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1 This article was downloaded by: [ ] On: 08 September 2015, At: 03:28 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: 5 Howick Place, London, SW1P 1WG Click for updates Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: Towards gender equality in health in Afghanistan Sima Samar a, Anwer Aqil b, Joanna Vogel c, Lora Wentzel d, Sharifullah Haqmal e, Etsuko Matsunaga f, Elena Vuolo g & Nigina Abaszadeh h a Afghanistan Independent Human Rights Commission, Kabul, Afghanistan b Westat, Rockville, MD, USA c Gender in Health Equity, WHO/EMRO, Cairo, Egypt d USAID, Kabul, Afghanistan e WHO, Kabul, Afghanistan f UNICEF, Kabul, Afghanistan g UNDP, Kabul, Afghanistan h UNFPA, Kabul, Afghanistan Published online: 18 Jul To cite this article: Sima Samar, Anwer Aqil, Joanna Vogel, Lora Wentzel, Sharifullah Haqmal, Etsuko Matsunaga, Elena Vuolo & Nigina Abaszadeh (2014) Towards gender equality in health in Afghanistan, Global Public Health: An International Journal for Research, Policy and Practice, 9:sup1, S76-S92, DOI: / To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content ) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims,

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3 Global Public Health, 2014 Vol. 9, No. S1, S76 S92, Towards gender equality in health in Afghanistan Sima Samar a *, Anwer Aqil b *, Joanna Vogel c, Lora Wentzel d, Sharifullah Haqmal e, Etsuko Matsunaga f, Elena Vuolo g and Nigina Abaszadeh h a Afghanistan Independent Human Rights Commission, Kabul, Afghanistan; b Westat, Rockville, MD, USA; c Gender in Health Equity, WHO/EMRO, Cairo, Egypt; d USAID, Kabul, Afghanistan; e WHO, Kabul, Afghanistan; f UNICEF, Kabul, Afghanistan; g UNDP, Kabul, Afghanistan; h UNFPA, Kabul, Afghanistan (Received 18 February 2012; final version received 8 January 2013) The Afghanistan gender inequality index shows that 70% loss in development is due to the limited participation of women in the workforce, low education and poor women s health outcomes. However, since the fall of the Taliban regime in 2002, gender inequalities in health have improved. This paper will review factors that led to these improvements. The review draws upon information from various sources, including formative and applied research, surveys and existing information systems. The review showed gender differentials in morbidity, mortality and accessing and utilising health services. Health professionals have expressed inadequate medical knowledge and interpersonal skills to address sensitive issues, such as domestic, physical and sexual violence. Discussing sexuality and its impact on health remains taboo both within and outside of the medical profession. Strict cultural norms restrict a woman s autonomy to seek health care, choose a marriage partner and have control over her body, indicating a need to increase awareness about how harmful social practices adversely affect health. The policy review showed that the Ministry of Public Health has made a commitment to reducing gender inequity in health and developed a two-pronged action plan to improve health providers skills in handling gendersensitive issues and mass media campaigns to change social norms. Keywords: gender; equality; health; domestic violence; gender-based violence Introduction A few years ago, a 13-year-old girl in the Bamyan province of Afghanistan was brought to a hospital in a coma with severe lacerations to her lower abdomen. The family claimed she was bitten by an animal, but soon the health workers discovered the grim details. Her mother used a razor blade to perform a makeshift caesarean section on the pregnant girl and stitched her wound using a string and needles from a sewing kit. The mother s motive was to retain the family honour and avoid shame by concealing her daughter s pregnancy after being raped. The saga illustrates how women can internalise and act on social and cultural norms that inadvertently harm their families well-being; while men perpetuate these practices without realising that these norms adversely affect the health outcomes of their families and themselves. This true story also alludes to the struggle that lies ahead for Afghan women in achieving their right to health. *Corresponding authors. simasamar@yahoo.com; anwer_aqil@hotmail.com 2014 Taylor & Francis

