Interpretation and synthesis of the relevant literature was used to capture the results below. Four broad areas emerged from a mixture of theoretical and empirical research: definitions and content of a gendered political economy and why it is important in health and conflict; the widespread health and non-health effects of armed conflict on women; the importance and lessons from work on gendered health systems in conflict and fragile contexts; and lastly, the relation between gender equality and sustainable peace. These are presented in turn below.
Applying a gendered political economy framework to conflict
Within the broader disciplines of political economy and related feminist theories, there are several theoretical frameworks which are useful for understanding what political economy of health in conflict means, how gender fits into this and why it is important in strengthening public systems in conflict and advancing policy reform that supports peacebuilding initiatives [23]. Political economy focuses primarily on two main facets, power and resources and how they are distributed and contested (either through violent or non-violent means) in different contexts: stable, conflict and post-conflict [11, 24]. A gendered political economy provides a deeper understanding of how power relations and patriarchy hinder progress on gender equality and equity. In conflict settings, it does this by interrogating how resources are allocated across different institutions, namely public services such as health care, and ultimately how these embedded structures work to disadvantage women [23, 25]. Pia Riggirozzi’s study further contributes to a gendered framework by drawing attention to the daily experience of gender-based social relations and tensions reflecting social, political, health divisions and economic stressors which prevent women from exercising their rights to equality [26]. Gendered power differences tend to shift constantly and in many conflicts, women’s new roles as economic providers seem to especially threaten masculine authority [6]. Alsaba et al., present the only conflict-specific political economy framework which helps to analyse how gendered dimensions of the Syrian conflict interact with market and state structures to reinforce gender inequalities, exposing women to particular forms of violence, increasing women’s vulnerability and forcing them into the informal labour market and the war economy [27].
Impact of conflict on women
Conflict effects men and women differently and exacerbates gender inequalities [27]. Men and boys make up the vast majority of direct victims of armed conflict, for example forced recruitment and arbitrary detention, while women and girls become more vulnerable to the indirect impacts of war, including sexual and gender-based violence, access to health, food, education [28]. Studies have shown conflict-affected countries since 1990 have consistently higher maternal and child mortality rates than non-conflict countries and access to essential reproductive and maternal health services for poorer, less educated and rural-based families was considerably worse in conflict versus non-conflict countries [29]. Alarmingly high rates of sexual and gender-based violence with a strong association of mental health disorders, such as Post Traumatic Stress Disorder and Depression, have long been documented in several conflict-affected settings [30, 31]. Women are disproportionately affected by the negative consequences of conflict-induced forced displacement [6]. Displaced women carry an unequal burden of care because of a gendered responsibility toward caring for children and the elderly. In many conflicts, women often are the last to flee, are usually fleeing with children, and may have to undertake in transactional sex to provide food for themselves and their children [6]. Yet the feminisation of care burdens and survival remains largely invisible in many conflicts and emergencies [32]. Most recently, with the added economic, health and social stressors of Covid-19, domestic violence cases are on the rise for women in conflict settings, such as in Yemen [33]. In the Yemen conflict, the number of female-headed households has risen considerably, forcing women to take on new roles with very limited support as many men are fighting in the conflict and are unable to return to their families [33]. Yemeni women’s increased vulnerability has led to negative coping mechanisms such as early marriages and child labour. Restrictive marital practices, gender norms, and experiences of conflict were major drivers of both partner and non-partner violence in the conflict in South Sudan [31].
Health systems in armed conflict
From a health systems perspective, political economy examines historical development and policies, the role of influential stakeholders such as the government (or in some conflict-affected areas, quasi-governments), humanitarian agencies and donors, the private sector and community-level organisations (such as the Idleb Health Directorate in northwest Syria). Incorporating gender into the political economy of health systems illustrates how females, males and peoples of other genders live, work and relate to each other at all levels of the health system. Factors such as vulnerability to illness, health seeking behaviour, access to health services, health expenditure and financing, nature of the health workforce (including capacity strengthening), data collection and management, design and use of medical products and technology, and health policies are all heavily influenced by the gendered political economy of health in conflict [34, 35]. The ReBUILD consortium provides useful analysis of gender within its post-conflict health systems analysis. Based on research in Sierra Leone, Zimbabwe, northern Uganda and Cambodia, their findings suggest women are under-represented in health management roles, they are prone to having lower paid positions within the health system, while also having additional household caring responsibilities, and their health system experiences are further influenced by intersectional factors including geography (rural vs. urban), poverty and household structure [36]. However, regulatory reforms and frameworks tend not to sufficiently address gender concerns. Armed conflicts have distinct burdens on men and women in the health workforce; studying these differences within health systems and their relation to job type, task distribution, exposures, and health outcomes in men and women is essential [37].
Sustainable peace and gender equality
A worrying trend from the literature is that the socioeconomic and political status of women directly impacts the likelihood of conflict. As highlighted, the larger the gender gap, the more likely a country is to be involved in inter- and intrastate conflict. Melander’s study suggests that more equal societies, measured as female representation in parliament and the ratio of female-to-male higher education attainment, have lower levels of intrastate (internal) armed conflict [38]. Studies suggest that sustainable peace and economic prosperity are more likely in countries with higher levels of gender equality and political participation during all phases of conflict – pre-conflict, active conflict and post-conflict [39]. Women’s meaningful participation in peace negotiations leads to better accord content (for health and socio-economic reforms for example), higher agreement implementation rates, and durable peace [39]. Women’s participation in economic and political life is therefore vital for conflict prevention and resolution [5].
Twenty years ago, the United Nations Security Council (UNSC) passed Resolution 1325 to support women’s participation in peace negotiations, post-conflict reconstruction, and to protect women and girls from wartime sexual violence [40]. Since then several subsequent UN Resolutions, the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), Millennium Development Goal 3 on promoting gender equality and empowering women, and Sustainable Development Goal 5 on gender equality have all strongly endorsed a gender perspective in addressing development, conflict and humanitarian challenges. The World Health Organisation envisages health as a neutral starting point in convening the myriad of actors in conflict, as they work towards shared health and economic goals [41]. However, it is important to note that conflict is often exacerbated particularly where there is inequity in health service delivery, often reflecting more broader societal inequality. Given this understated link between health in conflict settings and peace, linking the gendered political economy of health in conflict to peace agendas is crucial. It seems quite clear that if women’s participation in peace processes is more meaningful, there is more legitimate representation of both women and men’s health and socio-economic concerns, including those that impact health systems [42].