Background
Methods
Research Questions How were gender considerations integrated within the efforts to rebuild health systems in the post-conflict contexts of Mozambique, Sierra Leone, Timor Leste and Northern Uganda? What impact did post-conflict interventions within the health sector have on gender equity with the health system? | |
---|---|
Inclusion Criteria | Exclusion Criteria |
• Health interventions after peace agreement or cessation of hostilities (Mozambique after 1992, Timor Leste after 1999, Sierra Leone after 2002, Northern Uganda after 2006) | • Health interventions during active conflict |
• Interventions that addressed one or all WHO Health System Building Blocks • Health interventions that addressed gender and access to health care (maternal services) | • Disease Specific Interventions, including HIV/AIDS |
• Geographic scope: Research on Mozambique, Timor Leste, Sierra Leone, Northern Uganda | • Research from outside these four geographic areas |
• English peer reviewed articles • English reports from UN Women • English reports from international non-governmental organizations • English reports from national governments | • Non-English peer reviewed articles • Non-English reports from governments |
• Health system data from multilateral organizations • Health system data from national governments • Health systems data from Institute for Health Metrics and Evaluation | |
Evaluation of Available Evidence • Examined available evidence to assess if and how health systems functioned as measured against the ‘benchmarks’ of gender equity; • Grouped evidence into themes under the benchmarks as common patterns appeared in the evidence. |
Search Terms | Total Articles | Articles Reviewed | ||
---|---|---|---|---|
“Mozambique AND. ..” | Promed | Scopus | Promed | Scopus |
Health system | 78 | 401 | 2 | 4 |
Health system gender | 4 | 0 | 0 | |
Health system access | 42 | 94 | 1 | 5 |
Maternal health | 191 | 176 | 1 | 8 |
Reproductive health | 106 | 76 | 5 | 5 |
Health financing | 34 | 46 | 1 | 0 |
Human resources | 131 | 374 | 8 | 5 |
Health information | 221 | 272 | 4 | 8 |
Community health workers | 67 | 66 | 2 | 6 |
Gender mainstreaming | 2 | 1 | 1 | 1 |
Health Governance | 9 | 13 | 2 | 0 |
Gender Equity | 4 | 13 | 3 | 3 |
Health Equity | 26 | 23 | 8 | 2 |
“Timor Leste AND. ..” | Promed | Scopus | Promed | Scopus |
Health system | 24 | 58 | 2 | 2 |
Health system gender | 4 | 0 | 0 | 0 |
Health system access | 3 | 9 | 2 | 2 |
Maternal health | 26 | 34 | 3 | 3 |
Reproductive health | 10 | 13 | 2 | 3 |
Health financing | 10 | 9 | 0 | 0 |
Human resources | 15 | 54 | 1 | 2 |
Health information | 32 | 39 | 1 | 1 |
Community health workers | 11 | 10 | 1 | 1 |
Gender mainstreaming | 0 | 2 | 0 | 0 |
Health Governance | 2 | 4 | 0 | 0 |
Gender Equity | 1 | 1 | 0 | 0 |
Health Equity | 3 | 2 | 0 | 0 |
“Sierra Leone AND. .. ” | Promed | Scopus | Promed | Scopus |
Health system | 105 | 212 | 5 | 5 |
Health system gender | 2 | 1 | 0 | 0 |
Health system access | 12 | 38 | 2 | 5 |
Maternal health | 73 | 97 | 3 | 7 |
Reproductive health | 33 | 31 | 2 | 2 |
Health financing | 12 | 14 | 0 | 2 |
Human resources | 65 | 152 | 0 | 3 |
Health information | 84 | 117 | 2 | 4 |
Community health workers | 35 | 46 | 1 | 2 |
Gender mainstreaming | 0 | 0 | 0 | 0 |
Health Governance | 7 | 11 | 0 | 0 |
Gender Equity | 0 | 3 | 0 | 0 |
Health Equity | 18 | 7 | 0 | 0 |
“Northern Uganda AND. .. ” | Promed | Scopus | Promed | Scopus |
Health system | 37 | 43 | 3 | 3 |
Health system gender | 2 | 2 | 0 | 2 |
Health system access | 8 | 11 | 1 | 2 |
Maternal health | 22 | 23 | 2 | 2 |
Reproductive health | 24 | 21 | 4 | 4 |
Health financing | 0 | 0 | 0 | 0 |
