Myanmar

Gender blind: Rebuilding Health Systems in ConFLict-Affected States – Myanmar

---

CONTEXT AND CONFLICT:

Download PDF >

Myanmar has over 130 ethnicities clustered into eight main groups, with the Bamar being the largest (60% of the total population). Other groups include: Shan (8.5%), Kayin (6.2%), Rakhine (4.5%), Mon (2.4%), Chin (2.2%), Kachin (1.4%) and Kayah (0.4%).1 The diverse setting has led, in part, to decades of internal conflict since its liberation from Great Britain in 1948. In the 1960’s, a parliamentary democracy was replaced by a military regime that took the country by force and plunged its population into nearly 50 years of poverty and oppression. During this time, General Ne Win and his regime altered the social, political and economic structure of the country, perpetuating the unequal role women played in society. Years of civilian uprisings and protests resulted in deadly backlash from the regime. Eventually, a civilian government was installed in 2011 and has slowly been gaining power- most recently, with the election of State Counsellor Aung San Suu Kyi and President Htin Kyaw in 2015 with the National League for Democracy (NLD). With the advent of a democratic path, rebuilding the country and its health system began.2 However, there is a long road to go as 600,000 people are still displaced within the country and nearly a quarter of the population lives in poverty.3

Conflict is still ongoing in some regions, namely between the Rohingya Muslim minority and Rakhine Buddhists. The Rohingya have been “stateless” since the 1982 Burmese Citizenship Law, when the predominantly Buddhist regime denied citizenship to the population, exposing them to systematic discrimination within the country. Today, there are between 800,000 and 1,100,000 Rohingya in Myanmar, with a poverty rate of 78% in the Rakhine state, where most live. Years of intense fighting between government forces and Rohingya insurgents, now the Arakan Rohingya Salvation Army (ARSA), have made peace nearly impossible with recent events raising tensions even more. As a result, the government is pursuing “clearance operations,” which has consisted of mass killings, the razing of entire villages, and huge forced displacement.4 As of August 2017, it is estimated that 688,000 Rohingya have fled across the border into Cox’s Bazar, Bangladesh in fear of persecution.

Gender equality

Myanmar is ranked 145 out of 188 countries in the Human Development Index (HDI) for 2015, a 57.4% increase since 1990, placing it within a medium human development category. Within the newly created indicator, Gender Inequality Index (GDI), Myanmar is ranked 80 out of 159 countries, compared to Cambodia and Lao People’s Democratic Republic rankings of 112 and 106, respectively. This indicator evaluates gender inequalities based on three factors: reproductive health, empowerment, and economic activity. While the GDI is lower than some surrounding countries, 27% of women, compared to 20% of men, completed at least a secondary level of education.5 The issue of domestic violence is still taboo and rarely discussed openly, due to the need for an appearance of harmony and social acceptance of violence as a “family matter.” Even now, there is no national data on intimate partner violence in Myanmar. One figure, from UNFPA, reports that 70% of women who visit their “Women and Girls Centres” across the country, experience domestic violence.6

ROHINGYA FOCUS: CURRENT ISSUES

Within Myanmar, international humanitarian aid is not being permitted into the Rakhine state, despite urgent calls for access from MSF.12 Every month, thousands of Rohingya refugees pour into the neighboring countries of Bangladesh and Malaysia, Thailand, and even Indonesia. Crowded and overburdened camps provide little support to those escaping ethnic cleansing in Myanmar.16 These refugees live without adequate food, water, sanitation, and healthcare. Risk of disease is rampant for measles, tetanus, diphtheria, and acute jaundice syndrome. Children are especiallyat risk as many never received vaccinations due to the inability of families to access care within Myanmar. Further compounding disease and unsanitary conditions, 60% of the water supply is contaminated in the Cox’s Bazar camp, hosting the largest number of refugees.

The human rights of the Rohingya have been violated at every turn as the international community struggles to coordinate a response to the ongoing crisis. Protests and sanctions attempt to pressure the Myanmar government to halt their campaign, to no avail. Meanwhile, governments in Southeast Asia lack established legal frameworks to protect refugee rights, while maintaining a “principle of noninterference” among their members. In Bangladesh and Malaysia, the Rohingya refugees have no legal status or right to work. Desperate and without aid, they face further exploitation.

