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On International Women’s Day we need to shine a spotlight on women in fragile and conflict-affected settings

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This blog post is part of a wider HSG blog series to celebrate International Women’s Day 2018. In this series, HSG members provide their perspectives on why gender should be a critical component of UHC, and what we can do about it.

By Sally Theobald, Valerie Percival and Kate Hawkins

Attention to fragile and conflict-affected states is critical to achieving universal health coverage, along with progress on other Sustainable Development Goals on gender equity and social justice. We need to ensure that women’s needs are met during crises and war, and that we join up action here with longer term, sustainable solutions.

Gender inequities neglected

In our work on gender and post-conflict health systems – Building Back Better – we explored the extent to which gender had been addressed in health systems rebuilding in several post-conflict states, including Mozambique, Sierra Leone, Northern Uganda, Timor Leste, Zimbabwe, Cambodia and Bangladesh. We found limited attention to gender equity in rebuilding efforts, and that conflict-related inequitable health outcomes linger in post-conflict health systems. These have wide-reaching implications for the health of communities, which need addressing urgently.

Post-conflict opportunities

To borrow the strapline for International Women’s Day 2018 we need to “#pressforprogress” against pernicious gender inequities in health systems in fragile and conflict-affected contexts. Health systems are key employers and respected institutions within society; they both reflect and shape the social, political and economic context that they are part of, and the lack of emphasis on gender equity within health systems is a significant missed opportunity. The health system could, and should, be an arena for building greater gender equity in all society.

Policymakers assume that if you build health systems they will be equitable; yet there is little guidance for people who may want to take a gendered approach to planning and implementation. To help address this, we developed bench marks for gender equity to be addressed within the health system, and produced case studies to highlight change and promising practice, including indigenous efforts towards embedding gender equity, such as in post-conflict Bangladesh.

Supporting female health workers

Health systems strengthening efforts require a strong and supported health workforce. There are challenges here in fragile and post-conflict contexts, where health workers are few, due to death or out-migration. In these settings there is a particular need to recognise and support the vital work of women health workers at all levels of the health system. This was an area of focus in a recent webinar jointly hosted by the World Health Organisation, the Global Health Workforce Network and Women in Global Health. Our research on the ‘gendered health workforce’, conducted through the ReBUILD and RinGs programmes, was presented, highlighting not only the multiple challenges women health workers face in Sierra Leone, Zimbabwe, Cambodia and northern Uganda, but also the incredible resilience they show in continuing to deliver vital services despite threats to their own lives, and risks of sexual and gender-based violence.

On International Women’s Day we call for women health workers working in contexts of ongoing crises and conflict, such as Yemen, to be recognised, celebrated, supported and kept safe.

Pressing for progress

The recent launches of Canada’s Feminist International Assistance Policy and DFID’s Strategic Vision for Gender Equality (which has a specific focus on protecting and empowering girls and women in conflict, protracted crises and humanitarian emergencies) shows increasing focus on this issue, which is welcome. “Pressing for progress” means that all actors need to focus seriously on gender in their work. Strong, joined-up and gender transformative approaches to health systems strengthening are required.

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How to get health systems evidence into policy and practice in fragile and conflict-affected settings

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By Kate Hawkins, Pamoja Communications

This week I struggled through the Southern Rail train strike to attend a ReBUILD meeting in London. The long commute aside, this was a great opportunity to reconnect with colleagues and hear more about the consortium’s work and synthesised learning from the last few years.

Being a communications person I was particularly taken by the discussions about how to encourage research uptake in fragile and conflict-affected settings. An eminent panel – Gibson Mhlanga, Ministry of Health and Child Care Zimbabwe; Lara Ho, International Rescue Committee; Rene Loewenson, Training and Research Support Centre; and Egbert Sondorp, KIT – gave us their views. They were chaired by Freddie Ssengooba from Makerere University, who plays this sort of role effortlessly.

What did we learn?

Barriers

Fragile and conflict-affected settings have their own particular set of challenges when it comes to research uptake. Gibson Mhlanga talked about how a lack of funding for the health sector can prevent the translation of good evidence to change on the ground. To some extent this is a problem faced by all countries that fail to meet their commitments to financing the health sector, but can be more pronounced in these settings. When conflict or crisis abates, policy engagement may be trickier due to the multiplicity of stakeholders that one needs to relate to. In addition to the usual governmental stakeholders a range of donor and humanitarian actors may need to be taken into account. Egbert Sondorp talked about policy complexity, in that influencing must be more than ‘SWAP+PRSP+budget support’, and that after conflict or crisis, there can be a range of new settlements, directives, and regulations under construction which need to be understood and analysed. Finally, traditional academic methods of evidence generation (with their focus on academic publication and other incentives) may be at odds with more action-oriented approaches to the generation of new knowledge.

