How Menstrual Regulation was introduced in post-conflict Bangladesh

The liberation war in Bangladesh ended in December 1971. It left many legacies, one of which is the provision of Menstrual Regulation services. Prior to the Liberation war, abortion services were restricted by the Penal Code of 1860.

In the aftermath of war in Bangladesh many women were pregnant due to rape by war perpetrators. Menstrual Regulation was a medically reliable, politically expedient, culturally acceptable, morally correct, and humane response to this.

Menstrual Regulation is the termination of pregnancy of up to 12 weeks gestation through Menstrual Regulation Medication (misoprostol) or manual vacuum aspiration.


  • The post-con ict moment in Bangladesh provided an opportunity for the introduction of Menstrual Regulation services in Bangladesh which have increased women’s reproductive health options and strengthened the realisation of related rights. It provides lessons for other countries which aim to adopt a gendered approach to health system reconstruction post-con ict or crisis.
  • In a plural health system, Menstrual Regulation services are delivered by both the public and private sectors, including informal providers like pharmacists and village doctors which raises challenges around providing timely information on safe Menstrual Regulation options, coordination of care pathways, quality of services, and training of health care providers.
  • While service access is widespread, stigma and social and religious norms and poverty affect women’s health seeking behaviour, as is the case in many countries. This needs to be taken into account in efforts to coordinate the health system and support uptake.


Service provision is widespread and has positive impacts: The Menstrual Regulation policy is pioneering and has far reaching consequences for reproductive rights in the country. While abortion remains illegal, Menstrual Regulation is part of the health system in Bangladesh. A large proportion of Menstrual Regulation services are provided by the public sector (about two thirds). Union Health and Family Welfare Centers are the primary providers in rural areas. They accounted for close to half (46%) of all Menstrual Regulation procedures performed in 2010.

Challenges remain:

  • An estimated 572,000 women suffer complications from unsafe abortion each year and only 40% of those who need treatment actually receive care from a facility. Women’s choice of health provider is mediated by complex factors: availability, accessibility, relationships with providers (formal and informal), expenses and perceived quality of care, the latter being shaped by notions of trust, respect, privacy and familiarity.
  • Women who use services may experience stigma at the community and family levels (e.g. as destroying fetus can been viewed as a sinful), face gossip, and worry about their reputations. Stigma is more pronounced against women who have non-normative sexualities (e.g. women who have extra-marital sex; sexually active single women, young working women, divorcees, widows, and older women who continue to have sex past an age deemed appropriate by mainstream society).
  • Care pathways to these services are by no means straightforward and are mediated by a number of formal and informal health systems actors. Bangladesh has a famously complex and plural health system with a range of paid, unpaid, public, private, formal and informal providers – many of whom cross these categories from time to time. There is no effective link or partnership between formal/private and informal sector for referral, coordination and communication regarding sexual and reproductive health services. Many clandestine operators and brokers exist in this mix of providers and some lack adequate training.
  • Many women have a preference for providers in the informal sector because they are cheaper, easier to access, with no waiting time, and their husband can purchase pills on their behalf from local pharmacies. Increasingly Menstrual Regulation Medication is available at pharmacies which women prefer to access, as some fear the invasive procedure (manual vacuum aspiration) of Menstrual Regulation. Informal providers are usually the rst point of contact even for those clients who subsequently access sexual and reproductive health services from formal providers. In addition, women who are often confused about the duration of their pregnancy, get rejected by formal clinics because they have passed the 12 weeks allowed for legal termination, and may seek assistance in the informal sector and from clandestine operators.
  • There is poor quality of care in many formal facilities, which included punitive behaviors by providers and discrimination against poor women. This includes mistrust around costs incurred, poor quality counselling services at facilities. Clinical services may also be sub-optimal, for example lacking standard protocols for infection prevention and insufficient drugs and supplies.


While the adoption of Menstrual Regulation services within the Bangladeshi health system has had positive effects to capitalize on this innovation in reproductive health policy further health system shifts are needed.

Quality Menstrual Regulation services remain inaccessible to a proportion of women who need them and they should be expanded as part of a simultaneous push to make modern methods of contraception available. This should be accompanied by health worker training to improve the quality of services, including the respectful treatment of clients in the public sector. Support and counselling for women should be oriented to their needs and stress the right to sexual and reproductive health services. There is a need for better linkages and partnerships between the informal and public and private sector, creating incentives for close-to-community and service providers to ensure timely referrals to Menstrual Regulation services and to ensure that appropriate care is given.

