Justine Namakula

Living through conflict and post-conflict: experiences of health workers in northern Uganda and lessons for people-centred health systems

Providing people-centred health systems—or any systems at all—requires specific measures to protect and retain healthcare workers during and after the conflict. This is particularly important when health staff are themselves the target of violence and abduction, as is often the case. This article presents the perspective of health workers who lived through conflict in four districts of northern Uganda—Pader, Gulu, Amuru, and Kitgum. These contained more than 90% of the people displaced by the decades of conflict, which ended in 2006. The article is based on 26 in-depth interviews, using a life history approach. This participatory tool encouraged participants to record key events and decisions in their lives, and to explore areas such as their decision to become a health worker, their employment history, and their experiences of conflict and coping strategies. These were analyzed thematically to develop an understanding of how to protect and retain staff in these challenging contexts. During the conflict, many health workers lost their lives or witnessed the death of their friends and colleagues. They also experienced abduction, ambush and injury. Other challenges included disconnection from social and professional support systems, displacement, limited supplies and equipment, increased workload and long working days and lack of pay. Health workers were not passive in the face of these challenges, however. They adopted a range of safety measures, such as mingling with community members, sleeping in the bush, and frequent change of sleeping place, in addition to psychological and practical coping strategies. Understanding their motivation and their views provides an important insight how to maintain staffing and so to continue to offer essential health care during difficult times and in marginalized areas.

Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone.

Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it.The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response.Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone).These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.

Evolution of policies on human resources for health: opportunities and constraints in four post-conflict and post-crisis settings

BackgroundFew studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post -conflict period offers increased chances for the opening of ‘windows for opportunity’ for change and reform and the potential to reset health systems.MethodsThis article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools - stakeholder mapping, key informant interviews and document reviews - in Uganda, Sierra Leone, Cambodia and Zimbabwe.ResultsWe found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were different – driven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a ‘window of opportunity’ will arise which allows health systems to be reset. Problems are well understood in all four cases but core issues – such as adequate pay, effective distribution and HRH management – are to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing them – including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions – are liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time.ConclusionsWindows of opportunity for change and reform can occur but are by no means guaranteed by a crisis – rather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented.

Experiences of using life histories with health workers in post-conflict and crisis settings: methodological reflections

Abstract Introduction: Life history is a research tool which has been used primarily in sociology and anthropology to document experiences of marginalized individuals and communities. It has been less explored in relation to health system research. In this paper, we examine our experience of using life histories to explore health system trajectories coming out of conflict through the eyes of health workers. Methods: Life histories were used in four inter-related projects looking at health worker incentives, the impact of Ebola on health workers, deployment policies, and gender and leadership in the health sector. In total 244 health workers of various cadres were interviewed in Uganda, Sierra Leone, Zimbabwe and Cambodia. The life histories were one element within mixed methods research. Results: We examine the challenges faced and how these were managed. They arose in relation to gaining access, data gathering, and analysing and presenting findings from life histories. Access challenges included lack of familiarity with the method, reluctance to expose very personal information and sentiments, lack of trust in confidentiality, particularly given the traumatized contexts, and, in some cases, cynicism about research and its potential to improve working lives. In relation to data gathering, there was variable willingness to draw lifelines, and some reluctance to broach sensitive topics, particularly in contexts where policy-related issues and legitimacy are commonly still contested. Presentation of lifeline data without compromising confidentiality is also an ethical challenge. Conclusion: We discuss how these challenges were (to a large extent) surmounted and conclude that life histories with health staff can be a very powerful tool, particularly in contexts where routine data sources are absent or weak, and where health workers constitute a marginalized community (as is often the case for mid-level cadres, those serving in remote areas, and staff who have lived through conflict and crisis).

How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia

Abstract This article is grounded in a research programme which set out to understand how to rebuild health systems post‐conflict. Four countries were studied—Uganda, Sierra Leone, Zimbabwe and Cambodia—which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in‐depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict‐affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political‐economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post‐conflict and epidemic contexts—particularly in relation to physical threats and psychosocial threats—while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict‐prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.

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

Abstract It is well known that the health workforce composition is influenced by gender relations. However, little research has been done which examines the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). We present mixed method research on HRH in four fragile and post-conflict contexts (Sierra Leone, Zimbabwe, northern Uganda and Cambodia) with different histories to understand how gender influences the health workforce. We apply a gender analysis framework to explore access to resources, occupations, values, decision-making and power. We draw largely on life histories with male and female health workers to explore their lived experiences, but complement the analysis with evidence from surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. Our findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level, affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences here shaped by gender, poverty and household structure. Most HRH regulatory frameworks did not sufficiently address gender concerns. Unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.

Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage

BackgroundA case study was prepared examining government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB.MethodsDocuments and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders.ResultsThree major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship’s evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the “good will” of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period.ConclusionsGRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. Governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.