Solutions

Lara Ho talked of the need for demonstration projects to show to policy makers how potential interventions that have been used elsewhere might be adapted and implemented in fragile and conflict-affected settings. Just knowing that evidence exists is not necessarily sufficient to prompt change – new ideas need to be ‘brought alive’ so that they prompt the imagination. She suggested that exchange visits – where policy makers are accompanied to other countries to better understand how innovations have been implemented – can be a powerful tool for the uptake of evidence.

Rene Loewenson explained how the ‘tactical generation’ of evidence may be needed, in a fashion that points to policy solutions rather than uncovering weaknesses and problems. In this, a less positivist approach to evidence, which is inclusive of different development sectors and utilises participatory methods, can be particularly powerful. She and Egbert pointed out that the traditional time horizons of ‘projectised’ research projects of 3-5 years may not be sufficient to implement a longer term, systemic approach that enables researchers to seize ‘windows of opportunity’ to effect change.

Several speakers talked of the need to design research projects that meet the policy and programmatic needs of multiple stakeholders – implementers, decision makers, and communities – and that this requires an approach to the generation of research questions and approaches which is deeply embedded in the setting one is working in.

Hearing from the panel I was struck by how seldom I get to go to meetings where research uptake – rather than findings – are the centre of attention. Learning from other communications professionals employed by health systems projects and hearing from those grappling with similar challenges is always reassuring (we are facing similar problems) and enlightening (there are routes to change that we can experiment with). I commend ReBUILD for creating such a space and hope that we can facilitate more of these shared opportunities for discussion.

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LIFE HISTORIES (A RESEARCH METHOD TO CAPTURE PEOPLE'S EXPERIENCES OF HEALTH SYSTEMS IN POST-CONFLICT COUNTRIES)

Life histories: a research method to capture people’s experiences of health systems in post-conflict countries

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By Sarah Ssali, Sally Theobald and Kate Hawkins*

This blog post is part of a series on people-centred research methods for health systems development published in conjunction with a Twitter chat on the same topic. Please see below for links to other blog posts in this series.

The ReBUILD Consortium is conducting health systems research in post-conflict contexts. This brings with it several challenges, including: lack of data, recall and memory lapses, ensuring confidentiality and the changing contexts of conflict and displacement. Often people have experienced multiple traumatic events which many may want to forget, although these memories could be of importance to the reconstruction process. Both conflict and post-conflict rebuilding are political processes. So, attempts to rebuild a health system will be influenced by power relations, which in turn are shaped by historical, regional and social inequalities, and there is need to ensure that the experiences and realities of affected populations feed into the rebuilding process: life histories bring particular opportunities here.

What are life histories?
Life history interviewing is a qualitative method of data collection where people are asked to document their life over a period of time. It is a personal account of their life, in their own words and using their own personal time lines. Accordingly, they tend to be selective, contingent upon remembered events that are amenable to being told, be they fact or fiction.

Our study involved 47 heads of poor households (aged 45 years and above) in Gulu District, northern Uganda. Of these, 26 were women and 21 were men. Each life history was conducted by a pair of researchers, one interviewing and the other recording both manually and electronically. The heads of households were asked to narrate the story of their life as far back as they could remember, from whichever year, as long as it was before the war. They were asked to mark significant life events on a timeline covering the three key phases: before the war, during the war and after the war. The aim was to document changes in their households’ ability to cope with household health care costs over the three time periods. For each phase, they identified their major life event, why they considered it significant, and what memories they attached to it. For illnesses, they named the illness, the treatment sought, where treatment was sought from, how much was paid and the treatment outcome. As they narrated their life story, the researcher in charge of recording drew the timeline, matching the events with the years (if the respondent could remember it) and the outcomes.

