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Background This paper explores the changing experience of giving birth in Cambodia over a 53-year period. During this time, Cambodian people experienced armed conflict, extreme privation, foreign invasion, and civil unrest. Methods An historical perspective was used to explore the changing place and nature of birth assistance given to Cambodian women between 1950 and 2013. Twenty-four life histories of poor and non-poor Cambodians aged 40–74 were gathered and analysed using a grounded thematic approach. Results In the early lives of the respondents, almost all births occurred at home and were assisted by Traditional Birth Attendants. In modern times, towards the end of their lives, the respondents’ grand-children and great grand-children are almost universally born in institutions in which skilled birth attendants are available. Respondents recognise that this is partly due to the availability of modern health care facilities but also describe the process by which attitudes to institutional and homebirth changed over time. Interviews can also chart the increasing awareness of the risks of homebirth, somewhat influenced by the success of health education messages transmitted by public health authorities. Conclusions The life histories provide insight into the factors driving the underlying cultural change: a modernising supply side; improving transport and communications infrastructure. In addition, a step-change occurred in the aftermath of the conflict with significant influence of extensive contact with the Vietnamese recognised. Trial registration None.

Background An adequate and qualified health workforce is critical for achieving Universal Health Coverage (UHC) and responding to the Sustainable Development Goals (SDGs). Frontline health workers who are mainly women, play important roles in responses to crisis. Despite women making up the vast majority of the health workforce, men occupy the majority of leadership positions. This study aims to understand the career progression of female health workers by exploring how gender norms influence women’s upward career trajectories. Methods A qualitative methodology deployed a life history approach was used to explore the perspectives and experiences of health workers in Battambang province, Cambodia. Twenty male and female health managers were purposively selected based five criteria: age 40 and above, starting their career during 1980s or 1990s, clinical skills, management roles and evidence of career progression. Themes and sub-themes were developed based on available data and informed by Tlaiss’s (2013) social theory framework in order to understand how gender norms, roles and relations shape the career of women in the health industry. Results The findings from life histories show that gender norms shape men’s and women’s career progression at different levels of society. At the macro level, social, cultural, political, and gender norms are favorably changing by allowing more women to enter medical education; however, leadership is bias towards men. At the meso organziational level, empowerment of women in the health sector has increased with the support of gender working groups and women’s associations. At the micro individual level, female facility managers identified capacity and qualifications as important factors in helping women to obtain leadership positions. Conclusion While Cambodia has made progress, it still has far to go to achieve equality in leadership. Promoting gender equity in leadership within the health workforce requires a long vision and commitment along with collaboration among different stakeholders and across social structures. If more women are not able to obtain leadership roles, the goals of having an equitable health system, promoting UHC, and responding to the SDGs milestones by leaving no one behind will remain unattainable objectives.

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. [Abstract copyright: © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.]

Globally, traditional medicine has long been used to address relatively common illness, mental ill health and during childbirth and post-natal care. However, traditional medicine is primarily provided by the private sector and it is unclear how far expenditures on traditional medicine contribute to household impoverishment. A life history method was used to understand the health seeking experience of 24 households over the last 60 years in Cambodia, a country with high out-of-pocket expenditures for health. The life histories suggest that traditional medicine in Cambodia has been undergoing a process of commercialization, with significant impacts on poor households. In the earlier lives of respondents, payments for traditional medicine were reported to have been flexible, voluntary or appropriate to patients’ financial means. In contrast, contemporary practitioners appear to seek immediate cash payments that have frequently led to considerable debt and asset sales by traditional medicine users. Given traditional medicine‘s popularity as a source of treatment in Cambodia and its potential to contribute to household impoverishment, we suggest that it needs to be included in a national conversation about achieving Universal Health Coverage in the country.

Background Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. Methods The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. Results Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. Conclusion The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

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).