Cambodia

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Cambodia

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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.


METHODOLOGY

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.


KEY FINDINGS

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

Barriers

“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.

Enablers

“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.

CONCLUSIONS

“...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.


A FEW KEY REFERENCES

Ang, S. (2004). A comparative analysis of traditional and contemporary roles of Khmer woman in the household: A case study in Leap Tong village. Master Degree Thesis.

Dhatt, R, S Theobald, S Buzuzi, B Ros, S Vong, K Muraya, S Molyneux, et al. 2017. “The Role of Women’s Leadership and Gender Equity in Leadership and Health System Strengthening.” Global Health, Epidemiology and Genomics 2: 8–1.

Downs, J., Reif, L., and Hokororo, A. (2014). Increasing women in leadership in global health. Academic Medicine, Vol. 89, No.8, pp.1103-1107

Doyal L. (2003). Gender and health sector reform: a literature review and report from a workshop at Forum 7. Geneva: Global Forum for Health Research.

Langer, Ana (2015). Women and Health: the key for sustainable development. Lancet, Vol 386, September 19, 2015.

MoH (2012). Annual health statistic report 2012. Department of Planning and Health Information, Phnom Penh.

Namakula, J. and Witter, S. (2014). Living through conflict and post-conflict: experiences of health workers in northern Uganda and lessons for people-centered health systems. Health Policy and Planning 29:ii6–ii14.

Newman, C. (2014). Time to address gender discrimination and inequality in the health workforce. Newman Human Resource for Health, 12(25).

Payne, C. (2000). Deathwork: Unbearable Witness. Canadian Medical Association Journal, 163 (9): 1176-1178.

Roome, E., Raven, J. and Martineau, T. (2014). Human resource management in post-conflict health systems: review of research and knowledge gaps. Conflict and Health, 8:18

Ssali, S., and Theobald, S. (2016). Using life histories to explore gendered experiences of con ict in Gulu District, northern Uganda: Implications for post-conflict health reconstruction. South African Review of Sociology 2016; 47(1)

Tlaiss, H. A. (2013). Women in Healthcare: Barriers and Enablers from a Developing Country. International Journal of Health Policy and Management, 1(1), 23-33.

WHM. (2009). WCHM Position Paper on Gender Sensitive Health Service Delivery

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


ACKNOWLEDGEMENTS

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)

Comment

Nepal

Comment

Nepal

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.


EXAMINING POST-EARTHQUAKE HEALTHCARE IN NEPAL

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.

METHODS

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.


LIMITATIONS OF THE STUDY

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


WHAT DID WE FIND?

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

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.

DIFFICULTIES FULFILLING BASIC NEEDS

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.

EMOTIONAL AND MENTAL HEALTH

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.

SEXUAL AND REPRODUCTIVE HEALTH

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.


FUTURE ACTIONS

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.


RECOMMENDATIONS

  • 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


KEY RESOURCES

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

Government of Nepal. (2015a) Nepal Disaster Risk Reduction Portal. Kathmandu: Government of Nepal. http://drrportal.gov.np/

Horton, R. (2013) ‘Of ine: Is global health neocolonialist?’, The Lancet, 382 (9906), pp. 1690. doi: http://dx.doi.org/10.1016/S0140-6736(13)62379-X

Internal Displacement Monitoring Centre (IDMC). (2015) Nepal. http://www.internal-displacement.org/south-and-south-east-asia/nepal/

Maguire, P. (1987) Doing participatory research: a feminist approach. Massachusetts: Center for International education, School of Education, University of Massachusetts. http://www.popline.org/node/369992

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

Swain, M. (2016) Nepal: one year after the earthquakes, an end to displacement is still years away. http://www.ifrc.org/ar/news-and-media/news-stories/ 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. http://www.undispatch.com/nepal-earthquake-facts- 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. www.unfpa.org/sites/default/files/sowp/downloads/State_of_World_Population_2015_EN.pdf


ACKNOWLEDGEMENTS

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.

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Timor-Leste

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Timor-Leste

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.

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Northern Uganda

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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). 

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Sierra Leone

1 Comment

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

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Mozambique

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.

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