In November 2017, Bangladesh and Myanmar signed a deal to repatriate the Rohingya refugees, though the deal has been postponed. Details remain vague about rights that would be granted, resettlement locations, and assurance from the government that this crisis would not be repeated.17

Health Equity

 As of 2014, life expectancy at birth for women was 69.9 years, and 63.9 years for men. The leading causes of death are related to chronic disease, such as cerebrovascular and ischemic heart disease, which is increasing as deaths from infectious disease decrease.7 Women have a lower probability of death by chronic disease, associated with tobacco and alcohol consumption. Yet, more women than men are reported overweight (23.4%, compared with 13.3% of men). There is little more disaggregated data available on the general health status of men and women in Myanmar.8

As of 2016, Myanmar has a low adult HIV prevalence of 0.8%, which has decreased by 51% since 2005. However, HIV-positive pregnant women are particularly discriminated against in hospitals, thus necessitating improved outreach and prevention to vulnerable women and girls essential. In 2016, the tuberculosis mortality rate was 53 per 100,000 people, which has decreased by 54% since 2005. The under-five mortality rate in 2016 was 27.7 per 1,000 live births and the maternal mortality ratio (MMR) was 236 per 100,000 live births (in 2016).9 While progress is being made in many of the health indicator categories, there remains large differences between rural (70% of population) and urban communities.

Impact of conflict on gender roles

During the militarization of the country, then known as Burma, traditional gender
roles were perpetuated in both politics and the workforce, influencing career choices and aspirations of individuals. Ideal men were depicted as strong and ambitious, while ideal women were depicted as obedient and family-orientated. These stereotypes are still deeply entrenched within social institutions in Myanmar.10

Moving forward in time, during the civil war, men experienced the highest number of casualties in combat. However, women were victims of conflict, through sexual violence, and other human rights abuses. They also suffered from the indirect consequences of conflict, such as reduced access to clean water and health services. Women were not just victims of Myanmar’s civil war; however, they have also played active roles in reconciliation and political change at the grassroots level, pushing for peace, community building, and reform. Despite their involvement at the community level, women were denied participation in initiatives towards peace at higher levels of government and their work in this area remains under acknowledged.11 However, efforts are underway to increase women’s participation in national and regional politics.

---

INTERNATIONAL HEALTH ENGAGEMENT AND GENDER

ROHINGYA FOCUS: GENDER CHALLENGES

UN Women estimates that 51% of the displaced Rohingya population in Cox’s Bazar, Bangladesh are women and girls. They have experienced trauma and violence disproportionately, in addition to being a marginalized population. Sexual and gender-based violence are rampant, inflicted by both the Myanmar army and the Ethnic Rakhine population. While vastly underreported, “mass rape” is used as a weapon of war, with almost every female having witnessed or experienced this and other forms of systematic violence.18 Furthermore, the cultural stigma of rape results in underreporting while post-rape care, through humanitarian assistance, is limited.

Once these refugees arrive in Bangladesh, the overcrowding and lack of access to services mean many do not receive treatment. Within the camp, most Rohingya women are without their burqa and thus, are forced to stay inside their small huts (around 4m2). Some cook food on wood-burning stoves to bring in extra income for the family. The closed huts and exhaust from cooking create a toxic environment, leading to respiratory and eye infections. Within the shared family living quarters, women build makeshift toilets and bathing areas, decreasing hygiene. Some aid organizations have developed “dignity kits” to provide women with necessities, such as soaps, clothes, scarves, menstrual hygiene products and flashlights. However, the immense demand from incoming refugees means there are not enough resources for all.