The choice of determining what was a significant life event and why, health, health events, treatment sought, cost, what was paid and what was foregone to pay the cost of health care was left to the respondent to define and articulate. This was considered more empowering than choosing for them. Having told us their life experiences, they went on to give us their expectations of what good health care meant and recommendations for reconstruction. That way, we ceded some of our power as researchers, to participants to tell their own story other than just reproducing knowledge as part of the post war research industry. In addition to the lifelines drawn, the results of these life history in-depth interviews were transcribed, translated from Acholi into English, and analyzed thematically using Atlas ti software.

Examples of extracts from life histories
“…just only two things stick out for me: the sodomy I endured and how we left home going to the camp. We were chased from our homes in a very bad way, we only survived by God’s grace, it was not a good experience at all. Also there was a time we were abducted by the government army and they tied us with ropes and they were pouring on us red peppers [red chilli powder] just direct on our faces. We just escaped death narrowly”. (70 year old man).

“… we were on the run. … Sometimes they seriously fought and killed people. Here in my home, I was captured three times [by the rebels]. That was the year when the Kony war was severe; it was in the middle years. It was very bad. I cannot recall the year very well. … If you slept in the house, they could come and knock the door…if you opened, they ordered you to take them where people are, you see. There they would go and kill people in that home. I stayed badly here. We really faced problems here. The year?…I was captured three times…They captured my boy and went with him. They went with him. We started sleeping in the mission for the three years. Then it ended we are now here.” (72 year old woman)

Challenges
Like any other method there are challenges and advantages to this method. It’s a lengthy process and given the traumatic nature of the events experienced including death, abduction, torture and rape of women, men, girls and boys, developing rapport and trusting relationships is critical. Conversations need to be carefully and sensitively carried out.

The transcripts created a lot of data which takes time to record and analyse. The ability of one person to textualise the life of another for unknown readers is a challenge the researcher has to be cognizant of as they translate the life story into research reports or participate in research engagement activities, deciding which aspects to highlight and which to omit. Furthermore, decisions have to be made on re-representing the private/intimate details on people’s lives. This can create ethical dilemmas. Ensuring the confidentiality of vulnerable groups discussing their experiences of conflict, including for example male rape, within a homophobic context is critical.

Advantages
But for all the challenges outlined above we found life histories to be useful. They helped us explore and identify the dominant narratives of people’s lives within particular events and situations. These narratives were contextualised – they described how a particular event came to be significant, and how opinions and decisions change over time.

Life histories are good at enabling people to recollect the past and document change, especially where some events could have been missed out through other methods requiring simple recall of facts. People may not remember the actual details but remember the significant events.

Furthermore it is participatory and gives the respondent more voice than other deductive methods. We found that it empowers the respondent, giving them a more prominent role to decide what is significant, why it is significant and to locate themselves within the experience. As part of this it helps people to evaluate their lives, clarifying what life would have been and why it was so. At the same time it provides a history beyond the personal, the analysis helps to show that lives are not free floating but occur in a social context, hence are socially constructed.

What life histories taught us about health
The method demonstrated to us that choices about health are determined by forces beyond the health sector, such as gender relations, livelihoods, conflict, etc. Consequently, strategies to rebuild post-conflict health systems cannot be reduced to health interventions, but also need to encompass a focus on people’s livelihoods and social relationships. While the post conflict effort emphasised building/renovating health facilities, our life history participants spoke more of income generation strategies because with money, they could navigate the new post conflict health context which is characterised by poorly functioning public facilities and expensive but well facilitated private facilities. The life histories highlighted the importance of mental health as a key component of post conflict health reconstruction. They made prominent how men and women had experienced sexual and gender based violence. There is need to ensure services respond to the realities of all groups: and both women and men’s health needs should be provided for. We need to address people’s physical and psychological needs, and subsequently end the cycle of violence. Life histories also challenged common assumptions about war and disease, showing opportunities that existed in the war, such as ease of delivery of health services due to encampment.

We would be very interested to link up with other health systems researchers who are using a life history approach in other contexts and to think further what this method – and others that are people-centred – can contribute to the body of knowledge that we have.

* Sarah Ssali is a Senior Lecturer at the School of women and Gender Studies, Makerere University and Co-Pincipal Investigator on ReBUILD. She is also part of Research in Gender and Ethics: Building Stronger Health Systems (RinGs).

Sally Theobald works at Liverpool School of Tropical Medicine and has wide ranging experience of designing and implementing gender sensitive qualitative research projects on HIV, TB, SRH and health systems in Africa and Asia.