These changes will require continued investment on the part of government – ensuring supplies, drugs, incentives for providers, continual training of providers, and other support required in clinics and facilities. Community awareness raising is needed and training for CTC providers on importance of timely referral, within an effective referral system.


“Menstrual Regulation and Induced Abortion and MR”, Guttmacher Institute, menstrual-regulation-and-induced-abortion-bangladesh

“Menstrual Regulation: Past, Present, and Future Challenges”, Policy Dialogue by Population Council, Bangladesh, (June, 1999)

Nashid, T. and Olsson, P. (2007), “Perceptions of Women about Menstrual Regulation Services: Qualitative Interviews from Selected Urban Areas of Dhaka”, Journal of Health, Population, and Nutrition, 25(4):392-398.

“Menstrual Regulation and Induced Abortion in Bangladesh”, (September, 2012), Guttmacher Institute https://www. al-regulation-and-induced-abortion-bangladesh

Mahmud et al. “Supporting the Health System to Respond to the Needs of Women in Bangladesh: Close to Com- munity Health Service Providers and Menstrual Regulation”, Health Systems Global, February, 29, 2016 http://www. Close-to-community-health-service-providers-and-Menstrual-Regulation.html

Nashid, T. and Olsson, P. (2007), “Perceptions of Women about Menstrual Regulation Services: Qualitative Inter- views from Selected Urban Areas of Dhaka”, Journal of Health, Population, and Nutrition, 25(4):392-398

“Menstrual Regulation and Induced Abortion in Bangladesh”, (September, 2012), Guttmacher Institute https:// strual-regulation-and-induced-abor- tion-bangladesh

Mahmud et al. “Supporting the Health System to Respond to the Needs of Women in Bangladesh: Close to Com- munity Health Service Providers and Menstrual Regulation”, Health Systems Global, February, 29, 2016 http://www. viders-and-Menstrual-Regulation.html

Vlassoff, et al. (September, 2012), “Menstrual Regulation and Post-abortion Care in Bangladesh: Factors Associated with Access to and Quality of Services”, Guttmacher Institute


This brief was written by based on research done by the BRAC JPG School of Public Health, BRAC University and the REACHOUT Consortium. The REACHOUT programme has received funding from the European Union Seventh Framework Programme ([FP7/2007- 2013] [FP7/2007-2011]) under grant agreement No. 306090. Research in gender and ethics (RinGs): Building stronger health systems is funded by the UKAID. The views expressed are not necessarily those of the Department for International Development.

Suggested reference:

Rashid SF, Mahmud I, Hawkins K, Theobald S, Mahfuza R, Chowdhury S, and Sarker M (2017) “How Menstrual Regulation policy and services were introduced in post-conflict Bangladesh”, Building Back Better/Research in gender and ethics: Building stronger health systems (RinGs)





In Zimbabwe, the National Gender Policy (2013-2017) promotes equality and equity, including equal opportunities at work. The results of implementing the policy are, however, unclear. Over the last 20 years, the country has suffered from a major shortage of skilled health workers, particularly in rural areas. During the political and economic crisis, the priority was to ensure an adequate workforce, however, this may have amplified gender imbalances in the posting and deployment of health workers.

Gender can have an impact on career choices and patterns as well as working practices. Yet evidence is limited on the ways in which gender roles and relations shape human resources for health (HRH), and gender is systematically overlooked in human resource policy and planning, particularly in low-income countries. Insufficient attention has been paid to gender inequities in the posting and deployment of staff, especially the structural and geographic location of men and women. Where health workers are located can influence their opportunities for advancement, training, promotion, and other benefits.

We have a limited understanding of the effects of posting and deployment policies and practices on female and male health workers during the economic crisis. Research was carried out by RinGs and ReBUILD to examine how gender roles and relations have influenced the posting, deployment, access to training, and career progression of health workers in rural Zimbabwe.


The study was conducted in four districts in the Midlands Province in Zimbabwe. A variety of research methods were used, including:

  1. A review of policies and documents.

  2. A qualitative life history approach to explore the personal experiences of 19 health workers (11 female and eight male) as well as the opportunities and challenges they faced.

  3. Key informant interviews with 11 human resource managers (five female and six male).

  4. Questionnaires were distributed to older health workers (including nurses, midwives and environmental health technicians), who had been employed since the year 2000. These explored their experiences of secondment, posting, transfers, training, promotion and career development from a gender perspective. In all, 140 health workers (83 female and 57 male) responded to the questionnaire.