Building post-conflict health systems: a gender analysis from Northern Uganda

The post-conflict trajectory presents an opportunity to rebuild health systems to better meet the needs of all citizens. However, there is limited literature or analysis on gender equity in health system reconstruction. Northern Uganda experienced multiple conflicts which ended with tentative peace and post-conflict reconstruction starting in 2007. Using a health systems approach and analysis of data from multiple methods (household survey, life histories and key informant interviews) and participants (women and men household heads, community members, health workers and key informants) this chapter analyses the extent to which gender equity has been considered and realized in the post-conflict reconstruction of the health sector in Gulu, Northern Uganda. The analysis across multiple data sets reveals four key findings. Firstly, health systems development has focused largely on health facility reconstruction with insufficient mechanisms to address ways in which gender, age and poverty interplay to limit access to health systems. Secondly, in terms of focus area, maternal and child health emerged as a key priority amongst most providers. This is limiting as the special health care needs of Northern Uganda as a post-conflict setting go beyond maternal and child health (MCH) services, and include psycho-social trauma, non-communicable illnesses, human resources, malnutrition, inadequate equipment and drug stock-outs. Thirdly, gender, generation and poverty shape household health events and care-seeking pathways. Female household heads who were older and widowed were most likely to be poor, and face challenges in raising the resources for accessing health care; care-seeking was often delayed. Fourthly, gender shapes health care workers’ expectations, experiences and strategies to deal with conflict. Gender segregation by roles, understaffing in remote areas and lack of responsiveness to life course events for workers with family responsibilities play a role in limiting access to training and promotion for women in particular, and especially those in remote areas. The commitment of largely female mid-level cadres in remaining in posts during the conflict in Northern Uganda has also been under-recognized and not appropriately celebrated. Drawing on this analysis the authors argue for a gender-aware post-conflict health care system, which considers health challenges facing different community members and health staff from a gender perspective. A gender-sensitive health care system needs to respond to women’s health care needs across their life cycle (as opposed to focusing only on the reproductive years), as well as men’s, and go beyond the provision of facilities to include a holistic analysis of livelihood challenges, which restrict women’s (and some men’s) ability to effectively access health care. This also requires action on the gender dimensions of health services provision, including human resources for health and budgeting. In conclusion, from a gender equity perspective there have been lost opportunities in the post-conflict reconstruction of the health sector. Health systems continue to evolve and future priorities need to focus on supporting vulnerable communities’ ability to access a range of vital health services, and ensuring women and men health workers’ gendered needs are met.

Are health systems interventions gender blind? examining health system reconstruction in conflict affected states

BackgroundGlobal health policy prioritizes improving the health of women and girls, as evident in the Sustainable Development Goals (SDGs), multiple women’s health initiatives, and the billions of dollars spent by international donors and national governments to improve health service delivery in low-income countries. Countries recovering from fragility and conflict often engage in wide-ranging institutional reforms, including within the health system, to address inequities. Research and policy do not sufficiently explore how health system interventions contribute to the broader goal of gender equity.MethodsThis paper utilizes a framework synthesis approach to examine if and how rebuilding health systems affected gender equity in the post-conflict contexts of Mozambique, Timor Leste, Sierra Leone, and Northern Uganda. To undertake this analysis, we utilized the WHO health systems building blocks to establish benchmarks of gender equity. We then identified and evaluated a broad range of available evidence on these building blocks within these four contexts. We reviewed the evidence to assess if and how health interventions during the post-conflict reconstruction period met these gender equity benchmarks.FindingsOur analysis shows that the four countries did not meet gender equitable benchmarks in their health systems. Across all four contexts, health interventions did not adequately reflect on how gender norms are replicated by the health system, and conversely, how the health system can transform these gender norms and promote gender equity. Gender inequity undermined the ability of health systems to effectively improve health outcomes for women and girls. From our findings, we suggest the key attributes of gender equitable health systems to guide further research and policy.ConclusionThe use of gender equitable benchmarks provides important insights into how health system interventions in the post-conflict period neglected the role of the health system in addressing or perpetuating gender inequities. Given the frequent contact made by individuals with health services, and the important role of the health system within societies, this gender blind nature of health system engagement missed an important opportunity to contribute to more equitable and peaceful societies.

Application of social network analysis in the assessment of organization infrastructure for service delivery: a three district case study from post-conflict northern Uganda

&NA; In post‐conflict settings, service coverage indices are unlikely to be sustained if health systems are built on weak and unstable inter‐organization networks—here referred to as infrastructure. The objective of this study was to assess the inter‐organization infrastructure that supports the provision of selected health services in the reconstruction phase after conflict in northern Uganda. Applied social network analysis was used to establish the structure, size and function among organizations supporting the provision of (1) HIV treatment, (2) maternal delivery services and (3) workforce strengthening. Overall, 87 organizations were identified from 48 respondent organizations in the three post‐conflict districts in northern Uganda. A two‐stage snowball approach was used starting with service provider organizations in each district. Data included a list of organizations and their key attributes related to the provision of each service for the year 2012‐13. The findings show that inter‐organization networks are mostly focused on HIV treatment and least for workforce strengthening. The networks for HIV treatment and maternal services were about 3‐4 times denser relative to the network for workforce strengthening. The network for HIV treatment accounted for 69‐81% of the aggregated network in Gulu and Kitgum districts. In contrast, the network for workforce strengthening contributed the least (6% and 10%) in these two districts. Likewise, the networks supporting a young district (Amuru) was under invested with few organizations and sparse connections. Overall, organizations exhibited a broad range of functional roles in supporting HIV treatment compared to other services in the study. Basic information about the inter‐organization setup (infrastructure)—can contribute to knowledge for building organization networks in more equitable ways. More connected organizations can be leveraged for faster communication and resource flow to boost the delivery of health services.