4 Global Public Health S77 Gender equality remains an unrealised achievement in most countries, as social dynamics persist in limiting equal opportunities for women in all spheres of life. This old gender-related power differential has been especially witnessed in Afghanistan where, Taliban forces have capitalised on gender inequality as part of their resistance and cultural ideology, making it particularly difficult for Afghan men and women to stand up for their rights. Health and preservation of human life, however, is neutral ground that is valued, respected and acknowledged in all cultures, and it is the responsibility of the state to protect and secure the health of its people, especially those vulnerable and with unequal access to resources needed for health. Identifying and analysing gender differences in health outcomes and vulnerabilities enables the opportunity for consensus building in gender-sensitive development programming. This paper provides an overview of genderrelated differences in Afghanistan and the consequences on health status. Background Often health sector approaches towards women s health are prioritised by their reproductive needs. It is less common for health sector approaches to consider vulnerabilities in terms of inequalities and power imbalances and its impacts on access and utilisation of services (Standing 1997). Without question, biological differences have critical impacts upon women s and men s specific susceptibilities to disease and ill health; however, the influence of behaviour, especially health-seeking behaviour, also has critical impacts on health outcomes. Household income, levels of education (Ahmed et al. 2005), proximity to health facilities (Ahmed et al. 2003), length of waiting times (Ali and DeMuynck 2005), perceptions of provider patient interactions (Johansson et al. 2000), as well as type, duration and perceived severity of illness (Giao et al. 2005) all influence health-seeking behaviour. The extent and manifestations of these influences can vary and differ among men and women (Ahmed 2001). For example, men tend to delay accessing health services longer than women, but consult medical practitioners directly, while women tend to try traditional practices first, before seeking to health care services (Ahmed et al. 2003). Distance from health care facilities and perceived severity of illness exert more influence on men s health-seeking behaviour while lower user fees and fear of social isolation are greater influencing factors for women (Ahmed et al. 2003). In addition, it has been found in India that lack of acknowledgement or awareness of health needs is an influencing factor for women, while lack of resources is an influencing factor for men (Iyer 2005). Although the Afghanistan Mortality Survey (AMS; APHI et al. 2010) showed lack of resources affecting women seeking care as well. Women s selfworth has also been found to influence health-seeking behaviour and is correlated with unwillingness to spend scarce household resources on their own health needs (Chamberlain et al. 2007). Cultural and social norms influence and determine men and women s productive and reproductive roles in the household, community, workplace and society. They structure decision-making capacities, power differentials and access to resources, including social capital (Moss 2002). Restrictions on women s decision-making (Gerstl et al. 2006), and restrictions on the mobility and autonomy of women (Ngom et al. 2003, Fikree et al. 2004), are barriers for women to effectively access and use health care services. Women faced with these constrictions are more likely to be economically vulnerable and dependent on others for their needs, including their health needs (Zimmerman and Legerski 2010). These variables influence women s and men s exposure to health risks,

5 S78 S. Samar et al. access to health information and services, health outcomes, health care response and the social and economic consequences of disease and ill health (WHO 2007). The brief literature on the intersection of health sector approaches with cultural and social norms in developing countries provides evidence that gender issues are important for the health of all and for country development. This paper does not debate theoretical constructions of gender equality but refers to it in the context of equal chances or opportunities to access and control of social, economic and political resources, including protection under the law (health services, education, voting rights, etc.). How much do Afghan women assert their individuality, autonomy and how much they are constrained by social attitudes, norms and practices in their ability to contribute to the development of the country? How do they compare with their neighbouring countries and especially Islamic countries in marching towards gender equality? How does gender inequality affect their health, and how do health systems create gender-sensitive health services, as well as advocate to health professionals and to greater society to change harmful norms and practices towards women? This paper will attempt to answer these questions, assess the status of gender and health equity in Afghanistan and propose strategies for further progress. Sources of information This paper utilises various sources of information, formative and applied research and published documents, which were collected through literature searches in Medline, Sociofile, PsychInfo databases, as well as drawing from experiences and interactions of the authors in Afghanistan. Results The results are organized in four sections overall gender inequality, situation analysis of gender inequality and health differentials, social norms and practices affecting health and lastly, policy review. Section 1: overall gender inequality The Gender Inequality Index (GII) 1 score of Afghanistan is in 2011, indicating a 70% loss in development due to gender inequality. The GII global average score is (49.2%; UNDP 2011). Comparing Afghanistan with regional countries (Figure 1), Afghanistan scores slightly better than Yemen but with less improvement over the past five years and scored lower than Pakistan, Sudan before partition and Bangladesh, indicating variations in socioeconomic influences affecting gender inequality. Afghanistan has shown minimal changes since 2005, similar to its static ranking in the human development index in the last 10 years, remaining at a rank of 172 out of 187 nations (UNDP 2011). Section 2: situation analysis of gender-related differentials in health Gender differentials in mortality and morbidity The latest AMS (APHI et al. 2010) showed that direct estimates of age-specific mortality rate based on survivorship of sisters and brothers of female respondents for a period of 0 6 years prior to the survey are 63 and 71 deaths per thousand for women and men, respectively. Figure 2 provides a trend in mortality in those aged based on sibling history. This trend analysis showed a sharp decreasing trend of mortality over the three

