https://orcid.org/0000-0001-5009-8470
Abstract
Gender-responsive monitoring and evaluation (M&E) for health and health systems interventions and programs is vital to improve health, health systems, and gender equality outcomes. It can be used to identify and address gender disparities in program participation, outcomes and benefits, as well as ensure that programs are designed and implemented in a way that is inclusive and accessible for all. While gender-responsive M&E is most effective when interventions and programs intentionally integrate a gender lens, it is relevant for all health systems programs and interventions. Within the literature, gender-responsive M&E is defined in different and diverse ways, making it difficult to operationalize. This is compounded by the complexity and multi-faceted nature of gender. Within this methodological musing, we present our evolving approach to gender-responsive M&E which we are operationalizing within the Monitoring for Gender and Equity project. We define gender-responsive M&E as intentionally integrating the needs, rights, preferences of, and power relations among, women and girls, men and boys, and gender minority individuals, as well as across social, political, economic, and health systems in M&E processes. This is done through the integration of different types of gender data and indicators, including: sex- or gender-specific, sex- or gender-disaggregated, sex- or gender-specific/disaggregated which incorporate needs, rights and preferences, and gender power relations and systems indicators. Examples of each of these are included within the paper. Active approaches can also enhance the gender-responsiveness of any M&E activities, including incorporating an intersectional lens and tailoring the types of data and indicators included and processes used to the specific context. Incorporating gender into the programmatic cycle, including M&E, can lead to more fit-for-purpose, effective and equitable programs and interventions. The framework presented in this paper provides an outline of how to do this, enabling the uptake of gender-responsive M&E.
Gender-responsive monitoring and evaluation (M&E) for health and health systems interventions and programs is vital to improve health, health systems and gender equality outcomes.
Within the literature, gender-responsive M&E is defined in different and diverse ways, making it difficult to operationalize; this is compounded by the complexity multi-faceted nature of gender and how it is translated into a gender lens in health and health systems programs and interventions.
A systematic approach for gender-responsive M&E is needed to ensure effective implementation and impact.
Introduction
Equity monitoring related to gender and other social stratifers is a global priority, enshrined in the sustainable development goals framework and elsewhere (WHO, 2013; Hosseinpoor et al., 2014; Sustainable Development Solutions Network, 2015). Gender-responsive monitoring and evaluation (M&E) for health and health systems interventions and programs is vital to improve health, health systems, and gender equality outcomes (Morgan et al., 2022). It can be used to identify and address gender disparities in program participation, outcomes and benefits, as well as ensure that programs are designed and implemented in a way that is inclusive and accessible to all people. While gender-responsive M&E is most effective when interventions and programs intentionally integrate a gender lens, it is relevant for all health systems programs and interventions.
M&E is an important component within the programmatic and intervention cycle (Reynolds and Sutherland, 2013). Monitoring is the current and ongoing assessment of a program or intervention’s progress or status. It is used to assess how well program activities are being implemented, track program performance, and recalibrate program activities as needed. Evaluation evaluates a program retrospectively by asking questions such as: how successful was the program in meeting its goals, was the program implemented as intended, was there improvement on the desired outcomes and/processes, by how much and were there any unintended consequences?
Gender inequality refers to context-driven socially constructed roles, norms, responsibilities, and attributes that unequally differentiate between men, women or gender minority individuals, and reflects systematic unequal power relations between and among them (Connell, 1987; Darmstadt et al., 2019; Heise et al., 2019). As a social construct, gender varies across settings and can change over time (WHO, 2020). This differs (but is related) to gender identity, which is an individual’s personal sense of having a gender, such as being a woman, man, or gender minority individual (Darmstadt et al., 2019). In the case of the former, gender operates within a system which creates structures, social systems, and processes that assign different degrees of power and social position to roles, responsibilities, norms, and attributes associated with men, women, and gender minority individuals—termed the gender system (Darmstadt et al., 2019; Heise et al., 2019). Gender differs from sex, which focuses on a person’s biological characteristics.
