Browsing by Author "Govender, Veloshnee"

Now showing 1 - 13 of 13
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    Assessment of user fee system : implementation of exemption and waiver mechanisms in Tanzania : successes and challenges
    (2010) Munishi, Victima; Govender, Veloshnee; McIntyre, Di
    The aim of this study was to evaluate the implementation of exemptions and waivers and to support efforts to address current challenges and promote use of public sector health services. The study was conducted in Bagamoyo and Mtwara rural districts. A qualitative approach (in-depth interviews and focus group discussions) was used since it was considered appropriate for a study focusing on the perceptions, views, and experiences of users and providers.
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    Disability Grant: a precarious lifeline for HIV/AIDS patients in South Africa
    (Biomed Central Ltd, 2015) Govender, Veloshnee; Fried, Jana; Birch, Stephen; Chimbindi, Natsayi; Cleary, Susan
    BACKGROUND:In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, we consider 1) inequalities in access to the DG for patients on ART and 2) implications of DG access for on-going access to healthcare. METHODS: Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. RESULTS: Grant recipients were comparatively worse off than non-recipients in terms of employment (9.1% vs. 29.9%) and wealth (58.3% in the poorest half vs. 45.8%). After controlling for socioeconomic and demographic factors, site, treatment duration, adherence and concomitant TB treatment, the regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed (p<0.001). Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG (significant at the 5% level). The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. CONCLUSIONS: These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.
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    Economic costs of seeking malaria care to households in the Kassena-Nankana district of Northern Ghana
    (2000) Akazili, James; Govender, Veloshnee
    Although, malaria is a major problem in Ghana, as III many Sub-Saharan Africa countries, there has been little research on its economlC impact, particularly at the household level. National statistics only show that malaria accounted for more deaths, more cases and more potential days of life lost than other cause, however little was said about the costs to households. The aim of the study was to estimate the economic costs (direct and indirect) of seeking malaria care to households and in doing this, the study used data collected from a randomly sampled 423 households in K-N district. Malaria was ascertained not by parasitological test but through self-reporting based on symptoms described by respondents using a one-month recall period. The estimation of direct cost involved the out-of-pocket expenditure on special foods, drugs, transportation, diagnostic and consultation and all other related costs (e.g. inpatient cost, toiletry cost, etc.). Indirect cost was estimated based on the number of days forgone and waiting time incurred due to malaria episode or caretaking and daily wage rate. The estimated costs were divided between direct and indirect costs, and examined in terms of location and case severity. Total direct cost per case in urban area was ¢6,701 ($1.79) compared to ¢7,822 ($2.09) in rural area. With regards to severity, direct cost per severe malaria was ¢11,182 ($2.98) compared to ¢5,317 ($1.42) of mild malaria. In the case of indirect cost and with regards to days lost, the average duration of severe malaria was 5.3 days, which was significantly higher when compared to 2.3 days of mild malaria. Estimated indirect cost per case in urban area was ¢20,804 ($5.55) compared to ¢15,842 ($4.22) in rural area. In terms of severity, 55% of the days lost were due to severe malaria and women in general lost more days and often incurred higher losses in potential earnings than men.
