Introduction This paper identifies and summarises tensions and challenges related to healthcare worker rights and responsibilities and describes how they affect healthcare worker roles in the provision of sexual and reproductive health (SRH) care in health facilities.
Method The review was undertaken in a two-phase process, namely: (1) development of a list of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review and (2) literature review.
Result A total of 110 papers addressing a variety of SRH areas and geographical locations met our inclusion criteria. These papers addressed challenges to healthcare worker rights, roles and responsibilities, including conflicting laws, policies and guidelines; pressure to achieve coverage and quality; violations of the rights and professionalism of healthcare workers, undercutting their ability and motivation to fulfil their responsibilities; inadequate stewardship of the private sector; competing paradigms for decision-making—such as religious beliefs—that are inconsistent with professional responsibilities; donor conditionalities and fragmentation; and, the persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities. The tensions lead to a host of undesirable outcomes, ranging from professional frustration to the provision of a narrower range of services or of poor-quality services.
Conclusion Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Despite the particularities of SRH, a whole of systems response may be best suited to address embedded challenges.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The health systems research and the sexual and reproductive health (SRH) literature describe key challenges related to the delivery of quality SRH care and to client experiences of this care. Overall, this research is focused on healthcare workers as professionals, rather than as rights holders.
WHAT THIS STUDY ADDS
The research question addressed by this paper zooms out and synthesises existing literature through the lens of healthcare worker rights, roles and responsibilities, identifying key themes and patterns. The review consolidates and fleshes out what is unique about these patterns in the context of SRH, such as how pervasive stigma as expressed in law, policy and socially; the treatment of women health providers; health systems hierarchy and ‘workarounds’ in limited material and various political contexts shape healthcare worker fulfilment of their responsibilities.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The review identifies and describes the ways that various health systems challenges relating to healthcare worker rights and responsibilities may influence their roles and the provision of comprehensive SRH care, with a particular focus on the perspectives of healthcare workers providing care in health facilities. It elevates themes for future research and policy-making.
Health workers are at the core of health systems. Strategies to realise universal health coverage and the Sustainable Development Goals (SDGs) related to sexual and reproductive health (SRH) rely on health workers at all levels of the health system to be responsible for the provision of quality care in a rights-based manner. However, a variety of factors undercut their ability to fulfil these responsibilities, affecting healthcare worker rights and the roles they ultimately play in health systems, including facilities and communities.
This narrative review addresses healthcare worker rights, roles and responsibilities in the context of the provision of SRH care in health facilities. Addressing rights in conjunction with responsibilities highlights the fact that these two constructs are inter-related. Health workers should have the material, technical and other resources and support required to do their job, and, health workers who feel respected are more likely to provide respectful care.1 2
The field of health policy and systems research offers the crucial insight that health systems are social institutions,3 4 and like all social systems, are shaped by the power dynamics that characterise human interactions.5 Health policies and priorities, training and the delivery of care are embedded in the broader social and political context, including norms and mores regarding gender and SRH. There are particular tensions related to healthcare worker rights and responsibilities in the provision of SRH care. These tensions stem in part from social norms regarding gender and other intersecting identities; related political and social contestation regarding some SRH services; and conflicts among national law, public health evidence and formal professional obligations regarding the content of SRH and rights.6–8
Some of the rights and responsibilities enshrined in formal frameworks, such as national policies, may comport with the rights and responsibilities health workers feel they have and/or feel they can reasonably realise, and some may not. Unwritten norms—such as altruism, respect for one’s supervisor, racism or casteism, or the right/need to take money from patients—can reflect deeply embedded social norms.9 These unwritten norms coexist with formal rules creating at times a complex system and ecology of pressures that health workers feel accountable to. This ecology also interacts with the given material context, where providers must contend with the day-to-day reality of funding and resource availability.
This narrative review identifies and summarises key tensions and challenges related to healthcare worker rights and responsibilities, and describes how they affect healthcare worker roles in the provision of SRH care. The primary intent of this review is to identify and describe the tensions and the ways that they manifest in diverse settings. The review focuses on the provision of care in health facilities, as health facilities are an important site for the provision of many types of SRH care, and the prevailing dynamics may be distinct from those affecting community-health workers and other cadres.
