Gender relations, livelihood security and reproductive health among women refugees in Uganda The case of Sudanese women in Rhino Camp and Kiryandongo Refugee Settlements Promotor: Prof. Dr. Ir Georg Frerks Hoogleraar Rampenstudies Wageningen Universiteit Promotiecommissie: 1. Prof.dr. ir. J.W.M. van Dijk Wageningen University 2. Prof.dr. A. Niehof Wageningen University 3. Dr. Gaim Kibreab South Bank University 4. Dr.ir. D.J.M Hilhorst Wageningen University Dit onderzoek is uitgevoerd binnen CERES Graduate Research School for Resource Studies for Development. Gender relations, livelihood security and reproductive health among women refugees in Uganda The case of Sudanese women in Rhino Camp and Kiryandongo Refugee Settlements Deborah Mulumba Proefschrift ter verkrijging van de graad van doctor op gezag van de rector magnificus van Wageningen Universiteit, Prof.dr.ir. M. Kropff in het openbaar te verdedigen op woensdag 26 oktober 2005 des namiddags te 16.00 uur in de Aula Deborah Mulumba Gender relations, livelihood security and reproductive health among women refugees in Uganda: the case of Sudanese women in Rhino Camp and Kiryandongo refugee settlements Ph.D. Thesis, Rural Development Sociology Group, Disaster Studies, Wageningen University With references – With summaries in English and Dutch ISBN: 90-8504-304-2 Copyright @2005 by D. Mulumba To Stanley and Joel Matthew Table of Contents List of Tables xiii List of Figures xiv Acronyms and Abbreviations xv Glossary xvii Acknowledgements xix Map of Uganda xxi Chapter 1 Background and Rationale for the Study 1 1.0 INTRODUCTION 1 1.1 THE RESEARCH MOTIVATION 2 1.2 OFFICIAL DEFINITION OF REPRODUCTIVE HEALTH 5 1.3 REFUGEE WOMEN PERCEPTION OF REPRODUCTIVE HEALTH 5 1.4 WOMEN REFUGEES 7 1.5 THE PROBLEM STATEMENT AND OBJECTIVES OF THE RESEARCH 8 1.6 OUTLINE OF THE THESIS 9 Chapter 2 Theoretical and Conceptual Perspectives 13 2.0 INTRODUCTION 13 2.1 WOMEN AND THE DEVELOPMENT PROCESS 14 2.2 THE SECOND WOMEN’S MOVEMENT 17 Women in Development (WID) 17 Gender and Development (GAD) 18 Third World Women Feminism 20 2.3 ANALYTICAL FRAMEWORK 22 An Actor-oriented Approach 22 Social Actors 22 Agency 2 2 Interface analysis 24 A gender perspective 25 The Negotiation of gender relations 26 Gender division of roles 27 Gender Needs 28 Power 2 8 2.4 CONTEMPORARY VIOLENT CONFLICT 30 2.5 UNDERSTANDING THE HOUSEHOLD 32 The African household and women-headed households 34 2.6 VULNERABILITY, CAPACITY, COPING AND ADAPTING 36 Vulnerability and refugees 37 Sex and Gender-based violence 38 2.7 INTERNATIONAL LEGAL AND INSTITUTIONAL FRAMEWORK 39 Definition of Refugees 39 The 1951 Convention 39 1967 Protocol and the OAU Definition 40 Further Guidelines on Refugee Women 41 Security Council Resolution 1325 41 Humanitarian Assistance 42 The Non Governmental Organizations (NGOs) 44 Chapter 3 Research Questions and Methodology 49 3.1 INTRODUCING THE RESEARCH QUESTIONS 49 3.2 M ETHODOLOGY 49 3.3 RESEARCH DESIGN 50 The Case Study Approach 51 3.4 THE DIFFERENT PHASES OF THE FIELDWORK 53 3.5 METHODS AND TECHNIQUES FOR DATA COLLECTION 56 Secondary Data 56 Primary Data 56 The Survey: 56 Interviews 57 3.6 UNITS OF A NALYSIS AND OBSERVATIONS 