Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study

Perceived Provider-Client/Community Interaction and Normalized Mistreatment

Perceived interactions between HCPs and clients in our sample were often based on individual experiences of power differences and information asymmetries and further influenced by provider/facility reputation in the community. HCP perspectives revealed that although clinical knowledge gave them relative power with clients, the quality of interactions with clients affected their ability to provide services effectively. No gender differences in HCP approaches to interacting with clients emerged in Kenya, Malawi, and Madagascar, and to a limited extent in Togo.

Power dynamics manifested in the communication and tone set and perceived between providers and clients during 1-on-1 service interactions. Across all countries, HCP cadre, and gender, we found that strategies, such as listening, coaching/mentoring, and dialoguing that emphasized communication style and tone, could foster a favorable power dynamic between providers and clients. These strategies enabled positive interactions that reduced provider power over clients and elevated provider power to achieve a service goal.

Listen to them [families of babies], encourage them to ask questions. Let the health worker be enthusiastic to answer, not assume they [families] do not understand. They do. In the process of question, answering, talking, you form a rapport. They gain confidence in what you are doing. —Female, hospital-based provider, newborn care, Kenya

In Togo, these strategies, alongside trusting HCP-client relationships and HCP age, were more relevant than an HCP's gender in affecting individual perceptions of provider-client interactions. However, there was a slight difference in how female HCPs counseled couples (separately first, then together) compared to how male HCPs approached the interaction (joint session). The following quote supports the influence of age on provider-client interactions.

In terms of difficulties, some people consider that we're not old enough to speak to them, so it's sometimes difficult. —Female, community-based provider, FP/reproductive health (RH), Togo

Contrastingly, when HCPs inadequately communicated with or showed disrespect toward, neglected, or verbally abused (“yelled”/“shouted at”) clients, negative power dynamics arose. In maternal newborn complication contexts, for example, these dynamics strained patient-provider relationships, led to reduced urgent care-seeking by the client, and attenuated the provider's ability to prevent adverse maternal newborn outcomes.

It [the experience] may affect them in future. If the outcome was poor, it may make them fear to seek health care … they will lose trust in me and they will never want to listen to me again. —Female, hospital-based senior provider/manager, newborn care, Kenya

We found across the studies that community perceptions of provider-client interactions—both 1-on-1 and group service interactions—influenced HCP reputations, which affected prevailing power relations between providers and communities. Our data showed community members' confidence and trust in HCPs working in community and facility settings empowered them to counsel clients. Irrespective of cadre and gender, positive HCP reputations were built and sustained when “good experiences” were shared within communities and providers engaged with clients to foster familiarity over time.

The midwife is not mean … If you do it [welcome kindly, smile at, and talk] to 1 person, it extends to the whole locality and it is a good advertisement for you: “She's very cool midwife there.” —Female, health center-based provider, PPH, Madagascar

Because I work in health, people tend to know me… they are not hesitant when it comes to accepting my appointments with them. So, I don't really have any difficulty. —Male, community-based provider, FP/RH, Togo

It is rare to hear negative messages or rumors about counseling activities. —Male, facility-based senior provider/manager, FP/RH, Togo

Negative reputations or normalized expectations of mistreatment arose when “bad experiences” were shared among clients and prevented future interactions with providers. Although negative HCP reputation appeared less likely of CHWs in Togo, where community-based HCPs shared socioeconomic and living similarities with clients, facility-based providers often described communities' fear that HCPs might inadequately respond to their needs. In Madagascar, Malawi, and Kenya, propagated community fear around potential negative provider-client interactions created a tense dynamic between clients and providers that limited HCPs' ability to provide necessary care. In some cases, providers expressed feeling mistreated by their communities, leading to a transference of HCP stress onto their clients.

We get accused, “I brought my child on time, this and this happened, you people killed my child,” such things. I wish this community understands that as much as we are HCPs, we are also parents and mothers, and we will not come here to make them suffer … it is hard for [parents] to understand their child was so sick, even if we were to do miracles, your child came in late. They blame us for no reason at all. —Female, hospital-based senior provider/manager, newborn care, Kenya

We found that some providers were aware of how their behavior was experienced or understood as mistreatment by communities. For example, in Malawi, self-reflection on this point differed by gender. Some male providers adopted a community-blaming approach, and some female providers recognized the provider's role in affecting a client's experience of care.