Gender roles and relations, within households and the health system, shape health workers’ access to training and career progression in rural Zimbabwe. Women – who make up the majority of health workers – face more barriers than men in undertaking training and advancing their careers. Yet the health system does not respond to these inequities.

  • Policy: Current policy and regulatory frameworks in the health sector in Zimbabwe fail to adequately respond to gender differences. No clear policy exists to address gender within HRH. Posting decisions were mainly based on human resource needs and skills, rather than responding to gender relations.
“Not very sure ...but they (the authorities) do not seem to consider gender, whoever they think must transfer and gets a post can just go.”
(Female State Certified Midwife in an in-depth interview)
  • Career pathways: In general, women and men chose different careers within the health sector, partly due to training recruitment processes. Women tended to choose careers in midwifery (which offered good prospects for promotion) and theatre nursing. Men usually opted for environmental health (which entailed riding motorbikes on rough ground) and psychiatric nursing (which required sufficient strength to restrain patients).
“Men dominate in Environmental Health....and usually Environmental Health Technicians are posted to rural areas: Women are there but they are just a handful.”
(Female State Certified Midwife in an in-depth interview)
“Here I have never seen a woman who went for psychiatric training, mostly its men who go... Ever since I came here, I have never seen women who went for that training.”
(Female State Certified Nurse in an in-depth interview)
  • Training and promotion: Faced with the training system which is based on seniority and number of years in service, men tended to pursue self-funded training courses and studies, whereas most women waited for training opportunities to arise. More women reported that they lost senior positions to men because the men were better qualified. Over a third (35%) of women reported losing training opportunities due to childcare responsibilities. This affected their chances of promotion and career advancement. Some women prioritised their children’s education before their own. When asked how her family roles affected her in advancing her career she said,
“I didn’t have the opportunity because of the role of caring for my family. I just noticed that if I go to school these children also want to go to school, so I wasn’t able to carry the burden of paying fees for both me and my children.”
(Female State Certified Nurse in an in-depth interview)
  • Impact of postings: The posting and deployment system affected men and women differently. During initial deployment, a greater proportion of male health workers than female reported taking advantage of opportunities for training and career development. Wives would usually follow their husbands when they relocated for work. Just over two-thirds (67%) of men who moved remained close to their families, however, gender expectations meant that women felt obliged to leave their jobs to find new ones, sometimes in a different sector. This resulted in female health workers losing the valuable years of service needed to access training, thereby forfeiting their chance of promotion, and higher pay.
“It affected me because when I went for upgrading, other upgradings were already done and I was told that my name was once listed at my previous posting location and it was said that “No this one resigned from this hospital so she will find other things where she is”, secondly most of my juniors are now Sisters-in-Charge, they always laugh at me that they have been promoted before me, so it affected me so much. I think if I was still there I was going to be one of the seniors there.”
(Female health worker)
  • Posting and career advancement: Men were usually selected by human resource managers to be deployed in very remote, rural areas. Rural postings benefited these male health workers who, in the absence of doctors, were able to gain a wealth of hands-on experience. This created opportunities for promotion, training (including outside Zimbabwe), and invitations to international workshops.

This has clear implications for women’s career advancement.


Despite a widely held perception among health workers and human resource managers that the health system provided equal opportunities for men and women, female health workers faced more barriers than men in accessing training and advancing their careers. Some of these barriers related to gender roles and responsibilities within the family, such as childcare.

Barriers also existed within the health system. Posting and deployment policies and practices in Zimbabwe fuel gender inequities, affecting female and male health workers differently with regard to their access to training, promotion and career development opportunities. Social norms dictate that women should leave their jobs and follow their husbands, however, the system is not responsive to these inequities, with the result that women lose out on training, promotion and pay. The tendency to deploy male health workers in remote areas benefits men, who gain valuable experience and further their careers faster than women.

Female health workers’ career progression in Zimbabwe is not only shaped by family roles and expectations, but also by the posting and deployment system. As the country enters a more stable period after the economic crisis, HRH policies must be urgently reformed so that they are truly gender equitable. Posting and deployment policies should take gender roles and relations into account and respond to gender differences. In a predominantly female sector, health system policies must ensure that women – as well as men – are able to take advantage of vital opportunities for training and career advancement.