Outside their huts, the camp can be unsafe, especially at night. Many women and girls are at risk for more violence and exploitation. Women-only areas attempt to provide safe spaces, but more is needed.19

Humanitarian

During the military regime in the 1990’s, most foreign investment into the country, intended for health and education, was sequestered by the military to gain economic power. Moreover, humanitarian organizations are rarely allowed into the country for emergency aid. Since 2016, UNFPA has aided the health ministry in supplying low- income women in qualified hospitals with free contraceptive implants, which has been widely received across the country. To date, they have spent $2.8 million on contraceptives and reproductive health medicine.10

Health System

Decades of conflict and the economic effects of conflict and sanctions have left the health system in disarray and unable to support the population. The development project, “People Centered Development,” is a government-backed programme that focuses on the average family’s access to basic necessities, as well as health and education facilities. This project aims to strengthen democracy and contribute to sustainable development through health, research, and access to services.

It has a focus on gender equity and ethnicity. In order to rebuild effective health services, a nationalized health information system is being developed through pilot testing at the university level. This research initiative has a special focus on women, particularly related to maternal and child mortality and morbidity.13 Since 2004, there has also been a Strategic Plan for Reproductive Health supported by the United Nations Population Fund (UNFPA). As part of this plan, the government initiated a policy in 2014 to provide delivery at health care facility free of charge, to reduce maternal and infant mortality rates.1

General gender programming

A 2016 UN Women report, “Gender Equality and Women’s Rights in Myanmar” suggested that the reform agenda of the new government does not specifically address gender equality and women’s rights nor adequately respond to inequality. However, the Ministry of Social Welfare, Relief and Resettlement has adopted the National Strategic Plan for the Advancement of Women 2013–2022 based on the Beijing Platform for Action. The head of the Ministry, Win Myat Aye, has taken responsibility for implementing women’s advancement and empowerment through the plan.8

---

IS THE HEALTH SYSTEM IN MYANMAR GENDER EQUITABLE?

In order to review whether the health system is gender equitable, we assessed the country’s progress against the framework of WHO’s six health system building blocks:

1) Health service delivery

Overall, little is known surrounding the non-epidemiological gender dimensions that influence health outcomes in Myanmar. However, MMR and child mortality rates are important proxy indicators for measuring overall health outcomes, as many women require ongoing and repeated access to reproductive health services over their lifetime. The high MMR in Myanmar is indicative of difficulties in accessing services, both socio-economically and culturally, and is also influenced by high rates of unsafe abortion (abortion is illegal). Compounding this issue, 1.8 million women of reproductive age do not have access to modern contraceptive methods. Additionally, many women do not receive the needed pre- and post-natal care because they cannot afford it and services are geographically inaccessible and limited, especially in villages. Women are restricted in their ability to travel outside the village as public transport in rural areas is nonexistent or too expensive and requires most to travel long distances by foot. Even today, around 90% of women are reported to have births at home, yet around 84% are attended by skilled health personnel.9,10 Overall, the weak health system affects women and girls more due to their caregiving roles in society.

Ethnicity also influences health outcomes in these remote regions, where all health indicators are the lowest among these communities compared to more urban provinces of Myanmar. Furthermore, slow-changing traditional ideas and conservative gender norms are still prevalent, further affecting ethnic minorities, who predominantly reside in these rural communities. Women have limited ability to make their own decisions regarding their health and are seen as caregivers- the topic of reproductive health, even with a doctor, is taboo. Finally, many adolescent girls and unmarried women report difficulties in and reluctance to accessing family planning services due to social stigma related to ideas around women’s sexuality.8

2) Health workforce

There is no Ministry of Health (MoH) central database for the health workforce; this is in process for medical doctors, but not for those from other medical professions. From 2006 to 2014, health workers (doctors, nurses, midwives) increased from 1.27 to 1.61 per 1000 population, with urban settings constituting the majority of this increase. While improving, the workforce to population ratio is still below the global standard of 2.28 per 1000. Related to reproductive health speci cally, the number of births attended by health workers increased from 56% in 1997 to 78% in 2010.1,14

3) Health information systems (HIS)

Myanmar’s HIS is composed of hospital, public health, human resources, and logistical information. It began with a Medical Records System, which collected information on morbidity and mortality in public hospitals. The system functions as a minimum essential data set to reduce the workload related to data management, which is still collected manually. While an electronic system has been proposed, logistical challenges related to electricity and Internet availability remain, as well as data sensitivity concerns. A 2006 health system assessment revealed that the current system is strong enough to report on indicators accurately. However, there remains a need for policy support and resources, as well as improved dissemination of information. Data which is disaggregated by sex, are available for public hospitals, but not in private facilities.1 Within private hospitals, there is limited research and data collection available, making evidence-based policy change even more challenging.