We have a community that does not appreciate our services, for instance, there [w]as a time when the radio announced that nurses were beating patients in the labor ward. —Male, health center-based provider, PPH, Malawi

We [providers] are really bad with how we talk … The patients are in pain, laboring is difficult. [If] a health worker does not talk nicely to the patients next time, they won't [come] because we've shouted at them. —Female, hospital-based provider, PPH, Malawi

Societal Beliefs and Social Norms

All HCP cadres in Madagascar, Malawi, Kenya, and Togo described how a community's societal (cultural and religious) beliefs and social norms at times misaligned with necessary medical procedures—causing friction in an individual provider-client relationship and affecting HCPs' power to provide timely care amid constraints. In Malawi and Togo, the religious belief that contraceptive methods were “sinful” or “against God” constrained facility- and community-based HCPs' power to provide care. In Madagascar, cultural beliefs and practices at odds with clinical guidelines could pose a risk to mothers and newborns.

I [Midwife] asked to bring the baby's clothes to prepare them because the woman was about to give birth, and I said, “Where are the baby's clothes?” and the answer that came was, “We don't have one … We are really forbidden to prepare for this.” Then I don't know what to do. There was also a time when where I was actually using the state-offered delivery kit, but, when I arrived in the room, she [mother] took off and handed over the loincloth [to cover baby]. It turns out that this is not done because it “wishes harm” on the baby. —Female, health center-based provider, PPH, Madagascar

In Kenya, traditional practices occasionally superseded allopathic medicine as providers described families' refusals of necessary medical care for sick newborns or seeking alternative care.

Once, I had a man who believed the child had been bewitched and wanted to go to a native doctor. He [father] later came and told us, the case is not to be treated at the hospital -it is related to their culture at home and his [neglect] of slaughtering a cow after burying his mother. He refused treatment for the baby [against HCP's medical advice]. So sometimes it is the culture or attitude and not failure of communication [between provider and client]. —Female, hospital-based senior provider/manager, newborn care, Kenya

We found social norms that preferred and elevated senior doctors over other facility-based providers (e.g., nurses and coordinators) affected HCPs' power to provide care in the face of constraints. A Kenyan facility-based senior provider/manager (e.g., nurse in-charge) expressed how a family wanted a doctor to perform a procedure that she could perform.

Sometimes when these babies come in, they may need an intravenous line. This procedure normally is done by a doctor, but as nurses we are trained to come in when the doctor is busy, put an [intravenous], to get medications on time. Somebody may have the attitude . . . . to wait for the doctor … But it is a procedure [nurses] can do. —Female, hospital-based senior provider/manager, newborn care, Kenya

Interprofessional Collaboration and Mechanisms

Power with and over other providers was experienced through interprofessional collaboration in decision-making and care processes as described through norms of working together in a particular context. Providers described the collaboration between cadres on critical cases as being positive but as reinforcing cadre-specific power relations between senior providers/managers and direct service HCPs. We found this in maternal health settings where advanced team-based care may have been required for managing PPH in Malawi. However, cadre-specific power relations might give privilege to senior providers/managers with higher medical education or managerial responsibilities over those closest to client care (i.e., senior provider over CHEW), which could have challenged a facility-based HCP's power to engage.

First, the midwife assists, if [she] fails, she calls the clinician, and if they fail, they call the doctor, then the gynecologist. The gynecologist makes the final decision that this condition cannot be controlled – so we refer. —Female, hospital-based provider, PPH, Malawi

The stress in the execution of my work … often the problem comes from the matron! What she could not do properly I have to do my best to take it back calmly … find out how to achieve this. —Female, hospital-based provider, PPH, Madagascar

Kenyan, Togolese, and Malawian providers—male and female—suggested that overcoming this hierarchical challenge and improving collaboration between cadres required understanding the unique value and skills each HCP brought to a care team, including their relationships with and proximity to clients/communities. Although community-based HCPs (CHWs and CHEWs) understandably lacked the skills required of nurses and doctors in times of acute emergency, they possessed higher familiarity with their clients, families, and communities. In Kenya, a facility-linked CHEW reiterated the importance of facility-based providers engaging with catchment communities as a way of increasing HCP power to deliver high-quality care for patients.

