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Sarah N. Ssali, Sally Theobald, Justine Namakula and Sophie Witter

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.

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Rachel Tolhurst, Esther Richards, Eleanor MacPherson, Dorcas M. Kamuya, Flavia Zalwango and Sally Theobald

This chapter explores the conceptualization and empirical evidence for gendered social processes for the production of health and illness within intimate relationships and households, drawing on international literature, additional grey literature from the Global South and four case studies from the authors’ own research. In particular, the chapter considers the capacity (by both women and men in different contexts) to exercise strategic agency in making decisions with regard to health and well-being both in their own lives and in those of their children. The authors explore how these capacities are conceptualized in both the development and health literature and the findings of empirical research in this area, particularly in three areas that have received particular attention in health: maternal, sexual and reproductive and child health. They then present and discuss four case studies from their own research in sub-Saharan Africa which illustrate the dynamics of the gendered production of health in intimate partnerships and households at different stages of the life cycle, including gendered bargaining processes (and their material and ideological bases), in order to explore these complex processes and outcomes in more depth. The case studies also examine the ways in which gender interacts with other axes of inequality to shape health experiences and outcomes, including for example age, livelihood strategies, socio-economic status, geographical location (for example, urban or rural), marital status and household structure. Finally, the authors discuss whether and how capacities for exercising strategic agency have been considered in health policies, programming and interventions within different contexts, and identify key areas for action and further research.

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Jeannie Samuel

This chapter explores the complexities of social inclusion and exclusion in health care. It presents a study of a group of indigenous women in Peru who act as ‘citizen monitors’ using a human rights-based approach to health. The monitors document and confront problems that indigenous health users face with discrimination, cultural insensitivity, poor treatment and illegal charges for services in public health care facilities. The study findings suggest that measures taken by the citizen monitors can help to address these problems. However, systemic deficiencies, including underfunding, poor management and neglect, are characteristic of the health system’s weakest segment which serves the monitors’ communities. These systemic issues underlie many of the problems identified by the monitors.

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Lynn M. Morgan

When the Rosa Parks Prize was awarded to a conservative Argentine senator in 2009 for her outspoken opposition to contraception, sterilization and abortion, it was clear that something odd was happening. This chapter documents the appropriation of ‘human rights’ discourses by conservative Catholics in Latin America, where the recent success of reproductive and sexual rights social movements has generated a significant backlash. It specifically traces an effort by Catholic legal scholars to justify what they term ‘a distinctively Latin American approach to human rights’ while ignoring decades of human rights activism by others. Opponents of reproductive and sexual rights are deploying rights-talk selectively and strategically, the author argues, using it as secular cover to advance pro-life and pro-family policies.

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Susan F. Murray

Maternity care processes reflect health systems’ relationship with society, sometimes ameliorating but often reproducing inequality and privilege. Analysis can highlight, inter alia, issues of gender, class inequalities and power on local and global scales. This chapter seeks to examine some of the ways in which women’s experiences of pregnancy, childbirth and post-partum and the related healthcare services in low-income and middle-income countries are being affected by commercialization trends that have been invigorated by recent ‘development’ policy and by the evolution of the transnational healthcare economy. Market exchange has come to be a central and accepted principle within health care in a number of ways, and commercial actors have been accorded new spaces and new roles. Examples range from the use of user fees and co-payments in public sector services, to the public subsidy of private sector maternity care providers and of businesses that construct and managing hospitals, to public sector and development non-governmental organization (NGO) ‘partnerships’ with commercial actors which become framed by their agendas. Effects of commercialization can be diverse, ranging from the sacrifice of rural maternal health to fund large public_private partnership (PPP) hospital projects promoted by international finance corporations, to the insidious marketing of infant formula via public sector services, to escalating private sector caesarean section rates. The search for profitable healthcare business investment has also resulted in a ‘boutique’ birthing centre industry aimed at the discerning middle-class consumer, and the commodification of women’s reproductive labour and the ‘renting’ of their wombs for commercial surrogacy. Maternity may not be as visible a feature of the global health care economy as joint replacement or cosmetic surgery. However, it is far from untouched by the contemporary trends that favour market principles and burgeoning national and transnational health care industries.

