“Most of the people living here are helpless,” said a woman in Jaffna, a district of northern Sri Lanka, nearly ten years after the country’s civil war ended. It was 2017, and I was conducting research with women in two villages in Jaffna. This woman’s sentiment reflected the challenges many in her community are still facing, including the ability to access health services. Through this research, my colleagues and I found that women’s access to healthcare was influenced by both their gender—particularly gender norms and gender roles—and household income. Better understanding of how gender and gender dynamics impact healthcare access will be essential to improving their lives. 

War undermines human development, human security, and health. After war, a country should aim to address the most pressing basic needs of the population. A healthy population is essential for a country to sustainably develop and rebuild after war. However, countries often struggle with ensuring access to care, especially in areas affected by war and especially for marginalized populations like women. 

Gender norms, gender roles, and access to health services 

Sri Lanka is an ethnically and religiously diverse country. One of the villages in our study is predominantly Tamil Hindu, and the other is predominantly Muslim. Though the two villages are ethnically and religiously different, they both practice certain gender norms and roles which influence women’s access to healthcare and reflect the communities’ patriarchal cultures. Our research identified four ways gender can impact women’s ability to access health services:  

First, the women prioritize their responsibilities in the home and to their families over their own healthcare. Public health services in Sri Lanka are free but often involve long wait times, which is a hurdle for women in Jaffna, who are often the primary caretakers in their household. Many of the women in our study said that the largest challenge for them to access health services is the need to fulfill their household and familial responsibilities. Consequently, if they spend too much time waiting at a health facility for their own care, this takes time away from their expected duties.  

Second, the women seek permission or have to inform other family members when leaving their homes. Many of the married women in our study said that they must inform their husbands before leaving the home, and the women who are not married said they must inform their parents. This reflects a gender norm highlighting Jaffna’s patriarchal culture and illustrating how a woman’s marital status can influence their daily lives. 

Third, in both villages, often the women do not travel alone to health facilities—they travel with a companion. Married women are often accompanied by their husbands. This can pose a challenging trade-off for families. With the majority of women participating in our study being in lower-income households, a husband missing a day of work can be detrimental to the family. If the husband sacrifices a day of work to accompany his wife to get care, it reduces their household income. 

Fourth, the women discuss their healthcare decisions with family members—specifically, with their husbands or mothers. Not only are women often the primary caretakers of their children’s health, including unmarried adult children, but decisions regarding their own health often must be preceded by discussion with their husband (if married) or mother (if unmarried). 

Intersectionality and access to healthcare  

Intersectionality means that a person’s experience is not solely impacted by one social category (e.g., gender, race, education level, religion or class), but that these categories intersect with one another. Reflecting on the four gender norms and roles discussed above, our research found that even though the women involved were ethnically diverse, they had similar experiences in accessing healthcare. Together, their gender (and associated norms) and household income level influenced the women’s ability to access health services. 

Almost all of the women participating in the study had below-average income for the district of Jaffna, limiting the type of health services they could receive. We saw this in their use of free public services instead of private services that require out-of-pocket payment. Additionally, their husbands tended to be the main income earners in both villages, which could make it difficult for the husbands to accompany them to health facilities or discuss healthcare decisions with them.  

Ways to improve access to healthcare after war 

While every post-war setting is unique and context-specific, our case study in Sri Lanka provides valuable insights about challenges women face when accessing health services in settings affected by war even years after armed conflict.  

Peacebuilding and development efforts in post-war settings must consider the gender dynamics which are specific to their locations and which affect access to basic services like healthcare. Governments and service organizations should recognize a key principle of intersectionality: women’s experiences are determined by more than just their gender.  

With a more comprehensive understanding, development, humanitarian, and peacebuilding actors can better create and implement more holistic post-war initiatives to address people’s most urgent and basic needs. This is important for women, who are often neglected in such efforts.