A narrative approach was selected as it allows us to examine heterogeneous literature, to fully explore the types of tensions that arise and to provide examples.10 While a narrative review may be vulnerable to bias, we felt it was most appropriate to the research question because the literature is quite varied. Many of the papers to be reviewed did not use the same terms and framing as our research, such that judgements about inclusion and exclusion were required. Moreover, we sought to produce a narrative paper exploring the themes of rights, roles and responsibilities that drew generously on the existing literature. Other, more strict approaches might have narrowed our focus to a much shorter list of papers that explicitly seek to address rights, roles and responsibilities.
As shown in figure 1, this narrative review was undertaken in a two-phase process. The first phase entailed the development of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review, and the second phase entailed the conduct of the literature search and analysis.
Phase 1: development of an informed search strategy
Prior to the formal literature search, the authors of this paper defined the terms and constructs to be studied. Reproductive health was defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes’.11 Similarly, WHO defines sexual health as ‘a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled’.12 The exact search terms used to operationalise these definitions are listed in the Methods section for phase 2.
Rights, roles and responsibilities were broadly defined and then fleshed out through the literature reviewed. Rights were defined as principles of freedom or entitlement for healthcare workers; these principles may be reflected in law, policy or social practice. Responsibilities are the inverse—obligations of conduct and or result applied to healthcare workers in law, policy or normative practice. Rights and responsibilities shape the role that healthcare workers play. The authors adopted a broad definition because the review seeks to explore tensions as documented in peer-reviewed literature using different methods in different contexts. These tensions are visible when the definition of rights, roles and responsibilities accommodates the heterogeneous approaches taken by researchers and the cultural and political contexts where research occurs.
Once the terms had been defined, the authors accomplished the preliminary scoping by agreeing on keywords, followed by a rapid review of the literature using the keywords. The keywords used included: ‘health care worker rights,’ ‘disrespect and abuse,’ ‘mistreatment of women’ ‘healthcare worker responsibilities’ and ‘healthcare worker roles.’ Each term was paired with ‘sexual OR reproductive health’ or ‘maternal health’ and they were searched in Google Scholar in June 2021, followed by citation chaining. The outcome of phase 1 was a literature-informed search strategy for phase 2. Such an approach was required as we anticipated that the pertinent literature would be vast and wide-ranging.
We report the results of phase 1 briefly here, as these are essential to understanding the methods for phase 2, the heart of the review.
The scoping resulted in 36 articles, revealing several key categories of tension among SRH healthcare worker rights, roles and responsibilities. We outline these tensions in table 1.
The authors decided to exclude ‘insufficient material and human resources’ from our phase 2 literature search, as these challenges are well-documented in the literature, and our preliminary findings pointed to well-trodden findings, such as the fact that lack of materials contributed to provider stress and inability to fulfil their responsibilities.13–15 Moreover, there was significant overlap between this tension and other tensions, such as rights and professionalisms of healthcare workers not respected.16
Phase 2: literature search and analysis
We conducted searches in PubMed and Google Scholar in June and July of 2022. The strategy was customised to the electronic database and limited to results in English, Spanish or French results. We also hand searched the citations of the included papers to identify additional papers.
The search strategy was developed by piloting search terms relating to the categories of tensions. The final search terms are listed in table 2. They are largely self-explanatory, but in a few cases, we added terms in order to produce the most pertinent results. For example, we added a term for ‘conscientious objection’ as we knew there was a growing literature regarding this issue and healthcare worker rights, roles and responsibilities. In addition, we were unable to produce many relevant results by using the terms ‘pressure to achieve goals’, so we tried several terms, including ‘performance-based financing’” ‘performance improvement’ and ‘pay for performance’, discovering that the third produced the most pertinent results. The search terms for the categories of tensions (second column) were applied to every search term for the domains of SRH (fourth column).
The inclusion and exclusion criteria are presented in table 3. We established a cut-off date of 2010 in order to ensure a manageable number of papers, and because there has been significant evolution in key areas such as conscientious objection and mistreatment of women in maternity care over the past decade. We did not apply quality criteria as we were considering heterogeneous literature in order to develop a paper that fleshed out themes, rather than undertaking an evidence review.
Key article details were recorded in an extraction spreadsheet that included basic data on the article (eg, title, authors) as well as the articles’ statements and findings relating to the categories of tensions.
Building on the principles of constant comparative method,17 we fleshed out each category as a theory, iteratively developing topic-specific memos that were refined over time and developed into the manuscript. The authors wrote the memos by creating an initial memo based on rapid review of the extraction tool, then going back and comparing each record in the tool with the memo. This comparison was also done across categories of tensions, to make sure that findings that were relevant to more than one category were accounted for in both, and to ensure internal coherence. The first author then read over each extraction record again, ensuring that the memos were complete and accounted for discrepant findings.
