The dissonance between the rhetoric and reality of health policy and service delivery : a case study of gender and primary health care in Gwassi, Kenya
This thesis exposes the gendered assumptions underlying primary health care policies and practices in developing countries and the power relations underpinning them. These are offered as reasons for the dissonance between the rhetoric of health policy and the reality of health service practice, drawing on a case study of primary health care in Gwassi in rural south-west Kenya, served by government, diocesan and international NGO health services. Theoretically the research is animated by organisational theory to develop an approach that goes beyond a traditional evaluative stance of the planning and delivery of health services, instead making visible and giving voice to the users. The thesis argues that gender frequently remains hidden, unexplored or untheorised, but is nevertheless embedded in the sociological, organisational, economic and medical models regularly used to both plan and research health care. The present globally prescribed model of primary health care rests on just such gendered premises, which have been incorporated and insinuated into national health policies and professions. Historical roots for today's rituals and practices in primary health care in Gwassi are examined using a gendered perspective. Due to the preponderance of maternal and child health activities in such rural locations, along with the use of community health workers in health care delivery, these aspects are focused upon in the literature review of primary health care that frames the research. The thesis concludes that the lack of attention paid to the gendered nature of primary health care by health policy analysts and planners has resulted in and perpetuated a health service, which is designed and delivered in response to a skewed view of the community and its health needs. This in turn limits effective and feasible solutions to health problems. Through a gendered analysis of the findings it is concluded that in practice, primary health care only recognises women's roles and consequently mandates health responsibilities and activities to women. Men's roles are ignored and their participation remains optional, with gendered consequences for all health care users as well as for the efficacy of the service.