Women s health policies and programmes and gender-mainstreaming in health policies, programmes and within health sector institutions

Transcription

1 Women s health policies and programmes and gender-mainstreaming in health policies, programmes and within health sector institutions TK Sundari Ravindran (ravindrans@usa.net) Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India Aarti Kelkar-Khambete (aartikhambete@rediffmail.com) Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India June 2007 Background paper prepared for the Women and Gender Equity Knowledge Network of the WHO Commission on Social Determinants of Health

2 Background to the Women and Gender Equity Knowledge Network The Women and Gender Equity Knowledge Network (WGEKN) of the WHO Commission on Social Determinants of Health was set up to draw together the evidence base on health disparities and inequity due to gender, on the specific problems women face in meeting the highest attainable standards of health, and on the policies and actions that can address them. The work of the WGEKN was led by two organizational hubs the Indian Institute of Management Bangalore (IIMB) and the Karolinska Institute (KI) in Sweden. The 18 Members and 29 Corresponding Members of the WGEKN represent policy, civil society and academic expertise from a variety of disciplines, such as medicine, biology, sociology, epidemiology, anthropology, economics and political science, which enabled the work to draw on knowledge bases from a variety of research traditions and to identify intersectoral action for health based on experiences from different fields. Acknowledgments This paper was reviewed by at least one reviewer from within the Women and Gender Equity Knowledge Network as well as by two external reviewers. Thanks are due to these reviewers for their advice on additional sources of information, different analytical perspectives and assistance in clarifying key messages. This paper was written for the Women and Gender Equity Knowledge Network established as part of the WHO Commission on the Social Determinants of Health. The work of the network was funded by a grant from the Swedish Ministry for Foreign Affairs through the World Health Organisation, the Swedish National Institute of Public Health and the Foundation of Open Society Institute (Zug). The views presented in this paper are those of the author and do not necessarily represent the decisions, policy or views of IIMB, KI, WHO, Commissioners, the Women and Gender Equity Knowledge Network or the reviewers. 2

3 Executive Summary This paper reviews published literature in English on experiences in mainstreaming gender within the health sector since the 1990s, with a focus on policies; programmes; research and health-provider training, and institutional changes within health sector organisations. While gender mainstreaming is a difficult undertaking in any sector, mainstreaming gender in health has to contend with some specific challenges. One, because there are biological differences between women and men in health needs and experiences, there is a tendency to attribute all male-female differences to biology. The consequence is that maternal health programmes are seen as an adequate response to addressing differences in health between sexes. The need for examining gender issues in all health problems as well as in delivery of health care services remains unrecognised. Two, while the disadvantages experienced by women in sectors like education, employment or political participation are evident from available data; the case of health is more complex. Women outlive men in most countries of the world, and for many health conditions, male mortality exceeds female mortality. Many policy makers and programme managers therefore remain unconvinced of any gender-based inequalities in health, and of the need for gender mainstreaming. Other dimensions of gender inequality in health -such as in morbidity, access to health care and in social and economic consequences of ill health are seldom examined. Three, health sectors in many countries are informed by a bio-medical approach to health and disease under the leadership of health professionals who may not see the relevance of understanding the social dimensions and determinants of health. Health care providers tend to see themselves as technical persons who solve a problem presented to them, and may believe themselves to be free from any gender (or other social) biases. Gender mainstreaming, in their view, may represent a diversion of valuable time and resources away from the far more important task of saving lives. 1. Main findings Progress has been notable in developing the tools and the know-how related to gender mainstreaming. And yet, the process has barely begun of applying these tools and know-how to integrate gender considerations into policies, programmes, research and training. The gap between intention and practice is palpable. 3