In cases were the articles reviewed discussed ways that these tensions were overcome, we included a summary in our memo and in the manuscript.
Patient and public involvement
Because this paper is not directly related to patient care, this research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient relevant outcomes or interpret the results. Nor were patients invited to contribute to the writing or editing of this document for readability or accuracy.
Given the somewhat academic nature of the research question, the public were not invited to participate. However, public participation in some form (including participation by healthcare workers) might be appropriate for future work that addresses some of the gaps and tensions identified in this paper.
During phase 2, we identified 97 articles for inclusion from PubMed, an additional 7 in Google Scholar and 6 more from handsearching the works cited of the other papers, yielding a total of 110 papers. As shown in online supplemental table 1, the papers addressed a variety of SRH areas and geographic locations. Many papers described multiple tensions. Overall, the review identified more articles relating to law and policy, informal norms, and the intrusion of competing moral paradigms than to pressure to achieve goals, inadequate stewardship of the private sector and donor conditionalities. On finalisation of the memos, the authors decided to integrate their findings relating to power and role ambiguity into the discussion of other categories of tensions, as the included papers always addressed power and role ambiguity as a manifestation of another type of tension, such as informal norms or the pressure to achieve goals. We also combined the discussion of conflicting and ambiguous policies in the results section below.
The following sections synthesise the key findings relevant to the categories of tensions identified in phase 1.
Conflicting laws, policies and guidelines
The papers reviewed identified conflicts that were explicit as well as some that were not explicit, but were perceived by healthcare workers.
Explicit discrepancies occurred when laws, policies and guidelines included provisions that directly contradicted one another. For example, Cleeve et al documented how in Uganda, the constitution, penal code and reproductive health policy were not compatible. Among other incongruities, the national guidelines and service standards specified that abortion was allowed in cases of rape, incest, fetal anomaly, or if the women was HIV positive. These exceptions were not provided for in the penal code, which outlawed abortion.18 While in the case of Uganda, the national guidelines are less restrictive than the law, in the Philippines, the opposite was described. The Philippine Obstetrical and Gynaecological Society’s 2011 ethical guidelines failed to explain Philippine legal exceptions to the criminal prohibition on abortion, and implied that abortion was always illegal.19 In both cases, provider capacity and/or willingness to provide the full spectrum of comprehensive abortion care was undermined, particularly when providers acted according to the more limited interpretation of abortion grounds.18 19
In other contexts, discrepancies identified were not explicit, but might be described as perceived or implicit, creating conditions where healthcare users’ ability to exercise their rights and entitlements were difficult. Two qualitative studies described situations where abortion was allowed by law in several different circumstances, but sex selective abortion was illegal. Providers in these contexts indicated that they felt that it was up to them to determine whether or not the rationale for a given procedure was sex selection, such that they felt like unwilling gatekeepers, arbiters or legally vulnerable.20 21 Several additional papers describing implicit tensions related how laws permitting conscientious objection—ostensibly a measure to protect provider rights to freedom of religion, belief, opinion and expression—could allow conditions where providers (or institutions) undermined legally enshrined entitlements to abortion, particularly where there were not enough providers willing to provide or refer to abortion services.22 More specifically, some conscientious objection laws allowed for institutional objection, such as by Catholic Hospitals; studies assessing the operationalisation of conscientious objection found that such laws made it difficult for women living in the hospital’s catchment area to obtain an abortion, irrespective of their rights to abortion under national law.23 24 Similarly, other papers described settings where a significant percentage of providers in a given geographical area exercised conscientious objection, undercutting or even obviating rights to health or abortion as they were enshrined in national law, as referrals, timely care and other requirements for abortion access were not able to be met.22 23 25 26
Several studies explored how laws and policies interfered in clinical decision-making, thus conflicting with providers’ ethical and legal obligations to ensure patient access to information and services.27 28 For example, state laws in the USA prohibited health providers working in publicly funded clinics from counselling or referring patients for abortion,29 thereby limiting patient care and communication,30 and ‘creating conflicts between professional values and legal obligations’.31–33 Similarly, a case study on Zambia described how a law requiring that three physicians sign a form affirming a patient’s need for an abortion undermined the judgement of the primary doctor as well as the entitlements of the patient in question.34 On the other hand, a study on ethical dilemmas among abortion providers found that some providers opted to break the law and provided abortions because they feared women denied abortions would result to unsafe alternatives.35
Almost all conflicts in law and policy identified related to abortion, but we encountered one in another SRH domain. In South Africa, the law allowed adolescents the right to receive contraception (and to obtain an abortion) after age 12, but the Sexual Offences Act established the age of consent to sex at 16 years. As a result, healthcare providers were expected to provide counselling and care to adolescents 12–16, and also to report sexual activity under the age of consent to law enforcement.36 Providers thus faced a tension between complying with the law and their responsibility to provide confidential care.