6 Global Public Health S Afghanistan Bangladesh Pakistan Sudan* Yemen Figure 1. Gender inequality index. *GII, Human development report, hdr.undp.org/en/statistics/gii. five-year periods. The mortality rate has dropped for both women and men since 1996, but remains higher for men. It should be noted that the mortality rate for females may be under-reported. The AMS (APHI et al. 2010) found that sister deaths were less reported in sibling history and estimated that for all Afghanistan 12% of sisters born years prior to survey appeared missing, less so in all Afghanistan except the south zone (7%) and more omission reported in north zone (21%), 2 indicating that there may be a gender bias in reporting female deaths. When excluding for maternal mortality, the rate drops from 63 to 39 per thousand. Pregnancy remains a high-risk factor for death in Afghanistan. The neonatal and infant mortality showed a similar gender differential with adult mortality. Neonatal mortality was 24 and 33 per thousand for females and males, respectively, and a similar pattern was observed for infant mortality (Figure 3) mirroring earlier surveys (ICON Institute 2009). Again, the AMS (APHI et al. 2010) indicated a gender bias in reporting fewer female deaths, which could account for some of the Per Female Male years years Figure 2. Adult mortality trend by sex by five-year period. Source: APHI et al. (2010).

7 S80 S. Samar et al. Neonatal Infant Female Male Figure 3. Neonatal and infant mortality rates per thousand. Source: APHI et al. (2010). differences in neonatal and infant mortality rates, in addition to the better biological survivorship of female over male children. Gender differentials in causes of mortality and morbidity The AMS (APHI et al. 2010) indicates that communicable and non-communicable diseases are major causes of deaths in early and later life, respectively, while injuries affect adolescents more. Interestingly, communicable diseases are more common in females (including tuberculosis [TB; National Tuberculosis program, 2011]) than in males in all age groups, partly a result of women s caretaking role of the sick and consequent greater exposure to infections. Injuries are more common in males and sharply decline in females aged Less mortality from injuries in women may be partially due to women s social responsibilities in Afghanistan that consign them to the household. Their fewer frequent exposure to the outdoor domains may result in less injury-related deaths, and greater exposure to confined, smoke-filled spaces may be contributing factors to their greater incidence of communicable disease (Figure 4) Total Total Female Male Communicable Non-communicable Injuries Unclassified Figure 4. Causes of death by age and sex differentials. Source: APHI et al. (2010).

8 Global Public Health S81 Female Male Unintentional injuries Intentional injuries Ill-defined injuries Figure 5. Percentage distribution of injury-related deaths by gender. Source: APHI et al. (2010). Note: Unintentional injuries include: Traffic accident, poisoning, fall, fire, downing and other intentional injuries: self-inflicted, violence and war. When breaking down injuries-related deaths by gender, Figure 5 reflects that deaths due to unintentional injuries are more common in women than in men. Unintentional injuries include traffic accidents, poisoning, falls, fire, drowning and other undefined injuries. It is important to note that gender-based violence (GBV) is not indicated among reported injuries or mortalities, including honour killing and self-immolation, both of which have been reported in other surveys (AIHRC 2011). Intentional injuries are greater for men (self-inflicted, violence/assault and war) as might be expected in a chronic conflict setting. Ministry of Public Health (MoPH)/HMIS (2011) data shows that overall women suffer from diseases more (59%) than men. Table 1 shows selected common diseases that are more prevalent in women and the pattern remained similar over time, indicating increased vulnerability to disease probably due to their stressful lifestyle. We also showed Table 1. Prevalence of common diseases by gender and year. Female Male Disease Cough and cold 684,073 1,750,811 2,839, ,572 1,545,992 2,458,146 Ear, nose, throat 562,926 1,371,009 1,994, ,754 1,160,066 1,651,704 Pneumonia 271, , , , , ,284 Acute watery diarrhoea 372, ,316 1,331, , ,334 1,317,058 Acute bloody diarrhoea 190, , , , , ,403 Diarrhoea with dehydration 54, , ,766 58, , ,586 Malaria 132, , , , , ,211 Urinary tract infections 337, ,466 1,225, , , ,340 Mental disorders 71, , ,828 45, , ,092 Trauma 76, , , , , ,087 Pelvic inflammatory disease N\A N\A 218,937 N\A N\A 6078 Sexually transmitted disease N\A N\A 35,316 N\A N\A 10,402 TB suspected case 31,832 92, ,277 19,678 57,849 93,837 Source: HMIS database (2011).