All of us, the CHEWs, the health workers work together. I have done the community strategy – going to the household level … When our newer colleagues go to the community … they have to change a little. If [a nurse] trained in Nairobi comes here [rural county] and you take her to [village], there are things that she has to change. —Male, CHEW, newborn care, Kenya

Male and female facility-based HCPs from Malawi and Kenya concurred that peer support and routine meetings where senior providers/managers and staff focused on “communication channels” and codeveloped “action plans” would bolster collaboration between HCP cadres and alleviate provider stress. Specifically, facility-based HCPs described how these strategies showed promise in distributing power equitably with each other to effectively provide care.

We receive support from our fellow health workers… there is teamwork; when there is a complication with a woman and you are unsure of what to do, you can consult and the other health workers are always there to help. —Female, health center-based provider, PPH, Malawi

Sparse data on the mechanisms through which collaboration took place across all 4 countries emphasized spending time and engaging in positive communication between colleagues. A popularly used and well-received feedback mechanism that encouraged interprofessional collaboration included ad hoc and routine meetings between peer providers and supervisors. Additionally, the use of phones to collaborate between HCPs and senior providers was commonly mentioned in Malawi and Madagascar, as often, the senior providers were not in the same physical space.

Challenging Authority

Given the HCP cadre-associated organizational norm of deferring to medical authority, we noted that community and facility-based providers had generally low levels of power to challenge senior providers'/managers' decision-making. The ability of lower-level providers to question those who ranked above them was examined in each country. Despite limited data, this low power manifested similarly among male and female HCPs and across cadres in all 4 countries. Few facility-based providers in Kenya and Malawi expressed their power restrained by senior providers as a stress-inducing practice.

[If] someone says no when you know that it is not the right thing – that stresses you because you know the right way [to manage PPH], but because he or she is a consultant she is saying no it gives you a hard time. —Female, hospital-based provider, PPH, Malawi

In Togo, while community-based HCPs held less power than facility-based providers, they felt comfortable engaging with authority figures (e.g., supervisors, facility and community nurses, and village chiefs). This was derived from their trusted relationships with clients and the autonomy embedded in their individual (non-team-based) nature of work providing FP/RH counseling in a community setting.

We are doing okay [in counseling], but if we could get some help to support us, it would be good. A good counselor needs read a lot and have a supervisor guiding him to improve the work … [Also] I involve the village chief by informing him about each session … even just after a training when I wanted to build awareness, the chief himself mobilized people for me. —Male, community-based provider, FP/RH, Togo

Opportunities for Advancement and Remuneration

Low power within providers manifested in providers' descriptions of limited opportunities for advancement and lack of timely remuneration. We observed this consistently across all HCPs—irrespective of cadre, sex, and work locations (i.e., hospitals vs. health centers). Some facility-based providers in Kenya described stagnating in their jobs for years without growth opportunities as demotivating. Opportunities beyond promotion, such as mentorships and training programs, could motivate and nurture facility-based HCPs, particularly nurses. Yet, these were held ad hoc and could be financially prohibitive to attend, as seen in Madagascar, Malawi, and Kenya.

Facility-based providers and senior providers/managers from Madagascar, Malawi, and Kenya noted delays in payroll disbursements, and the voluntary community-embedded cadre in Togo had different expectations of remuneration (e.g., snacks, water). Compensation/remuneration was mentioned as a motivational asset by all facility-based HCPs of all cadres and sex—with little variability in tone.

There is no motivation in relation to the salary received. The salary amount of is far from the volume of work we do … [although] you are very serious, sometimes you are a little sleepy because of the lack of motivation and remuneration. —Male, health center-based provider, PPH, Madagascar

Beyond inadequate remuneration, voluntary community-based HCPs in Togo expressed feeling underappreciated by the health systems in which they worked. This led to perceived unfair treatment with respect to CHWs' work compared to that of facility-based providers, placing higher value on the latter.

What I don't like as much is the fact that the work of a CHW is really heavy. We are the ones doing all the upfront work before people come to see a [facility-based] provider, but we are not treated as we should be. That is discouraging. —Female, community-based provider, FP/RH, Togo

Female providers, particularly nurses, struggled with and required additional support for balancing their intersectional gender roles in their professional and personal lives. A female nurse in Kenya reflected on her limited and delayed compensation in relation to her work and her role as the primary income earner and caregiver at home.