Ambiguous laws, policies and/or guidelines complicated healthcare worker rights and responsibilities in a variety of SRH areas. Examples included laws not clarifying which female genital mutilation/cutting practices were being criminalised,37 38 what elements of maternity care were mandated to be free,39 what fell under the health or other grounds for abortion,34 40 41 who could provide abortions and when abortion was permitted,42 the content and limitations of the right to conscientious objection,25 26 43 44 or when adolescents’ life or health were ‘in serious danger’, such that providers were unsure whether they were required to reach out to patients’ parents regarding the patient’s sexual health.45
Studies explored how explicit and implicit conflicts and/or ambiguities in laws, policies and guidelines resulted in the non-provision of care, the provision of non-standardised care, and/or created space for competing normative paradigms for provider decision-making, stigma and fear, and provider’s pecuniary motivation to play a larger role in healthcare worker decision-making. For example, in Mexico, healthcare workers reported not wanting to ‘get mixed up’ in providing abortion services, because they were not sure what their responsibilities were under the law,41 and in Tanzania, healthcare workers benefited from ambiguity about the cost of maternal health services to demand informal payments.39 In the case of abortion and the provision of contraception to adolescents, studies found that uncertainty had sometimes translated to provider hostility or reluctance to see patients seeking services for which the guidelines were unclear as providers preferred to avoid ambiguity and risk.19 46–48 On the other hand, some studies found that providers used the discretionary space provided by ambiguous laws or policy to act in favour of service provision. For example, in Ethiopia, many physicians exercised significant latitude in deciding when a pregnant woman’s life was in danger, and provided abortion services accordingly.34 In Colombia, there were few formal rules regarding the provision of fertility treatment, and so providers who had been trained in fertility treatment provided services, but were forced to ‘negotiate treatment boundaries based on their own morals, social values and professional obligations’ due to the lack of standardised clinical guidelines.49
Pressure to achieve goals
We identified several ways and SRH areas where the pressure to meet coverage, quality, and other goals engendered healthcare worker behaviour that was inconsistent with healthcare worker responsibilities to patients and, in some cases to their fellow providers, as these responsibilities are commonly defined in human rights and medical ethics. This included healthcare provider behaviours such as coercing women into giving birth in health facilities due to pressure to increase the percentage of births in health facilities, and falsifying hospital maternal death records or other data.50 51 One paper described single-minded governmental emphasis on institutional delivery in India as leading to safe, but violent deliveries, where patients in overwhelmed facilities experienced disrespect and abuse and health workers struggled to realise their responsibilities in facilities with unsupportive management and inadequate supplies.52 In Tanzania, where there was governmental pressure to decrease stillbirths, midwives reported that they would slap women during the second stage of labour because they feared stillbirths and the investigations associated with them.53 Punitive supervision was one way that compliance with aggressive performance improvement goals was exacted. For example, an ethnographic study found that facility managers compelled auxiliary nurse midwives to meet unrealistic targets by threatening to withhold their salaries, public scolding or limiting their ability to exercise their full scope of practice.51
Rights and professionalism of healthcare workers not respected, undercutting their ability and motivation to fulfil their responsibilities
Healthcare worker desire and ability to fulfil their responsibilities and respect the rights of their healthcare worker peers depended on the conditions in which they worked, including the extent to which their rights were respected, and the morale and overall culture of the workplace, among other factors.