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    Gender analysis: Sub-Saharan African nurses' migration experiences - a systematic review
    (2017) Mavodza, Constancia; Shung King, Maylene; Govender, Veloshnee
    Alleviating the global shortage of health workers, particularly nurses, is critical for health systems and health worker performance. Nurses are mostly women and make up the majority of the health workforce. Several factors have been identified as key players in the shortage crisis and migration is one of these factors. Nurses' migration from Sub Saharan Africa (SSA) increases the nurse shortage in the region and further constraints the already struggling health systems. Migration literature has dominantly focused on macro push-pull, brain drain and ethics theories of migration with limited exploration of relationships, interaction, norms, beliefs and values shaping migration trajectories and decisions. Despite the potential role of gender as an influential component of migration trajectories, there has been little research done to investigate gender in the context of migration of SSA nurses. This review aims to identify, describe, and summarize SSA nurses' migration experiences by assessing the influence of gender on these experiences. The dissertation is organized into 3 parts. Part A is a systematic review protocol that describes the background, justification and methodology of the review. A scoping exercise is conducted to to familiarize with the literature. This is followed by a qualitative systematic approach is utilised and the literature in eight databases is searched using key words and terms derived from an initial scoping exercise and the review questions. Suitable articles are defined and selected using a set inclusion and exclusion criteria. The suitable articles are then appraised and a thematic analysis using a gender focal lens is applied to them. Part B is a literature review of existing primary and theoretical research on health worker shortages; migration and gender analysis in health worker migration and shortages. It provides a background for the systematic review by defining migration, gender and gender analysis as well as presenting the scope on health worker and nurse shortages. The literature review encompasses the scoping exercise and concludes on the relevance of a gender-focused research on nurse migration. Part C. is the full systematic review presented as an article for Human Resources for Health Journal. Articles published on Sub-Saharan African (SSA) nurses' migration experiences between 2005 and 2016 are presented, subjected to a gender analysis to illuminate the results. The discussion and conclusion then follow. The results indicate that there is a paucity of empirical work on nurse migration experiences that is explicitly gender-focused. Gender analysis that is situated in social contexts and identifiers revealed that SSA nurses continuously renegotiate and reconfigure gender roles in child care as they move from one social context to another. Moreover migrating SSA nurse face challenges and limitations at macro, meso and micro levels of the system- that are linked to their identities as either professionals, African migrants and/or women. Therefore, the review underscores the importance of the relationships between gender and local/individual nuances and global/national determinants of migration. However, these studies are limited in their explicit gender and social focus and how it contextually affects health worker performance and quality care provision. More empirical studies are needed to investigate gender influences for migrating male nurses; nurses who remain; and by different geographical & cultural region – to allow comparison across different groups of nurses and determine conceptual generalizations for doing gender research. This dissertation will likely increase understanding of the role of gender in migration decision-making and experiences for SSA nurses across different professional, migrant and woman identities. This understanding has impacts on nurse motivation, capacity and capability as well quality care provision. Additionally, the dissertation provides a better understanding for incorporating gender analysis in health systems research, and also identifies avenues for future research.
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    Impact of user fees removal on facility utilisation in rural Zambia
    (2008) Banda, Patrick; Thiede, Michael; Govender, Veloshnee
    User fees were introduced in Zambia as an additional source of revenue in response to the economic down-turn that the country experienced in the early 1990s. There is increasing evidence that user fees are a major barrier to accessing health services especially for the poor and in response the Zambian government abolished user fees in all public health facilities in rural based districts in April 2006. The aim of this study is to provide empirical evidence on the immediate impact of the abolition of user fees in the context of the Zambian health sector so as to identify optimal strategies in the delivery of health care. Both qualitative and quantitative data collection techniques were used to address the research objectives. The study focused on six 6 health facilities in two rural districts. The data collection tools included utilisation data reviews, patient exit polls, providers interviews, focus group discussions, informant interviews and drug availability data reviews. The results demonstrated that, the impact of the abolition of user fees at the district level was dependent on location of the district. Information flow was mainly cited as one of the reasons for the quick response to the user fee policy change. This brings in the need for a more deliberate and appropriately managed communication process when such policy change is being planned. The results of the study revealed that there was an impact on facility utilisation after the removal of user fees. In addition, there were shortages of drugs, low staff morale and poor maintenance of the surroundings. Patient-provider relationships seemed to be strained as a result of the increase in provider workload.
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    Leadership experiences and practices of South African health managers: what is the influence of gender? -a qualitative, exploratory study
    (BioMed Central, 2018-09-18) Shung-King, Maylene; Gilson, Lucy; Mbachu, Chinyere; Molyneux, Sassy; Muraya, Kelly W; Uguru, Nkoli; Govender, Veloshnee
    Background The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women’s full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being ‘left behind’ in terms of career development and progression into senior health leadership positions. Methods Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments. Results Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the ‘first’ to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture. Conclusion This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play.
