Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period

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1 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period Consolidation Programme Health / Policy Analysis & Formulation in the Health Sector (PAF) -Indonesia

2 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF Period By: Dr. Lieve Goeman Dr. Rahmi Sofiarini With contributions by Karsten van der Oord and Dr. Paul Rueckert Download at: The Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH was formed on 1 January It brings together the longstanding expertise of the Deutscher Entwicklungsdienst (DED) ggmbh (German development service), the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH (German technical cooperation) and InWEnt Capacity Building International, Germany. For further information, go to

3 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period Background Fifteen years after the establishment of the global Beijing Platform for Action and the commitment to adhere to the Beijing Declarations, the pivotal role of gender equality in development has been recognized at all levels. That gender inequality hinders development is widely accepted (1, 2). Even one of the eight MDG goals refers explicitly to gender i.e. Promotion of gender equality and the empowerment of women (3). The importance of addressing gender issues in the health sector has been discussed widely. Moreover, it has been pointed out that fostering poverty and gender issues are essential in improving maternal health. Questions like How can gender equity be addressed through the health system and Who get the power to transform health system for women and children triggered international discussion and resulted in the design of gender sensitive projects (4, 5). Experiences of four countries in South East Asia, including Indonesia, show that the Paris Declaration Principles provide a useful framework to develop effective partnerships between governments, civil societies and development agencies, which create opportunities for gender equality efforts (6). However, according to UNIFEM the major challenge today is turning this recognition and acceptance into actions (7). 1 At country level, achievements of gender mainstreaming in development are reflected in the values of the Gender Development Index (GDI) and the Gender Empowerment Measurement (GEM). These are two of the five indicators used by UNDP in its annual Human Development Report. GDI measures the standard of living reflecting inequalities between men and women in the following areas: long and healthy life, knowledge and decent life standard (8). While GEM measures the inequalities in opportunities between men and women in the areas of political and economic participation and decision making, and power over economic resources (9). In 2008, Indonesia ranked compared with 177 other countries for its GDI at the 94th place and for its GEM at the 107th place (10). The importance of gender mainstreaming in all aspects of development in Indonesia was recognized by the Indonesian Government and resulted in the issuing of the Presidential Instruction number 9 in 2000 (11). All ministeries were instructed to accelerate gender mainstreaming in their sectors. In 2008 the Ministry of Women s Empowerment prepared a revision of this Presidential Instruction but up till now the draft is still waiting to be approved (12). The Ministry of Home Affairs translated the Presidential Instruction into an Implementation Decree for provincial and district level (13).

4 In 2004 and 2006, the Ministery of Health (MoH) followed up the national policy and issued two Ministerial Decrees. The first decree stipulates the establishment of a gender training unit within existing Health Training Centres (14). The second decree stipulates the establishment of a team to mainstream gender in the health sector and the integration of a gender focus in certain health programs such as tuberculosis (TB), Maternal and Neonatal Health (MNH), nutrition and sanitation (15). In addition, the MoH, supported by the AusAid funded project IWHFP, developed a guideline to improve the gender sensitivity of health providers and conducted together with WHO a survey to assess the fulfillment of human rights in maternal and neonatal health using WHO s tools (16, 17). Currently MoH collaborates with the Ministry of Women s Empowerment to draft a guideline with training modules on gender planning and budgeting in the health sector (18). In 2008, Puskabangkes or the former Center for Health Policy Analysis and Development with facilitation of the GIZ PAF project conducted a study on the gender responsiveness of health policies and found that health policies at the managerial level do not have a gender perspective. As a result, many current technical health policies e.g. the policy on Maternal and Neonatal Health (MNH), the national guideline of Making Pregnancy Safer (MPS), the development of Basic and Comprehensive Emergency Obstetrics and Neonatal Care (B/CEONC), the national strategy on Breastfeeding and Reproductive Health (RH) are formulated in a gender-blind way. They are not gender sensitive and focus only on women as target population. Women are still considered as being solely responsible for all related health affairs in the community (19). The needs, experiences and responsibilities of men should be equally being integrated in health policies, planning processes and implementation and this at all levels of the health system and in the community (20). 2 Despites all these political efforts, the achievements of Indonesia in gender mainstreaming are not very impressive (21), confirmed by a steady state of the GDI between 2004 and 2008, respectively 0,663 and 0,664, and a slight increase of the GEM over the same period from 0,597 to 0,623. Gender equality in social, health, economic and political areas is still weak and more efforts at all levels and in all processes of development are required, including in the health sector (18). GIZ, as an international cooperation enterprise for sustainable development with worldwide operations, is putting gender equality as an integral part of its corporate values and work. In its current gender strategy, GIZ has as one of its priorities Improving gender mainstreaming in the technical cooperation measures (22). Since 2000, GIZ has been active in the health sector in Indonesia and implemented together Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

