Throughout the world, gender norms, roles and expectations restrict and undermine women's potential, behaviour and freedom. The turmoil and violence of war can exacerbate inequalities between men and women.
As the conflict fades, however, possibilities are created for profound change. Donor funds flow, social norms are in a state of flux and there may be an appetite for political change.
After the destruction, death and devastation of war, a window of opportunity can open for social reform in gender and health. A chance to "build back better”.
Have countries which have experienced war and then undergone a process of reforming their health systems seized this valuable opportunity? Have policy-makers taken into account the different health needs of men and women when rebuilding the health system? Have they considered the impact of health reform on gender equity? And has research into health systems provided guidance to inform policy? The Stockholm International Peace Research Institute (SIPRI) working group on gender and the ReBUILD consortium sought to answer these questions. An analysis of how gender is addressed in humanitarian assistance and health system reform in developing countries and countries affected by conflict shows:
The relationship between gender and health is complex. Understanding the context of gender and health is critical in order to build health systems that are gender equitable.
Men and women's health is influenced by their biology as well as gender norms. The pervasive effect of gender discrimination can mean that men and boys receive more food than women and girls: a study in Timor-Leste found that 29% women were malnourished. Men’s health can also suffer under gender norms which encourage boys to take excessive risks, increasing their exposure to violence.
The Women and Gender Equity Knowledge Network has identified four categories of gender disparities which undermine women's health:
The value ascribed to women and girls compared to men and boys directly affects their health. This spans the entire life cycle: from pregnancy (sex-selective abortion of girls), son preference, attempts to restrict girls' sexuality, harmful practices such as forced marriage, limited access to sexual and reproductive health and rights, and a lack of protection for widows.
Women's limited access to land, income and education means that they are disproportionately poor compared to men. In post-conflict northern Uganda, a study found that widows were vulnerable financially. In addition, social norms may discourage women from seeking health care for themselves in order to look after other family members.
Reproduction is an area where men and women are clearly exposed to different health risks. Women may also be more susceptible to illness, for example malaria during pregnancy, and less able to obtain protection and treatment than men.
Health systems are not neutral, and mirror the unequal status of men and women in society. In countries that denigrate women, health workers may not acknowledge a woman’s specific health problem. Social, geographic or financial barriers may prevent women from accessing health care.
Gender inequalities not only affect women who seek care but also those who provide it: female health workers are likely to be paid less, or not at all, and have fewer opportunities for promotion.
Research has been slow to consider the relationships between gender and health. Data which is broken down by sex is not systematically gathered, especially in war zones. This evidence is, however, vital to inform policy.
War has an immediate and detrimental impact on the health of men, women and children. The displacement of large numbers of people, lack of food, shelter and clean water, and injury as a result of violence all heighten illness. Just when people - especially women due to their reproductive role - are in greater need of health care, the destruction of clinics and hospitals and shortage of health workers and medical supplies limit the ability of the health system to cope.
Initiatives by the international community to improve health in countries affected by conflict encompass:
The turmoil of conflict often intensifies the inequalities between men and women, and heightens disparities in health. Women and girls are at increased risk of sexual and gender-based violence, such as rape, torture and slavery, not just during the conflict but afterwards, leading to increased rates of STIs and pregnancy. In Mozambique, a survey found that more than half of women had been victims of physical and sexual violence, long after civil war had ended.
Men are not immune from sexual violence, however, their need for health care is less than women's. The lack of available health services, obstacles to travel and women’s limited ability to pay, mean that women are often unable to access health care. Research shows that during war unsafe abortion and the number of women dying in pregnancy and childbirth rise.
The prevalence and impact of domestic violence is often underestimated. In Sierra Leone, enforcing domestic violence legislation is difficult due to the widespread acceptance of "customary law".
SIPRI and the ReBUILD consortium looked closely at five consolidated appeals (the tool used to coordinate humanitarian funding and projects) to examine how gender is integrated in humanitarian programming. Analysis showed that:
Two key interventions in the humanitarian phase can have a significant impact on health systems: health surveys and a vision document outlining the future health system. This document should go beyond a narrow focus on maternal health and sexual violence.