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    Linkage to treatment following RR-TB diagnosis in the Western Cape
    (2015) Tomlinson, Catherine Reid; Govender, Veloshnee; Orgill, Marsha
    Patients diagnosed with rifampicin resistant (RR) tuberculosis (TB) in South Africa frequently fail to link to appropriate drug resistant (DR) TB treatment. The aim of this study was to explore barriers and enablers to expedited linkage to treatment following RR-TB diagnosis in the Western Cape Province, within the context of ongoing decentralisation of DRTB services and the scale-up of Xpert MTB/RIF diagnostics. Methods: An embedded case study approach, using qualitative research methods, was employed to explore barriers and enablers to expedited treatment linkage following RR-TB diagnosis. The case of investigation in this study was 'treatment linkage following RR-TB diagnosis in the Western Cape Province during the ongoing decentralisation of DR-TB services and scale-up of Xpert diagnostics'. DR-TB is used in this study as an encompassing term to refer to RR, multidrug resistant and extensively drug resistant TB. The embedded units of analysis in this study were patients' linkage outputs, defined as: (1) expedited treatment initiation, (2) delayed treatment initiation and (3) non-initiation of treatment following sputum collection on which RR-TB was diagnosed. Seventeen patient, 8 family member, 49 healthcare worker and 4 key informant open-ended, in-depth interviews were conducted and 59 patient folders were reviewed. Additionally, an extensive literature review was conducted. The tools used for data collection in this study were developed from the literature review and Coker et al.'s (201) conceptual framework for evaluation of a communicable disease intervention. A framework approach using Coker et al.'s conceptual framework was applied for analysis. Results: This study identified multiple factors that enabled and constrained expedited treatment linkage following RR-TB diagnosis. Enabling factors included: 1) the availability of clinic level DR-TB counsellors and tracers; 2) living in walking distance of decentralised services and 3) having a strong social support network. Constraining factors included: 1) low usage of Xpert diagnostics, 2) delays in acting on results and missed (or unseen) results, 3) rotation of nurses or the lack of dedicated TB nurses in clinics, 4) limited clinic-level administrative support, 5) information systems challenges and 6) waiting lists for beds and limited access to transport services in rural areas . In linking to treatment, patients commonly face challenges due to competing subsistence needs and household or employment responsibilities. Additionally, substance addiction, having a history of treatment interruption, hopelessness regarding treatment, as well as not having a stable place to stay or social support may increase patients' risks of linkage failure. Conclusion: Within the Western Cape Province, there is significant opportunity to improve linkage to treatment through strengthening the health systems mechanisms to link patients to treatment following RR-TB diagnosis. Expanding access to psychosocial services (substance abuse rehabilitation and psychosocial evaluations) following RR-TB diagnosis may assist in linking high-risk patients to treatment. Additionally, the provision of food support (in addition to social grants) should be evaluated as a tactic to improve treatment linkage and adherence.
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    Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals
    (BioMed Central, 2017-09-15) Erasmus, Ermin; Gilson, Lucy; Govender, Veloshnee; Nkosi, Moremi
    Background: This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies – the Uniform Patient Fee Schedule (UPFS) and Patients’ Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems’ people-centeredness and “software”. Methods: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. Results: Regarding the UPFS, the hospitals’ implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals’ PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people’s values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions: Achieving equity in practice requires managers to take account of “unseen” but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation “hardware” such as putting in place necessary staff and resources, it emphasises “software” implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers’ status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.
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    Out-of-pocket payments, health care access and utilisation in South-Eastern Nigeria : a gender perspective
    (2011) Onah, Micheal N; Govender, Veloshnee
    Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by investigating the research objectives through a combination of quantitative (cross-sectional household surveys) and qualitative (Focus-Group Discussions) analysis of the gendered impact of OOPs on health care access in south-eastern Nigeria.
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    Out-of-pocket payments, health care access and utilisation in south-eastern Nigeria: a gender perspective
    (Public Library of Science, 2014) Onah, Michael N; Govender, Veloshnee
    Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households.
