Medical technologies and abortion care in Eastern Uganda

A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities

INTRODUCTION

This paper identifies and summarises tensions and challenges related to healthcare worker rights and responsibilities and describes how they affect healthcare worker roles in the provision of sexual and reproductive health (SRH) care in health facilities.

METHOD

The review was undertaken in a two-phase process, namely: (1) development of a list of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review and (2) literature review.

RESULT

A total of 110 papers addressing a variety of SRH areas and geographical locations met our inclusion criteria. These papers addressed challenges to healthcare worker rights, roles and responsibilities, including conflicting laws, policies and guidelines; pressure to achieve coverage and quality; violations of the rights and professionalism of healthcare workers, undercutting their ability and motivation to fulfil their responsibilities; inadequate stewardship of the private sector; competing paradigms for decision-making-such as religious beliefs-that are inconsistent with professional responsibilities; donor conditionalities and fragmentation; and, the persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities. The tensions lead to a host of undesirable outcomes, ranging from professional frustration to the provision of a narrower range of services or of poor-quality services.

CONCLUSION

Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Despite the particularities of SRH, a whole of systems response may be best suited to address embedded challenges.

Reproductive materialism and justice for women with abortion care needs in Uganda

While reproductive health justice is often assumed to be inherent in reproductive health interventions, the nature of injustices, and the reasons for and mechanisms of concealment, are often unclear. In this article, we draw on an ethnography of priority setting and healthcare practice in eastern Uganda to illuminate these injustices and the mechanisms of concealement. We focus on discursive practices as the mechanisms through which power is activated and navigated, such that health practitioners are able to evade state surveillance and retribution. While language discourses conceal and normalise reproductive health injustices, discursive practices of care and priority setting enable reproductive controls to be navigated in ways that amplify these injustices and create new ones. In interventions, precarious conditions that impact women's reproductive health and living circumstances are often overlooked or concealed. We illustrate the convergence of biopower and necropolitical strategies to illuminate these conditions. Using the concept of reproductive materialism, we show how neoliberalism cultivates particular conditions of everyday life, in which populations are positioned as instruments for pecuniary motives, and normative controls are used to further financial gain.

Power, policy and abortion care in Uganda

Unsafe abortion practices remain the major contributor to maternal death in Uganda, impeding the achievement of universal health coverage and quality of maternal health care. Using an ethnographic design and critical discourse analysis, we explored the operations of power in setting maternal healthcare priorities, as evident at the 2018 Reproductive, Maternal, Neonatal, Child and Adolescents Health Conference. Observational data were collected of the policy-making activities, processes and events and key informant interviews were conducted with 27 participants. We describe how neoliberal and state governance through the structure and organization of policy-making, epistemic governance and universal concepts of ‘high-impact’ interventions, results-based financing, cost-effectiveness and accountability converge to suppress the articulation of local conditions associated with unsafe and risky abortion. By defining maternity along the continuum of birth and emphasizing birthing women, priority-setting was directed towards interventions promoting women’s normative role as mothers while suppressing unmet abortion care needs. Finally, discursive and communicative materials controlled how women of reproductive age in Uganda managed reproduction.