Within the literature, gender-responsive M&E is defined in different and diverse ways, making it difficult to operationalize (Morgan et al., 2022). This is compounded by the complexity and multi-faceted nature of gender and how it is translated into a gender lens in health and health systems programs and interventions (Morgan et al., 2016; Heise et al., 2019). To understand gender and its role on an individual’s health and health systems experiences and outcomes, we first need to understand the ways in which gender manifests as inequities. These have been well documented within different gender frameworks (JHPIEGO, 2016; Morgan et al., 2016). Gender as a social construct manifests through inequitable: access to resources, roles and practices, norms and beliefs, autonomy and decision-making, and policies, laws and institutions (JHPIEGO, 2016; Morgan et al., 2016). Proxies are often used to unpack gender and how it manifests as inequities, such as access to education, age of marriage, and income; many programs and interventions are likely already integrating gender dimensions into their development, implementation, and M&E without realizing it.
The purpose of this methodological musing is not to explore the different ways in which gender-responsive M&E is approached and defined within the literature, but to present our evolving approach to gender-responsive M&E which we are operationalizing within the Monitoring for Gender and Equity (MAGE) project (MAGE). We welcome feedback and debate on this approach with the hope that the field can come to a common understanding of what gender-responsive M&E is, and how it can be operationalized within health and health systems programs and interventions. The MAGE project aims to advance and strengthen the capacity and execution of gender-responsive M&E and build sustainable systems and capacity for the use of data to improve gender equality and reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH-N) outcomes, with a focus on women, children, and adolescents.
We define gender-responsive M&E as intentionally integrating the needs, rights, preferences and power relations among women and girls, men and boys, and gender minority individuals, as well as across social, political, economic and health systems, in M&E processes (Morgan et al., 2023). Each of these components is defined in greater detail below. Given the focus of MAGE, and since gender inequality and power relations systemically disadvantage women and girls, our examples below focus predominately on women and girls in the context of RMNCAH-N. We are not, however, conflating gender with women and girls, nor are we saying that programs or interventions that focus on women and girls are in and of themselves gender-responsive. Instead, we argue that in order to be gender-responsive, health and health systems programming and subsequent M&E efforts need to consider and incorporate individuals’ needs, rights, and preferences, as well as gender power relations and systems.
Moving beyond sex- or gender-specific and sex- or gender-disaggregated data and indicators
There are different types of gender data and indicators, which we have grouped into: sex- or gender-specific, sex- or-gender disaggregated, and gender power relations and systems (Morgan et al., 2023). Each of these is described in Table 1. Many of the examples provided come from the MAGE project, which focuses on RMNCAH-N outcomes, with a focus on women, children, and adolescents. Projects focusing on other topics will need to adapt these accordingly. We have also included some examples focused on gender minority individuals to show how these indicators can apply to different groups. Of note, the terms sex-specific and sex-disaggregated have been predominately recognized and utilized within the M&E field. We have chosen to label these as sex- or gender-specific, and sex- or gender-disaggregated, as in some cases, indicators used will be related to biological characteristics (i.e., sex), while in others, they will be related to socially constructed roles, norms, responsibilities, and attributes (i.e., gender). Sex- or gender-specific and sex- or gender-disaggregated data and indicators, by their nature, focus on people. From a gender perspective, this allows us to identify where inequities or gaps exist. What they do not do, however, is explain ‘why’ inequities or gaps might exist. They therefore act as entry points for further gender analysis (or increased gender-responsiveness). Sex- or gender-specific and sex- or gender-disaggregated indicators can be made to be more gender-responsive by, for example, stratifying by subgroups that reveal compounding inequities (e.g., household wealth, educational attainment, urbanicity) or integrating women’s, men’s, and/or gender minority individuals’ needs, rights and preferences.
