The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts

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.

Why do people become health workers?Analysis from life histories in 4 post‐conflict and post‐crisis countries

“…Through their lives and experiences, we sought to obtain understanding of the evolution of the health system and the different processes related to the work environment. Their lived experiences provided us with a personal perspective on the effectiveness and intended as well as unintended consequences of human resource policies and their evolution …”

“…Their lived experiences provided us with a personal perspective on the effectiveness and intended as well as unintended consequences of human resource policies and their evolution. 12 These life histories were conducted between October 2012 and December 2013 in the 4 settings with health workers meeting specific criteria (including length of service in the area, to capture experiences of conflict and post-conflict periods) in selected health care facilities in the study areas using an open-ended topic guide. The topic guide covered the following areas:…”

“Having More Women Humanitarian Leaders Will Help Transform The Humanitarian System”: Challenges and Opportunities for Women Leaders in Conflict and Humanitarian Health

“…Women are also expected to occupy lower-level roles due to culturally coded linkages between leadership and masculinity. For example, women remain largely underrepresented at all levels of governance in the Arab region with the average proportion of female members of parliament is 19 percent, which is below the global average (25 percent) (44,57). Even in "women friendly" sectors, a study conducted on women leadership in academia in the Arab world, found that women lead fewer than 7 percent of Arab higher-education institutions (48 out of 702 universities) (58).…”

The importance of gender analysis in research for health systems strengthening

“…Papers on health financing ( Witter et al 2017a . multiple contexts) and human resources for health in fragile/post conflict contexts ( Witter et al 2017b . Cambodia, Zimbabwe, Sierra Leone and northern Uganda) discuss why and how gender shapes core health functions/health systems building blocks in complex and often unanticipated directions.…”

“…Cambodia, Zimbabwe, Sierra Leone and northern Uganda) discuss why and how gender shapes core health functions/health systems building blocks in complex and often unanticipated directions. Two papers emphasise the importance of health system governance and gender responsive leadership ( Nyamhanga et al 2017 ; Witter et al 2017b ). The papers use a range of methods to show how gender analysis can be used in different ways and at different time points.…”