4 Very few national health policies or policies related to specific health issues have integrated gender concerns in their goals, targets or strategies. National health programmes that have gender integrally woven into their objectives and activities are rare. While there have been micro-level experiments with gender-mainstreamed health interventions, few of these have been systematically evaluated, or compared with gender-blind interventions. Moreover, these experiments have focused mostly on training of women and men; there does not seem to be many experiments in engendering service delivery settings and the organisation and management of health services. Two areas that constitute the foundation for gender mainstreaming policies and programmes health research to generate gender and sex-specific data; and health provider training have not received the attention they deserve except in a few countries of the North. Without integrating gender in public health and medical and nursing training, it would not be possible to find personnel, who have the skills to develop, implement or manage gender-mainstreamed health policies and programmes. And identifying priority areas as well as monitoring progress will be severely hampered without investing in generating the necessary data and information through gender-sensitive research. The record in terms of institutional mainstreaming is disheartening, because of the apparent tendency to appear to do much rather than making fundamental changes. Institutions seem to have superficially gone through the motions of adopting a gender policy and creating a few structures, without investing any more into making these actually work. 2. What are some reasons cited for the limited progress with respect to gender mainstreaming in health? In addition to the specific challenges inherent in mainstreaming gender within the health sector, the process has been rendered difficult by several generic problems that have affected mainstreaming gender in all sectors. Confusion about concepts: Mainstreaming has been interpreted to mean that there is no more need for working for women s equality and empowerment. Towards the end of the 1990s the institutional apparatus for promoting gender equality was downsized in many bilateral aid agencies and international organisations. There were drastic cuts in resources available to these, although gender mainstreaming was being adopted as an organisational strategy at the same time. 4

5 De-politicisation of gender mainstreaming: Gender equality work has been reduced to a set of tools and activities. Gender mainstreaming has also tended to become delinked from the women s movement and from any social transformation or social justice agenda. Mainstreaming gender in health (and in other sectors) has not only failed to identify the structures that perpetuate the continued exclusion of and discrimination against women. It has also failed to challenge the many shortcomings and other forms of inequities perpetuated by the health seek but sought to just add women and stir.. Top down integration of gender Providing technical and financial support to countries for formulating policies and developing strategies on gender mainstreaming, and top-down approaches within national and international organisations have contributed to de-politicisation of gender mainstreaming. Changes in the global policy environment The global policy environment is increasingly hostile to justice and equity concerns.. Conservative governments in many donor countries are less willing to commit to development aid overall. The Millennium Development Goals which are guiding development priorities and funding have failed to integrate gender issues in all the goals, narrowing the scope of funding for gender mainstreaming. New aid modalities such as budgetary support based on Poverty Reduction Strategy Papers may further constrain development funding for gender, given their track record of scant attention to gender. Paradigm shifts within the health sector Paradigm shifts within the health sector in favour of privatisation and retraction of the state s role in health, and in support of promoting the development of a market for health care are developments that have the potential effect of widening the gender (and other social) gap(s) in health. Also, the focus is more on efficiency rather than on equity and hence policy support for gender mainstreaming as an equity issue will be limited. The bigger issue is what shape gender mainstreaming should take in a health sector that is increasingly privatised. How do we ensure gender-sensitive health facilities and services within the private sector? How can we enforce any policy in a weak-regulatory environment? 5

6 3. Where do we go from here? It may be time to frame gender mainstreaming explicitly as an issue of equity, rights and justice: health as a basic human right, and gender equality as a basic consideration in health The focus should shift from integration of gender issues into existing agendas, to reframing the agenda in a way that promotes gender and social equity in health. For example, rather than make sure that women s interests do not get excluded from the health sector reform agenda, the attempt would be to transform the agenda to make it equity-oriented. The approach would consider gender inequity within the context of inequities by caste, class, ethnicity and so on, as a cross-cutting issue. The creation of demand for gender equity in health through political mobilisation must be seen as necessary ground work. 6

7 Key Messages 1. Although much has been written about the need for mainstreaming gender, and on how to go about it, the gap between intention and practice is palpable. 2. The World Health Organization adopted a gender policy only as late as in National health policies and programmes that have gender integrally woven into their objectives and activities are rare. Health research to generate gender and sex-specific data; and integrating gender in health provider training, have received scarce attention. Mainstreaming gender within institutions has remained superficial, investing more on form than on content. 3. The health sector is faced with some specific challenges in taking forward the mainstreaming agenda. Because there are biological differences between women and men in health needs and experiences, there is a tendency to attribute assume that maternal health programmes are an adequate response to addressing differences in health between sexes. Women outlive men in most countries of the world, and male mortality exceeds female mortality for many health conditions. As a result, policy makers and programme managers remain unconvinced of the need for gender mainstreaming. Other dimensions of gender inequality in health -such as in morbidity, access to health care and in social and economic consequences of ill health are seldom examined. Gender mainstreaming is viewed by many health providers as diversion of valuable time and resources away from the far more important task of saving lives. 4. Progress in mainstreaming gender in health is also affected by more generic problems facing mainstreaming gender in any sector. These include: Interpreting gender mainstreaming to mean that there was no need for initiatives for women s empowerment; and the consequent downsizing of previously existing organisational structures such as Women s Bureaus, which had expertise in gender depoliticisation and delinking of gender mainstreaming from social transformation and social justice agendas adoption of top-down approaches to mainstreaming growing hostility within the global policy environment to justice and equity concerns; and increasing privatisation and retraction of the state s role in social sectors, including health. 5. The way forward lies in Adopting the language of equity, rights and justice; and promoting gender equity in health within the context of inequities by caste, class, ethnicity and other sources of health inequalities 7

