Abstract
It is well known that the health workforce composition is influenced by gender relations. However, little research has been done which examines the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). We present mixed method research on HRH in four fragile and post-conflict contexts (Sierra Leone, Zimbabwe, northern Uganda and Cambodia) with different histories to understand how gender influences the health workforce. We apply a gender analysis framework to explore access to resources, occupations, values, decision-making and power. We draw largely on life histories with male and female health workers to explore their lived experiences, but complement the analysis with evidence from surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. Our findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level, affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences here shaped by gender, poverty and household structure. Most HRH regulatory frameworks did not sufficiently address gender concerns. Unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.
Highlights
Universal Health Coverage cannot be achieved at the global level if the issues of conflict and crisis-affected states are neglected (Witter 2015)
Patterns of employment The health workforce in post-conflict areas, like other settings, reflects a strongly gendered pattern, with a preponderance of women employed in mid- and lower-level cadres
This was echoed in our research samples—with a higher ratio of women to men interviewed in the health worker life histories, but a higher ratio of men interviewed in the key informant interviews, across all settings but especially in Cambodia, where all key informants were male
Summary
Universal Health Coverage cannot be achieved at the global level if the issues of conflict and crisis-affected states are neglected (Witter 2015). There is need for a stronger focus on gender across all aspects of the health system (Horton and Ceschia 2015) including human resources for health (HRH) (Standing 1997, George 2008, Newman 2014). This is arguably critical in fragile and post-conflict contexts where HRH are often extremely limited and gender relations are in transition—in short, where there is an opportunity to build back better. There can be an influx of actors to support HRH reconstruction, these are frequently poorly coordinated, leading to distortions across areas, sectors and over time (Pavignani and Colombo 2009)
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