It is about the employer … because a happy employee does things … I am [a] human being, a nurse, with a family to feed. [If] you do not pay me in time or well, as much as I am giving care, I am not comfortable. How can I give a good quality care … knowing that when I go home, I am unable to afford supper for my kid … I see myself as a failure to my children. —Female, hospital-based provider, newborn care, Kenya

Access to Material/Spatial Resources

HCPs across all 4 countries (least in Togo) described feeling that an extreme lack of material and spatial resources limited their power to effectively care for clients. We found that limited medicines and lack of basic and complex medical equipment (e.g., gloves, soap, stethoscopes, thermometers, intrauterine devices, and resuscitators) constrained facility-based workers in Kenya (at hospitals), Madagascar, and Malawi (at hospitals and health centers). In contrast, Togolese community-based HCPs described sufficient counseling tools (e.g., job aids) but limited logistical and material support when meeting clients living in remote areas. In Madagascar, health center-based providers mentioned additional challenges with the lack of basic utilities (e.g., water and electricity) compared to hospital-based providers. In Malawi and Madagascar, some HCPs—all cadres and both genders—suffered greater resource strain at the health center level, as described by male and female nurses.

The equipment used daily at the health center are all obsolete … The materials are worn, beds all broken and even the most minimal objects—step ladders [are broken]. —Male, health center-based provider, PPH, Madagascar

… sometimes we don't have the materials, we improvise using other things to work effectively. —Female, health center-based provider, PPH, Malawi

During the rainy season, we suffer a lot to do the visits. After several complaints, we were given overcoats. There is also distance; we have to travel kilometers to a household and sometimes, if the couple in the household is not there, it totally discourages you. —Male, community-based provider, FP/RH, Togo

We found that provider stress, influenced by the resource environment, affected their power to function optimally without transferring that onto their clients. HCPs in Madagascar described a lack of staff, amenities, space, and salary combined with high patient volume—a combination that resulted in little time for HCPs to build rapport with patients and ensure comfort. Instances where transference of provider stress to clients occurred left patients and communities feeling dismissed and unheard—in Kenya and Malawi, the pervasiveness of these sentiments normalized poor quality. HCPs reflected that they and their clients were so accustomed to inadequate resources and high client volume that the resultant stress-induced poor quality of care was normalized in the community.

Some of them [families] do not even understand that it is poor quality. They think it is just normal. —Female, hospital-based provider, newborn care, Kenya

Supervision Quality and Emotional Support

Across countries, cadres, and gender, supervision quality and emotional support emerged as salient themes that affected providers' agency (power within), power to work with peer HCPs, and ability to interact with clients effectively.

HCPs noted supervisor availability and responsiveness, including unlocking resources and providing technical feedback, were key components of supervision quality across all health areas and countries. Some facility-based providers in Malawi, irrespective of practice location, felt supported by their supervisors in resource requests—if they needed something, they were able to ask for it. In Kenya, facility-based providers felt that senior providers/managers should be doing more to provide supportive supervision and ensure timely and adequate dispersal of resources.

Being a team leader comes with the rules and responsibility of making sure that the rest of the team are fully equipped in terms of knowledge, skills, and the necessary things they need to be able to offer services. —Female, hospital-based senior provider/manager, newborn care, Kenya

In contrast, in Togo, community-based providers reported positive and active feedback, including moral and technical support, from supervisors who offered encouragement during trainings, back-stopping during community education sessions (e.g., answering questions beyond the HCPs' capacity), as well as provide feedback through routine mechanisms (e.g., individual meetings and reports).

When I ask him [supervisor] to assist me, he does it without hesitating, so I can say that my supervisor supports me in my activities. There is a nice relationship between us. —Female, community-based provider, FP/RH, Togo

Emotional support, although not always available, was expressed as enhancing provider power within facility-based critical care settings. We found that Malawian providers experienced burnout and frustration while trying to work. These providers described feeling supported emotionally by peers and supervisors rather than facility management. Providers in Kenya commiserated about feeling overwhelmed and expressed a need for better mental health support for those working in high-stress health areas. In both countries, emotional support interventions offered mechanisms to empower providers in their balancing work and stress (e.g., nurturing power within).

When something affects your psychological well-being, it interferes with your work and your home relationships, so there is need to have mental health personnel to assist … We have seen providers just shout at anyone at home without reason because of the stressful situations they had at work…having psychological debriefings is vital. —Female, health center-based provider, PPH, Malawi

We have a big gap in management of emotional stress, we don't have a psychologist so that's an area of big gap even for us health providers. —Female, hospital-based senior provider/manager, newborn care, Kenya

Across the 4 countries, there was little explicit mention of how being a female provider or supervisor influenced supervision quality or emotional support. We found in Madagascar and Kenya that HCPs recognized the need for extra sensitivity and support for cross-cadre female providers who were balancing their intersectional caregiving roles at work and home.