9 S82 S. Samar et al. that data on pelvic infection and sexually transmitted infections (STIs) were available only for 2011, which substantiate the common perceptions among health providers that women use of unsanitary cloth during menstruation make them more susceptible to infection; however, shame prevents them from seeking care until they become severely ill. STIs are most likely to be under-reported because HMIS data only represent those who seek care at public health facilities. Gender differentials in accessing and seeking health care Gender differentials in accessing and seeking health care can be divided into three categories: (1) economic/geographical, (2) cultural/social and (3) health system. Economic/geographical barriers. In the AMS, 77% of women reported not having enough money to access health care services when having a serious health problem (Table 2), indicating that poverty and lack of disposable income remain barriers in use of health services. Distance and lack of transportation are other major factors for women not using services (72%). These barriers were reported more by women in rural areas and by women with low or no education or belonging to low income groups. In AMS (APHI et al. 2010), half of the women who gave birth in the previous five years indicated lack of money, distance to a health facility and difficulties in getting transportation as reasons for not giving birth in a facility. In another study (MoPH et al. 2011), men reported clinic hours and lack of transportation to be the major barriers to access health services. Cultural/social barriers: autonomy/decision-making. Seeking health care is a combination of knowledge of what to do when sick, where to go to seek help and having the decision-making power to seek care. Table 2 showed that around 10% of women did not know where to go when sick, while 16% of women reported that they could not get permission to go to the health facility. This was more pronounced in the south and with women having no education or only madrassa education 3 (APHI et al. 2010). Low decision-making among females was similarly observed in another study (MoPH et al. 2011). It further showed that 32.9% of women and 31.8% of men sampled, reported making autonomous decisions to seek care in acute emergencies when the principal decision-maker was not at home. Interestingly, less than 50% of men stated that they had the power to decide about the number of children to have and deferred those decisions to the elders in the family, indicating that elders have more decision power in family matters. Cultural/social barriers: mobility. Autonomy affects mobility to go out of the house: Several studies show that lack of autonomy among women is directly associated to poor reproductive health (UNICEF et al. 2002, Mashal et al. 2008). Autonomy is curtailed by a religious/cultural practice called Mehram, where an escort is needed to take women outside of the house or to travel. Mehram is a kin or relative with whom a sexual relationship is taboo. Almost one-third of the women reported incidences of not going to the health facility because of the absence of someone to take them there (Table 2) and 14% of women stated the absence of a chaperone as reasons for not giving birth in a health facility (APHI et al. 2010). This pattern was less marked among the educated, the wealthy and women living in urban areas, indicating education, urbanisation and better economic levels interact and lead to better female autonomy and mobility (APHI et al. 2010).

10 Table 2. Percentage of women with a birth in last 5 years preceding survey who reported having serious problem in accessing health care for themselves when sick by socio-demographic characteristics. Economic and geographical barriers Cultural/religious barrier Insecurity barriers Health system barriers Lack of money Too far Transportation problem No one to accompany Did not get permission Religious reasons Afraid of bad people Security Afraid of facility No female provider Good services not available Drugs not available Long waiting time Inconvenient hour Residence Urban Rural Zone a North Central South Mother s education No education Madrassa Primary Secondary Higher Age group < Wealth quintile Lowest Second Middle Fourth Highest Total Source: APHI et al. (2010). a North: Badakhshan, Baghlan, Balkh, Faryab, Jawzjan, Kunuz, Samangan, Sari Pul and Thakar; Central: Baghdis, Bamyan, Daykundi, Farah, Ghor, Hirat, Kabul, Kapisa, Logar, Panjsher, Parwan and Maydan wardak; South: Ghazni, Hilmand, Kandahar, Khost, Kunar, Laghman, Nangahar, Nimroz, Nuristan, Pakika, Paktya, Uruzgan and Zabul. Global Public Health S83