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    The role of gender in patient-provider trust for tuberculosis treatment
    (2017) Govender, Veloshnee; Gilson, Lucy
    Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is among the three cities in the country with the highest TB burden. Despite implementation of Directly Observed Treatment Short-Course (DOTS), and improvements in the organisation and delivery of TB care, poor treatment adherence challenges treatment outcomes and the health system's ability to reach international targets. TB requires long-term care, where the relationship with healthcare providers is one of the important influences on decisions to seek care and adhere to treatment. This study sought to explore and deepen insight into how trust is built and experienced between patients and healthcare providers for TB treatment in primary care settings from a gender perspective. Methods: The research was located in three local government-managed clinics in the City of Cape Town's Metropole health district, similar in TB patient load and performance indicators, but differing in level of TB-HIV integrated services. A case study design employing qualitative data collection approaches (non-participant observations in clinics, focus group discussions and in-depth interviews with patients and providers) was applied. Findings: Trust plays a central role for both patients and providers in treatment for TB. On the part of patients, many expressed a deep desire and motivation to complete their treatment. However, patient vulnerability, a complex outcome of intersecting factors at all levels (personal, community and health service level), across which gender was an underlying influence, emerged as a critical influence over patient trust in providers and the health system, with consequences for a range of outcomes including treatment adherence. The ability of providers and the health system as an institution to recognise and respond to patient vulnerability and needs beyond the illness, including to access socio-economic and psycho-social support for the patient, was critical for building trust and enabling adherence. On the part of healthcare providers, vulnerability was a consequence of a range of factors, including professional status and gender, with implications for how trust was built in patients and managers and its outcomes. Patient trustworthiness was based on judgements of competency, integrity and recognition. The ability of managers to mitigate the challenges healthcare providers faced, through providing a supportive and enabling work environment, had implications for providers' experiences and judgements of institutional trustworthiness. Conclusion: Reflecting on the findings within broader national, provincial and global health policy reforms, specific strategies for building patient and provider trust in each other, and in the health system, are proposed. Recommended strategies addressing both patient and provider vulnerabilities rooted in the personal, community and health facility environment are considered. While many of the recommendations are specific to the TB and TB/HIV model of care, they have wider relevance for building mutual trust between patients and providers and enhancing the responsiveness of the health system as a whole. This is important in the context of South Africa, where the vision espoused under proposed National Health Insurance reforms towards universal coverage is transformative, even revolutionary, but its implementation and ultimate achievements are likely to be dogged by challenges of patient and provider trust in the health system, unless themselves addressed. Globally, the study's conclusions also offer important insights about patient-provider trust relevant to health system development, as well as ideas for future, related research.
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    Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme
    (BioMed Central, 2018-01-04) Goudge, Jane; Alaba, Olufunke A; Govender, Veloshnee; Harris, Bronwyn; Nxumalo, Nonhlanhla; Chersich, Matthew F
    Background: Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC. Methods: Using a cross-sectional survey across four of South Africa’s nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status. Results: A quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits. Conclusions: By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country’s financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.
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    Socioeconomic inequalities of childhood obesity in South Africa
    (2016) Nakimuli, Brenda; Alaba, Olufunke; Govender, Veloshnee
    Obesity is a public health concern in both high- and low-middle income countries. In South Africa obesity is not only limited to adults but is also evidenced in children. In order to contribute useful insights for developing effective obesity policy and programme interventions, this study assesses socioeconomic (SE) inequalities related to childhood obesity in South Africa. Using data from the South African National Income Dynamics survey (2012), the study assesses the extent of SE inequalities in obesity using concentration index (CI). The study also assesses the determinants that underpin these inequalities using decomposition analysis of the CI. Overall, the positive CI from the results indicates that the burden of obesity is more concentrated among the rich compared to the poor with girls having slightly greater SE inequalities compared to boys. The decomposition analysis further indicated that the determinants of these inequalities were an interplay of individual (i.e. race), household (i.e. household head characteristics) and contextual (i.e. household location) level factors. These findings suggest that there is a continuous need for surveillance of obesity in children over time across different social economic status (SES) especially in low- and middle- income countries. Finally, the results suggest that both childhood obesity and inequalities are complex issues with different underlying determinants that vary with the different SES, gender and may require coordinated policy and programmatic interventions at individual, household and contextual level.