Human resources | 11 | 40 | 1 | 2 |
Health information | 38 | 48 | 1 | 2 |
Community health workers | 19 | 16 | 1 | 1 |
Gender mainstreaming | 0 | 2 | 0 | 0 |
Health Governance | 0 | 0 | 0 | 0 |
Gender Equity | 2 | 0 | 0 | 0 |
Health Equity | 0 | 0 | 0 | 0 |
The gender blind nature of health system interventions
Introduction to the four contexts
Mozambique | Timor Leste | Sierra Leone | Northern Ugandaa | |||||
---|---|---|---|---|---|---|---|---|
Women | Men | Women | Men | Women | Men | Women | Men | |
Population Indicators | ||||||||
Population | 28 million (2015)b | 1.13 million (2013)c | 5.98 million (2012)d | 14.46 millione | ||||
Life Expectancy | 59.9b | 54.3b | 70.1f | 66.5f | 46d | 45d | 57.6 (2011)e | 52.9 (2011)e |
Percent of Population under 15 | (2012) 45%g | 46% (2013)c | 41.74% (2012)d | Not disaggregated for Northern Uganda | ||||
Economic Indicators | ||||||||
Development Assistance for Health 2014 (million USD)h | 864.54 | 22.78 | 179.84 | Not disaggregated for Northern Uganda | ||||
Estimated Gross Domestic Product per Capita 2014 (2011 PPP $)i | 1040 | 1210 | 3122 | 7530 | 1582 | 1981 | Not disaggregated for Northern Uganda | |
Social Development | ||||||||
Some Secondary School Education (percent) | 1.5j | 6.0j | No data available | No data available | 6.3 (2012)e | 26.4 (2012)e | ||
Literacy % of total population | 28 (USAID 2016) | 60 (USAID 2016) | 43 (UNDP 2011) | 59 (UNDP 2011) | 32.6k | 54.7k | 53.2%e | N/A |
Labour Force Participation Rate (percent) | 26.3j | 75.8j | 24.6f | 50.8f | 65.7l | 69l | 88.9 (2012/13)e | 90 (2012/13)e |
Selected Health Statistics | ||||||||
Fertility Rates | 5.9 (2011)m | N/A | 5.9 (2013)c | N/A | 5 (2012)d | N/A | 6.8 (2011) | N/A |
Contraceptive Prevalence (% women aged 15–49) | 12n | 22.3o | N/A | 11p | N/A | Not disaggregated | N/A | |
Antenatal care % at least 1 visit | 90.6q | N/A | 84.4o | N/A | 93r | N/A | Not disaggregated for Northern Uganda | |
Skilled attendant delivery % | 54.3q | N/A | 61p | N/A | 62.5r | N/A | Not disaggregated for Northern Uganda | |
Maternal Mortality Ratio | 248.7 (151.4–365.4)s 490j | N/A | 270c | N/A | 1100 (2013)d | N/A | 438 (Uganda)e | N/A |
HIV Prevalence – 15-49 years | 10.8%t | Not reportedo | 1.5% | Not disaggregated for Northern Uganda | ||||
HIV – Children 0–14 yearst | 190,000 (est) | Not reportedo | 5800 | Not disaggregated for Northern Uganda | ||||
HIV Prevalence – Young adults (15–24) | 11.1% (est)t | 3.7% (est)t | Not reportedo | 1.0 | 0.3 | Not disaggregated for Northern Uganda | ||
HIV – Adults 15–49 | 1,400,000 (est)u | Not reportedo | No data available | Not disaggregated for Northern Uganda | ||||
820,000 (est) | 580,000 (est) |
Post-conflict health system engagement and gender
Applying the benchmarks: Assessing gender equity in the health system
Building block one: Health systems governance benchmark
Moreover, what the Ministry of Health considered as “gender” was confined to interventions on ‘maternal conditions’, sexual violence, and HIV/AIDS – particularly Prevention of Mother to Child Transmission (PMTCT) [55]. This finding is consistent with evidence from other contexts – gender mainstreaming is generally interpreted as ensuring health systems provide maternal health services, not necessarily ensuring that they respond to the differential health needs of women (and men) across the lifespan.The limited expertise in gender mainstreaming skills, the lack of capacity in gender sensitive policy formulation and programme analysis, the feminization of certain conditions such as STI/HIV/AIDS and the poor integration of initiatives against gender-based violence are some of the challenges to overcome ([54] p. 6).
