By Doris Kirigia and Martin Njoroge, Kemri-Wellcome Trust, Kenya
E-Health or the use of Information and Communication Technology (ICT) for health is increasingly being adopted in Kenya to bridge the gap in access to health services, and improve efficiency and governance of the health system in an effort to achieve better health outcomes. In Kenya, a mobile technology revolution is evolving with mobile coverage estimated to be over 80% and internet use through mobile subscriptions 99%. This ubiquitous use of mobile technology and applications has made it easier for the country to adopt ICT in all facets of the society. For example, Kenya is leading in mobile applications such as M-pesa (mobile phone money transfer).
Mobile phone ownership and usage, however, is associated with gender, level of education, literacy, urbanization and the socio-economic status of the individuals (Zurovac et al. 2013 and Wesolowski et al. 2012), but due to lack of gender-disaggregated data, it is always a challenge to quantify whether the benefits of adopting ICT or e-Health are evenly distributed. Gender considerations are important in ensuring that factors such as ownership, affordability, and ability to use mobile phones are analysed to ensure neither women or men face any barriers. Additionally, gender relations and the gender distribution of the population is a key consideration whilst implementing e-Health projects. Kenya has an approximate sex ratio of 0.998 (998 males per 1000 females) of the total population. It is therefore important to ensure that each e-Health implementation’s benefits are equitably distributed in the entire population.
A mixed methods study we are conducting in Kenya to evaluate the impact of e-Health in strengthening the Kenyan health system (through reducing health inequities and promoting good governance), gender considerations was not a factor taken into account during eHealth project formulations and implementation. Our research project conducted in-depth interviews with the e-Health implementers, the users or target population including the front-line health workers, key informants, government officials and policy makers, with majority indicating gender was not a consideration. However, since the vast majority of e-Health projects implemented in Kenya focused on maternal and child health, HIV/AIDS and primary care services, women were more likely to access these services than men. As a result, it became clear that gender considerations needed to be identified and incorporated into the study.
The key gender issues that were identified in the study were:
- the differential health needs of men and women (e.g. biological health needs) that were not necessary factored into the e-health interventions;
- the inadequate gender distribution in e-Health interventions among implementers (most of the implementers interviewed were males);
- gender disparities in access to and experience of care in terms privacy, confidentiality, treatment offered;
- access to resources amongst the different genders – cost remained the greatest barrier to mobile ownership by women, who generally have less financial independence than men in Kenya;
- effects of gender roles and responsibilities on ability to travel to health centre to seek health care – women are likely to be taking care of children;
- engagement and participation of both men and women in the development and implementation of e-health interventions – women are likely to have low technology technical literacy and confidence to use technologies hence represented less.
The study preliminary findings indicated that most implementers of e-Health interventions did not consider these gender dynamics, even as they targeted women while implementing their specific interventions. The lack of deliberate focus on gender can lead to systemic barriers that negatively impact access to and use of mobile phones by women, including reduced buy-in or ownership of the e-health interventions that particularly target them i.e. maternal and child health.
The challenge of gender relations among policy and decision makers interviewed was evident. The technical teams from the Ministry of Health were predominantly men highlighting the issue of women’s capacity in technology. This gender imbalance could exacerbate gender inequities in e-Health policy development and implementation. As a result, the importance of gender has been highlighted and discussed with e-Health teams to facilitate inclusion in future e-Health policies and innovations formulation and implementation.
In relation to outcomes, it is important to consider the positive and negative unintended consequences of e-Health interventions in terms of gender to the overall health system, community and household. While interventions do not have to explicitly try to progressively change gender relations, they should at least ensure that they do no harm and do not exacerbate negative gender relations. This should especially be considered while developing national policy, standards and regulatory frameworks to ensure the benefits of e-health implementations are equitably distributed amongst men and women.
It is important to note since the majority of the e-Health interventions targeted women related services, the user interviews conducted were mainly with women, as a result, how gender can affect the household gender relations within the data collection process could not be considered. We acknowledge the usefulness and benefits of conducting interviews with the husbands of targeted women (users), especially given the access to resources and power relations in a household, however, it is not feasible to include this important component in the course of this study. It became clear from this study that gender is an important component that must be considered and incorporated within eHealth interventions. As a result, we recommend further research with defined approaches to assess all aspects of gender from study inception.
This work was supported by the Canadian International Development Research Centre (IDRC)