Research for stronger health systems post conflict

Experiences of using life histories with health workers in post-conflict and crisis settings: methodological reflections

Authors: Sophie Witter, Justine Namakula, Alvaro Alonso-Garbayo, Haja Wurie, Sally Theobald, Wilson Mashange, Bandeth Ros, Stephen Buzuzi, Richard Mangwi and Tim Martineau.

Health Policy Plan. (2017) doi: 10.1093/heapol/czw166

This article describes and discusses the use of life histories as a potentially powerful tool for investigating health systems in post-conflict and post-crisis settings, where routine data sources are absent or weak, and where health workers constitute a marginalized community.

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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).