Types of gender data and indicators
| Gender data and indicators | Description | Examples | Examples with needs, rights and preferences lens |
|---|---|---|---|
| Sex- or gender- specific | Sex- or gender-specific data and indicators focus on only one sex or gender group—such as women, men or gender minority individuals, or subgroups among them. | Percentage of women receiving antenatal care. Percent of family planning facilities offering women a contraceptive method. Teen girls aged 15–19 who are mothers. Percentage of rural vs urban pregnant women assisted by a skilled birth provider during delivery. Percentage of transgender women aged 15–49 who received an HIV test in the past 12 months and know their results. | Percentage of women receiving antenatal care that meets quality of care standards. Percent of family planning facilities offering women contraceptive methods of choice. Incidence of disrespectful, neglectful and/or abusive treatment from healthcare providers towards female/women patients.a Percentage of transgender women aged 15–49 who received hormone replacement therapy when they wanted it. |
| Sex- or gender- disaggregated | Sex- or gender-disaggregated data and indicators explore differences between different sex or gender groups (and subgroups among them), such as between women and men, in relation to a particular metric. | Percentage of girls vs boys aged 15-19 with HIV/AIDS. Percentage of men and women accessing primary healthcare. Percentage of women and men who are beneficiaries of health insurance. Percentage of key populations, including transgender and gender diverse individuals (disaggregated by gender), reached with HIV prevention programs | Percent of family planning facilities offering women and men contraceptive methods of choice. Percent of health facilities managed by women vs men supervisors. Access to and cost coverage for support services for pre-puberty transgender and gender variant children (disaggregated by gender) is ensured.a Incidence of disrespectful, neglectful, and/or abusive treatment from healthcare providers towards transgender and gender diverse individuals (disaggregated by gender).a |
| Gender power relations and systems | Gender power relations and systems data and indicators focus on the ways in which gender power relations and systems manifest as inequities to affect differences in health and health system outcomes and experiences, such as through inequitable: access to resources; roles and practices; norms, values and beliefs; and decision-making power and autonomy (both formal and informal). | Control over own earnings. Percent of health facilities managed by women supervisors. Coverage of reproductive and maternal health services in health insurance schemes. Coverage of gender affirming care in health insurance schemes. | Access to diverse banking systems. Women’s ability to visit preferred healthcare centre without asking permission. Coverage of reproductive and maternal health services which meet essential needs in health insurance schemes. |
| Gender data and indicators | Description | Examples | Examples with needs, rights and preferences lens |
|---|---|---|---|
| Sex- or gender- specific | Sex- or gender-specific data and indicators focus on only one sex or gender group—such as women, men or gender minority individuals, or subgroups among them. | Percentage of women receiving antenatal care. Percent of family planning facilities offering women a contraceptive method. Teen girls aged 15–19 who are mothers. Percentage of rural vs urban pregnant women assisted by a skilled birth provider during delivery. Percentage of transgender women aged 15–49 who received an HIV test in the past 12 months and know their results. | Percentage of women receiving antenatal care that meets quality of care standards. Percent of family planning facilities offering women contraceptive methods of choice. Incidence of disrespectful, neglectful and/or abusive treatment from healthcare providers towards female/women patients.a Percentage of transgender women aged 15–49 who received hormone replacement therapy when they wanted it. |
| Sex- or gender- disaggregated | Sex- or gender-disaggregated data and indicators explore differences between different sex or gender groups (and subgroups among them), such as between women and men, in relation to a particular metric. | Percentage of girls vs boys aged 15-19 with HIV/AIDS. Percentage of men and women accessing primary healthcare. Percentage of women and men who are beneficiaries of health insurance. Percentage of key populations, including transgender and gender diverse individuals (disaggregated by gender), reached with HIV prevention programs | Percent of family planning facilities offering women and men contraceptive methods of choice. Percent of health facilities managed by women vs men supervisors. Access to and cost coverage for support services for pre-puberty transgender and gender variant children (disaggregated by gender) is ensured.a Incidence of disrespectful, neglectful, and/or abusive treatment from healthcare providers towards transgender and gender diverse individuals (disaggregated by gender).a |
| Gender power relations and systems | Gender power relations and systems data and indicators focus on the ways in which gender power relations and systems manifest as inequities to affect differences in health and health system outcomes and experiences, such as through inequitable: access to resources; roles and practices; norms, values and beliefs; and decision-making power and autonomy (both formal and informal). | Control over own earnings. Percent of health facilities managed by women supervisors. Coverage of reproductive and maternal health services in health insurance schemes. Coverage of gender affirming care in health insurance schemes. | Access to diverse banking systems. Women’s ability to visit preferred healthcare centre without asking permission. Coverage of reproductive and maternal health services which meet essential needs in health insurance schemes. |
Also a gender power relations and systems indicator.
