From press headlines, television debates and online commentaries, the whole world seems to have understood the significance of building strong and resilient health systems given the recent catastrophic events occurring in Sierra Leone, Liberia and Guinea. But how does gender play a role in health systems reconstruction and how might a gendered lens make health systems more robust after conflict?
Esther Richards and Val Percival
Estimates by the World Bank suggest that by 2015 just under one third of the global population will live in conflict-affected settings. At the same time, cross-national quantitative analysis suggests that states with higher levels of gender equity exhibit lower levels of violence in international crises, and are less likely to initiate the use of force. Despite this, the health systems literature does not sufficiently address the issue of gender equity, let alone in conflict-affected and post-conflict settings.
A paper we have recently published in Conflict and Health explores this very issue: how health systems can best integrate gender equity considerations during this important post-conflict period.
Building a gender analysis into health system strengthening
Our paper set out to explore if and how the rebuilding and reform of health systems in conflict-affected and post-conflict contexts addresses gender. We used the six WHO building blocks as a way of framing our findings, so we explored available literature on gender equity aspects of 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance. Using this framework we reflected on the key components of a gender-equitable health system that should be considered as part of health system reform in conflict-affected and post-conflict states.
Our review highlights key areas where work needs to be done to develop gender-sensitive approaches relevant to conflict-affected settings and based on each of the building blocks, for example:
- A key area of action in the development of human resources is to address gender disparities in advancement, planning, retention, supervision and remuneration across all areas of the health workforce.
- In the critical area of health financing there is a need from a gender perspective to pay more attention to those working in the informal sector; to move to public financing mechanisms, to enrol entire households, not simply male ‘breadwinners’, to include comprehensive sexual and reproductive health services, and to prohibit exclusion due to pre-existing conditions, which may particularly affect women.
- And in the area of leadership, that there should be more input from gender advocates to ensure that gender-specific health needs are considered in the governance of health systems. We argue that this is particularly relevant to post-conflict settings, where greater opportunities for social reform – such as promoting the advancement of women to health leadership positions – often exist.
Why did we focus on gender?
The paper in Conflict and Health describes how we explored the literature, but in our broader report we also undertook desk studies of gender equality and equity in health system reconstruction in four countries, Timor-Leste, northern Uganda, Mozambique and Sierra Leone. But why did we choose to focus on gender equity in the rebuilding of health systems in these settings? Especially as fragile health systems require transformation in so many areas and with many structural and social factors taken into consideration – why was gender so important to us?
The fact is, for the vast majority of the world’s population, social and cultural views on gender norms and roles devalue and denigrate women and girls, and undermine and restrict their social status, livelihood opportunities, behaviours and freedoms. These same norms encourage excessive risk taking behaviour among boys and men which has negative consequences for their health outcomes too. It is well documented the health service provision itself is not gender neutral and can exacerbate or alleviate gender inequities.
By identifying what’s required in a gender equitable health system, and making those changes, health system reform can contribute to a foundation of gender equality. But how will states implement these changes without clear guidance or incentives to implement gender sensitive reforms? Our paper argues that given the opportunities for implementing change during the post-conflict period, and the importance of gender equality to broader social well-being. It is time for policy makers, advocates and researchers to investigate and establish much-needed policies, guidance and indicators required to ‘build back better’.
The paper is part of a wider report that was commissioned by the Stockholm International Peace Research Institute (SIPRI) on the opportunities and challenges of building gender sensitive health systems in post conflict contexts. The report was also a joint output from the ReBUILD project: re-building health systems in post conflict states in Cambodia, Sierra Leone, Uganda and Zimbabwe, funded by the UK Department for International Development (DFID). Views represented in this blog are not necessarily those of DFID. If you would like to be part of this debate you can join the Working Group on Health Systems in Fragile and Conflict Affected States which is part of Health Systems Global.