Chapter 20: Building post-conflict health systems: a gender analysis from Northern Uganda
The post-conflict trajectory presents an opportunity to rebuild health systems to better meet the needs of all citizens. However, there is limited literature or analysis on gender equity in health system reconstruction. Northern Uganda experienced multiple conflicts which ended with tentative peace and post-conflict reconstruction starting in 2007. Using a health systems approach and analysis of data from multiple methods (household survey, life histories and key informant interviews) and participants (women and men household heads, community members, health workers and key informants) this chapter analyses the extent to which gender equity has been considered and realized in the post-conflict reconstruction of the health sector in Gulu, Northern Uganda. The analysis across multiple data sets reveals four key findings. Firstly, health systems development has focused largely on health facility reconstruction with insufficient mechanisms to address ways in which gender, age and poverty interplay to limit access to health systems. Secondly, in terms of focus area, maternal and child health emerged as a key priority amongst most providers. This is limiting as the special health care needs of Northern Uganda as a post-conflict setting go beyond maternal and child health (MCH) services, and include psycho-social trauma, non-communicable illnesses, human resources, malnutrition, inadequate equipment and drug stock-outs. Thirdly, gender, generation and poverty shape household health events and care-seeking pathways. Female household heads who were older and widowed were most likely to be poor, and face challenges in raising the resources for accessing health care; care-seeking was often delayed. Fourthly, gender shapes health care workers’ expectations, experiences and strategies to deal with conflict. Gender segregation by roles, understaffing in remote areas and lack of responsiveness to life course events for workers with family responsibilities play a role in limiting access to training and promotion for women in particular, and especially those in remote areas. The commitment of largely female mid-level cadres in remaining in posts during the conflict in Northern Uganda has also been under-recognized and not appropriately celebrated. Drawing on this analysis the authors argue for a gender-aware post-conflict health care system, which considers health challenges facing different community members and health staff from a gender perspective. A gender-sensitive health care system needs to respond to women’s health care needs across their life cycle (as opposed to focusing only on the reproductive years), as well as men’s, and go beyond the provision of facilities to include a holistic analysis of livelihood challenges, which restrict women’s (and some men’s) ability to effectively access health care. This also requires action on the gender dimensions of health services provision, including human resources for health and budgeting. In conclusion, from a gender equity perspective there have been lost opportunities in the post-conflict reconstruction of the health sector. Health systems continue to evolve and future priorities need to focus on supporting vulnerable communities’ ability to access a range of vital health services, and ensuring women and men health workers’ gendered needs are met.