Using a health systems approach and analysis of data from multiple methods (household survey, life histories and key informant interviews) and participants (women and men household heads, community members, health workers and key informants) this chapter analyses the extent to which gender equity has been considered and realized in the post-conflict reconstruction of the health sector in Gulu, Northern Uganda. The analysis across multiple data sets reveals four key findings. Firstly, health systems development has focused largely on health facility reconstruction with insufficient mechanisms to address ways in which gender, age and poverty interplay to limit access to health systems. Secondly, in terms of focus area, maternal and child health emerged as a key priority amongst most providers. This is limiting as the special health care needs of Northern Uganda as a post-conflict setting go beyond maternal and child health (MCH) services, and include psycho-social trauma, non-communicable illnesses, human resources, malnutrition, inadequate equipment and drug stock-outs. Thirdly, gender, generation and poverty shape household health events and care-seeking pathways. Female household heads who were older and widowed were most likely to be poor, and face challenges in raising the resources for accessing health care; care-seeking was often delayed. Fourthly, gender shapes health care workers’ expectations, experiences and strategies to deal with conflict. Gender segregation by roles, understaffing in remote areas and lack of responsiveness to life course events for workers with family responsibilities play a role in limiting access to training and promotion for women in particular, and especially those in remote areas. The commitment of largely female mid-level cadres in remaining in posts during the conflict in Northern Uganda has also been under-recognized and not appropriately celebrated. Drawing on this analysis the authors argue for a gender-aware post-conflict health care system, which considers health challenges facing different community members and health staff from a gender perspective. A gender-sensitive health care system needs to respond to women’s health care needs across their life cycle (as opposed to focusing only on the reproductive years), as well as men’s, and go beyond the provision of facilities to include a holistic analysis of livelihood challenges, which restrict women’s (and some men’s) ability to effectively access health care. This also requires action on the gender dimensions of health services provision, including human resources for health and budgeting. In conclusion, from a gender equity perspective there have been lost opportunities in the post-conflict reconstruction of the health sector. Health systems continue to evolve and future priorities need to focus on supporting vulnerable communities’ ability to access a range of vital health services, and ensuring women and men health workers’ gendered needs are met.

Population mobility is associated with higher-risk sexual behaviors in sub-Saharan Africa and is a key driver of the HIV epidemic. We conducted a longitudinal cohort study to estimate associations between recent mobility (overnight travel away from home in past six months) or migration (changes of residence over defined geopolitical boundaries) and higher-risk sexual behavior among co-resident couples (240 couples aged ≥ 16) from 12 rural communities in Kenya and Uganda. Data on concurrent mobility and sexual risk behaviors were collected every 6-months between 2015 and 2020. We used sex-pooled and sex-stratified multilevel models to estimate associations between couple mobility configurations (neither partner mobile, male mobile/female not mobile, female mobile/male not mobile, both mobile) and the odds of higher-risk (casual, commercial sex worker/client, one night stand, inherited partner, stranger) and concurrent sexual partnerships based on who was mobile. On average across all...

Background Uganda has registered an increased investment in family planning (FP) programmes, which has contributed to improvement in knowledge of modern contraceptive methods being nearly universal. However, this has not matched uptake of modern methods and reduction in unmet need of FP. Due to these challenges, a programme on improving awareness, access to and uptake of modern contraceptives is being implemented. We therefore conducted a formative study to determine the influences, key sources and media consumption habits of contraceptive information at the onset of this programme. Methods Using a qualitative study design, we conducted thirty-two focus group discussion and twenty-one in-depth interviews involving men and women of reproductive age. We also carried out twenty-one key informant interviews with people involved in FP service delivery. Data was collected in 4 districts where implementation of the program was to take place. Audio recorders were used to collect data and to...

Background Uganda has registered an increased investment in family planning (FP) programs, which has contributed to improvement in knowledge of modern contraceptive methods being nearly universal. However, this has not matched the uptake of modern methods or the reduction in the unmet need for FP. This may be explained by the different influences which include health workers, family, and friends. Due to the limited uptake of contraceptive methods, a program on improving awareness, access to, and uptake of modern contraceptives is being implemented in selected regions in Uganda. We, therefore, conducted a formative study to determine the influences on contraceptive uptake at the onset of this program. Methods Using a qualitative study design, we conducted thirty-two focus group discussions and twenty-one in-depth interviews involving men and women of reproductive age. We also carried out twenty-one key informant interviews with people involved in FP service delivery. Data was collect...

Background Advocacy for equity in health service utilization and access, including Family Planning (FP) continues to be a cornerstone in increasing universal health coverage. Inequities in Family planning are highlighted by the differences in reproductive health outcomes or in the distribution of resources among different population groups. In this study we examine inequities in use of modern contraceptives with respect to Socio-economic and Education dimensions in seven sub-regions in Uganda. Methods The data were obtained from a baseline cross-sectional study in seven statistical regions where a program entitled “Reducing High Fertility Rates and Improving Sexual Reproductive Health Outcomes in Uganda, (RISE)” is implemented in Uganda. There was a total of 3,607 respondents, half of whom were women of reproductive age (15-49 years) and the other half men (18-54 years). Equity in family planning utilization was assessed by geography, wealth/economic and social-demographics. The use...

