Building Back Better: Gender in post-conflict health systems development

The post-conflict or post-crisis period provides the opportunity for wide-ranging public sector reforms; social norms are in a state of uncertainty, donor funds are available and there is often a political will for change and to ‘build back better’. Health system reform can improve the quality and accessibility of health care; increase the effectiveness and efficiency of the health system; expand social protection; and improve population health. A common assumption though is that strengthening the health system will automatically lead to better and equal health and access to healthcare for men and women. However, health systems are not neutral: they reflect gender norms and can reinforce gender inequalities and discrimination often exacerbated during the turmoil and violence of war.

Despite all the demands placed on a humanitarian response, humanitarian assistance acknowledges the need for integrating gender into its programming but often fails to do so and fails to address the different impact conflict has on men and women. A focus on sexual violence against women (while neglecting health and sexual violence against men) and maternal health enables donors and relief organisations to claim that they are addressing gender, without an understanding of how gender differences shape men and women’s health in other areas.

Research into the importance of reconstructing health systems after a crisis or war is relatively new and challenges and best practices related to gender equity is weak and the evidence base limited. Further study is required into the impact of strengthening the health system on gender equity but measuring of health programs on gender equity is challenging. For example, there is no agreed definition of what is encompassed by the term ‘gender equitable health system’ and there is a lack of consensus on how to build such a system and which indicators should be measured to determine the success of the rebuild. Moreover, disaggregated data reflecting the differential burden of conflict on men and women, is not routinely collected.

Last week saw the launch at the Liverpool School of Tropical Medicine of the new Building Back Better e-resource developed from a collaboration between the Stockholm International Peace Research Institute (SIPRI) working group on gender, led by Associate Professor Valerie Percival at Carleton University, Canada, the ReBUILD Consortium and Research in Gender and Ethics: Building stronger health systems (RinGs) collaboration between three UK Department for International Development funded Research Programme Consortia exploring whether and how gender equity considerations are taken into account in the reconstruction and reform of health systems in conflict-affected and post conflict countries. As part of the resources available on this site, a set of six new policy briefs were also launched covering Gender in Humanitarian Responses, Health Systems Strengthening and four case studies:

At the launch event there was a series of short presentations on the research which has contributed to the resources available on the Building Back Better website, including presentations on the perspectives from Sierra Leone by Haja Wurie from the College of Medicine and Applied Health Science, Freetown, Sierra Leone, and the perspectives from Northern Uganda by Sarah Ssali, Department of Women & Gender Studies, Makerere University, Uganda, Justine Namakula, Department of Public Health, Makerere University and Tim Ensor from the University of Leeds. This was followed by a panel discussion and an opportunity for questions and comments.

Val Percival from The Norman Paterson School of International Affairs, Carleton University, Canada presented findings from her and colleagues narrative literature review based on the questions “How gender sensitive is the reconstruction and reform of health systems in post conflict countries, and what factors need to be taken into consideration to build a gender equitable health system?” This review “Health Systems and gender in post conflict contexts: Building back better” was published in the special issue of Conflict and Health ‘Filling the Void: health Systems in Fragile and conflict Affected States’ in 2014. Val Percival spoke of “doing more than patching up women and sending them back out there” but of the need to “change the circumstances that led them to seek healthcare in the first place”. A key point of Val’s presentation was that there is no clear definition of a gender equitable health system which is required as a starting point to assess whether a health system is gender equitable and if not, did the rebuilding of the health system result in a gender equitable health system. Within this paper, the authors propose the following definition of a gender equitable health system:

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
Ensures equitable health outcomes among women and men, and across age groups; and,
Provides equal opportunities for male and female health professionals working within the health system

Getting humanitarian programming right in the immediate post-conflict period is critical as these decisions shape and have lasting ramifications for the functioning and equity of the health system. Overlooking gender concerns in the humanitarian response is a missed opportunity to introduce key social reforms in the immediate aftermath of a crisis or war. Gender equitable societies are more peaceful and prosperous. Policy-makers, donors, researchers and advocates need to be part of the solution to ensure that future health systems foster gender equity and help build gender equality in society and the Building Back Better platform provides a useful repository of resources, guidance and discussion to ensure that rebuilding of health systems does not remain gender blind.

Blog by Kerry Millington, Liverpool School of Tropical Medicine