Kate Hawkins is Director of Pamoja Communications. She likes writing about health, gender and sexuality.

 

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A webinar to help define a health systems research agenda in fragile and conflict affected states

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By Kate Hawkins

For some months now our team within the Thematic Working Group on Health Systems in Fragile and Conflict Affected States has been involved in a process of canvassing opinions on key research needs. This has included face-to-face meetings, a survey, and online discussion. This has enabled us to reach out to over 500 people in 28 different countries (over half of which could be characterised as fragile). This week we added a webinar to the portfolio of tools we have used to try and build a consensus with a wide range of stakeholders.

The challenges of conducting research
Our colleague Egbert Sondorp explained that as the work has developed the sheer magnitude of research needs has become apparent. We have also become aware of some of the barriers to high quality work in this area. These include infrastructural issues such as insecurity which can lead to the risk of ‘convenience sampling’. Travel bans imposed by donors can sometimes mean that bureaucracy trumps the need for good data. In many settings there is a shortage of researchers and data collectors and disruption of research infrastructures hinders health system research and can make processes like ethical clearance more challenging. Among donors there can be a lack of political will to provide ongoing, flexible financial support and so it is difficult to maintain continuity to manage the research process in a sustainable manner. There are real difficulties when it comes to research uptake. Too often research agendas are concocted by outsiders and therefore don’t necessarily tackle the issues that decision makers on the ground feel are most pressing. The plurality of stakeholders involved in the health sector post-conflict make it difficult to know who to target. Lack of state leadership and ownership of research can make it less likely that findings get used.

What have we learnt so far?
Aniek Woodward ably gave us a taste of some of the research issues that have been prominent in our discussions so far. These included the transition from emergency support to long term health system building. The importance of resilience – particularly in settings where populations experience recurrent shocks. She also raised the issue of non-state actors and how to ensure accountability in settings where the state is weak.

We were lucky to be joined by two great discussants Khalifa Elmusharaf and Nigel Pearson who interrogated some of the findings of our work. Khalifa pointed out that wars destroy trust, identity and social ties – community cohesion – and this has implications for health systems. What is needed in these settings are methods that bring the voice of marginalised citizens (women, refugees, disabled people etc.) into decisions about health systems. He made the great point:

‘If we don’t listen to people how will we plan accessible people-centered health services in post conflict settings?’

Nigel reiterated the point that we don’t just need enthusiastic outsiders to conduct this type of research. What is required are people with a deep knowledge of the context and environment – this calls for research into the type of research partnership models we employ and how funding is delivered. He stressed that too often shortcuts are taken in the research process – either in terms cherry picking the geographical areas covered or the methods that are used. In addition research can be hampered by problems of government legitimacy and sensitivity about questioning government decision making. He also made interesting points about gender and the employment of women in research and health care delivery its potential impact on equity and the amelioration of conflict.

Ethics, community engagement, local ownership and more!
Are webinars like, ‘talking to an invisible public’, as one of our panellists put it? Not in this case. With 32 audience questions in an hour we had great participation and a lot of important inputs to the research process to mull over. It is impossible to do justice to them all here but questions and issues raised included:

The importance of governance and leadership
How to conduct research in areas controlled by those who are hostile to outside interference – such as Al-Shabab in Somalia

The perception is of research not being a priority, particularly during first stages of emergency when there are pressing humanitarian needs

  • The need to build capacity in local research institutions
    The ethics of research in these settings (risks to informants and ethical clearance, for example)
  • Is it right to sacrifice the highest quality of the research in order to get some insights?
  • What can we do in fragile settings in order to achieve community cohesion?
  • The need to focus not only on volume of aid but also how it is implemented/disbursed
  • Research on different service implementation strategies and models of care at the ground – health outcomes
  • How to ensure cross-sharing of evidence-based best practices and fragile state comparison

One particularly perplexing question related to whether this agenda applies to countries in an economic crisis such as Greece? So we certainly have a lot to consider as we move forward!

We will be contacting people who joined the webinar and following up on the issues raised. If you would like to join our group and be part of the discussion you can find us on LinkedIn. We hope to continue a discussion of these issues online. Be part of the conversation. Read our Storify of the event. Alternatively please contact Jan Randles Jan.Randles@lstmed.ac.uk.

A recording of the webinar can be found here: https://attendee.gotowebinar.com/recording/76320767420240641

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