Background Child marriage is a human rights violation disproportionately impacting girls in low- and middle-income countries. In the Middle East region, conflict and displacement have prompted concerns that families are increasingly resorting to child marriage to cope with economic insecurity and fears from sexual violence. This study set out to examine child marriage among Syrian refugees residing in Egypt with the aim of understanding drivers of child marriage in this context of displacement as well as how child marriage affects refugee girls’ wellbeing. Methods This analysis draws from 15 focus group discussions (FGD) conducted with married and unmarried girls, as well as parents of adolescent girls in three governorates in Egypt. FGDs included a participatory ranking exercise and photo-elicitation. Additionally, we conducted 29 in-depth interviews with girls and mothers, as well as 28 key informant interviews with health providers, community leaders, and humanitarian actors. The data was thematically analyzed using a combination of inductive and deductive coding. Results A prevalent phenomenon in pre-war Syria, child marriage has been sustained after the influx of Syrian refugees into Egypt by pre-existing cultural traditions and gender norms that prioritize the role of girls as wives and mothers. However, displacement into Egypt engendered different responses. For some families, displacement-specific challenges such as disruptions to girls’ education, protection concerns, and livelihood insecurity were found to exacerbate girls’ vulnerability to child marriage. For others, however, displacement into urban areas in Egypt may have contributed to the erosion of social norms that favored child marriage, leading to marriage postponement. Among girls who were married early, we identified a range of negative health and social consequences, including lack of family planning use, disruption to schooling and curtailment of girls’ mobility as well as challenges with marriage and birth registration which accentuated their vulnerability. Conclusion Efforts to address child marriage among Syrian refugees must acknowledge the different ways in which displacement can influence child marriage attitudes and practices and should capitalize on positive changes that have the potential to catalyze social norm change. Moreover, targeted, focused and contextualized interventions should not only focus on preventing child marriage but also on mitigating its impacts.
Background Active and protracted conflict settings demonstrate the need to prioritise the peace through health agenda. This can be achieved by reorienting attention toward gender diverse leadership and more effective governance within health systems. This approach may enable women to have a greater voice in the decision-making of health and social interventions, thereby enabling the community led and context specific knowledge required to address the root causes of persistent inequalities and inequities in systems and societies. Methods We conducted a qualitative study, which included semi-structured interviews with 25 key informants, two focus group discussions and one workshop with humanitarian workers in local and international non-governmental organisations (NGOs), United Nations (UN) agencies, health practitioners, and academics, from Sub-Saharan Africa, Middle East and North Africa (MENA), and Latin America. Findings were then applied to the peacebuilding pyramid designed by John Paul Lederach which provides a practical framework for mediation and conflict resolution in several conflict-affected settings. The purpose of the framework was to propose an adapted conceptualisation of leadership to include women’s leadership in the health system and be more applicable in protracted conflict settings. Results Five interrelated themes emerged. First, perceptions of terms such as gender equality, equity, mainstreaming, and leadership varied across participants and contexts. Second, armed conflict is both a barrier and an enabler for advancing women’s leadership in health systems. Third, health systems themselves are critical in advancing the nexus between women’s leadership, health systems and peacebuilding. Fourth, across all contexts we found strong evidence of an instrumental relationship between women’s leadership in health systems in conflict-affected settings and peacebuilding. Lastly, the role of donors emerged as a critical obstacle to advance women’s leadership. Conclusion Continuing to empower women against social, cultural, and institutional barriers is crucial, as the emerging correlation between women’s leadership, health systems, and peacebuilding is essential for long-term stability, the right to health, and health system responsiveness.
The Health Workforce Accreditation and Regulation (HWAR) is a key function of the health system and is the subject of increasing global attention. This study provides an assessment of the factors affecting the Palestinian HWAR system, identifies existing gaps and offers actionable improvement solutions. Data were collected during October and November 2019 in twenty-two semi-structured in-depth interviews conducted with experts, academics, leaders, and policymakers purposely selected from government, academia, and non-governmental organizations. The overall perceptions towards HWAR were inconsistent. The absence of a consolidated HWAR system has led to a lack of communication between actors. Environmental factors also affect HWAR in Palestine. The study highlighted the consensus on addressing further development of HWAR and the subsequent advantages of this enhancement. The current HWAR practices were found to be based on personal initiatives rather than on a systematic evidence-based approach. The need to strengthen law enforcement was raised by numerous participants. Additional challenges were identified, including the lack of knowledge exchange and salary adjustments. HWAR in Palestine needs to be strengthened on the national, institutional, and individual levels through clear and standardized operating processes. All relevant stakeholders should work together through an integrated national accreditation and regulation system.
The Revised National Community Health Services Policy (2016-2021) (RNCHSP) and its program implementation, the Liberian National Community Health Assistant Program (NCHAP), exhibit a critical gender imbalance among the Community Health Assistants (CHAs) as only 17% are women (MOH, 2016). This study was designed to assess the gender responsiveness of the RNCHSP and its program implementation in five counties across Liberia to identify opportunities to improve gender equity in the program. Using qualitative methods, 16 semi structured interviews were conducted with policymakers and 32 with CHAs, other members of the community health workforce and community members. The study found that despite the Government of Liberia’s intention to prioritise women in the recruitment and selection of CHAs, the planning and implementation of the RNCHSP were not gender responsive. While the role of community structures, such as Community Health Committees, in the nomination and selection of CHAs is central to community ownership of the program, unfavourable gender norms influenced women’s nomination to become CHAs. Cultural, social and religious perceptions and practices of gender created inequitable expectations that negatively influenced the recruitment of women CHAs. In particular, the education requirement for CHAs posed a significant barrier to women’s nomination and selection as CHAs, due to disparities in access to education for girls in Liberia. The inequitable gender balance of CHAs has impacted the accessibility, acceptability, and affordability of community healthcare services, particularly among women. Strengthening the gender responsiveness within the RNCHSP and its program implementation is key to fostering gender equity among the health workforce and strengthening a key pillar of the health system. Employing gender responsive policies and programs will likely increase the effectiveness of community healthcare services.
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