5 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period with MoH several projects at national, provincial and district level. They have been considered as gender sensitive and are in line with the MDGs, the Paris Declaration principles and the existing gender related agreements and commitments in South East Asia and Indonesia (23). This document describes the gender awareness of the strategy and activities of two former GTZ health projects: GTZ SISKES and HRD during their last phase ( ). Both projects developed gender sensitive tools and products enabling evidence based action. The document documents as well the currently ongoing GIZ project PAF for the period Gender awareness of GIZ Health projects in Indonesia 2.1. GTZ SISKES and HRD Projects (phase III, ) 3 The former GTZ SISKES and HRD projects in NTB and NTT provinces had a strong gender orientation. The project promoted gender equality proactively and supported women and men to make rational decisions concerning their sexual and reproductive health. The use of a gender sensitive lens can be demonstrated in all areas of support of the project e.g. Health Information System (HIS), Human Resources Information System (HRIS), health financing, referral system and Community Empowerment activities. The products and tools developed during this period are all capable of producing gender sensitive data e.g. sex disaggregated data, leading to appropriate action and promotion of gender equality. In addition, the project advocated for gender equality by promoting women s involvement in all project-supported training and installed a compulsory minimum proportion of women participating in each training (24). Thus, it is proven that gender equity can be addressed through a strengthening health system approach. Gender sensitivity in key areas of work: HIS and HRIS GTZ SISKES and HRD supported the strengthening of HIS and HRIS in NTT and NTB. The systems are developed in such a way that gender related information can easily be collected and analyzed.

6 The HMIS software provides both medical and social information e.g. kind of disease and source of payment and this disaggregated by sex, age, economic status and location (village and sub-village). For instance: TABLE 1. HEALTH CENTER SENGKOL JANUARY - DECEMBER 2009 SEX JAMKESMAS ASKES OUT OF POCKET TOTAL # PATIENTS MEN % z18% % % WOMEN % % % % TOTAL % The data in Table 1 shows that during 2009 in the Health Center of Sengkol, most patients were female and that the share of out of pocket payments was higher for women than for men ( test, p< 0,0001). Findings like these can lead to further examination and discussion why this is happening and whether this is correct and acceptable. The development of HRIS aims to provide accurate information to support planning and decision making processes in the areas of human resources for health e.g. retention, redeployment, training, mobilization and promotion. The HRIS software provides sex disaggregated information for each work unit (section, division) on education and training, staff on leave for study, retirement and staff promotion. This information is available in hospital and Provincial and District Health Offices. It allows to undertake affirmative action to ensure a correct gender balance when positions are assigned by the local government. The information system introduced by the project aims at facilitating personnel decisions based on performance and qualification, and limits assignments and promotions based on political, family or gender preference. For example: 4 TABLE 2. HEALTH PERSONNEL DATA IN NTB, 2009 MANAGEMENT POSITIONS IN PHO, DHO AND HOSPITALS RANK WOMEN MEN TOTAL II 2 2% 10 5% 12 III 19 21% 69 31% 88 IV 70 77% % 211 TOTAL 91 29% % 311 4% 88% 68% 100% Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