58 3.7 SELECTION OF THE STUDY AREA AND SAMPLING 58 Selecting the Study Area 58 Masindi District 59 Selection of Kiryandongo Refugee Settlement 59 Sampling technique in Kiryandongo 60 Arua District 60 Rhino Camp Refugee Settlement 61 Selecting the Respondents 61 Participant Observation 62 Selecting the Case Studies 63 Employing Assistants 65 3.8 DATA MANAGEMENT AND ANALYSIS 65 3.9 REPRESENTATIVENESS, VALIDITY AND RELIABILITY 66 3.10 PROBLEMS AND LIMITATIONS 67 Chapter 4 The History and Management of Refugees and Displacement in Uganda 69 4.0 INTRODUCTION 69 4.1 PRE-INDEPENDENCE MIGRATION AND SECOND WORLD WAR REFUGEES 69 The Banyarwanda migrants 70 Second World War Refugees 70 Administration and welfare of refugees 71 4.2 REFUGEES IN UGANDA 72 Rwandese Refugees 72 Banyarwanda refugees and local politics 73 The Banyarwanda during the Amin regime 73 The Sudanese in Uganda 74 The Congolese 76 Other nationalities 77 Durable Solutions 77 Resettlement 77 Local Integration 78 Voluntary Repatriation 79 Humanitarian Protection and Assistance 79 Education 80 Health care services for refugees 81 Food and Non Food Requirements 82 The Self-Reliance Strategy (SRS) 83 4.3 ARMED CONFLICT AND INTERNAL DISPLACEMENT IN UGANDA 88 The Buganda Crisis (1964-1966) 88 The Military Regime of Idi Amin (1971 – 1979) 89 The National Resistance Movement (1981-1985) 89 Banyarwanda involvement in rebel movement 90 Armed conflict in Northern Uganda (1986 to date) 90 Women leadership in rebel alliances 91 The Lords Resistance Army (LRA) 92 Conflict and peace making process 92 The Teso Insurgency (1986-1991) 93 Allied Democratic Forces – Rebel Activity 93 4.3 UGANDA – PRODUCER OF REFUGEES 94 4.4 CONCLUDING REMARKS 94 Chapter 5 The International and National Health policies 97 5.0 INTRODUCTION 97 5.1 AN OVERVIEW OF THE HEALTH POLICIES BEFORE ALMA ATA DECLARATION 97 5.2 THE 1978 ALMA A TA DECLARATION: PRIMARY HEALTH CARE (PHC) 98 5.3 PRINCIPLES OF PRIMARY HEALTH CARE 99 5.4 THE MATERNAL AND CHILD HEALTH (MCH) STRATEGIES 101 The Safe Motherhood Initiative 102 The Bamako Initiative 103 5.5 STRUCTURAL A DJUSTMENT PROGRAMMES (SAPS) 104 5.6 REPRODUCTIVE HEALTH POLICIES 107 The International Conference on Population and Development (ICPD) 107 Fourth World Conference of Women (FWCW) 111 Beyond ICPD and FWCW 111 5.7 THE NATIONAL POLICIES 113 National Health Policy (1999-2004) 113 Components of the minimum health care package 114 Control of Communicable Disease 114 Sexual and Reproductive Health and Rights 116 5.8 NATIONAL POLICY GUIDELINES FOR REPRODUCTIVE HEALTH 118 5.9 CONCLUDING REMARKS 118 Chapter 6 Ministries, Organizations and Programmes Dealing in Reproductive Health Issues 121 6.0 INTRODUCTION 121 6.1 An overview of health care in Uganda 121 The illusion of health care service expansion 123 The period from 1986 to date 124 6.2 THE CURRENT HEALTH CARE DELIVERY SYSTEM 125 Context 125 The Providers of health care 127 Government Health services 128 6.3 THE TRAINING OF HEALTH PROVIDERS 130 6.4 REPRODUCTIVE HEALTH PROGRAMS 132 Sexual and Reproductive Health Minimum Package 132 Maternal and Child Health (MCH) 133 Antenatal care and Delivery 134 Sexually Transmitted Infections (STIs) and