11 S84 S. Samar et al. Cultural/social barriers: segregation. Strict cultural norms that inhibit interaction between men and women who are not related or married restricts access to health care services. One study found that many pregnant women did not deliver in a health facility or hospital because of cultural taboos around labour and delivery and the potential of the mother being seen by a male health worker (Save the Children 2008). Women also feel ashamed disclosing their health problem to the family, which not only compounds the severity of the health problem but also affects health-seeking behaviour. Cultural/social barriers: security. Security remains a major concern in seeking health care. Almost one-third of the women reported insecurity as a reason for not visiting the health facility when sick (Table 2), especially for women in rural areas or the south zone, and those having low or madrassa education. It is important to note that besides fear of insecurity, almost one-fifth of women sampled expressed mistrust in people outside their homes and mistrust in health facility staff and avoided seeking care as a result. Twelve per cent of deliveries did not take place in a health facility due to security reasons (APHI et al. 2010). Health system barriers: utilisation and female health staff. Since 2002, the availability of health services has improved tremendously and by 2008, 85% of the population lives within a two hour distance from a health facility (ICON Institute 2009). Large improvements are noted between 2003 and 2010 in the priority maternal health indicators contraceptive prevalence rate (CPR) improved from 10% (CSO and UNICEF 2003) to 21% (CSO and UNICEF 2012) and APHI et al. (2010) reported 19% CPR. The proportion of women who attended at least one antenatal care (ANC) visit with a skilled provider increased from 16% (CSO and UNICEF 2003) to 48% (CSO and UNICEF 2012), while APHI et al. (2010) reported higher (60%) at least once ANC visit coverage; the proportion of live births attended by a skilled attendant was raised from 14% (CSO and UNICEF 2003) to 39% (CSO and UNICEF 2012) and 34% skilled birth attendant was reported by APHI et al. (2010). Both CSO and APHI surveys validated improvements in maternal health services indicators. Similarly, there are improvements in human resources for health, especially female health providers. There are 2234 medical doctors in the public sector, out of whom 37% are female. There are only 305 obstetrician/gynaecologists, out of whom 5% are males who primarily handle complications of pregnancies and provide specialised services. Only 11% of females are in director/senior management positions from a total of 132 positions in the Ministry of Public Health and Provincial Health Directorates (HMIS 2012). More midwifery schools have opened, thus increasing the number of midwives from 467 in 2003 (MoPH 2002) to 3100 in 2011(HMIS 2011). It is estimated that there are currently 3651 general nurses and assistant nurses in Afghanistan, 15% of whom are female. While 1185 additional nurses are currently receiving training, according to MoPH estimates, 5713 nurses are required to meet the basic needs of the health sector. Seventy-seven per cent of the health facilities have at least one health provider compared to 50% in 2004 (HMIS 2011). However, despite these improvements, Afghan women still face health systems barriers in access to health care due to absence of female health providers (Table 2) and other previously discussed factors. Of the women surveyed in AMS 2010, 13% of the women who gave birth in past the 5 years indicated the absence of a female health provider as a reason for not giving birth in a health facility (APHI et al. 2010). Lack of female staff is also identified as a serious barrier to women reporting abuse or sexual violence at health facilities. Females entering the health workforce are hampered by low education (ICON Institute 2009, Todd et al. 2012) and traditional norms that