7 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period Table 2 shows the number of men and women working in management positions in the health sector in NTB in 2009, meaning in Provincial and District Health Offices and hospitals, and this according to their position or rank. Rank II means a high level fully managerial position, rank III a half managerial - half technical position and rank IV means a fully technical position. Service delivery functions e.g. doctors, nurses and midwives are considered as staffing positions and are not included in these numbers. These figures should draw attention to the inequality between men and women in employment. Less women are hired for managerial and technical positions then men, respectively 29% women versus 71% men. But, once employed, there is no difference between men and women in distribution over the different ranks of employment. Men and women have equal chances in career development and promotion. For instance for rank II positions, 2% of the women employed are employed in this position versus 5 % of the men but this difference is not significant ( ² test, p> 0,05) and this is similar for rank II and rank IV positions ( ² test, p> 0,05). However, challenges of data completeness and reliability still exist and jeopardize the use of the tools for decision making. Health Financing The Provincial and District Health Accounts (P/DHA) are tools that can be used to evaluate how the health budget was spent, to which facility or program resources have been allocated and who benefited most. Graph 1 on the opposite page shows public expenditure per function and district in NTB

8 GRAPH 1. PUBLIC EXPENDITURE PER FUNCTION AND DISTRICT, NTB, Millions of IDR Inpatient Services Outpatient Services Pharmaceuticals & Consumables Therapeutics & Others Medical Equipment MCH, FP & Counseling Health Services for School Communicable Diseases Non Communicable Diseases Environmental Health Health Promotion & other Public Health Pro Health Administration & Local Government Health Administration & Private Insurance Related Health Function Mataram City Central Lombok East Lombok West Lombok Bima District Bima City West Sumbawa Sumbawa Dompu Source: P/DHA - NTB 2008 Graph 1 shows that most resources were allocated to health administration, inpatient and outpatient services but that the allocation was relatively low for the province s priority programs e.g. maternal and child health, family planning and counseling, communicable disease control and health promotion. This kind of data can be used as evidence to advocate to release more budget for maternal health. Trends in time can be followed up to asses and install more gender sensitivity in budgeting and planning. 6 Referral System Awareness of the importance of generating sex disaggregated data and gender sensitive statistics is also reflected in the referral system reporting data. The forms of referral and counter referral include the sex of the patient. This is of particular importance as decisions on referral in the community (from home to the health centre or from the health centre to the hospital) are very often based on socio-cultural considerations, which can interfere or jeopardize further clinical treatment when the referral is considered as unnecessary. The referral data enables analysis on which sex gets more and or further referral or not and this evidence can be used to undertake appropriate action. Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

9 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period Graph 2. Percentage of female and male patients at the Mataram Provincial Hospital in NTB, Jan - July 2009 (n=41). Male Female 55% 45% Source: Monitoring and Evaluation of Referral Guidelines Pilot, GTZ, 2009 Graph 2 shows that more men are referred to the provincial hospital than women. This kind of data should lead to further analysis of the reasons of referral and role of socio-cultural behavior in decision making for referral. Appropriate action can then be undertaken. Community Empowerment activities 7 The Community Empowerment activities, following the Desa Siaga concept of the MoH, focus on behavioral change to improve access to quality health services for women and newborns (25). The activities, supported in NTT and NTB province by GTZ SISKES, empower the community in taking up their own responsibility for safe pregnancy and delivery by establishing five Alert Networks. These activities have a strong gender approach as pregnancy and delivery are no longer accepted as being a women s affair only but involve the entire community, especially in societies where men take the decisions. The program promotes this behavior change using existing traditions of mutual help in case of marriage and death and these are expanded to pregancy and delivery related events. Men are encouraged to be involved in all steps of pregnancy and delivery. Men are stimulated to take care of their wives, accompany

