Case study

Sexual and reproductive health, HIV, health systems and violence

What is your research project about?

I have been developing a programme of work with a colleague, Professor Di Cooper, at the University of the Western Cape in South Africa. We have been working together for three years on a project about the impact of community violence in low income neighbourhoods in Cape Town on young people’s access to healthcare. We have also looked at the impact it has on health care workers working in these areas. There is concern that high levels of community violence, such as gang warfare, may deter young people from going to their local health centre to access HIV treatment. It may also have an impact on health care workers who work in these areas and act as a deterrent to recruitment and retention.

Our initial study found high levels of resilience to violence both in the community and among healthcare workers. Even though violence in the areas we studied was endemic, young people developed strategies and found ways to access treatment and healthcare workers generally managed to continue to deliver care.

Professor Gill Green
Access to good health and well-being is a human right and is essential to sustainable development. Urban violence can impede access to care and also negatively impact the operation of an effective health system.
Professor Gill Green School of Health and Social Care

What activities did your GCRF@Essex funding support, and how do your GCRF funded projects support your wider research plans?

GCRF@Essex funded a short visit for my colleague Di to come to the UK last summer. This gave us the opportunity to develop our project further and discuss plans for a future project built upon our initial preliminary findings. As luck would have it, during her visit the National Institute of Health Research (NIHR) released details of a relatively new funding scheme, the Global Health Policy and Systems Research (Global HPSR), and called for proposals. We were able to work together intensively on this bid for a Global HPSR Development Award and identify partners to join us. Our bid was based on our initial research but looks at healthcare more broadly, not just HIV care, and brought in two new partner institutions from Brazil - the Universidade Federal do Rio Grande do Sul (UFRGS) in Porto Alegre and the Universidade Estadual de Campinas (UNICAMP) in São Paolo.

We were awarded NIHR funding for the project ‘Collaborative partnerships addressing the effects of urban violence on youth access to health services in South Africa and Brazil.’ This is largely a capacity building project funded initially for nine months (extended by a further six due to the disruption caused by COVID-19).

South Africa and Brazil experience high levels of urban violence, including assault and homicide often linked to gangs. This puts pressures on the health workforce and disrupts health service access, particularly for youth, who are disproportionately affected. Our project aims to improve understanding of the barriers (and ways to overcome such barriers) created by urban violence on youth healthcare access. We seek, through collaboration and partnerships in South Africa and Brazil, to develop a conceptual framework and identify possible, context-specific selected health system interventions to address this. We are doing this through learning how to work together which isn’t that straightforward especially as COVID-19 has meant that the partners haven’t yet been able to meet face to face. We also plan extensive engagement with stakeholders in local health services and youth in affected communities. The plan is to identify which interventions may help in different international contexts and then apply for further funding for proof-of-concept testing of these.

You have been looking at health in South Africa, how is your project benefitting this ODA country and which Sustainable Development Goals (SDGs) are being addressed?

This proposal aims to promote the development goal of funding sustainable good health and well being. Access to good health and well being is a human right and is essential to sustainable development. Urban violence can impede access to care and also negatively impact the operation of an effective health system.

Urban violence affects many countries globally, not just low and middle-income countries (LMICs). There is, however, evidence that LMICs are most severely affected, particularly in low income neighbourhoods where violence is often linked to gangs and drugs, and young people, particularly young girls, are disproportionally affected. This creates inequalities in healthcare access as young people living in such areas face additional barriers to others. It affects healthcare delivery, by creating additional challenges for the health workforce, as well as the functioning of health services, which may be forced to close down at times of extreme violence, for example when there is active gang fighting in the vicinity. It impacts negatively at various levels in the health system and the project thus directly addresses the priority area 'healthcare systems'.

South Africa and Brazil have among the highest rates of violence internationally, particularly in low income neighbourhoods, due to the intersectionality of gender, class, race, sexuality and histories of exclusion. These countries are classified as ‘middle income’ but our project will take place in low income neighbourhoods similar to those found in lower income countries with urban violence. The findings will thus have relevance to a number of LMIC countries at different developmental stages. Our overall goal is to identify potential sustainable solutions to enable youth living in low-income violent neighbourhoods to access services (e.g. for sexual and reproductive health needs) and enable services to function effectively, whilst protecting the safety of the workforce and their premises.

Your GCRF activities involve colleagues from South Africa and also Brazil, how did you find your collaborators?

I started looking for collaborators with a colleague at Essex, Dr Doreen Tembo, who has since moved to the University of Southampton (although she has remained involved with this project). We both had an interest in HIV research and she had some links with people working in South Africa. My collaborator in South Africa had links with one of the new partners in Brazil who she had met at a Global South networking meeting. The Brazilian colleague also brought in colleagues from another University in Brazil who she was working with. It takes time to build a solid and trusting partnership in which everyone feels they have an equal voice. We hope to achieve this during the project, notwithstanding COVID-19 which has made face to face meetings impossible for the time being, plus unstable internet connections and the fact that English is not everyone’s first language.

Tell us a bit more about the next stages of your work and what you hope to achieve?

This project builds upon an established research partnership and enables us to expand this beyond HIV and develop a partnership with the requisite expertise and with a broader geographical scope.

Engagement with local stakeholders will identify similarities and differences in LMIC-specific health systems’ elements and potential solutions that may reduce the impact of urban violence on young people’s healthcare access. This will help us to identify potential interventions that can be applied in diverse settings, to minimise urban violence’s impact on young people’s healthcare access. This will be the basis for an application for a larger project to the NIHR Global Health Systems and Policy Research Programme or other global health funders.