Chimbari MJ., Madhina D., Nyamangara F., Mtandwa H. and Damba V. (2008). Retention incentives for health workers in Zimbabwe. EQUINET Discussion Paper 65. EQUINET: Harare;

George, A. (2007). Human Resources for Health: A Gender Analysis, Gender Equity Knowledge Network (WGEKN) of the WHO’s Commission on Social Determinants of Health.

Gupta, N. and Alfano, M. (2011). Access to non-pecuniary bene ts: does gender matter? Evidence from six low-and middle-income countries, Human Resources for Health 2011, 9:25.

Health Service Board (2007, 2009, 2010, 2011). Annual Report, Harare, HSB

Standing, H. (2001). Equity, equal opportunities, gender and organization performance, Institute of Development Studies, University of Sussex, UK.

ILO (2009). International Labour Conference, 98th Session, Gender equality at the heart of decent work, Report VI, Geneva.

Standing, H. (2000). Gender - A missing dimension in human resource policy and planning for health reforms. Human Resources for Health Development Journal, 4(1), 27-42.

Government of Zimbabwe (2000). Public Service Regulations (Statutory Instrument 1 of 2000), Government Printers, Harare.


This brief was written by Sarah Hyde based on research by Stephen Buzuzi. Suggested reference:

Hyde S. and Buzuzi S. (2017) “How gender roles and relations affect health workers’ training opportunities and career progression in post-crisis rural Zimbabwe”, Building Back Better/Research in gender and ethics: Building stronger health systems (RinGs)

RinGs is funded by UKAID. The views expressed are not necessarily those of the Department for International Development.





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Although women account for the vast majority of the global health workforce, they are under represented in leadership positions. Gender inequity in the workforce can restrict entry into the health sector, career progression, access to professional education opportunities, and motivation.

Gender disparities in health leadership are also prevalent in post-conflict settings, where incentives to motivate health workers, particularly women, to continue working during and after a crisis have been overlooked. During conflict, abduction, injury, displacement, and lack of support can deter health workers, especially women, from taking on a leadership role. In Cambodia, civil war and conflict lasted almost 30 years, from 1970 to 1998. Health workers were among the 3.3 million professionals who were executed during the Khmer Rouge regime (1975- 1979). After the fall of the Khmer Rouge, it is believed that only 40 doctors were left in the country.

Now, after a 20-year period of strengthening the health system and developing human resources for health (HRH), over 19,000 people are employed in the health sector in Cambodia. Women make up most of the health workforce, and yet rarely hold senior roles, and have fewer opportunities than men to re-train for new positions. Only one in five leadership positions in the Ministry of Health are held by women. Just 16% of senior health workers (such as doctors) are female, compared to 100% of midwives. This is problematic for several reasons. Women’s concerns, for example, are not reflected in health policies, including HRH strategies. Human resource policies, such as those related to career advancement, do not take into account women’s life course events, such as childbearing and childcare. And, finally, in a country where most women prefer to be cared for by female health workers, the shortage of female doctors limits women’s access to health services.

Research on gender equity in human resource management for health in post-con ict settings is limited. To fill the gap in the evidence base, ReBUILD and RinGs, carried out qualitative research in Battambang province, Cambodia.


In-depth interviews were conducted in February 2016 with 14 female and six male health managers in two districts. A life history approach was used to record health workers’ views. This approach enables researchers to capture personal perceptions and experiences over time, and can empower participants by giving them the opportunity to tell their own stories.

Participants who started their career in the 1980s or 1990s were chosen, in addition to one younger health manager. All had advanced their careers. Interviews were recorded and transcribed in Khmer and translated into English. Transcripts were analysed to identify the impact of gender on motivation and barriers at the individual, household, community, and institutional levels.

The study has some limitations. More women than men were selected for interview on purpose in order to explore women’s views, perceptions and experiences. As there was just one young interviewee, it was difficult to explore the views of young managers in the post- conflict period. Finally, the life history approach relied on people’s memory of past events.


Female and male senior health workers’ views of their career progression was explored, from the period of conflict to the present day. Researchers sought to understand how gender has influenced their entry into the health sector, their career path and development of technical skills, and what this means for women in leadership positions today. While they evolve over time, gender norms shaped women and men’s engagement in the health sector. This was especially true for women.

1980s (the government began to rebuild the health system after the fall of the Khmer Rouge)

“There was also a Khmer social tendency that girls should not study much as they would still become someone’s wife in the future.” (64-year-old married man)
  • In general, women were encouraged to stay at home rather than study at medical school. This was due to safety concerns as well as gender roles.