10 them to antenatal care services, prepare transportation, money and potential blood donors when their wives are giving birth or when a medical emergency occurs. The shift in people s mindset is monitored and evaluated (26). Graph 3 shows that the Community Empowerment activities in NTB have an impact on the behavior of men in the community. More men accompany their wives for delivery after the establishment of the Alert Networks of Desa Siaga (DS) in the village (p<0,05). 100 Graph 3. Gender Impact: Men accompanying women for delivery n=120; p> Before establishment of DS After establishment of DS Source: DS evaluation, GTZ 2009 (26). Household Survey in 2007 In 2007 GTZ SISKES facilitated a large scale Household Survey in both the NTB and NTT provinces (27). Special attention was given to gender related issues. The findings related to gender indicated that equality in decision-making at household level appears to exist, particularly when dealing with health or illness of a household member. Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

11 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period However, girls and young women are still vulnerable in nearly all dimensions of reproductive health. Early marriage is still practiced in NTT (especially in rural areas), exposing adolescents to early sexual relations and pregnancy. Early child-bearing often leads to health problems including maternal morbidity and mortality, infants with low birth weight, and high parity for women in later life. Girls and young women lack comprehensive reproductive sex education, and most feel that they do not have enough know-ledge of reproduction when married. Both, legal barriers and the stigma associated with premarital sex and pregnancy act as serious barriers preventing girls and young women from accessing family planning and RH services. The lack of these essential RH services leaves girls and young women especially vulnerable to resorting to unsafe methods of abortion. Based on these findings specific activities were developed. Gender specific activities: Reproductive Health Classes In NTT, six Making Pregnancy Safer priority districts were selected and the activities were implemented in collaboration with VSO (Voluntary Services Overseas) and a local NGO for the Training Of Trainers (TOT). The participants of the TOT were DHO staff, and village and district facilitators. They organized Focus Group Discussions and RH classes for adolescents and parents in their villages. In NTB, the classes were designed to gather unmarried adolescents between 13 and 19 years old, both male and female. They discussed RH issues in a participatory way. The classes focused on understanding the human body, including male and female reproductive organs and the procreation system. 9 The modules included discussions about STIs and HIV/AIDS and integrated gender perspectives in health, self esteem, and reproductive/sexual rights especially those related to women. The acceptance of RH classes by parents and religious leaders is seen as a first step towards opening minds in regards to Family Planning needs of unmarried youth.

12 Gender budgeting In 2008, the project facilitated in close collaboration with GTZ Good Local Governance (GLG) a national workshop on mainstreaming gender budgetting. The workshop was organised by ASHOKA, an Indonesian NGO promoting gender and human rights. The purpose of the workshop was to build the awareness of the participants for problem based budget allocation and expenditure, taking into account the implications on the lives of men and women when using this approach. Gender Related Policies The project also strongly supported the introduction of new innovate gender sensitive MCNH policies in both provinces: The local government of NTB introduced the AKINO strategy or Zero maternal death in the village and the local government of NTT launched the Revolusi KIA or The MCH revolution to reduce maternal deaths (28, 29). Research on gender specific issues: The Human Reproductive Rights Survey GTZ SISKES used and adapted the WHO Tools to assess the fulfillment of human rights in reproductive health (30). This study was conducted in 2 districts in NTB and in 2 districts in NTT in collaboration with provincial and district health officers, other relevant government stakeholders and NGOs in The study results were published in the national report Using Human Rights for Maternal and Neonatal Health: A tool for strengthening laws, policies and standards of care. The report shows that the provincial laws, policies and standards of care in both provinces do not meet the commitments of the Indonesian Government to Human Rights in Maternal and Neonatal health. Recommendations were formulated for appropriate action to meet the National Requirements (30). 10 Key results of the survey: Women have limited knowledge of reproductive health issues: o Only 14.5% out of 1004 women interviewed had ever received any kind of formal reproductive and or sex education. o Only 14% out of 1004 women felt they had enough knowledge of reproduction & sexuality at the time of marriage. Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