12 Global Public Health S85 prevent women from enrolling in training schools, working at night, in addition to the need for a Mahram or male family member escort to travel and husband or family elders permission to work (Todd et al. 2012). Health system barriers: inadequate skills. The gender assessment (MoPH et al. 2011) showed that only 49% of health care providers surveyed felt comfortable handling medical emergencies, but the majority did not feel capable to treat spontaneous, incomplete or unsafe abortions, miscarriage and domestic violence. Fifty per cent or more indicated that they need more training on reproductive health problems. Only 20% of doctors and 21.1% of midwives said that they could treat survivors of sexual violence. Inadequate skills to treat gender-sensitive health issues were substantiated by Global Rights: Partners for Justice (2008), which concluded that both male and female health care providers are often unresponsive to reports of abuse, and patients do not report for fear of further humiliation and abuse. It is also observed that health providers negative judgments of survivors of sexual violence prevent them from seeking assistance. Moreover, most health facilities do not have standards for documenting suspected cases of domestic abuse or sexual violence. Section 3: social norms and practices affecting health Early marriage/forced marriage Early marriage often results in early childbirth, and early childbirth doubles the risk of a spontaneous abortion and can result in low birth weight and higher rates of stillbirth (Shawky and Milaat 2000, Rashad et al. 2005). Early marriage also means more lifetime births, negatively affecting the woman s health. Overall, women marry early in Afghanistan with 92% of the women married by the time they reach 25 years of age. However, a positive trend in age of marriage in Afghanistan (APHI et al. 2010) is emerging. More young women are waiting longer than their mothers to get married. For example, a quarter of women aged reported being married by age 15, while only 4% of women aged reported being married. The same survey also showed a positive correlation between the median age of marriage and education women with higher education, on average, waited an additional five years to get married, indicating that education delays early marriage. Early marriage is also a critical risk factor for obstetric fistula. Preliminary findings from a UNFPA (2011) report revealed that the prevalence of obstetric fistula is estimated to be 4 cases per 1000 among women in the reproductive age. Large age differentials are often characteristic of these unions (WCLRF 2008), which further reduce decisionmaking power of the wife in view of ageism norms. Forced marriage perpetuates social isolation and other forms of mental strain for women living with their in-laws (UN- Women 2011). Forced marriage is common in Afghanistan; a UNIFEM (2008) study estimated that in 70 80% of Afghan marriages, one or both partners did not consent to the union. It has also been found that some men and boys who are forced into marriages or forced to pay a high dowry price may take out their frustration on their wives and other family members, suggesting a potential connection between violent behaviour and forced marriage (Global Rights: Partners for Justice 2008, Smith 2009). Several studies found evidence that individuals questioned early marriage practices in Afghan society and people are countering existing gender norms and social expectations about harmful practices (Smith 2009, UN-Women 2011). A large proportion of the respondents felt that cultural practices such as forced marriage were counterproductive and damaging to happiness and suggest that individual opinions often diverged from social norms (Smith 2009). This finding reflects the nuanced and complex nature of these

13 S86 S. Samar et al. practices and suggests that the decision-makers in the family might advocate for a forced union to conform to social pressure in a culture where gender roles are strictly defined. The Afghanistan Independent Human Rights Commission (AIHRC 2011) also cited an upward trend in the reporting of forced marriage cases because of better awareness created by media and civil society condoning the practice, and acknowledged that these cases still represent the tip of the iceberg. Gender-based violence Gender inequity within household dynamics can perpetuate violence. Beyond the increased risk of injuries that leads to disability or death, the victim is more susceptible to mental health disorders, unwanted pregnancy, sexually transmitted diseases and adverse neonatal and infant outcomes (WHO 2009). Domestic violence in Afghanistan appears to be an accepted social norm with women reporting satisfactory marital relationships while at the same time describing episodes of violence in their household. A Global Rights: Partners for Justice (2008) National Report found that 87.2% of women reported some type of physical, sexual or mental mistreatment with almost 40% of women reported being hit by their husband in the past 12 months. AIHRC (2011) reported 2260 cases of violence against women between April 2010 and March 2011, which is likely grossly under-reported because of fear and shame in disclosing abuse. Sexual health Aqil (1998) in Pakistan found that people are concerned about their sexual health and shy away from family planning methods because of perceptions that it can interfere in sexual performance. Sexual orientation and associated health issues are taboo for discussion. Health providers do not get training to discuss these issues and cannot respond to clients concerns. Aqil in his interaction with Afghan health professionals found similar shortcomings in Afghanistan (personal communication). We have not found data on sexual behaviours affecting health and only limited data on sexually transmitted diseases (MoPH\HMIS 2011), indicating internalisation of social norms that keep these issues silent and unresolved. Section 4: Policy/institutional development and environment on gender and health equity After the fall of Taliban regime, the 2001 Bonn Agreement led to the establishment of the Ministry of Women s Affairs (MoWA) to play the key role for gender mainstreaming in Afghanistan. The Afghan Government ratified the Convention of the Rights of the Child in 1994 and the Convention on the Elimination of all forms of Discrimination against Women (CEDAW) in The Constitution of Afghanistan (2004) guarantees equal rights for men and women in Article 22, based on the CEDAW ratification, and declares the fundamental rights and duties of citizens. Article 7 of the Constitution incorporates the major principles of the Universal Declaration on Human Rights. The AIHRC was established by the transitional government in 2002, which monitors the rights of women and children, and promotes the respect of human rights in Afghanistan. The Government of Afghanistan, through its various ministries, has developed policies and programmes to address gender inequalities since These policies are summarised in Table 3. Some policies are broader in scope and consider gender as a development issue [The National Action Plan for Women in Afghanistan (NAPWA) ; Afghanistan National Development Strategy (ANDS) ; Ministry