4) Health system FInancing

Between 2001 and 2011, Myanmar invested just 2% of its GDP on health expenditure, the lowest among countries in the WHO South-East Asia and Western Pacific Regions. The MoH focused most of its allocated budget on tertiary care hospitals as opposed to primary healthcare. Currently, there is no state-subsidized universal health coverage in Myanmar. In the 1990’s, health financing reform resulted in household out-of-pocket (OOP) payments being the dominant source of financing for healthcare costs. This continues to affect women’s access to health care, as most have little control over the household finances. As of 2011, around 79% of health expenditure in Myanmar were OOP, having decreased from 90% since 2005. However, a Social Security System, put in place in 2012, has gradually been expanding to cover public- and private-sector employees. This care will include maternity leave, maternal care, and family assistance. Despite these advances, there is still no system in place for the poor or informal sector, affecting many women in rural areas.1

5) Medical products and technologies

Around 10% of the total national pharmaceutical expenditure is spent on purchases from the Myanmar Pharmaceutical Industry (MPI), which produces pharmaceutical products and medical devices in five national factories. Those medicines and products not available from the national system are purchased from private companies by the central medical store depot (CMSD). As a supplement to the government budget, UN agencies and international NGOs supply medicine and support the distribution process within the country. However, there is a need for more space in the CMSD’s distribution warehouses for products, resulting from the 20-fold increase in the health budget in 2012. Another issue resulting from this budgetary increase is a lack of professional staff for efficient pharmaceutical management. Despite these challenges, people who can afford to, can generally access pharmaceutical products through private companies.

6) Leadership and governance:

Myanmar has ratified and endorsed the major international conventions and agreements on gender equality and women and children’s rights. Yet, while the country’s Constitution (2008) guarantees all people equal rights (Section 347) and does not discriminate based on sex (Section 348), there are still sections that use gender discriminatory language. It includes references to women principally as mothers and makes the statement “nothing in this section shall prevent appointment of men to positions that are naturally suitable for men only,” regarding appointments to government posts.15 This is reflected in UNDP’s Human Development Report on Myanmar, where just 13% of parliamentary seats are held by women.5 Since the 2015 elections, a new Constitution has been put forward, which appears to promote women’s reproductive rights and gender equality more than before.

---

ACKNOWLEDGEMENTS

This brief was written by Alexandria Williams with support from Sally Theobald and Valerie Percival. Suggested reference: Williams A. (2018) Rebuilding health systems in conflict affected states – Myanmar, Building Back Better.

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

---

REFERENCES:

1. Asia Pacific Observatory on Health Systems and Policies. The Republic of the Union of Myanmar, Health System Review. Vol 4.; 2014. http://www.wpro.who.int/asia_paci c_observatory/hits/series/myanmar_health_systems_review.pdf.

2. Peace Direct. Myanmar: Conflict profile. https://www.peaceinsight.org/conflicts/myanmar/. Published 2017. Accessed September 17, 2017.

3. USAID. Healthy Resilient Communities: Fostering a Healthy Population. :1-2. https://www.usaid.gov/sites/default/ les/ documents/1861/2016 USAID Burma_Healthy Resilient Communities_Fact Sheet.pdf.

4. Equal Rights Trust. Rohingya Briefing Report. Warzone Initiative. 2015;(October):20.

5. United Nations Development Programme. Human Development Report 2016 Human Development for Everyone- Myanmar. 2016:1-40. http://hdr.undp.org.

6. UNFPA. A silent emergency: Violence against women and girls. http://myanmar.unfpa.org/news/silent-emergency-violence- against-women-and-girls.

7. Institute for Health Metrics and Evaluation. Myanmar. http://www.healthdata.org/myanmar. Published 2016. Accessed September 5, 2017.