13 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period o Only 27% out of 1004 women ever heard of a STI other than HIV/AIDS. o Lack of comprehensive knowledge about contraceptive methods. o Lack of knowledge of and education for STI s, HIV and AIDS. Women experience lack of power o Premarital sex is prohibited by all religions and by customary law in NTB, those who seek RH services prior to marriage experience stigmatization and refusal. o Polygamy & divorce are accepted by Muslims and are being practiced in NTB. The divorce rate is particularly high in NTB compared to other parts of Indonesia. o While age of marriage is rising across Indonesia, it remains low in NTB with a high number of births among adolescents. The legal age to get married is 20 for men and 22 years for women. In NTB marriages at younger age are or not officially registered or a false higher age is used for registration. Lack of services and appropriate national and local policies in FP and RH o Policies on FP programs and RH services for adolescents are limited and the provided services especially for STI s and HIV-AIDS are insufficient. o Limited access: Availability of facilities which offer information, testing & treatment possibilities for STI s, HIV & AIDS are limited. Not all districts offer these services. o Services are not integrated especially those concerning STI s, HIV and AIDS. o A policy on safe abortion is absent. o Lack of attention and concern for women having an unwanted pregnancy and who wish a safe abortion. Unmet need for safe abortion services. o Access to FP services: limited to married couple only. 11 Other issues identified by the study include: o Discrepancies in the criminal law with regards to family planning information. The law forbids public showing of contraceptive devices & materials or pictures illustrating the anatomy of women and men. This is in contradiction with the provision of the Law on Population and Family Welfare. o Low level of birth registration. The survey was used to develop action plans in 2 districts in NTB and NTT with specific interventions to address the issues raised by the study results.

14 2.2. GIZ PAF project: Policy Analysis & Formulation in the Health Sector Besides providing gender sensitive input on the development of policies papers, the GIZ PAF project provided technical advice to the Gender Task Force in the MoH during This collaboration resulted in the special chapter of Gender in Health for the revision of the Presidential Instruction In addition the project advised in the drafting of the gender planning and budgeting modules and guidelines, as well in the conduct of the gender health policies study in The PAF project has a gender specific indicator, namely, that Policy papers supported by the project are in line with the gender guideline of the MoH and verifiably refer to it. An assessment of the achievement of this indicator has been done late 2010 (32). Six policy papers have been assessed. These are the policy papers on Tobacco Law, Hospital Law, Desa Siaga (Community Empowerment programme), and on Human Resources for Health (33, 34, 35, 36). Two other policy papers served as input for and were directly integrated into the National Health system (NHS) and the Guideline for developing Long Term National Health Development Plan (37, 38). As a specific gender guideline of the MoH does not exist, the national gender guideline as attached to the Presidential Instruction of 2000, has been used as reference instead (11). 12 The methodology used to assess this alignment consists of four steps: Step 1: Collecting the policy papers and check whether a direct reference to the national gender guideline could be found Step 2: Assessing the document on the presence and use of gender related terms and differentiation between men and women, and this by using a search function on predetermined terms Step 3: Assessing the general gender sensitivity and orientation of the document in a qualitative way Step 4: Assigning a score for each document For this process a matrix has been developed allowing screening the documents in a systematic way while following the different steps. The overall result serves to report on the achievements of the project indicator. Only one policy paper out of the six documents, namely the draft of National Health Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