8 Recognising the need for a dual focus in content: one of working on womenspecific health issues, even while ensuring that gender concerns are identified and addressed in all dimensions and areas of health Rather than trying to integrate gender within the existing structures, make mainstreaming gender a part of all agendas for change within the health sector Within institutions of the health sector, o placing responsibility for mainstreaming gender with senior management, o including gender equity in health among priority objectives for the sector as a whole; o allocating adequate financial and human resources for a central unit with gender expertise; o creating monitoring and accountability mechanisms for progress in mainstreaming gender o seriously pursuing capacity-building in mainstreaming gender in policies, programmes, research and health provider-training. 8

9 o Table of contents 1. INTRODUCTION BACKGROUND GENDER-MAINSTREAMING: DEFINITIONS AND CONCEPTS MAINSTREAMING GENDER IN HEALTH Early experiences: Women s health policies and programmes and implications for gender mainstreaming Goals and specific challenges of mainstreaming gender in health ENABLING FACTORS FOR MAINSTREAMING GENDER IN HEALTH INTERNATIONAL AND REGIONAL MANDATES PRESENCE OF POLITICAL WILL AND A POLITICALLY CONDUCIVE ENVIRONMENT EQUALITY LEGISLATION AVAILABILITY OF RESOURCES PRESENCE OF A STRONG WOMEN S HEALTH AND/OR HUMAN RIGHTS MOVEMENT, AND A CULTURE OF ACTIVE CIVIL SOCIETY PARTICIPATION OPERATIONAL GENDER MAINSTREAMING IN HEALTH STEPS AND TOOLS USED FOR OPERATIONAL GENDER MAINSTREAMING IN HEALTH Carrying out gender analysis of the issue being addressed by the policy or programme intervention Integrating gender considerations within policy / programme interventions Plan for monitoring and evaluation from a gender perspective MAINSTREAMING GENDER IN HEALTH POLICIES Sweden s public health policy Mainstreaming gender in Kenya s HIV/AIDS Strategic plan Mainstreaming gender in health sector reform strategies Gender analyses of policies pertaining to specific health issues MAINSTREAMING GENDER IN PROGRAMME INTERVENTIONS Mainstreaming gender within community-based NGO health interventions Mainstreaming gender within government health and allied programmes: MAINSTREAMING GENDER IN HEALTH RESEARCH Tools for mainstreaming gender in health research Examples of mainstreaming gender in health research MAINSTREAMING GENDER IN HEALTH PROVIDERS TRAINING POLICIES AND PROGRAMMES ADDRESSING GENDER-BASED VIOLENCE AGAINST WOMEN INSTITUTIONAL GENDER MAINSTREAMING STEPS AND GUIDELINES FOR INSTITUTIONAL MAINSTREAMING IN HEALTH Creating structures, mechanisms, processes and resources Guidelines for mainstreaming gender in institutions within the health sector MAINSTREAMING GENDER WITHIN NATIONAL HEALTH SECTORS Gender policy guidelines for the health sector, South Africa [42] Gender Equity Strategy of the Ministry of Health and Family Welfare, Bangladesh INSTITUTIONAL MAINSTREAMING IN INTERNATIONAL ORGANISATIONS The World Health Organisation Other multilateral and bilateral organisations and international NGOs

10 5. SUMMARY AND CONCLUSIONS SUMMARY OF MAIN FINDINGS FACTORS CONSTRAINING MAINSTREAMING GENDER IN HEALTH WHERE DO WE GO FROM HERE? REFERENCES