Building block two: Health service delivery
Research in Mozambique also cited the “unfriendly environment” in health centres, including health workers’ disrespectful treatment of women during childbirth [84, 101], despite the government’s humanizing initiative [80]. Female sex workers acutely felt such barriers, as they did not trust health workers to treat them with respect, compassion or to maintain privacy and confidentiality [102]. Patients in Timor Leste also reported disrespectful behaviour that included shouting at patients, blame and shame attitudes as well as nepotism [41]. Ensuring appropriate care “did not require complex or expensive technology, a major overhaul or significant costs. Rather, it implied listening to and observing the experience and feeling of women patients, encouraging and supporting staff to embrace change, and monitoring the process and data to observe the impact” ([32] p. 11).One main barrier identified across the sites, and especially in Northern Uganda, included past unpleasant experiences or fear of such experiences at the hands of health providers at the health facility, discouraging some women from seeking services (60%). With extensive impoverishment among the rural women who were temporarily displaced from their communities during the conflict, many of them felt despised, looked down upon, and poorly received by health personnel when visiting the health facility ([88] p. 6).
Women may also be prevented from leaving the house to seek care. In Maputo, Mozambique in 2011, skilled health workers attended only 54% of live births [107]. “Reportedly the decision to seek care was taken by the woman herself in [only] 29.3 percent of the near miss cases, while in the remaining cases, the woman depended on the husband’s or other family members’ decisions” ([108] p. 4).“One-quarter of women indicated they would decide for themselves where to deliver, while 32% said their husband or partner would decide, 30% said the decision would be taken jointly between themselves and their partner, and 11% indicated others would decide – including mother, mother-in-law, other family member or traditional birth attendant” ([32] p. 6).
For women living with HIV/AIDS, stigma and fear undermine access to health care. “For women, disclosing their health status could lead to divorce, which would result in the loss of their children and their financial stability, as men could force them to leave the family home” ([110] p. 7).“ [. . .] another reason women did not reveal the onset of their labour related to the fear of being accused of immoral behaviour if the labour was considered to be taking too long. Many participants in the villages spoke about infidelity as a potential cause for a delayed or obstructed birth as another man’s sperm had ‘contaminated’ the pregnancy. In such cases the woman in labour needed to ‘ speak out’ or confess to the adultery in order for the birth to proceed” ([104] p. 7).
Building block three: Human resources
Building block four: Health information systems
Building block five: Health system financing
Building block six: Medical products and technology
“We do not measure the blood pressure because we do not have the device. We have many tensiometers but we do not have the stethoscopes. We only received sphygmomanometer [ . . . ] I’m here since February, and we haven’t assessed pregnant women’s blood pressure [. . .]” ([80] p. 5).
In Timor Leste, clinics also lacked regular supplies of vaccines, which appeared to differentially impact on girls: girls 12–23 months were less likely to be fully immunised in comparison to boys in the same age range (23.4% compared to 29.8%). The gap increased in urban areas to 26% for girls and 40% for boys [73]. In rural areas, women needed to travel long distances to access reproductive technologies, and local midwives may not have received sufficient training to provide the range of modern methods of contraception [76].Only 53% (n=78) of all facilities surveyed indicated that they distribute contraceptives. However, of the 83 non-Catholic facilities, 93% (n=77) do distribute contraceptives ([134] p 16).
Discussion: Key findings
The challenge of health system engagement
To what extent has post-conflict health system engagement met our benchmark of a gender equitable health system?