Several studies revealed how gender-based mistreatment and violence against female health workers affected the disproportionately female SRH workforce. Women health workers from varying cadres reported widespread verbal abuse, bullying, and sexual harassment in the workplace by colleagues and by people in the community.51 54–56 Midwives—who often occupy a lower status by virtue of their being women—experienced disrespect, lack of support and lack of recognition from their supervisors.56–59 This disrespect could manifest in blame, with midwives reporting that they were blamed irrespective of who—if anyone—was at fault for a complication.51 57 58 60
Midwives also experienced disrespect and aggression from patients and their families, including violence, particularly when the midwife was young and/or when the patient was of a higher social status than the midwife.58 59 61 Other SRH healthcare providers also experienced violence, such as actual or threatened violence by patients’ partners against providers who reported likely intimate partner violence to law enforcement,62 or fear of violence among providers who provided contraception to women under 18 years of age.63 Providers who were low in the health facility hierarchy explained in multiple contexts that these infringements on their rights engendered behaviour at odds with their mission as healthcare providers, such as reluctance to provide care or mistreatment of patients.60
A significant subset of articles explained how the stigma associated with SRH may lead to social or professional isolation of health workers providing these services. In some contexts, health workers assisting in childbirth have lower status than other health workers, as childbirth was believed to be ‘women’s work’ or ‘dirty’.54 56 64 Studies on abortion stigma and abortion providers found that some experienced significant stress resulting from exclusion and condescension from their professional peers, at times so deep that they felt they had no colleagues to whom they could turn for clinical or moral support; and social condemnation of them and their families.65–72 Stigma can have a range of impacts on providers, including enhanced feelings of legal jeopardy.73 In addition, abortion providers in various contexts experienced violence, including murder66 68 as well as regular harassment from the police, even if they were acting within the confines of the law.18 74
While these studies are diverse in terms of focus, together, they illustrate some of the many ways that material, political, and social factors influence healthcare providers’ labour and other rights, and their experience of the workplace more broadly. Many papers linked these experiences to their ability and willingness to provide care, as assessed primarily through self-report.
Inadequate stewardship of the private sector
We considered both for profit and non-profit institutions not run by the government to be the private sector. Overall, we found few articles exploring private sector SRH provision and its regulation. The articles that we did find addressed a few discrete areas, including private sector midwifery, contraception services and abortion.
Several studies explored instances where, in the absence of adequate regulation, the profit motive potentially undermined the ethical obligations of health workers or the mission of the health sector overall. For example, a study assessing a government-supported private midwifery programme in Pakistan found that, in the context of financial pressures, skilled birth attendants from the private sector were disincentivised from providing services to poor, non-fee-paying patients.75 While the private sector provides family planning services to many patients in Uganda, Nalwadda et al found that these services were not necessarily well-regulated or monitored as part of the national reproductive health strategy.76
In the context of conscientious objection, we identified an article finding that some providers claimed conscientious objection in the public sector, and then provided the service (for a fee) in the private sector.41 Relatedly, people seeking abortion in legally restrictive environments could be diverted to the private sector, where there was a higher financial payoff for the risk assumed by the provider.77 In contrast, a study on a programme that contracted out maternity care in India found that at least some private providers felt that the contracting merely outsourced the risk of maternal mortality to private providers; these providers lacked the protection of a government employer.78
In sum, though limited in scope, the articles reviewed suggest that poor regulation of the private sector contributed to fragmentation and the impingement of financial motives in a way that could undercut fulfilment of healthcare worker responsibilities, altering their role to be more focused on making money. Providing SRH services in the private sector carried a different risk calculus, though this was found to be different in diverse contexts.
Competing paradigms for decision-making that are inconsistent with professional responsibilities
Many articles referred to or explicated conceptual frames that guided healthcare worker behaviour in ways that were inconsistent with professional responsibilities. These paradigms fell into a number of categories, but were typically in the general family of social mores and moral/religious values. Providers themselves acknowledged that these beliefs sometimes guided their decision-making about what kind of SRH care to provide and to which patients.43 Studies detailed provider stigma associated with a variety of patient populations, including adolescents45 76 79–81 LGBT individuals,81 unmarried women seeking SRH services82; HIV positive women who try to become pregnant or who are pregnant83–85 HIV positive people overall86; pregnant women with high parity or who are undocumented87; people who have mental illness83 or men who have sex with men seeking sexual health services.88 Beliefs were manifest in provider decisions such as refusal to provide certain services or making judgemental statements when providing care.89 90
Studies exploring the provision of abortion services found that providers might judge the patients based on a variety of factors relating to a religious or moral values or stigma, such as on whether or not the person seeking abortion was married,91 92 raped,41 the duration of her pregnancy and whether she was ‘convincing enough’ in articulating her desire for abortion, whether or not the sexual act that resulted in the pregnancy was socially sanctioned, and if contraception was used.41 43 93 94