Types of gender data and indicators
| Gender data and indicators | Description | Examples | Examples with needs, rights and preferences lens |
|---|---|---|---|
| Sex- or gender- specific | Sex- or gender-specific data and indicators focus on only one sex or gender group—such as women, men or gender minority individuals, or subgroups among them. | Percentage of women receiving antenatal care. Percent of family planning facilities offering women a contraceptive method. Teen girls aged 15–19 who are mothers. Percentage of rural vs urban pregnant women assisted by a skilled birth provider during delivery. Percentage of transgender women aged 15–49 who received an HIV test in the past 12 months and know their results. | Percentage of women receiving antenatal care that meets quality of care standards. Percent of family planning facilities offering women contraceptive methods of choice. Incidence of disrespectful, neglectful and/or abusive treatment from healthcare providers towards female/women patients.a Percentage of transgender women aged 15–49 who received hormone replacement therapy when they wanted it. |
| Sex- or gender- disaggregated | Sex- or gender-disaggregated data and indicators explore differences between different sex or gender groups (and subgroups among them), such as between women and men, in relation to a particular metric. | Percentage of girls vs boys aged 15-19 with HIV/AIDS. Percentage of men and women accessing primary healthcare. Percentage of women and men who are beneficiaries of health insurance. Percentage of key populations, including transgender and gender diverse individuals (disaggregated by gender), reached with HIV prevention programs | Percent of family planning facilities offering women and men contraceptive methods of choice. Percent of health facilities managed by women vs men supervisors. Access to and cost coverage for support services for pre-puberty transgender and gender variant children (disaggregated by gender) is ensured.a Incidence of disrespectful, neglectful, and/or abusive treatment from healthcare providers towards transgender and gender diverse individuals (disaggregated by gender).a |
| Gender power relations and systems | Gender power relations and systems data and indicators focus on the ways in which gender power relations and systems manifest as inequities to affect differences in health and health system outcomes and experiences, such as through inequitable: access to resources; roles and practices; norms, values and beliefs; and decision-making power and autonomy (both formal and informal). | Control over own earnings. Percent of health facilities managed by women supervisors. Coverage of reproductive and maternal health services in health insurance schemes. Coverage of gender affirming care in health insurance schemes. | Access to diverse banking systems. Women’s ability to visit preferred healthcare centre without asking permission. Coverage of reproductive and maternal health services which meet essential needs in health insurance schemes. |
| Gender data and indicators | Description | Examples | Examples with needs, rights and preferences lens |
|---|---|---|---|
| Sex- or gender- specific | Sex- or gender-specific data and indicators focus on only one sex or gender group—such as women, men or gender minority individuals, or subgroups among them. | Percentage of women receiving antenatal care. Percent of family planning facilities offering women a contraceptive method. Teen girls aged 15–19 who are mothers. Percentage of rural vs urban pregnant women assisted by a skilled birth provider during delivery. Percentage of transgender women aged 15–49 who received an HIV test in the past 12 months and know their results. | Percentage of women receiving antenatal care that meets quality of care standards. Percent of family planning facilities offering women contraceptive methods of choice. Incidence of disrespectful, neglectful and/or abusive treatment from healthcare providers towards female/women patients.a Percentage of transgender women aged 15–49 who received hormone replacement therapy when they wanted it. |
| Sex- or gender- disaggregated | Sex- or gender-disaggregated data and indicators explore differences between different sex or gender groups (and subgroups among them), such as between women and men, in relation to a particular metric. | Percentage of girls vs boys aged 15-19 with HIV/AIDS. Percentage of men and women accessing primary healthcare. Percentage of women and men who are beneficiaries of health insurance. Percentage of key populations, including transgender and gender diverse individuals (disaggregated by gender), reached with HIV prevention programs | Percent of family planning facilities offering women and men contraceptive methods of choice. Percent of health facilities managed by women vs men supervisors. Access to and cost coverage for support services for pre-puberty transgender and gender variant children (disaggregated by gender) is ensured.a Incidence of disrespectful, neglectful, and/or abusive treatment from healthcare providers towards transgender and gender diverse individuals (disaggregated by gender).a |
| Gender power relations and systems | Gender power relations and systems data and indicators focus on the ways in which gender power relations and systems manifest as inequities to affect differences in health and health system outcomes and experiences, such as through inequitable: access to resources; roles and practices; norms, values and beliefs; and decision-making power and autonomy (both formal and informal). | Control over own earnings. Percent of health facilities managed by women supervisors. Coverage of reproductive and maternal health services in health insurance schemes. Coverage of gender affirming care in health insurance schemes. | Access to diverse banking systems. Women’s ability to visit preferred healthcare centre without asking permission. Coverage of reproductive and maternal health services which meet essential needs in health insurance schemes. |
Also a gender power relations and systems indicator.