  • Female and male health workers’ decision to go to medical school was not only based on personal or financial reasons, but also shaped by the wider social and political context, such as wanting to avoid military conscription.

  • During conflict, female health workers faced challenges, such as risks to their personal safety, travelling long distances on poor roads, lack of contact with family, and nowhere to stay. Women who worked in remote conflict-affected areas were, however, motivated by the recognition they received from the community, as well as peer support.

  • In most cases, the women who pursued further studies were single, did not have children, or were supported by husbands and family members.

1990s (health sector reform started in 1996, but civil conflict did not end until 1998)

“My aunt was also a doctor and this also pushed me more to love this position. Wearing white uniform was what I dreamed about when I was a child.” (44-year-old married women)
  • The importance of role models was highlighted, for example, a successful senior health worker who inspired participants to study medicine and enter the health sector.
  • Women were constrained by gender norms in carrying out their jobs, for example, facing the disapproval of family and community members when they worked a night shift. They reported feeling undervalued by male colleagues, however, they welcomed support from other women.
  • No participants pursued further studies at this time. Barriers to education included traditional gender responsibilities – women’s role childbearing and caring for children, and men’s role as the breadwinner – as well as lack of encouragement from managers.

2000s to present day (peace was restored in Cambodia in the early 2000s)

“My husband’s salary was enough to support me when I was studying... My husband also agreed to let me study.” (46-year-old married woman)
  • Gender equality advanced, and it was widely accepted that young women could study at medical school - often far from home.
  • Female health workers were expected to look after the children and home, as well as work. Some women were supported by their husbands and family members, and others hired help.
  • A gender working group was created to support female members of staff, and gender training helped build women’s skills and confidence.
  • Women who had children valued their partners’ support in being able to continue their studies, in spite of challenges. Some men shared responsibility for housework and childcare. Participants were motivated by role models, such as women who combined further studies with motherhood.

Women currently in health leadership positions


“For me, I was often in a hurry when I went out and soon after I finished doing the injections, I often returned home and breastfed my children...” (59-year-old married woman)

Female health managers identified constraints which effect their leadership role:

  • Juggling work with looking after older family members, breastfeeding and housework. Some women, however, considered this an inconvenience rather than a barrier.

  • Many women felt that, as leaders, they were treated with less respect than men. On the whole, men had developed their technical skills to a higher level, but even when women were sufficiently qualified, they were still not considered suitable for leadership positions.


“My husband is often the one who cooks the rice... Once we finish eating, I do dishes and return to work... It does go against the gender norms, but my husband understands my condition.” (58-year-old married woman)

Female health managers identified the following factors as furthering their career progression:

  • Support from their partners and family.
  • Support from the head of the local health institution, particularly early on in their leadership position.
  • Drive and determination to succeed, hard work, and a willingness to take on new challenges.
  • Qualifications and skills in order to gain respect from male and female colleagues.


“...I always perceive that whatever men can do, women can also do it. I always want to show my output and results to others.” (58-year-old married woman)

After the defeat of the Khmer Rouge, government HRH policies focused on recruiting and training health workers, while failing to address barriers to gender equality. Female health workers made a substantial contribution to saving lives during the crisis and rebuilding the health system. Their needs, experiences and the challenges they faced were different to men’s. Without gender-sensitive policies, women’s potential to fully engage in the health sector cannot be realised. This study underlines the need for government policy to acknowledge and act upon the impact of gender on health service delivery both during and after conflict.

The study captures the voices of dedicated female health workers who stayed in their jobs during the violent con ict, despite risks to their safety. Recognising the factors that empowered them to continue working – namely, social recognition, managerial support and backing from their peers – is important, and may be relevant for staff retention policies today.

Since the conflict, gender roles and responsibilities have evolved in Cambodia. Women are increasingly aware of their right to study and work outside the home. Some men share household tasks. The government has strengthened its policy and support for gender equality, and respect for human rights. Nevertheless, gender norms and expectations perpetuate the division of traditional roles, with domestic tasks largely assigned to women and decision-making to men. Women are still significantly under-represented in health leadership positions.

In order to promote women’s leadership in the health sector, an understanding of the obstacles faced by female health professionals in Cambodia, and how
they overcame them, is valuable. A number of factors contributed to their success. The women are highly motivated. Support from partners, family members
and managers is crucial, illustrating the importance of achieving gender equity at home as well as at the workplace. Finally, skills and qualifications are necessary.