Many papers explicitly sought to describe and assess the impact of provider religiosity on SRH care, sometimes as their primary research question. In contexts both with and without a formal conscientious objection regime, there were healthcare workers who explicitly said that they objected to abortion on religious grounds and would not provide it.35 43 65 93–97 A study in Malawi documented how this moral or religious objection extended to the provision of postabortion care, with healthcare workers interviewed describing women seeking post abortion care as ‘sinners’ or ‘criminals’.98
Quantitative cross-sectional studies assessing the association of provider religiosity with particular practices found that it was associated with support for conscientious objection,99 HIV stigma,100 negative attitudes towards abortion care101 and pharmacist unwillingness to dispense emergency contraception and medical abortifacients.102 Religiosity and other moral approaches to decision-making that compete with SRH guidelines and ethical guidelines were not static or monolithic; papers reviewed suggested they changed over time and in different contexts, with a diversity of opinions likely held by healthcare workers in the same facility.93 96 103
Providers are not just shaped by the broader social environment; they too, are active agents that shape that environment. For example, one study found that providers used their institutional power to encourage others to use conscientious objection, advancing their objective of decreasing the number of providers willing to provide abortions.44 In a different setting, hospital leadership, based on their own religious or moral codes, sought to limit the provision of abortion services in their own department by not facilitating staff training and not procuring manual vacuum aspiration kits.42 Finally, providers can seek to directly influence the decision-making of their own patients, such as by trying to convince women seeking an abortion not to obtain one, even if they have a legal right91; or dissuading adolescents from obtaining contraception,76 or anyone seeking fertility treatment.49
Several studies researched directly the question of how competing paradigms for decision-making might be reconciled with public health imperatives and healthcare worker responsibilities as these are enshrined in relevant national guidelines. Many providers included in these studies explained that their own or others’ religious convictions or moral concerns should be overridden by professional obligation to provide care18 93 94 99 104 or by their obligations to their employer or the ‘ethos of the hospital’70 105 by religious values relating to forgiveness106 or by payment to provide services to which they are purportedly religiously or morally opposed, such as abortion or FGM.26 37
Donor conditionalities and fragmentation
Most of the articles identified in this category evaluated the impact of the Global Gag Rule (GGR) or other conditionalities. As per the most recent iteration of the Rule (2017–2021), providers working for non-governmental organizations (NGOs) and private facilities that received bilateral US global health assistance or that had donors who received US global health assistance were disallowed from counselling their patients on abortion, undercutting their professional responsibilities, particularly in countries where abortion is permitted.107 108 Healthcare workers narrated how the GGR limited their ability to realise what they felt were their professional obligations, due to limited resources and limitations on what they could say, even in environments where abortion was already illegal or available on very limited grounds.109
In addition to research documenting the impact of the GGR, we identified one paper exploring how funding restrictions shape the environment in which healthcare workers work. The Helms Amendment, a US law that restricts the use of US government funds to provide or support abortion services, has reportedly had a chilling effect on NGO and health provider ability to provide abortion in humanitarian emergencies, despite the heightened need.110
Finally, one narrative review found that ‘new public management’ and other donor trends that resulted in cuts to the public sector wage bill and the marketisation of healthcare could harm healthcare worker rights and their ability to meet their responsibilities in providing maternal health services, though our search terms did not produce any other research assessing the impact of these broader trends on healthcare worker rights, roles and responsibilities within SRH.111
Persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities
Several papers that applied a social science lens to the SRH workforce relied on theories of informal norms or produced findings that the authors then pointed to as evidence of the importance of such informal norms. A review on midwives’ perspectives on disrespect and abuse of patients during the intrapartum period in sub-Saharan Africa found that prevailing professional norms played out in ways that established social distance between midwives and other providers and their patients, through controlling women’s bodies (eg, not letting them choose a birthing position) or withholding information about their status and care, relegating the woman in labour to the role of bystander; the review authors grouped these normative behaviours under an analytical theme of ‘maintaining midwives’ status’.64 Of the papers that explicitly described social distancing and disrespect and abuse as an informal norm, there was agreement that differences in social status between patients and providers as well as hospital set up and operations (eg, design of space, organisation of services, distribution of tasks) and medical education and training buttressed social distance.56 58 64 83 112 113 Research in India found further that provider fear of formal and informal accountability mechanisms mobilised by patients and their families deepened provider/patient distance; providers remained remote and invoked administrative safeguards to help to protect themselves from such mechanisms.113
Social distance did not apply to all patients equally. One study examined the quality of care for certain populations, finding that social distance and prioritisation of provider needs was more acute in the context of refugees, ethnic minorities and others for whom the health system setup is foreign.114 Such distinctions among clients may be expressed by, for example, an implicit norm of preferences—such as shorter wait times and nicer treatment—for patients who were friends and relatives of providers or who paid for the services provided.57 83 115