15 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period System, is fully and explicitly in line with the gender guideline. Three other policy papers are implicitly in line with the gender guideline and their content is gender sensitive. The remaining two policy papers, namely the paper on Tobacco control and Human Resources for Health did not touch gender issues as such. Other activities in the current consolidation phase to promote gender equality are the provision of inputs and technical advice on the development of the local regulations (Perda) and priority strategies in NTB province. One of the local regulations in NTB stipulates the protection and improvement of maternal and child health. This regulation ensures more budget allocation for maternal and children health, equal access for women and men in the utilization of health services, increase of men s participation in maternal health quality improvement of health services, and health protection for women and children (39). AKINO or No maternal death in the village is one of the priority strategies of NTB province and is supported by the project. The gender sensitive tools developed during the former GTZ SISKES and HRD projects e.g. HMIS, HRIS, P/DHA support the efforts to achieve this strategy. 3. Conclusion This inventory of gender sensitive activities and approaches illustrates the awareness of the importance of gender equality and gender promotion in the GTZ health projects SISKES, HRD and PAF. This has been translated into appropriate action at all levels. 13

16 4. Glossary Gender According to WHO, gender refers to the socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women. While sex refers to the biological and physiological characteristics, that define men and women (40). There are multiple different gender roles which vary according to different cultural, historical and economic circumstances. Gender roles to some degree determine the rights and obligations of women and men within a given society, as well as the power relations between them. Since these roles are learned through socialization, they can also be changed and change over time (41). Gender analysis Gender analysis identifies, analyses and informs action to address health inequalities that arise from the different roles of women and men, or the unequal power relationships between them, and the consequences of these inequalities on their health. People are born female or male but learn to be girls and boys who grow into women and men. This learned behaviour makes up gender identity and determines gender roles (42). Gender approach A gender-based approach to public health begins from the recognition of the differences between women and men. It helps us to identify the ways in which the health risks, experiences, and outcomes are different for women and men, boys and girls, and to act accordingly. In most societies, women have lower social status than men, producing unequal power relations. For example, women have lower status in families, communities and society: They have less access to and control over resources and they have less of a say in decision-making than men. These factors have led to a systematic devaluing and neglect of women s health (43). 14 Gender-blindness Gender-blindness refers to a failure to identify or acknowledge difference on the basis of gender where it is significant. The use of neutral language and concepts may in fact obscure the importance of a person s sex or gender and impedes the achievement of balance and equity (44). Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

17 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period Gender equality Gender equality means that women and men enjoy the same status. This implies that they have equal conditions for realising their full human rights and potential to contribute to national, political, economic, social and cultural development. It does not mean that women and men will become the same, but that their rights, responsibilities and opportunities will not depend on whether they are born male or female. Gender equality refers to the absence of discrimination on the basis of gender, and to equal treatment of women and men in laws and policies (45). Gender equality can also be seen as the social order in which women and men share the same opportunities and the same constraints on full participation in both the economic and the domestic realm (46). According to the WHO definition, Gender equality is the absence of discrimination - on the basis of a person s sex - in providing opportunities, in allocating resources and benefits or in access to services. determines gender roles (42). Gender equity The concept of gender equity refers to parity, fairness and justice in terms of gender relations. It acknowledges the differences in women and men s living circumstances and allows for preferential treatment and affirmative action, addressing the fact that women have been systematically discriminated against (47). There are no universally agreed definitions; however, the concept of gender equality appears to be more commonly used, and understood to be the more encompassing one. Gender equity refers to fairness and justice in the distribution of benefits and responsibilities between women and men. The concept recognizes that women and men have different needs and strengths and that these differences should be identified and addressed to rectify the imbalance between the sexes (42). 13 Gender mainstreaming Gender mainstreaming can be understood as a strategy for making the concerns and experiences of both men and women integral to the design, implementation, monitoring and evaluation of policies and programmes in all spheres. It is a way of thinking and acting geared to creating gender equality in day-to-day working life. Gender Mainstreaming is therefore a process-oriented cross-sectional task. Comprising systematic stages of analysis, implementation and controlling, it relates to all decision-making processes in all subjective areas and impacts on all policy fields at all levels (47). Gender perspective The gender perspective looks at the impact of gender on people s opportunities, social roles and