11 Women s health policies and programmes and gender-mainstreaming in health policies, programmes and within the health sector institutions TK Sundari Ravindran and Aarti-Kelkar Khambete 1. Introduction 1.1 Background The concept of gender mainstreaming has its origins in the 1970s, in attempts to improve women s share of the gains of development. In the decades covering the 1950s and 1960s, women were covered mainly by social welfare projects for improving women s education, nutrition, and health. In the early 1970s, efforts at poverty alleviation ignored gender-based inequalities, and developmental efforts in targeted only men, leaving women s productive roles unrecognised [1]. This led to women s exclusion from mainstream development efforts in sectors such as agriculture and manufacturing. During the International Women s Decade ( ) and following it, the focus was on changing policies and legislation that led to women s economic and social subordination, and also in involving women in their own empowerment through consciousness-raising initiatives at the grass-roots level. By the early 1990s it became clear that trying to improve women s status while ignoring the structures and processes that cause and sustain women s subordination was a dead end. The focus shifted to examining gender-power inequalities between women and men. Also, focusing exclusively on women during the previous decades had led to the creation of addon women s programmes and projects within the Women s Bureau s of countries or women s departments of organisations, while the country or organisation s overall policies and approaches continued with business-as-usual. The gender mainstreaming approach was a response to this realisation. The word mainstream indicates that issues of gender inequality should be dealt with in every aspect of organisational structure and programming, rather than as a separate, add-on activity. Parallel to the development of an appreciation of the ways in which gender-power inequalities affect women and men has been the evolution of knowledge about the consequences of gender inequalities in different sectors, including health. Differences between women and men in health needs, health-seeking behaviour, and ability to access health services and receive appropriate treatment have now been established by many studies, and have received 11

12 endorsement in major international conferences, notably in the ICPD in Cairo (1994) and the Fourth World Conference on Women in Beijing (1995). During the past decade, there have been numerous initiatives attempting to mainstream gender in health policies, programmes, projects and research, and within institutions responsible for training health providers and delivering health care services. This paper is an attempt to draw on recent (since 1995) published information in English 1 on experiences in gender mainstreaming 2 in health across regions and at various levels, in order to understand what has been achieved, what the challenges have been and to discuss how we may move the agenda forward. However, the paper is by no means exhaustive or comprehensive, given the limited time in which the review was carried out. The review is also limited by the nature of evidence available. While there were hundreds of articles and publications dealing with gender mainstreaming, those dealing with gender mainstreaming in health were far fewer. Also, more was available on what needs to be done and how to go about it; and on descriptions of projects, than on the process of implementation, and even less, on the outcomes of gender mainstreaming. The paper is structured as follows. The first section includes, besides this introduction, a discussion of concepts related to gender mainstreaming in general, and gender mainstreaming in health in particular. The second section outlines issues to consider when planning for gender mainstreaming in health. Section three presents an overview of examples of gender mainstreaming in health policies, programmes and project, in training of health providers and in health research. Experiences with institutional mainstreaming of health sector institutions are presented in section four. Section five presents the summary and raises some questions on how we may move the agenda forward on gender mainstreaming Gender-mainstreaming: Definitions and concepts 1 This is a limitation imposed by the authors language skills. 2 A wide range of terminologies are found in the literature on gender mainstreaming, such as integrating gender considerations, or adopting a gender-perspective. In so far as they refer to the same processes described above, we have treated these as synonymous to gender mainstreaming. 12

13 The most widely known and used definition of gender mainstreaming is from the UN Economic and Social Council (ECOSOC): Mainstreaming a gender perspective is the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in all areas and at all levels. It is a strategy for making women s as well as men s concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated. The ultimate aim is to achieve gender equality. [2] Several dimensions of gender mainstreaming may be delineated from this definition: The aim of gender mainstreaming is to achieve gender equality. Gender mainstreaming calls for initiatives that reduce gender inequalities; it also means that no initiatives are implemented that further exacerbate or perpetuate inequalities. Gender mainstreaming may require that changes are made in overall organisational goals; rules for running the organisation; the entire range of programmes and policies; allocation of resources; and monitoring and evaluation systems [3]. Although not explicitly mentioned in the ECOSOC definition, mainstreaming gender within institutional structures extends beyond organizations to all social institutions including the family and community, all of which play an important part in the implementation and success of polices, programmes or interventions promoting gender-equality. Another dimension of gender mainstreaming is highlighted by the Commonwealth (1999) definition, according to which gender mainstreaming calls for focusing less on providing equal treatment for men and women (since equal treatment does not necessarily result in equal outcomes), and more on taking whatever steps are necessary to ensure equal outcomes [1: p18]. Gender mainstreaming will not do away with the need for women-specific programmes. The depth of inequality facing women makes it necessary to target women specifically to ensure a level playing field for women and men over a period of time. Initiatives, which specifically target women, are complementary to mainstreaming initiatives. The Beijing Platform for Action clearly states the need for a dual focus: 13

