BackgroundGender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems.MethodsThe research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised.ResultsFive core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research.ConclusionThe implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

BackgroundThe Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.MethodsThis paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams’ experiences along four potential uses of ToCs, namely planning, communication, learning and accountability.ResultsThe three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams’ experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams’ initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.ConclusionsThe ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-017-0272-y) contains supplementary material, which is available to authorized users.

Worldwide, an estimated 536 000 maternal deaths occur each year [1]. Of these, approximately 25% occur in India alone [2]. Postpartum maternal morbidity, defined by the WHO as morbidity occurring in the first 6 weeks after delivery, is a serious problem in resource-poor settings that contributes to maternal death [3]. Despite the high prevalence of postpartum morbidity and the danger of maternal mortality, women in low-resource settings such as rural India frequently fail to seek care from formal health providers [4]. Understanding the factors that influence care-seeking behavior for postpartum health problems in India is vital to setting program priorities and designing appropriate interventions. Our study sought to elucidate these factors in the rural district of Murshidabad, India.We conducted secondary data analysis using multinomial logistic regression methods, using data collected through a household survey involving interviews with 2114 mothers carried out in February 2008 in the Murshidabad district of India. IRB approval was obtained from Johns Hopkins University Bloomberg School of Public Health.A total of 929 (43.9%) mothers were reported to have had postpartum morbidities in the 6 weeks after delivery and were included in our analysis. Of these women, 54 (5.8%) did not seek care, 457 (49.2%) sought care from informal providers, and 418 (45.0%) sought care from formal providers. Most mothers lived in rural areas, were of lower socioeconomic status, were unemployed, and did not deliver at health facilities. The majority of mothers (62.5%) were Muslim, and most women and household heads had low educational levels. The mean distance to the nearest healthcare facility from a household was 3.9 kilometers (Table 1).Women who sought care for their morbidities from formal providers were compared with those who sought care from informal providers. In households in which the household head had a high school or higher level of education, the women were more likely to have sought care from a formal rather than an informal provider (relative risk ratio [RRR] 1.79; P b 0.05). Women who had delivered at a health facility were nearly 4 times more likely to seek care from a formal provider (RRR 3.85; P b 0.001). Women who were reported to have had a severe postpartum morbidity were more likely to have sought care from a formal provider (RRR 1.48; P b 0.05). Hindu women

Background: Visual impairment disproportionately affects people in the low-income countries. A high proportion of visual impairment can be prevented or cured. Yet, care seeking for eye health is restricted for women and older adults. This article uses the intersectionality approach to understand how eye care seeking behaviour changes in men and women with increase in age and visual impairment in a poor and underserved region of India. It brings forth the commonalities and differences between the various groups. Methods: The article is based on qualitative data. Persons aged 50 years and more are categorized into young-old, middle-old and old-old. Men and women with low vision/ high visual impairment have been selected from each of the three age groups. In-depth interviews have been carried out with 24 study participants. Data saturation has been attained. The JHPIEGO Gender Analysis Framework underpins the study. The narrative data has been coded in NVivo 10 software. Results: Various symptoms are associated with visual impairment. The young-old with low vision do not report much difficulty due to visual impairment. Study participants with high visual impairment, and in the older age groups do. Difficulty in the discharge of regular chores due to visual impairment is rarely reported. Impaired vision is considered to be inevitable with advancing age. Care seeking is delayed for eye health. Typically, outpatient care from nearby health care facilities has been sought by men and women in every group. Inpatient care is limitedly sought, and mostly restricted to men. Eye care seeking behaviour changes among men with increase in age and visual impairment. Women consistently seek less care than men for both outpatient and inpatient eye care. Study participants of both genders become dependent with increasing age and visual impairment. Traditional patriarchal privileges enjoyed by men (such as mobility and economic independence) decrease with age. The vulnerability of women gets compounded with time. Conclusions: The article presents a granulated understanding of eye care seeking behaviour among older adults in India. Such differentials need to be taken cognizance of in programmes promoting universal access to health care. Existing conceptualizations on access to health care need to be revisited.

performance (7). The maintenance of time schedule has been considered crucial proxy indicator of the quality of coverage of immunization (7-9). The other possible ways to look into the quality of immunization is to consider the availability of manpower, equipment, and drugs (10-12). The results of studies in Africa and Asia report that the quality of vaccination services still leaves much to be improved in developing countries (12). They found that the principal problems in maintaining the quality in vaccination process are as follows:• Inadequate supplies, particularly of vaccines, vaccination cards, registration materials, and other drugs• Lack of providing appropriate information on vaccines, vaccine-preventable diseases, and vaccination schedules in the vaccination sessions• Poor training facilities for health workers adversely affecting the frequency and regularity of vaccination sessions• Inaccuracies in the registration of vaccinations. Access and Barriers to Immunization in ABSTRACTWhile many studies attempted to evaluate performance of immunization programmes in developing countries by full coverage, there is a growing awareness about the limitations of such evaluation, irrespective of the overall quality of performance. Availability of human resources, equipment, supporting drugs, and training of personnel are considered to be crucial indicators of the quality of immunization programme. Also, maintenance of time schedule has been considered crucial in the context of the quality of immunization. In addition to overall coverage of vaccination, the coverage of immunization given at right time (month-specific) is to be considered with utmost importance. In this paper, District Level Household and Facility Survey-3 (DLHS-3) 2007-2008 data have been used in exploring the quality of immunization in terms of month-specific vaccine coverage and barriers to access in West Bengal, India. In West Bengal, the month-specific coverage stands badly below 20% but the simple non-month-specific coverage is as high as 75%. Among the demand-side factors, birthplace of the child and religion of the household heads came out as significant predictors while, from the supply-side, availability of male health workers and equipment at the subcentres, were the important determinants for month-specific vaccine coverage. Hence, there should be a vigorous attempt to make more focused planning, keeping in mind the nature of the barriers, for improvement of the month-specific coverage in West Bengal.