Objective: This paper establishes levels and patterns of ability and willingness to pay (AWTP) for contraceptives, and associated factors. Study design: A three-stage cluster and stratified sampling was applied in selection of enumeration areas, households and individuals in a baseline survey for a 5-year Family planning programme. Multivariable linear and modified Poisson regressions are used to establish factors associated with AWTP. Results: Ability to pay was higher among men (84%) than women (52%). A high proportion of women (96%) and men (82%) were able to pay at least Ug Shs 1000 ($0.27) for FP services while 93% of women and 83% of men who had never used FP services will in future be able to pay for FP services costed at least Shs 2000 ($0.55). The factors independently associated with AWTP were lower age group (<25 years), residence in urban areas, attainment of higher education level, and higher wealth quintiles. Conclusion: AWTP for FP services varied by different meas...

Supplemental Material, Interview_Guide_for_PLHIV for Paying to Normalize Life: Monetary and Psychosocial Costs of Realizing a Normal Life in the Context of Free Antiretroviral Therapy Services in Uganda by Esther Kalule Nanfuka, David Kyaddondo, Sarah N. Ssali and Narathius Asingwire in Journal of the International Association of Providers of AIDS Care (JIAPAC)

<b>Copyright information:</b>Taken from "Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention"http://www.biomedcentral.com/1471-2458/8/263BMC Public Health 2008;8():263-263.Published online 30 Jul 2008PMCID:PMC2529297.

Purpose: Universities have responded to sexual harassment by putting in place formalized reporting processes through which victims can seek redress. Despite these processes, victims seldom invoke the grievance handling mechanisms that are enshrined in university sexual harassment policies. This study therefore sought to investigate why the vice is grossly under reported. Given the asymmetrical relationship between students and faculty as well as the gendered position of female students, this study specifically focused on why female undergraduate students seldom reported faculty perpetrated sexual harassment. Methodology: The study was carried out at a large public university in East Africa, was purely qualitative and involved 42 participants who included students, members of faculty and university administrators. The data was analyzed thematically Findings: These indicated that institutional and social cultural barriers coupled with power asymmetries and financial inadequacy play a role in the non-reporting of sexual harassment amongst female university students. Unique contribution to policy and practice: These findings are beneficial to universities especially as they seek to revise their existing sexual harassment policies. University managers ought to ensure that complaint handlers are well positioned to fairly handle sexual harassment complaints. This may help victims to build trust in the grievance handling mechanisms thus encouraging them to report the vice

Introduction: There are significant knowledge gaps concerning complex forms of mobility emergent in sub-Saharan Africa, their relationship to sexual behaviours, HIV transmission, and how sex modifies these associations. This study, within an ongoing test-and-treat trial (SEARCH, NCT01864603), sought to measure effects of diverse metrics of mobility on behaviours, with attention to gender. Methods: Cross-sectional data were collected in 2016 from 1919 adults in 12 communities in Kenya and Uganda, to examine mobility (labour/non-labour-related travel), migration (changes of residence over geopolitical boundaries) and their associations with sexual behaviours (concurrent/higher risk partnerships), by region and sex. Multilevel mixed-effects logistic regression models, stratified by sex and adjusted for clustering by community, were fitted to examine associations of mobility with higherrisk behaviours, in past 2 years/past 6 months, controlling for key covariates. Results: The populatio...

Background Voluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV/AIDS in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. We therefore conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district. Methods A population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men. Results Overall VCT use among men was 23.3% (95% CI 17.2–2...

Antiretroviral therapy (ART) is considered the treatment that enables people living with HIV (PLHIV) to lead a “normal life”. In spite of the availability of free treatment, patients in resource-poor settings may continue to incur additional costs to realize a normal and full life. This article describes the monetary expenses and psychosocial distress people on free ART bear to live normally. We conducted in-depth interviews with 50 PLHIV on ART. We found that the demands of treatment, poverty, stigma, and health-system constraints interplay to necessitate that PLHIV bear continuous monetary and psychosocial costs to realize local values that define normal life. In the context, access to free medicines is not sufficient to enable PLHIV in resource-poor settings to normalize life. Policy makers and providers should consider proactively complementing free ART with mechanisms that empower PLHIV economically, enhance their problem-solving capacities, and provide an enabling environment ...

There are significant knowledge gaps concerning complex forms of mobility emergent in sub-Saharan Africa, their relationship to sexual behaviours, HIV transmission, and how sex modifies these associations. This study, within an ongoing test-and-treat trial (SEARCH, NCT01864603), sought to measure effects of diverse metrics of mobility on behaviours, with attention to gender. Cross-sectional data were collected in 2016 from 1919 adults in 12 communities in Kenya and Uganda, to examine mobility (labour/non-labour-related travel), migration (changes of residence over geopolitical boundaries) and their associations with sexual behaviours (concurrent/higher risk partnerships), by region and sex. Multilevel mixed-effects logistic regression models, stratified by sex and adjusted for clustering by community, were fitted to examine associations of mobility with higher-risk behaviours, in past 2 years/past 6 months, controlling for key covariates. The population was 45.8% male and 52.4% fema...

This editorial discusses a collection of papers examining gender across a range of health policy and systems contexts, from access to services, governance, health financing, and human resources for health. The papers interrogate differing health issues and core health systems functions using a gender lens. Together they produce new knowledge on the multiple impacts of gender on health experiences and demonstrate the importance of gender analyses and gender sensitive interventions for promoting well-being and health systems strengthening. The findings from these papers collectively show how gender intersects with other axes of inequity within specific contexts to shape experiences of health and health seeking within households, communities and health systems; illustrate how gender power relations affect access to important resources; and demonstrate that gender norms, poverty and patriarchy interplay to limit women's choices and chances both within household interactions and with...