The concept of needs concerns what a sex- or gender-based group needs in terms of health services, programs, and care (Morgan et al., 2023). These can include vital and essential services, such as maternal healthcare. While many needs are universal, it is important to note that some may be politicized [such as access to abortion or contraception for unmarried women (Blystad et al., 2020)]. Applying a needs-based lens to health and health systems programming, therefore, requires careful consideration to ensure it is appropriate for the context.
The concept of rights concern what a sex or gender group have a right to in terms of health services, programs, and care (Morgan et al., 2023). Rights are often enshrined in international global conventions, and gender equality and the right to health are recognized as fundamental human rights. Similar to needs, while universal human rights exist, these may not be applied consistently across contexts. Applying a rights-based lens requires careful consideration to ensure it is appropriate for the context. Many needs and preferences can also be considered rights. Rights-based indicators can be difficult to operationalize, however, as many needs and preferences are also considered to be rights. As a result, rights as a category of indicators may not need to be used if indicators are being delinated by needs and preferences.
The concept of preferences concern what a sex or gender group prefers in relation to health services, programs, and care (Morgan et al., 2023). Preferences are important to consider, as when they are not met, they may act as barriers to access and utilization. Preferences will be context specific and differ across different sex and gender groups. In some cases, integrating needs, rights, and preferences into sex- or gender-specific and sex- or gender-disaggregated indicators can help us to begin to understand why inequities between and among different sex and gender groups exist. Table 1 provides examples of sex- or gender-specific and sex- or gender-disaggregated indicators integrating needs, rights, and preferences. Because an indicator can be both a need, right, and/or preference at the same time, ‘needs, rights, and preferences’ can be used as an umbrella term to categorize such types of indicators.
Gender power relations and systems (Table 1) are the third type of gender data and indicators. Within the M&E literature these have been referred to as gender equality indicators (WHO & UNAIDS, 2016). These indicators build upon sex- or gender-specific and sex- or gender-disaggregated data and indicators by not only helping us to understand where inequities and gaps exist but also ‘why’ they might exist. These types of indicators directly measure gender constructs and help us to understand the ways in which gender manifests as inequities, such as through inequitable: access to resources, roles and practices, norms and beliefs, autonomy and decision-making and policies, laws and institutions (JHPIEGO, 2016; Morgan et al., 2016). These indicators do not always involve people and may instead focus on the presence or absence of laws and policies. In some instances, a gender power relations and systems indicator could also be considered a sex- or gender-specific or sex- or gender-disaggregated indicator, particularly those that incorporate needs, rights, and preferences. Figure 1 outlines the relationship between the different types of gender data and indicators.
Shows different types of gender-responsive data and indicators and how they intersect with one another
Towards more gender-responsive approaches to M&E
To be gender-responsive, health and health systems program implementers and evaluators should seek to move beyond only including sex- or gender-specific and/or sex- or gender-disaggregated data and indicators, and instead ensure they are incorporating needs, rights, and preferences, as well as gender power relations and systems, data and indicators (Figure 2). Active approaches (Figure 2) can enhance the gender-responsiveness of any M&E activities. Such approaches include incorporating an intersectional lens across all data and indicators and tailoring the types of data and indicators included and processes used to the specific context. For example, the use of digital tools in data collection is increasing but does not always consider women’s disproportionate phone ownership and access to phones and the internet (Acilar and Sæbø, 2023). Or, depending on the type of data being collected, it might be most appropriate to only employ women data collectors (Vollmer et al., 2021). These types of issues can be unearthed and addressed by ensuring meaningful participation and representation of relevant stakeholders and communities through the program development, implementation, and evaluation processes. For example, a project could include an advisory board made up of members of relevant stakeholder groups and communities, or these groups could be part of the project team. Community-based participatory research, which emphasizes equitable involvement of communities within the research (or project) process, is a useful methodology for identifying community and stakeholder engagement strategies (Brush et al., 2020; Parker et al., 2020).