Papers exploring informal norms were not solely focused on provider responsibilities and roles regarding patient care. These norms can also undercut provider rights, particularly for those providers at the bottom of the hierarchy, and particularly for women providers. In addition to the vulnerability to assault mentioned earlier, nurses and midwives often worked within rigid hierarchical systems where disrespectful treatment by providers above them in the hierarchy was normalised, demands that they undertake unpleasant tasks outside of their scope of practice were prevalent, and seemingly arbitrary assertions of power by more senior providers were not easily mutable.2 54 116 117
Providers created informal arrangements in order to navigate a challenging environment, make a poorly resourced health facility function and protect their own rights. These arrangements were not necessarily consistent with their responsibilities. For example, in the face of unreasonable expectations and insufficient resources, Auxiliary Nurse Midwives in India sometimes intentionally decided not to apply their clinical knowledge to service provision (the so-called ‘know do gap’), by such behaviours as not sterilising equipment and augmenting labour. This included creating their own informal management system, such as informal rosters and manipulated labour room registers.51 Health providers explained that since they are the main interface with patients, they were often the ones who have to devise or implement such informal systems, such as asking women to pay for services or medicines that should be free because the governmental system of funding was not functioning properly39 or because they felt their remuneration was insufficient,51 and referring women in ways that were inconsistent with protocol because they lacked requisite personnel or equipment.118
This narrative review provides an overview of how key types of tensions among healthcare worker rights, roles and responsibilities in SRH, and provides examples of how these challenges manifest in different settings. Much of the literature focuses on abortion and the particularly thorny problem of conscientious objection. The high number of articles on maternal health likely reflects its priority within the global health community. There is comparatively less exploration of other SRH areas, particularly reproductive cancers, assisted fertility and sexually transmitted infections (outside of contraception). The bias towards abortion reflects its especially contested status. Some abortion-specific findings might be applicable to other contested areas, such as adolescent SRH services.
The tensions lead to a host of undesirable outcomes, ranging from professional frustration to social distance between patients and providers. Importantly, all of the tensions explored were associated with reduced scope and quality of care, at least in some contexts. These overlapping and inter-related adverse outcomes are collapsed into broad categories of impacts and summarised in figure 2.
Though providers—rather than patients—are the focus of the review, the link between provider responsibilities and patient rights is clear in many instances, in part because many studies focus on the provision of care as the primary outcome of interest. Provider failure to fulfil their responsibilities harms patient care. Greater fulfilment of provider rights can enable fulfilment of their responsibilities—and thus patient rights—though this is complicated in cases where provider rights are perceived in an expansive manner and without adequate consideration of government obligations to fulfil the right to health, for example, provider rights to refuse to provide abortion or other services. The limited articles responding to our search terms that explored ways to overcome the misalignment of patient and provider interests and priorities—particularly in the context of religion—found that provider focus on public health goals and their responsibilities therein can lessen the salience of providers’ personal religious or other codes in the provision of care.
Figure 3 provides an idea of what negative outcomes are the most oft-cited (represented by the larger ovals) as well as how they relate to the provision of SRH care. It is important to note however, that the logic underlying the figure 3 is somewhat tautological (eg, persistence of embedded norms leads to the intrusion of religious frames in provider behaviour), that the constructs (circles) may overlap, and, that the papers reviewed employed diverse approaches and operationalised different constructs at different levels or investigated different elements of a causal chain whose entirety is not represented here. Moreover, figures 2 and 3 are concerned with negative outcomes; these outcomes are not the only kind identified in the review. For example, some providers used ambiguity in law or policy to provide more comprehensive care.
While we can sketch out some of the negative impacts that the tensions we explored have on the realisation of provider rights, roles and responsibilities, the drivers and manifestations of these tensions are not always well articulated or explained. Few of the papers focus exclusively on tensions in rights, roles and responsibilities as we describe them here; we applied a research question to the literature that resonates to varying degrees with the approach of the articles that responded to our search terms. Notably, the discussion of healthcare worker responsibilities is typically implicit with the unspoken responsibility being the provision of quality healthcare. Healthcare worker rights are rarely described as such, though there is ample literature exploring healthcare worker morale, experiences and motivation. In particular, there is little exploration of healthcare worker rights from a labour rights perspective, or of the role professional organisations play. Given the consistent finding that working conditions, support and morale influence the quality of services provided, greater research and policy focus on healthcare worker rights and key drivers—such as public sector salaries or high-level (grand) corruption in the healthcare sector and its impact on providers—is merited. Roles are also not typically discussed as such, but there are extensive findings regarding healthcare worker behaviours that can be synthesised.