The career path of today’s female leaders was forged not only by their own history but also by the social and political context. Therefore, to accelerate progress in advancing female leadership within the health workforce, the collaboration of a wide range of stakeholders at various levels – individuals, organisations, institutions and society – is required. This is a long-term process that begins with increased access to education for women.

Gender should be mainstreamed within health workforce policy. Key actions include: combating gender bias at the workplace, promoting role models and mentoring, providing supportive supervision for woman leaders, and generating commitment for quotas for female candidates.

Increased political will is required to advance gender equity in the health workforce. This is an ambitious goal. The benefits, however, are far-reaching. There is some evidence that, as decision-makers, female health managers are better able to respond to the needs of the entire population, especially women. Promoting women’s leadership can improve health system resilience and responsiveness, ultimately advancing equity and improving health outcomes.


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WHO (2010). Gender, women and primary health care renewal: a discussion paper. Geneva: World Health Organization.

Witter, S., Namakula, J., Wurie, H., Chirwa, Y., So, S., Vong, S., Ros, B., Buzuzi, S., Theobald, S. (forthcoming) The gendered health workforce: mixed methods analysis from four post-conflict contexts.

Witter, S. Namakula, J. Alonso-Garbayo, A. Wurie, H. Theobald, S. Mashange, W. Ros, B. Buzuzi, S. Mangwi, R. Martineau, T. (2017) “Experiences of using life histories with health workers in post-con ict and crisis settings: methodological re ections” Health Policy and Planning, Health Policy Plan 2017, 1–7 doi: 10.1093/heapol/ czw166


This brief was written by Sarah Hyde and Kate Hawkins based on a longer paper: Why women are not rising on top? The analysis of gender in health workforce leadership in Cambodia by Sreytouch Vong and Bandeth Ros.

Suggested reference:

Hyde S. and Hawkins K. (2017) “Promoting women’s leadership in the post-conflict health system in Cambodia”, Building Back Better/Research in gender and ethics: Building stronger health systems (RinGs)





Natural disasters affect 200 million people every year, and since 2008 an average of 26.4 million people have been displaced due to natural disasters per year (UNFPA, 2015).

In April and May 2015, two earthquakes struck Nepal. 8,856 people died and almost three times more were injured. Damage to infrastructure was extensive - 887,356 houses and 963 health facilities were affected. In May 2015, the United Nations Office for the Co-ordination of Humanitarian Affairs estimated that 2.8 million people had been displaced by the earthquake. In April 2016, 2.6 million of these remained displaced.

Research suggests that disasters are experienced as a gendered event - their impact is both more extensive and different for women than men. In 2002, the World Health Organization (WHO) published a briefing note highlighting both the general lack of research into the gendered impact
of disasters and displacement on health. In 2013, the United Kingdom’s Department for International Development repeated the WHO’s call for further research into these specific concerns and the Internal Displacement Monitoring Centre echoed the need for research enabling a better understanding of displaced women’s experience. However, research into these issues remains sparse.


We explored the impact of the earthquake in Nepal on internally displaced women’s health in Dhading district which was one of the worst affected. In Dhading district, there are estimated to be 2852 internally displaced people living in nine camps. We looked at:

  • Participant’s constructions of ‘health’;
  • How the earthquake and displacement impacted their health and ability to access healthcare; and

  • Potential solutions identified by women to meet their health concerns and remove barriers to healthcare.


Our work was informed by critical theory and feminist paradigms and methodological approaches attempted to redress the traditionally male-orientated production of knowledge. This included acknowledging the gendered nature of knowledge, contemplating researcher positionality, and articulating the impact of bias on knowledge.

Between May-July 2016 a research team of four women collected the data. The team was comprised of a Nepalese gender-based violence lawyer, an English MA student, a Nepalese conflict, peace and development master’s student, and two internally displaced Nepalese women who were of the same indigenous group as the participants and were working as camp volunteers for a local NGO. We conducted ten semi-structured interviews, three key informant interviews and six focus group discussions (FGDs), involving 58 participants. The participants were women over 18 living in the internally displaced person’s camps. All participants identified as ‘Tamang’ a marginalised indigenous ethnic group. Participants were a mixture of religions and aged between 18-62. All of them had been residing at a camp in Dhading district from within one month after the earthquake.

We allowed participants to de ne their own notions of health and discuss the impact of the earthquake on their own terms; the topic guide was constructed from participants construct of what health was and iteratively adjusted according to participant feedback, allowing participants to guide the data that was produced. The research was preceded by a discussion with camp volunteers and female NGO staff about how best to convey to participants that we wanted them to have equal roles in the research and how to increase participation during data collection. We gave consideration to how to make data collection a ‘safe space’.