18 interactions. Successful implementation of the policy, programme and project goals of international and national organizations is directly affected by the impact of gender and, in turn, influences the process of social development. Gender is an integral component of every aspect of the economic, social, daily and private lives of individuals and societies, and of the different roles ascribed by society to men and women (48). Gender sensitivity Gender sensitivity is the awareness and insight into the state of the other sex, with reference to historical roots of sexist stereotyping, discrimination and violence. It acknowledges the different roles & responsibilities of women and men in the community and the relationships between them. Therefore their experiences, needs, issues and priorities are different. Strategies are also different to achieve equitable outcomes for women and men (49). 5. Reference list 1. consulted on 28 September Paruzzolo, at.all Targeting poverty and gender inequality to improve maternal death in Women Deliver. 3. Achieving the Millennium Development Goals in era of Global Uncertainty. Hesp Sarah Payne, Policy Brief 12, How can gender equality be addressed through health system. European Observatory on Health System and Policies. 5. Task Force on Child Health and Maternal health: Who s got the power? Transforming health system for women and children. Millennium Project. 6. Rosalind Eyben, at.all Gender Equality and Aid Effectiveness. Challenges and Opportunities for International Practices: Experiences from South East Asia. 7. UNIFEM, 2009, Making the MGDs Work Better For Women. Hesp Consulted on 28 September Consulted on 28 September Pembangunan Berbasis Gender, Kementerian PP & PA dan BPS. 11. Inpres no 9/2000 (President Instruction) on Gender Mainstreaming in National Development. 12. Draft revision of Precedential Instruction, Ministry of Women and Empowerment. 13. Kepmendagri, 132/Kemmendragi/2003, Pedoman Umum Pelaksanaan Pengarusutamaan Gender dalam Pembangunan Daerah. Disempurnakan menjadi Permendagri no 15 tahun 2008 tentang Pedoman umum Pelaksanaan penguarusutamaan gender (PUG) di daerah. 14 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

19 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period Surat Edaran Menkes 615/Menkes/E/VI/2004; Pelaksanaan PUG-BK. 15. Kepmenkes 878/Menkes/X/2006, tanggal 12 September 2006 Tim Pengarusutamaan Gender bidang kesehatan. 16. Departemen Kesehatan RI dan AusAid, Buku Pintar. Panduan Pelayanan yang sensitive gender bagi Petugas Kesehatan. 17. MoH and WHO. A Report of Indonesia Field Test Analysis, Using Human Rigths for Maternal and Neonatal Health: A tool for strengthening laws,policies and standart of care. 18. Kementerian Kesehatan dan Kementrian Negara Pemberdayaan Perempuan dan Perlindungan Anak, Draft Panduan Perencanaan Penganggaran Responsif Gender bidang Kesehatan. 19. Kajian kebijakan Kesehatan Responsif Gender, 2008; Pusat Kajian Pembangunan Kesehatan, Departemen Kesehatan RI consulted on 2 September UNDP. Human Development Report, 2004 and GTZ Gender Strategy , Link GTZ SISKES NTT, Lieve Goeman Gender Strategy of GTZ SISKES and HRD in its approach and activities, Unpublished paper. 24. GTZ SISKES and HRD, Gertrud Ehry-Schmidt Final Report, SISKES & HRD Indonesia, NTT and NTB Province, Community Empowerment in MNH, Toolkit GTZ SISKES and PHO NTB. uploads/media/knowledge/alert Village Toolkit pdf 26. GTZ, Report on Desa Siaga Evaluation in NTB, Anwar Fachry, Rahmi Sofiarini, Lieve Goeman, Village Evaluation pdf 27. Report 2007, Household Survey on Maternal and Child Health Practices & Care-seeking behaviour at Community Level in East and West Nusa Tenggara, MoH, UI, and GTZ SISKES 28. Lombok Post, 17 December 2008: Governor NTB lauches AKINO, ABSANO and ADONO in NTB, 17 December, Pedoman Revolusi KIA di NTT (Pergub, Juklak dan Juknis), DInas Kesehatan Provinsi NTT. 30. WHO, Using human rights for maternal & neonatal health, a tool for strengthening laws, policies & standard of care. 31. GTZ. Report on Measuring the Fulfillment of Human Rights in Maternal and Neonatal Health, MOH, NTT and NTB province supported the Indonesian German Development Cooperation Health Sector Support Team. 32. GTZ Health, Indicator Matrix Policy paper on Tobacco Control in Indonesia, Sectretariat General of the Ministry of Health RI, Centre for Health Development Analysis, Unpublished.