Attributes of Gender Equitable Health System | Manifestation in Mozambique | Manifestation in Timor Leste | Manifestation in Sierra Leone | Manifestation in Northern Uganda |
---|---|---|---|---|
Provision: Health services addressing most urgent health care needs of men and women across life span in an appropriate manner. | While the delivery of health services has improved, adolescent girls and women lacked access to reproductive health care services. Concerns regarding respectful delivery. | Health service provision had improved dramatically, yet problematic health indicators for women and adolescent girls, particularly in rural areas. | Free health care initiative has prioritized care for women and children, although Ebola significantly weakened health system. | Health service delivery improved since war, yet significant shortfalls in service provision particularly for reproductive needs of women and girls. Concerns regarding respectful delivery. |
Access: Ensure men and women across the life span are able to access and utilize services unimpeded by financial, social, geographic barriers. | Significant financial, geographic and cultural barriers existed for both men and women, while women faced the added burden of lack of autonomy over their health care decisions. | Barriers for health access existed, particularly geographic barriers. | Free health care initiative officially removed financial barriers, but research indicates that people still needed to pay out of pocket fees to secure care. Geographic barriers still exist as well as gender norms undermining women’s ability to make decisions. | Significant financial, geographic and cultural barriers to access, which were shaped by, gender norms. |
Relevant, sex-disaggregated health information that informs policy. | Not consistently available. | Efforts to implement health information system with sex-disaggregated information underway. | Not consistently available, but planning is underway | Not consistently available. |
Equitable opportunities for male and female health professionals working within the health system. | No strategy developed or implemented to promote gender equity in the human resources of the health system. | No strategy developed or implemented to promote gender equity in the human resources of the health system. | No strategy developed or implemented to promote gender equity in the human resources of the health system. | No strategy developed or implemented to promote gender equity in the human resources of the health system. |
Equitable health outcomes among men and women and across age groups | HIV/AIDS rates 3–4 times higher among adolescent girls than boys; maternal health mortality among highest in the world. | Reproductive health outcomes for girls and women still problematic. | Double challenge from conflict and Ebola, health indicators significantly worsened, MMR particularly challenging. | Outcomes among women and adolescent girls remained problematic. |
-
Provides health care services that address the most urgent health care needs of men and women across the life span in an appropriate manner;
-
Ensures men and women across the life span are able to access and utilize those services unimpeded by social, geographic and financial barriers;
-
Produces relevant, sex disaggregated health information that informs policy;
-
Provides equitable opportunities for male and female health professionals working within the health system; and
-
Ensures equitable health outcomes among women and men, and across age groups.
Checking the gender box?
What is the value-added of the framework of gender equitable health systems?
Gender norms: Bricks and mortar
Health systems as promoting gender equity and equality? Who should take responsibility for engendering change in post-conflict contexts?
Limitations
Conclusions
Acknowledgements
Funding
Availability of data and materials
-
Institute of Health Metrics and Evaluation. http://www.healthdata.org
-
Mozambique Country Profile. Institute for Health Metrics and Evaluation; 2017. http://www.healthdata.org/mozambique. Accessed June 12.
-
WHO. Timor-Leste: WHO Statistical Profile. Dili: WHO; 2015.
-
WHO. Factsheets of Health Statistics. Brazzaville: WHO Regional Office for Africa; 2014.
-
UNDP. Uganda Human Development Report 2015: Unlocking the Development Potential of Northern Uganda. Kampala: UNDP;2015.
-
UNDP. Timor-Leste: Briefing note for countries on the 2015 Human Development Report. New York: United Nations Development Programme;2015.
-
WHO. Mozambique: Country Cooperation Strategy at a glance. Maputo: World Health Organization; 2014.
-
IHME. Financing Global Health 2016: Development Assistance, Public and Private Health Spending for the Pursuit of Universal Health Coverage. Seattle: University of Washington; 2017.
-
UNDP. 2015 Human Development Statistical Tables: Gender Development Index. New York: UNDP; 2015.
-
UNDP. Human Development Report 2014: Explanatory Note on the 2014 Human Development Report composite indices Mozambique. Sustaining Human Progess: Reducing Vulnerabilities and Building Resilience. New York: United Nations Development Program; 2014.
-
Mundi i. Sierra Leone Literacy. 2011; http://www.indexmundi.com/sierra_leone/literacy.html. Accessed May 13, 2016.
-
UN Data. Sierra Leone. New York: United Nations; 2013.
-
PRB. Fecundidade e Planeamento Familiar no Inquérito Demográfico e de Saúde de Moçambique 2011 (IDS). In: Estatistica INd, ed. Maputo: Insituto Nacional de Estatistica & Population Reference Bureau; 2013.
-
WHO. Mozambique: health profile. Geneva: World Health Organization;2012.
-
UNICEF. At a glance: Timor-Leste. 2013. Accessed January 25, 2016.
-
WHO. Sierra Leone: Factsheet of Health Statistics. Brazzaville: WHO Regional Office for Africa; 2014.
-
UNICEF. Information by Country: Mozambique Statistics.. 2012; http://www.unicef.org/infobycountry/mozambique_statistics.html. Accessed August 21 2012.
-
UNICEF. At a glance: Sierra Leone. 2013; http://www.unicef.org/infobycountry/sierraleone_statistics.html. Accessed May 13, 2016.
-
Nicholas Kassebaum et al... Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study. The Lancet. 2014;384:980–1004.
-
CNCS. Global AIDS Response Progress Report. Maputo: Conselho Nacional de Combate ao HIV e SIDA 2014.
-
UNAIDS. Mozambique: HIV and AIDS estimates. Geneva: UNAIDS; 2013.