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Gabriela Alvarez Minte

The chapter analyzes the ways in which women’s sexual and reproductive rights are disputed and blocked in Chile. As in the rest of the region, Chile’s demographic trends have changed with a decrease in fertility and mortality rates, educational levels have risen, and women have increased their access to employment. However, efforts to advance sexual and reproductive rights and health have met the resistance of conservative groups that have been successful in restricting women’s _ and men’s _ reproductive choices. Focusing on the legacy of the 1973–1990 authoritarian dictatorship; the processes to ensure free and universal access to emergency contraception; and the development, implementation and evaluation of the national sexual education programme, the chapter illustrates the resistances that come into play when policies on these issues are spearheaded, and the institutional constraints that still exist. Concluding that to understand the resistance and backlashes relating to advances in women’ sexual and reproductive rights in Chile, it is important to look not only at policy outcomes but also at their implementation, looking at all actors, going beyond the political left/right divide, and searching for what is driving conservatism and the strategies used to resist social change. Chileans live in the divide between social practices and social discourse, where the practices are more progressive and liberal and the discourse is driven by an elite and is conservative and traditional; where the institutional weight of the dictatorship, and the combined public_private and decentralized educational and health system diminish the state’s capacity to implement exiting progressive legislation such as the case of emergency contraception and sexual education.

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Deborah Johnston

Neoliberal policy has an impact on health through several channels: through health policy, economic policy, health policy and social protection policy. This chapter provides an overview of these. Evidence on health reform suggests that health access has become more dependent on income and unpaid time. Women, especially poor women, have been particularly affected. To understand why this is, it is also necessary to investigate the way that economic and social policies provide women and men with income, alter time constraints and change health claims. Underlying neoliberal policy is a particular vision of health rights and responsibilities, with growing emphasis on the health-seeking behaviour of individuals. The libertarian paternalist strand of neoliberal thought has been particularly keen on intervening to change individual behaviour and this has led to a new health emphasis on cash transfer interventions. The chapter argues that cash transfers have been associated with increased use of health services and improvements in nutritional outcomes, although there are less clear impacts for other health indicators. Libertarian paternalist interventions focus on decision-making about health, rather than the way that gender and class intersect to shape health outcomes. Such interventions obscure the social and economic factors leading to poor health, appear easily implementable and place responsibility on the ill for being sick. As such they are the apotheosis of a neoliberal approach to health that ignores the socio-economic production of poor health.

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Karen Devries, Heidi Grundlingh and Louise Knight

This chapter explores how experiences of maltreatment in childhood lead to both use and experience of violence in adulthood. The authors draw on literature from the diverse disciplines of genetics, developmental biology, psychology and psychiatry, and consider how gendered social contexts interact with children’s biology and psychology to shape development. Early experiences of violence can lead to changes in children’s cognitions and behaviours and poor mental health; gendered contexts teach and reinforce the acceptability of certain forms of violence. These in turn can affect interactions with early intimate partners, increasing or decreasing the risk of violence. There are a range of intervention strategies that can interrupt this cycle: parenting interventions, school-based interventions and social norm change interventions all hold promise.

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Rochelle Ann Burgess

The movement for global mental health has signalled women as a group of focus in its efforts since 2007. Despite critique of the potential harm of the global movement more broadly, this has not fed into a discussion of the specific problems that will be faced women in the Global South who are the targets of an expansion of Western psychiatric thought within an era of ‘global mental health’. Does the intersection of global forces and local realities create new opportunities for women to challenge contexts that place their mental health at risk? Or is the expanding hand of psychiatric practice merely repeating mistakes of old: a silencing of women’s voice and power to determine their own well-being? This chapter engages with these concerns, through an exploration that attempts to locate the ‘voice’ of women within current global mental health discourses. Via a content analysis of key articles on women’s mental health since the start of the movement in 2001, it highlights a silencing of women’s voices that occurs through the use of methods of data collection, engagement with women that reduces the complexity of their social realities to biomedical conditions, and the problematic positioning of women as objects of treatment rather than autonomous subjects. It argues that for the movement to maintain its relevance it must create opportunities to include local women within processes of service design, and develop more meaningful opportunities for women to challenge the complex social realities that reside at the heart of their mental distress.

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Marianna Leite

This chapter examines the political strategies and the bureaucratic processes related to the implementation of women’s human rights to health in health sector reforms in Brazil. It uses maternal health reduction political and policy strategies as a case study to assert whether or not the use of human rights-based discourses have incurred in a progressive policy praxis. It discusses the processes associated with the appropriation and reappropriation of feminist discourses by the different policy networks and their influence in the depoliticization of the wider human rights movement. This chapter therefore considers the extent to which progressive reproductive health strategies have been marginalized by the reform processes in Brazil’s health sector over the past three decades. This marginalization has had significant implications that are reflected in the country’s continued failure to effectively tackle maternal mortality as a priority.