There was a participatory element to all parts of the data collection, aside from the key informant interviews, through participatory ranking exercises. These were used to generate data about priority needs and increase participant involvement. Based on issues and barriers to access identified by participants and previous participants a set of pictorial cards were presented to the participant or focus group and they were asked to rank them in order of priority; to the extent possible they were left to complete this activity independently and in the FGDs were encouraged to come to a consensus decision.


The research process facilitated participants in proposing solutions to issues but could not facilitate taking action for ethical and logistical reasons. Participants were not involved in the research process prior to data collection. We planned to include participants as equals in the collection and analysis of data. However, for practical and ethical reasons it was challenging to get FGD participants to meet more than once.

Trustworthiness was increased through a rigorous approach to data collection and analysis, a reflexive approach to the process and the use of a wide range of methodologies. However, challenges to trustworthiness included: difficulties in translating between Tamang, Nepali and English, difficulties in direct translation of some phrases pertaining to psychological symptoms, the positionalities of the research team and the emergence of dominant FGD members during participatory ranking exercises.

The results may be broadly transferable to other women living in the IDP camps included in the study. Limitations included that:

  • Disabled and older women were under-represented in the sample

  • Women under 18 were excluded due to ethical concerns

  • The dominance of Tamang participants in the sample reflected distinctive sociocultural influences on the construction of meanings around health and access to health care

  • The relative proximity of all sample camps to the district headquarters (a large town) meant that the health issues and barriers raised may be different in camps with less access to urban amenities


Alongside specific health issues, participants often identified the ‘social determinants of health’ when asked about the health issues women face in internally displaced people’s camps. Participants spoke of structural mechanisms, such as culture, societal values, and their socioeconomic position, and intermediary factors, such as their material circumstances.

These were not identified as health problems after their displacement, perhaps due to the removal of these two driving factors. After the earthquake, menstrual hygiene represented a widespread concern amongst participants, although only one participant related this to specific health issues such as rashes and wounds. Participants identified not being able to dry menstrual cloths in view of men as a challenge. Displacement exacerbated this, by reducing private space and access to water.

Participants reported vaginal discharge, vaginal itching, pain on intercourse, and lower abdominal pain as concerns. Denial of family planning access by family members was a barrier to healthcare. Inaccurate, or poor health education, relating to contraception further reduced participant’s control over their health.


Gender based violence (GBV) is a health issue in its own right, and a determinant of other health problems. Intimate partner violence was identified
as a health problem for women both pre- and post- displacement. Post-displacement feelings of insecurity and fear were widespread due to aspects of camp life such as long distances to toilets and insecure shelters. Fears (as well as accounts of violence that had occurred) centred around sexual assault by strangers. Another key dimension of GBV was sociocultural pressure on women to remain silent about violence and the lack of legal structures to allow reporting of violence. Furthermore, victim-blaming by communities was identified as fuelling the silencing of women in their community both before and after the earthquake.


Often lack of fulfilment of basic needs was the first things mentioned during the FGDs and interviews. These were primarily caused by displacement;
and poor governance has played a role in this displacement becoming protracted. In the ranking exercise participants said that the three main health issues facing women are shelter, water and food.


Whilst no internally displaced women identified mental health as a health issue for women before the earthquake, key informants felt the mental health of women had been directly affected by the earthquake and one felt there were ‘high levels’ of mental illness in in rural Dhading prior to the disaster. Commonly, when participants were asked about the main health concerns for women in their communities, discussion turned to the worries women have. When participant’s identified symptoms related to emotional and mental health, they were often expressed in the context of concern about the current instability and lack of security for their future.

Women expressed two main areas they worried or were fearful about: their children’s future and an earthquake re-occurring. Beyond their fears and worries, some participants described various symptoms of mental ill-health such as: anxiety, tearfulness, suicidal ideation, sleeplessness, and lack of energy.


The main sexual and reproductive problems described by participants, prior to the earthquake, were problems in pregnancy, including miscarriage, and uterine prolapse. Participants emphasized the role of heavy workloads and poor geographic access to health clinics as causing these problems.