HIV/AIDS 135 Adolescent Sexual and Reproductive Health 135 Reproductive Health Cancers 136 Gender- based violence 137 6.5 HOW THE ABOVE REPRODUCTIVE HEALTH PROGRAMMES ARE IMPLEMENTED 138 The Ministry of Health and the district health network 138 NGO Hospitals 139 Family Planning Association of Uganda (FPAU) 139 The Current FPAU Programme 139 Mode of Service delivery 140 Naguru Teenage Information and Health Centre 141 Marie Stopes (Uganda) (MSU) 142 The United Nations Population Fund (UNFPA) 143 Delivery of Improved Services for Health (DISH) 145 6.6 CONCLUDING REMARKS 148 Chapter 7 The Study Area and ‘host environment’ 151 7.0 INTRODUCTION 151 7.1 UGANDA 151 Geography 151 Demographic Characteristics 152 Rebel Activity in Northern Uganda 153 The Economy 154 The Politics in Uganda 155 Decentralisation and the Local Councils 155 7.2 ARUA DISTRICT 157 Demographic Characteristics 158 Economy 159 Health Services 160 Other basic services – water, power and communication 161 7.3 RHINO CAMP REFUGEE SETTLEMENT 161 Geographical and Physical Features 161 Refugee Administration 162 A Narration of How Refugees Moved to Rhino Camp 163 Implementation of refugee programmes 164 Health Services 165 7.4 MASINDI DISTRICT 166 Geography and history 166 Economic activities 166 Health Care Provision in Masindi 167 7.5 KIRYANDONGO REFUGEE SETTLEMENT 168 Background 168 Organizations in the settlement and refugee integration 169 Refugee Integration and self-sufficiency in Kiryandongo 169 Land Allocation 170 Panyadole Health Facility 170 7.6 CONCLUDING REMARKS 171 Chapter 8 Gender Relations, Livelihood Security and Reproductive Health: Discussion of Findings and Experiences From Rhino Camp Refugee Settlement. 175 8.0 INTRODUCTION 175 8.1 THE GENDER RELATIONS AMONG THE MADI 175 Rules, norms and practices 176 Marriage, bride wealth, parenthood and division of labour 177 Kinship, Descent and Family 179 The triple role of women 180 The multiple activities of women associated with reproduction 181 The multiple roles of men and women 182 The activity profile in Rhino Camp 183 8.2 LIVELIHOOD SECURITY 185 Livelihood Strategies 186 Food Security 188 Food Distribution System 190 Land and food production 191 NGOs and gender planning 191 Hindrances to livelihood security 192 8.3 EDUCATION 196 Gender-specific characteristics of refugee primary education in Rhino Camp 196 8.4 SOCIAL ACTORS AND UN-FUNDED PROGRAMMES 200 Non Governmental Organizations - German Development Service (DED) 201 The District Health Authority and the appointment of a medical coordinator 201 The number of Health Providers and beneficiaries 202 United Nations High Commissioner (UNHCR) and United Nations Population Fund (UNFPA) 203 Uganda Government (OPM) Daily Practice in Reproductive Health Programmes 206 8.5 SEXUAL AND GENDER-BASED VIOLENCE 224 Vulnerability of women 224 Gender-based vulnerability 224 8.6 A CONCLUSION 229 Gender relations and access to resources 229 Power 230 Refugee aid and social actors 231 Chapter 9 Gender Relations, Livelihood Security and Reproductive Health: Discussion of findings and Experiences From Kiryandongo Refugee Settlement 235 9.0 INTRODUCTION 235 9.1 GENDER RELATIONS AMONG THE A