14 Table 3. Policy/strategies summary : gender and health. # Policy/strategy Year Implementing agency Theme/issues addressed Strengths Weaknesses 1 National Reproductive Health Strategy Revised in 2006 and 2012 (MoPH 2003, 2006) 2 National Health Policy and Strategy (MoPH 2005) , , MoPH Reduce maternal and infant mortality based on millennium development goals MoPH Better health for all Afghans in order to contribute to economic and social development 3 NAPWA MoWA Women s holistic well-being, addressing gender issues in Afghanistan Reducing poverty Multi-sector approach 4 ANDS (Government of the Islamic Republic of Afghanistan 2008) 5 National Health and Nutrition Strategy 6 National Child and Adolescent Health Strategy ANDS Oversight Committee Comprehensive development strategy in all the sectors including health MoPH Improving nutritional status to reduce maternal and child mortality MoPH Integrated package of all the priority strategic interventions for child survival/adolescent health/ establishment of the national/ provincial maternal and child health committees Strong emphasis on increasing number of female health providers; human rights-based approach in RH focus on women, vulnerable and marginalised groups 18 strategies, prioritising strengthening female health workforces and delivery of safe motherhood, FP services Beside addressing gender issues in various sector, emphasise health and developing female health workforce Reproductive health and child health/human resources in health Various nutrition strategies described Early marriage of girls, adolescent pregnancies addressed as causes of high maternal and infant mortality/emphasis on community-based health care In 2006, revised policy addressed the weakness of basic package of health services and incorporated it Less emphasis on gender equality and health rights Lack of investment plan (budget plan) for action points and M&E plan Less gender-oriented in health sector Weak emphasis on gendersensitive M&E system (few gender disaggregation mentioned) Roles of different institutions of MoPH defined but less emphasis on RH Directorate (current Gender Department)/ establishment of different committees scattered? Global Public Health S87

15 Table 3 (Continued) # Policy/strategy Year 7 Ministry of Women s Affairs National Priority Programme 8 National Gender Strategy National Health and Human Rights Strategy Implementing agency Theme/issues addressed Strengths Weaknesses MoWA Addressing gender issues Focus on gender training of government staff MoPH Reproductive and child health/ disability/mental health/gbv MoPH Health equity as human rights/ reproductive and child health/ disability/mental health/gbv RH: reproductive health, FP: family planning, GBV: gender-based violence Gender training of MoPH staff Review of policies and strategies on gender and health/strategy as guiding principles for Gender Department/MoPH Review Emergency and humanitarian crises, access to quality medication addressed/ disaggregated gender-sensitive indicators for M&E Time and follow-up mechanisms not described Similar contents as National Health and Human Rights Strategy Similar contents as National Gender Strategy S88 S. Samar et al.