8. Asian Development Bank, United Nations Development Programme, United Nations Population Fund and the UNE for, Gender Equality and the Empowerment of Women. GENDER EQUALITY AND WOMEN’S RIGHTS IN MYANMAR: A SITUATION ANALYSIS. Mandaluyong City, Philippines: Asian Development Bank; 2016.

9. Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Health-related Sustainable Development Goals (SDG) Indicators 1990-2030. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2017. Myanmar. https://vizhub.healthdata.org/sdg/.

10. HO N. WOMEN’S RIGHTS IN MYANMAR: A WORK IN PROGRESS. 2017. http://warwickaseanconference.com/womens- rights-in-myanmar-a-work-in-progress/.

11. Transnational Institute (TNI). No Women, No Peace: Gender Equality, Conflict and Peace in Myanmar. 2016;(January).

12. Doctors Without Borders (MSF). Myanmar: International humanitarian access to Rakhine State must urgently be permitted. http://www.msf.org/en/article/myanmar-international-humanitarian-access-rakhine-state-must-urgently-be-permitted.

13. Norad. Health and Sustainable Development in Myanmar. https://www.norad.no/en/front/funding/norhed/projects/health- and-sustainable-development-in-myanmar--competence-building-in-public-health-and-medical-research-and-education/. Accessed October 2, 2017.

14. Sommanustweecha iA,Putthasri W,Nwe ML, et al. Community health worker in hard-to-reach rural areas of Myanmar: Filling primary health care service gaps. Hum Resour Health. 2016;14(1):64. doi:10.1186/s12960-016-0161-4.

15. Nations U. Convention on the Elimination of All Forms of Discrimination against Women Consideration of reports submitted by States parties under article 18 of the Convention on the Elimination of All Forms of Discrimination against Women Initial reports of States pa. 2012;41482 (November 2011):1-103.

16. Human Rights Watch. Burma: Ethnic Cleansing, Repression, Denials. https://www.hrw.org/news/2018/01/18/burma-ethnic- cleansing-repression-denials.

17. Albert E. The Rohingya Crisis. https://www.cfr.org/backgrounder/rohingya-crisis.

18. UN Women. GENDER BRIEF ON ROHINGYA REFUGEE CRISIS RESPONSE IN BANGLADESH.; 2017.

19. UN Women. Solar lamps, alternative fuel, feminine hygiene products—relief that counts in the practical needs of Rohingya women refugees. http://www.unwomen.org/en/news/stories/2018/2/feature-relief-that-counts-in-the-practical-needs-of- rohingya-women-refugees. Published 2018.

Bangladesh

Download a PDF brief >

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.

---

KEY MESSAGES

• The post-conflict 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-coflict 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.

---

IMPACT OF THE CHANGES

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 a 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 first 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 includes punitive behaviors by providers and discrimination against poor women, mistrust around costs incurred, and 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.

---

CONCLUSIONS

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 close-to-community providers on importance of timely referral, within an effective referral system.

---

A FEW KEY REFERENCES

“Menstrual Regulation and Induced Abortion and MR”, Guttmacher Institute, https://www.guttmacher.org/fact-sheet/ menstrual-regulation-and-induced-abortion-bangladesh

“Menstrual Regulation: Past, Present, and Future Challenges”, Policy Dialogue by Population Council, Bangladesh, (June, 1999) http://www.popcouncil.org/uploads/pdfs/banglapolicydialogue9.pdf

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. guttmacher.org/fact-sheet/menstru- 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. healthsystemsglobal.org/blog/99/Supporting-the-health-system-to-respond-to-the-needs-of-women-in-Bangladesh- 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:// www.guttmacher.org/fact-sheet/men- 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. healthsystemsglobal.org/blog/99/Supporting-the-health-system-to-respond-to-the-needs-of-women-in-Bangladesh-Close-to-community-health-service-pro- 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

---

ACKNOWLEDGEMENTS

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)

Zimbabwe

Download PDF >

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.

---

METHODOLOGY

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.

---

KEY FINDINGS

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.

---

CONCLUSIONS

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.

---

A FEW KEY REFERENCES

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; www.equinetafrica.org

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.

---

ACKNOWLEDGEMENTS

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.

Cambodia

Download briefing >

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)

Nepal

Download PDF >

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.