20 34. Kertas Kebijakan: Hasil Kajian Kebijakan terkait Manajemen Rumah sakit. Unpublished. 35. Kertas Kebijakan Pengembangan Desa Siaga, unpublished. 36. Kertas Kebijakan Distribusi SDM Kesehatan di Daerah terpencil, perbatasan dan kepulauan. Unpublished. 37. Rancangan final. Sistem Kesehatan Nasional, Bentuk dan cara penyelenggaraan Pembangunan Nasional, Departemen Kesehatan RI, Jakarta, Pedoman Penyusunan RPJMN , Badan Perencanaan Pembangunan Nasional, Unpublished. 39. Rancangan Peraturan Daerah Provinsi Nusa Tenggara Barat tentang Perlindungan dan Peningkatan Kesehatan Ibu, Bayi dan Anak balita, Badan Pemberdayaan Perempuan dan Keluarga Berencana (BPP & KB), NTB Consulted on the 8th of October gender paper, see GTZ folder Tanzania Consulted on the 8th of October Consulted on the 8th of October Consulted, the 8th of October Consulted on the 8th of October of&area=all. Consulted on the 8th of October Consulted on the 8th of October Consulted on the 14th of October Consulted on the 8th of October Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia

21 Echoing Gender Sensitivity in GIZ Health Development Measures in Indonesia: Analysis of GTZ SISKES, HRD and PAF - Period List of abbreviations and Indonesian Terms: 17 Askeskin: Asuransi Kesehatan Masyarakat Miskin (Health Insurance for the poor ) AusAid: Australian Aid AKINO: Angka Kematian Ibu No-Zero maternal death B/CEONC: Basic/Comprehensive Emergency Obstetric and Neonatal Care DHO: District Health Office BPS: (Badan Pusat Statistik) Statistical Beureau DS: Desa Siaga FP: Family Planning GDI: Gender Development Index GEM: Gender Empowerment Measurement GIZ: German International Cooperation (former GTZ) GLG: Good Local Governance GM: Gender Mainstreaming GTZ: German Technical Cooperation GLG: Good Local Governance HIS: Health Information System HRIS: Human Resources Information System HRD: Human Resource Development HIV/AIDS: Human Immune deficiency Virus/ Acquired immune deficiency Syndrome IWHP: Indonesian Women Health Project Jamkesmas: Jaminan Kesehatan Masyarakat ( Social Health Insurance for the poor) MNH: Maternal and Neonatal Health MCH: Maternal and Child Health MOH: Ministry of Health MDG: Millennium Development Goals MPS: Making Pregnancy Safer NTB: Nusa Tenggara Barat (West Nusa Tenggara) NTT: Nusa Tenggara Timur (East Nusa Tenggara) NGO: Non-Governmental Organization Puskesmas: Health Centre P/DHA: Provincial/District Health Account PAF: Policy and Analysis Formulation RH: Reproductive Health SISKES: Sistem Kesehatan (Health System) UNIFEM: United Nation Fund for Women STI: Sexual Transmitted Infection TB: Tuberculosis TOT: Training Of Trainers VSO: Voluntary Services Overseas

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