Gender Equality & Social Inclusion; Disparities in U5 Service Utilisation

Learning Brief

Gender Equality & Social Inclusion: Disparities in U5 Service Utilisation

January 2021

SHINE Supply (2018-2021) is a component of the Somalia Health & Nutrition (SHINE) programme, funded by UK aid from the UK government.

SHINE aims to reduce mother and child deaths in Somalia and Somaliland by improving health and nutrition services.

SHINE Supply is a component of the UK aid-funded Somalia Health & Nutrition (SHINE) programme. SHINE aims to reduce mother and child deaths in Somalia and Somaliland by improving health and nutrition services. SHINE Supply is being implemented in four regions, namely Galgadud and Banadir Regions in Somalia, and Awdal and Togdheer Regions in Somaliland. Gender Equality and Social Inclusion (GESI) is a cross-cutting component of all SHINE Supply activities.

Figure 1Photo credit: Ismail Taxta/Mercy USA

The issue SHINE Supply has been tracking the female:male utilisation of Under 5 (U5) outpatient services since 2019. From the monthly facility reports, we have observed a consistent pattern of higher utilisation among female U5s in a ratio of 0.9/1 (male / female). This pattern has been seen across programme facilities and districts in both Somalia and Somaliland. In December 2020, the SHINE Supply Team initiated a small operational study to better understand these gender disparities in U5 service utilisation.

Methodology for investigation The study covered 12 districts and 17 health facilities across the four SHINE Supply implementation areas. The 17 health facilities were purposefully sampled based on consistently high female:male U5 utilisation ratios in monthly reports. With technical support from the Monitoring and Evaluation Lead, SHINE Supply’s Implementing Partners visited the selected facilities to verify reports against primary records over a sixmonth timeframe - May-Oct 2020. They also conducted interviews with facility staff to interrogate and interpret the data. All findings (quantitative and qualitative) were captured in standardised data entry templates.

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Preliminary Findings •

The study confirmed higher female U5 service utilisation in three of the four implementation areas. Over the six-month timeframe, the highest disparities were seen in Awdal Region and Togdheer Region (see chart). In these regions, 55% of U5 service users were female and 45% were male over the study period.

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This was consistent with routine data, although there were also some minor data quality issues.

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From interviews with facility staff across these implementation areas, the most common explanations for female utilisation of U5 outpatient services related to:

Nurse’s explanation of higher female U5 attendance: “Somali culture places priority on care of the male child so the girls get sick frequently. Also divorced mothers with female children do not receive as much support compared to when they have male children”

- Perceptions that U5 females have greater health needs due to relative neglect.

- Perceptions that there are more girls than boys born in the community. 1 Nurse’s explanation of higher male U5 attendance in Galgaduud Region: “There are more boys than girls in the community. For example, today its 9 o’clock and I have attended to 5 boys and no girls”

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The three health facilities sampled for the fourth implementation area (Galgaduud Region) showed a slight reversal of the trend with 52% of U5 service users being male and 48% being female over the six-month timeframe.

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From interviews with facility staff in this implementation area, the most common explanations for the somewhat higher utilisation of outpatient services by U5 males related to: - Perceptions that male children are prioritised in local household decisions on accessing health care.

- Perceptions that there are higher numbers of male births in the community.2

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There was no significant difference in disparities month on month and no apparent seasonality in findings. Across the board, facility staff suggested there was no local preference for use of private health services. From staff interviews, there was little to suggest that decision-making authority in households explained gender differences in service uptake.

Next steps Based on these preliminary findings, the SHINE Supply Team will aim to: •

Work collaboratively with key partners and researchers to conduct further investigation into gender disparities in U5 service utilisation. This is likely to include expanding the study to include more districts and under five data sets, as well as a wider literature review to inform our analysis and interpretation of findings.

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Review and assess the specific data quality control issues arising from this study.

We will use this to inform a) staff training, guidance and data audit tools and b) dialogue with government partners on strengthening routine HMIS reporting systems, guidelines and supportive supervision mechanisms.

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If evidence of systematic neglect of female children is confirmed, we will act fast to alert government, key partners, community and religious leaders. We will prioritise a coordinated response that includes intensified information, communication and behaviour change efforts, as well as more targeted health and nutrition services.

The SHINE Supply consortium is led by Mott MacDonald. The Essential Package of Health Services (EPHS) is implemented in four regions of Somalia and Somaliland by Action Against Hunger (Banadir), Mercy USA (Galgaduud) and Health Poverty Action (Awdal and Togdheer).

The Health Systems Strengthening component is supported by the International Procurement Agency (IPA), Charlie Goldsmith Associated (CGA), Mott Macdonald IHE and the Tropical Health and Education Trust (THET).

This perception is not supported by the available demographic survey data e.g. The Somali Health and Demographic Survey 2020.

2 As above, this perception is not supported by the available demographic survey data e.g. The Somali Health and Demographic Survey 2020.

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