16 Global Public Health S89 of Women s Affairs National Priority Programme ], while some specifically address one or two issues, such as the Nutrition Strategy ( ) or the Child and Adolescent Health Strategy ( ). The National Gender Strategy (MoPH 2012a), the National Reproductive Health Strategy (MoPH 2012b), National Priority Programme on Health (MoPH 2012c) and the National Health and Human Rights Strategy ( ) overcome some of the weaknesses of earlier policies and focus on gender health programming, such as addressing domestic violence, training of health providers on gender-sensitive communication and identifying mental health issues resulting from imbalanced gender relationships. These policies tend to interact with and contribute to reducing gender inequality in other sectors. Coordination among different departments remains weak and some policy work is outside the purview of the health sector. For example, the issue of increasing female health workers cannot be handled unless female education is promoted and communities acknowledge and promote female education. There is a room for better integration and combining supply and demand sides for improved gender equality. In addition, the translation of policies into actions on the ground needs more attention. Discussion The review shows improvements in addressing gender inequalities in health in Afghanistan, especially in terms of accessibility of health services, and in institutional commitments to gender and health equity. There is growing acknowledgement in the health sector, especially among policy-makers, that gender inequality has adverse impacts on health status and country development, which is reflected with the presence of the Gender Directorate in the MoPH and other policy and development strategies. The gender inequality score, which has remained unchanged for several years, will show improvement when the maternal mortality rate (327/100,000 live births; APHI et al. 2010) replaces the outdated figures of 1600/100,000 (Bartlett et al. 2005). Increased access to ANC and post natal care, as well as increased availability of skilled birth attendants, and increasing use of FP are driving factors behind the reduced maternal mortality rate. This represents commendable achievements by the Afghanistan MoPH. Challenges do remain in extending these benefits to populations in remote rural areas and to less educated, impoverished women. Another positive trend is the increasing age of marriage for women. This finding is supported by an increase in the number of girls attending school. Increased age at marriage will not only reduce fertility (Shawky and Milaat 2000, Rashad et al. 2005), but also reduces complications of pregnancy at early age, which can lead to infertility and vaginal fistula. Several studies found evidence that individuals questioned existing gender norms and social expectations that sanctioned harmful practices (Smith 2009, UN-Women 2011). A large proportion of the respondents acknowledged that many harmful cultural practices, such as forced marriage, were counterproductive. This finding suggests that complex social dynamics in which individual opinions often diverge from social norms (Smith 2009). Unfortunately within most communities, harmful practices continue even though individuals acknowledge these behaviours are mentally and physically damaging (UN- Women 2011). For example, the persistence of gender inequalities in decision-making, autonomy and mobility continue to present challenges for women s optimal access to health services and ability to make informed decisions on their health. In addition, insufficient presence of female health care providers continues to present barriers to

17 S90 S. Samar et al. women s access and use of health services. These challenges require transformative change, which is a lengthy and difficult process. Health providers have a distinct role to play in transformative change towards gender equity, through provision of gender-sensitive services. Health providers have acknowledged inadequate competencies in treating complicated RH issues and domestic and sexual violence. Perceptions remain ingrained in the health care that gender inequities, such as limited autonomy and mobility of women, domestic and sexual violence and early and forced marriages, do not fall under the rubric of medical profession, despite their myriad of health consequences. There is a need for more systematic data on the prevalence, scope and health impacts of gender-based violence and traditional harmful practices. Health policies and programmes cannot be optimally responsive to women s vulnerabilities without this information. The review found evidence of a gradual shift towards disapproval of harmful practices, including among health professionals. Research shows it is critical that organisations engage equally with men and women to prevent forced marriage and violence against women in the family (UN-Women 2011). Building on scientific evidence and strengthening the attitudinal shift, there is a need for demand creation to change behaviours. Mass media and community awareness campaigns should focus on suggesting alternatives to social practices that perpetuate violence and increase psychological harm to women and men. In addressing these harmful practices in the Afghan context, it is critical not to oversimplify marriage as forced or unforced as nuanced social dynamics are at play leading to a great deal of variations found in the decision-making processes (Smith 2009, UN-Women 2011). Mainstreaming social determinants of health, specifically gender issues, requires a distributional shift from a predominantly supply side perspective to both a supply and a demand side perspective of health. Especially in contexts of rigid social expectations, where behaviour is strictly regulated and gender inequalities are firmly rooted, such as Afghanistan, an exclusive health supply focus will not lead to health for all. Notes 1. The GII is a compilation of five indicators comprising variables of reproductive health, empowerment and labour force participation. 2. South zone includes provinces Ghazni, Hilmand, Kandahar, Khost, Kunar, Laghman, Nangahar, Nimroz, Nuristan, Pakika, Paktya, Uruzgan and Zabul. 3. Religious education. References The Afghanistan Independent Human Rights Commission (AIHRC), Fifth report situation of economic and social rights in Afghanistan. Qaus 1390 (November/December 2011). Afghan Public Health Institute (APHI), Ministry of Public Health, et al., Afghanistan mortality survey Kabul: Ministry of Public Health. Ahmed, S., Differing health and health-seeking behavior: ethnic minorities of the Chittagong Hill Tracts, Bangladesh. Asia pacific journal of public health, 13, doi: / Ahmed, S., et al., Changing health-seeking behaviour in Matlab, Bangladesh: do development interventions matter? Health policy and planning, 18 (3), doi: / heapol/czg037 Ahmed, S., et al., Socioeconomic status overrides age and gender in determining healthseeking behavior in rural Bangladesh. Bulletin of the world health organization, 83, Ali, M. and DeMuynck, A., Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan a qualitative study. Child: care, health and development, 31 (5), doi: /j x

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