The provider has her own small baby to take care of day and night, we come to annoy her in the middle of the night, so we must help her as best as possible. —Female, health center-based provider, PPH, Madagascar

The health care provider needs some time off. If we have correct nurse to patient ratio … [then] the nurse has time for the mother. That is not possible here. You [nurse] go to work, do the cleaning, give drugs, make beds … [and] it's us doing the technical work. —Female, hospital-based provider, newborn care, Kenya

Human Resource Availability and Capability

Facility-based providers in Madagascar, Malawi, and Kenya described human resource shortage among all cadres as a structural challenge to teamwork and sharing of power. In these settings, few providers covered large patient volumes, which could lead, even in resource-rich moments, to suboptimal care quality.

If 1 care provider is going to run a clinic with 30 to 40 patients … we don't have enough time to [provide] dignified care and [cater to the] needs of these children … because of time shortage because you end up doing, clearing and forwarding … it's a challenge - you don't have 1-on-1 attention. —Female, hospital-based senior provider/manager, newborn care, Kenya

The scarcity of sufficient training limited power within/provider's ability. For example, male and female providers in Malawi and Kenya described lacking technical knowledge and communications skills. There were limited data in Madagascar and Togo to investigate this. Sometimes, in cases of staff turnover, the data showed that new hires created more burden than they alleviated for senior providers/managers because of oversight responsibilities and training requirements. In Kenya, HCPs lamented that mistakes could create more work for supervising and collaborating providers. Malawian supervisors described an inability to exert power within their roles—balancing their coordination and mentorship role with time required for formalized in-service clinical and reporting skill-building. In Madagascar, a facility-based HCP described limited and additional human resources as perpetual problems without recourse.

He [supervisor] gives advice on the organization of work but in our locality in the countryside, this is not really effective … We cannot do otherwise because it is a problem of insufficient staff … human resources … and it would always persist no matter what you do. —Male, health center-based provider, PPH, Madagascar

Policies, Protections, and Practice Guidance

Providers' power over their interactions and practices in the facility was derived from the institutional policies, protections, and guidance in place. While health area-specific technical and operational policies and protocols existed to some degree across country contexts, there was little mention of provider protections or institutional mechanisms to guide practice. We found Kenya's role distinction guidelines within a newborn unit were clear, while Malawi's conflict resolution, referral, and outdated PPH protocols challenged HCPs' ability to care for women with PPH. A subset of HCPs described the downstream effects of staff rotation policies in Kenya. Provider transfers to units in which they had little to no experience endangered patients and increased HCP vulnerability and stress.

It doesn't matter if it is a consultant, doctor, or a nurse, there should be a hospital protocol. For example, when a patient comes, it doesn't need a consultant or doctor to tell you to do this … there must be a guideline to follow. —Female, hospital-based provider, PPH, Malawi

I have experienced someone working at the ward … or someone who isn't supposed to deal with a newborn is brought to the newborn unit … now she wants to catch up because this is not an area that she's trained in. —Male, CHEW, newborn care, Kenya

A few Kenyan HCPs reported lacking quality-of-care policies to guide them on how to communicate with parents about their child's care. Others noted that although guidelines existed at the facility level, limitations in the access to assets domain constrained HCPs' power to integrate quality-strengthening programs in practice.

The guideline is that we discharge babies at 2 kilos … some facilities discharge earlier because of crowding within the facilities. Spatial limitations makes implementation of baby-friendly initiatives a bit difficult, but we try. —Female, hospital-based senior provider/manager, newborn care, Kenya

Translation of policies into practice affected provider power and capability to practice. We found that HCPs across the 4 countries felt continued professional development would ensure quality care provision—irrespective of cadre and gender. In Kenya and to a lesser extent Malawi, where attending continued professional development sessions was an accepted facility norm, providers noted the importance of free trainings for updating HCPs on the latest guidelines. They also described that translation and dissemination should expand beyond hospitals to health centers and could be a slow process.

We need to be updated now and again in knowledge and new skills because there are new protocols. This facility that we are [in, there are] a lot of providers … it takes time for someone to improve [their] skills. —Male, hospital-based provider, PPH, Malawi