Despite the slippages between our question, the rights, roles and responsibilities framing, and the papers responding to our search terms, this review adds value insofar as it starts to consolidate and flesh out what is unique about some of these challenges in SRH, including the many ways that practice diverges from policy. Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Social norms emerged in our analyses of several categories of tensions. These were often—but not always—a component of informal, workplace norms. Olivier de Sardan proposes the empirically derived concept of ‘practical norms’, which are both contrary to official norms and implicit, but also widespread and embedded in civil servant practice.119 120 Practical norms reflect latent norms, including social norms, as well as beliefs and expectations that are specific to the professional context, including the material context in the workplace.120 The conceptually similar theory of street-level bureaucracy121 has also been applied to SRH, such as to assess how abortion providers exercise discretion regarding the provision of abortion as they navigate religious values.106 While comparatively few papers explicitly adopt this framing, the related notions of the know-do gap, healthcare worker workarounds, social distance and other related lenses for behaviour that is at odds with formal rules are a leitmotif of many of the studies reviewed.
Future research could focus specifically on emic accounts of provider rights or responsibilities as such, given that these are often implicitly assumed—rather than named. Rights and responsibilities are typically explored in the breach, that is, when practice differs from what is commonly assumed to comprise rights and responsibilities. Emic explorations of what the attributes of rights and responsibilities are in different contexts could shed light on how providers as individuals and as social groups perceive and navigate tensions. Provider accommodation and engagement in cultural norms relating to childbirth or sexuality and the relationship between labour rights and mistreatment of women and others giving birth may be especially fruitful areas for exploration.
This review has a few key limitations. First, it addresses many issues that are amply explored in other streams of literature, outside of SRH. While reading articles specific to SRH offers particular insight into how the SRH health workforce is affected, it means that this paper offers only a partial lens into these same issues from a health systems perspective. For example, there is a robust literature on performance-based financing that goes well beyond SRH. Second, our review tries to address the interface of three key areas—SRH, healthcare workers and areas where challenges might arise in terms of their rights, roles and responsibilities. This necessitated a lengthy list of search terms and search term combinations. It is possible that there are other articles that are pertinent to our research question that were not identified by the search terms. We noted that some key SRH areas that have not been extensively researched from the provider perspective, such as gender-affirming care and SRH care for people in closed institutions such as prisons or psychiatric facilities, were not well represented—if at all—in the articles reviewed. Relatedly, key issues such as reproductive cancers; STI prevention, care and treatment (other than HIV and services provided as part of contraceptive care); and obstetric fistula were not adequately identified through our search terms, or have not been explored in relation to our research question. Finally, we recognise that the situation, particularly as regards to law and policy—may have changed in many countries since some of the articles cited were published. However, as noted, our objective was to raise and describe themes, rather than to comprehensively survey the literature.
The research question addressed by this paper by definition zooms out; we are concerned with broad patterns in SRH healthcare worker rights, roles and responsibilities. Some responses to the challenges described might be high level, such as reforming law, policy, training curricula, performance metrics and healthcare sector funding arrangements. Others might be more localised and contextual, particularly strategies to reduce the impingement of informal norms or stigma. Given the salience of informal norms, it is unlikely that changes solely to formal structures will be sufficient to significantly lessen tensions among provider rights, roles and responsibilities. The paper raises questions that are often the subject of research—such as abortion stigma—as well as questions that are comparatively underaddressed, such as providers providing superior care to patients that are known to them. Synthesising the literature on all of these tensions in the same paper reveals commonalities and linkages, suggesting that a whole systems approach to reform is needed. Both emic research and participatory policy-making processes with SRH healthcare providers should inform such whole systems reform; indeed, many solutions may require zooming in to explore adequately localised dynamics.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Patient consent for publication
Ibadat Dhillon of WHO had the initial idea for the framing of this paper and commented on foundational work that became the basis of the paper. Maayan Jaffe, an independent consultant, provided research assistance on the foundational work.
Handling editor Manasee Mishra
Contributors MS conducted the narrative review with support from all authors. MS wrote the first draft with inputs from all authors and leadership from UR. All authors have approved and accepted for publication. UR is the guarantor of the manuscript.
Funding This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Research), a cosponsored program executed by the WHO.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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