Post-earthquake health interventions in Nepal need to address the underlying social determinants of health, rather than just health conditions. Women’ lack of autonomy and access to resources due to patriarchal oppression underlies many issues women face in relation to their health, which have been exacerbated by the earthquake and their displacement. This needs to be a focus of health interventions as without transformation in harmful norms many of the challenges found in this study will not be addressed. As many internally displaced people show no signs of imminently leaving the camps, the instability of their current situation needs to be immediately addressed, which would involve creating more permanent shelters, improving access to water and providing gender segregated wash areas and toilets.


  • Government and donors should prioritise psychological assessments and counselling to female internally displaced people which is gender-sensitive

  • Good health is reliant on the provision of financial support so that women can access healthcare services (including mental health and gender-based violence) and health education and information

  • Camp design should prioritise female-only spaces to facilitate better management of menstrual hygiene

  • Participatory interventions should be instituted within the camps in order to educate communities about sexual and reproductive health and rights and tackle the patriarchal norms which are a hazard to women’s health and well being

  • Income generating activities, employment and educational and vocational training should be introduced in order to increase livelihood opportunities and support their access to health services


Bradshaw, F. (2013) Women, girls and disasters a review for DFID. system/uploads/attachment_data/ le/236656/women- girls-disasters.pdf

Government of Nepal. (2015a) Nepal Disaster Risk Reduction Portal. Kathmandu: Government of Nepal.

Horton, R. (2013) ‘Of ine: Is global health neocolonialist?’, The Lancet, 382 (9906), pp. 1690. doi:

Internal Displacement Monitoring Centre (IDMC). (2015) Nepal.

Maguire, P. (1987) Doing participatory research: a feminist approach. Massachusetts: Center for International education, School of Education, University of Massachusetts.

Stanley, L., and Wise, S. (2002) Breaking out again feminist ontology and epistemology. London: Routledge. writing/philosophy/breaking%20out%20again.pdf

Swain, M. (2016) Nepal: one year after the earthquakes, an end to displacement is still years away. asia-pacific/nepal/nepal--thousands-displaced-by-floods-and-landslides-66670/

United Nations Office for the Co-ordination of Humanitarian Affairs (UNOCHA). (2015) Nepal earthquake facts and figures. Geneva: UNOCHA. and-figures/

United Nations Population Fund (UNFPA). (2015) SHELTER FROM THE STORM. A transformative agenda for women and girls in a crisis-prone world. Geneva: UNFPA.


We would like to thank Anjila Bhatta, Tola Pathak, FOCUS Nepal camp volunteers, Rachel Tolhurst, the Staff of Green Tara Nepal & FOCUS Nepal, Padam Simkhada and Sara Parker. This brief was written by Kitty Worthing and edited by Kate Hawkins.





The Indonesian invasion of Timor-Leste began in 1975 and lasted for 24 years. Although brutal in many ways, the Indonesian government introduced an education system which meant that more boys and girls in rural areas could go to school. During the occupation, gender-based violence, including rape, sexual torture and sexual slavery was common.


Northern Uganda


Northern Uganda

Northern Uganda has suffered cycles of intense violence since 1986, leaving many dead and internally displaced persons (IDPs). A number of community women's groups were involved in peace processes long before the Juba peace agreement took place in 2006 between the Ugandan government and the Lord's Resistance Army (LRA). 


Sierra Leone

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Sierra Leone

 Sierra Leone is almost bottom in the Human Development Index, ranking 180th out of 187 countries. There is significant gender inequality: a mere 23% of women are literate, half the rate among men. Infectious diseases such as malaria, TB and HIV/AIDS are the leading causes of deaths and illness. In spite of improvement in women's and children's access to services, the under-five mortality rate is the highest in the world. The conflict in Sierra Leone, which began in 1991 and did not end until 2002, left two million displaced, up to 20,000 dead and 7,000 amputees. Civilians suffered extreme violence; men and women were victims of sexual violence. The Ebola epidemic has had wide reaching impacts on the health sector, health workers and communities. Gender plays a part here too:  women are more vulnerable to Ebola due to caring roles within the household; men on the other hand are more involved in burial rites, putting them also at risk.

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Mozambique health system reconstruction supports the team’s conclusion that the reconstruction of health systems is mainly “gender blind”. Policy-makers in Mozambique have not adequately considered the role of gender in contributing to health or addressed women’s and men’s different health needs. Despite government commitment to gender mainstreaming, the health system is far from gender equitable. Donors have shied away from tackling the thorny issue of the social and cultural norms, including gender, which drive ill health. As such, an opportunity has been missed not only to promote gender equity in the health system but also gender equality in society.