By Andrew Alyao Ocero, Liverpool School of Tropical Medicine, ReBUILD and RinGs
The Ugandan Government has been recognised for adopting policies that have promoted a universal gender mainstreaming agenda. Uganda has been a relatively stable country for the last 30 years though its Northern region sustained a confined 20-year civil war. In the post-conflict setting, there is a convergence of this gender mainstreaming agenda with other dynamics that are changing traditional society’s attitude to gender roles. In contrast, the more formal institutions of decentralised government seem less malleable and remain as purveyors of male hegemony. Leadership and governance are one of the key pillars of the health system according to the World Health Organisation. I am currently writing my Ph.D. thesis, and one of its objectives is to evaluate how health system governance influenced maternal health care utilisation in post-conflict Northern Uganda.
At national level, women parliamentarians had played a pivotal role in keeping maternal health care on the policy agenda. Understanding the role of women in health system governance at the sub-national level was key to understanding how they could contribute to maternal health care utilisation, and ultimately to Uganda’s attainment of the new Sustainable Development Goals. One theme that kept popping up during my interviews and discussions with community leaders, health workers and officials in the district governments was the role women in leadership played in shaping health service delivery for the better. Two distinct patterns emerged: women’s leadership within their communities; and within decentralised government.
Leadership in the community
In Northern Uganda’s patrilineal-based society, women still belonged to the “outer court”– so to speak – they were not recognised as important actors in the community. There were indeed some volunteering roles increasingly taken up by women in the post-conflict communities that had an element of leadership. These included: volunteering as budget monitors (like community level ombudsmen monitoring the quality of health service delivery); community health workers; and, prefects supporting the distribution of humanitarian aid to resettling households. These activities certainly had a positive impact on health care but had a major drawback: they were not culturally rooted and this would not portend their survival once NGOs funding these activities shut down.
However, an incident took place in Northern Uganda that gained some media attention. It was not directly related to health but still spoke to this issue. In Amuru District, a more remote area of the region hundreds of villagers sat across a road in a desperate bid to block a team of government surveyors flanked by senior politicians and armed enforcement that had come to redraw the boundaries of their ancestral land. The government team were just as unflinching, determined to get this vacillating dispute out of the way. The confrontation was about to turn violent were it not for some elderly women that suddenly stepped out of the now emotionally charged crowd, they stripped themselves bare and marched towards the armed foe. The standoff came to an abrupt end as the government’s team withdrew in embarrassment. So far, the exercise has been shelved following the national outrage that the incident generated. Granted, this may have merely been an act of desperation, rather than an orchestrated strategy but it was a pointer to the sense of responsibility that women felt.
Leadership in local government
Conversely, further afield in the corridors of decentralised power, a very different scenario was playing out. Women politicians were being portrayed as totally cowed individuals, unable to effectively represent their constituents in Council. They were said to be actively avoiding engagement with the electorate and their impact was impalpable. Women respondents that I interacted with felt that male politicians were more proactive and had done a lot more for maternal health care. Many argued that the women politicians were still acting in obeisance to tradition norms that expected women to maintain silence as men deliberated. It was also considered that the lowly education of women councillors limited them in debate with their better-educated, more exposed male counterparts.
What does this mean for health systems?
In his book, “Displacing Human Rights: War and Intervention in Northern Uganda”, Branch spoke of this. The war in Northern Uganda diminished the absolute authority of the traditional leader and propagated the leadership role of women. Before the war, older men were often seen as community leaders and protectors of the region’s age-old patrilineal tradition. According to Branch, the authority of these male elders was further buttressed by the direct links that communities in the region had to state power. The war eroded these links and disrupted community ties as people were dispersed into internally displaced camps or out of the region. In the camps, men’s role as a breadwinner was superfluous; women became the household contact for the distribution of food rations and were more engaged in livelihood support activities. Redundancy, it is stated, drove many men into drunken debauchery. This pattern was seen to continue even after people returned to their homes at the end of war.
On the other hand, echoing my findings in decentralised government, a recent UNDP report recognises that women are limited to playing a “seconding, signing and supporting” role in the District Councils. The report explicitly attributes this to adherence to cultural norms that “thrive on the subordination of women”.
Just like the MDGs, the SDGs will be difficult to attain if women do not play a role in supporting the prioritisation of maternal health care. The government’s gender mainstreaming agenda has provided an enabling environment for post-conflict tradition societies to harness the women’s leadership roles at community level. However, the formal governance establishment remains insulated from such positive trends. Health systems strengthening efforts require more concerted efforts to promote and engage women’s governance roles in all echelons of society if they are to be successful.