Outlines actions that can be taken to increase the gender responsiveness of relevant data and indicators
What we have presented has focused on quantitative approaches to M&E. However, qualitative approaches allow exploration of topics in more depth and provide the nuance and complexity needed when dealing with systems and structures of power—which are always present when people are involved. The focus of qualitative data is different than, but complimentary to, that of quantitative data. Qualitative data, such as in-depth interviews, focus group discussions, and observations, gives greater weight to participant experiences and provides rich insight into how existing structures and systems impact program and intervention implementation. A qualitative portion can be conducted at various timepoints, including in formative stages to end-line evaluation. Further, a gender lens can be incorporated in the ways in which we collect both qualitative and quantitative data, such as the identity and positionality of interviewers or enumerators. Gender-responsive data collection approaches ensure that participants feel comfortable engaging and sharing, as well as promote the safety and well-being of participants while limiting or addressing potential negative unintended consequences, such as how women’s participation in research can sometimes lead to increased workloads, or in more extreme cases, experiences of gender-based violence (Jennings and Gagliardi, 2013).
Robust gender-responsive M&E requires gender-responsive programs (and vice versa) as it is difficult to monitor or evaluate something if it was not integrated at the development or implementation stage. That said, gender can be integrated at any point of a program cycle—just to different degrees. If a program has already been implemented, the gender-responsiveness of its evaluation plan can be strengthened by inclusion of a gender lens (e.g., are there ways the data can be disaggregated by sex and/or other social stratifiers?) for example. If the program planning and development stage is already finalized, you may look at how you can increase gender-responsiveness through the integration of more active approaches or within your implementation and/or data collection processes.
Meeting programs and interventions where they are
When integrating a gender lens into a program or intervention, it is important to meet that program or intervention where it is—and small incremental forms of gender integration are better than none. Political and programmatic buy-in is needed to institutionalize such changes, which can be difficult or protracted to achieve. For example, if a program does not even disaggregate its data by sex, ensuring that all relevant data are disaggregated and reported by sex can be a major win. If data is already disaggregated by sex, ensuring that it is disaggregated by other social stratifiers and/or ensuring that some of the indicators incorporate a needs, rights, and preferences lens (even if you are only able to revise or add a very small number of indicators) is further supportive. Being able to incorporate a needs, rights, and preferences lens, as well as gender power relations and systems indicators, advances a gender lens. Incorporating qualitative approaches to M&E, in addition to the above, can be an even bigger gain.
Gender power relations affect everyone—women and girls, men and boys, and gender minority individuals. As a result, incorporating gender considerations into program planning, design, implementation and M&E is always relevant. Incorporating gender into the programmatic cycle, including M&E, can lead to more fit-for-purpose, effective, and equitable programs and interventions. Gender-responsive M&E therefore creates a pathway for health programs and systems and decision-makers to be more responsive, enhance access, and address inequities. The framework presented in this paper provides an outline of how to do this, enabling the uptake of gender-responsive monitoring and evaluation.
Data Availability
There are no new data associated with this article.
Funding
This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation, investment INV032701.
Acknowledgements
The Monitoring & Action for Gender & Equity (MAGE) project is a partnership between Johns Hopkins University (JHU) and the Global Financing Facility for Women, Children and Adolescents (GFF), a multi-stakeholder global partnership housed at the World Bank that is committed to ensuring all women, children and adolescents can survive and thrive. MAGE aims to advance and strengthen the capacity and execution of gender- and equity-intentional monitoring and evaluation and build sustainable systems and capacity for the use of data to improve gender equality and reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH-N) outcomes for women, children and adolescents in GFF partner countries and beyond.
Author contributions
R.M., A.K., M.D., S.E., T.I., A.L., O.A.T., M.N., I.P., A.M.were involved in conception or design of the work. No data are available for data collection. No data are available for data anlysis and interpretation. R.M., A.K.were involved in drafting the article. A.K., M.D., S.E., T.I., A.L., O.A.T., M.N., D.H.P., I.P., A.M. were involved in critical revision of the article. A.K., M.D., S.E., T.I., A.L., O.A.T., M.N., D.H.P., I.P., A.M.—all named authors approved the paper prior to submission.
Reflexivity statement
All authors are based at high-income country institutions. Diverse genders, races, nationalities and seniorities are included in the authorship list, including authors from Uganda, Egypt, Indonesia and Nigeria. Two authors are current Ph.D. students.
Ethical approval.
This is not a study, and no ethical approval was required.
Conflict of interest:
None declared.