14 on the one hand, programmes aimed at meeting the basic as well as the specific needs of women for capacity building, organisational development and empowerment; and on the other, gender mainstreaming in all programme formulation and implementation activities. [4]. Two dimensions of gender mainstreaming strategy were emphasised in the Platform for Action of the United Nations Fourth World Conference on Women in Beijing, both of which are equally important. One concerns the content of policies, programmes and interventions also known now as operational mainstreaming. The second dimension concerns the institutional structures that are responsible for formulating, implementing and monitoring and evaluation of these, also known as institutional mainstreaming. Operational mainstreaming calls for the integration of equality concerns into the analysis and formulation of policies, programmes and projects, to ensure that these have a positive impact on women and reduce gender inequalities. The process of operational mainstreaming depends on the institutional support provided by various structures, starting from formal agencies to family and community units, and hence the need for institutional gender mainstreaming. Institutional mainstreaming involves making changes in institutional strategies and mechanisms that will enable women to formulate and express their views and participate in decision-making at all levels. This means addressing the internal dynamics of formal as well as informal institutions, such as their goals, agenda setting, governance structures and procedures related to day-to-day functioning. The task of transforming the internal dynamics of the various informal institutions such as the family, are likely to be far more complex and challenging than mainstreaming gender in formal institutions may be [3, 5,6]. 14

15 1.3. Mainstreaming gender in health Early experiences: Women s health policies and programmes and implications for gender mainstreaming Integrating gender considerations in health needs to build on experiences with developing and implementing women s health policies and programmes in different parts of the world. Organised efforts by feminist movements across the globe in the 1970s demanded changes in legislation, policies, programmes and services affecting women s health. Women s health centres were established in many countries of the North and also in some countries of the South. Grassroots activism to promote women s control over their fertility and sexuality, to demystify medical knowledge and to advocate for women-centred policies and programmes was widespread in many developing countries. All these contributed to the emergence of an International Women s Health Movement in the early 1980s, providing further impetus to women s health advocacy. One outcome of advocacy was the development of women s health policies in some countries. Brazil was the first country to create a comprehensive women s policy, in The Australian National Women s Policy was formulated in 1988, the Colombian Health for Women, Women for Health policy in Efforts were also made in South Africa in 1994, to develop a women s health policy agenda. In all instances, the policies have gone beyond sexual and reproductive health concerns to address violence against women, occupational health and mental health. They have also drawn attention to health needs of women and girls in all age groups. The policy process, initiated by the women s health movement, involved a wide cross-section of stakeholders such as health providers, trade unions, social workers and government departments. The fate of these policies has varied. In Brazil and in Australia, the policies were successfully implemented for several years, till they gradually merged with gender mainstreaming attempts. In Columbia, the policy suffered from limited political and financial commitment 3. In South Africa, various components of the women s health policy agenda were successfully integrated into new policies: for example, a policy was implemented for the prevention of domestic violence against women, another on Choice of Termination of Pregnancy, and so on [7]. 3 The Columbian Health Policy for Women was not implemented and continues to remain so. 15

16 In all instances, women s health policies were grounded in a gender analysis of the causes of women s health problems, and sought to address these through programme strategies that were empowering to women. For example, information and counselling respect for women s choices and attention to quality of services was all given importance [7]. Goals and specific challenges of mainstreaming gender in health According to the World Health Organisation s Gender policy (2002), the goal of gender mainstreaming in health is to contribute to better health for both men and women, through health research, policies and programme which give due attention to gender considerations and promote equity and equality between women and men. Gender mainstreaming is expected to increase coverage, effectiveness and efficiency of all interventions. Further, it aims to promote equity and equality between women and men throughout the life course, and at the least, ensure that interventions do not promote or perpetuate inequitable gender roles and relations [8: p.2]. More simply, the goal of gender mainstreaming in health is, to identify where gender differences exists and provide balance when needed [9]. In the years following ICPD and the Fourth World Conference on Women, the agenda shifted from women s health to gender-mainstreaming. How does a gender-mainstreaming approach differ from a women s health approach? The women s health approach was firmly based on an understanding of health as having both biological as well as social determinants. The approach extended attention to women s health issues beyond maternity such as mental health, domestic violence and occupational health. In addition, it applied a gender analysis to all women s health issues including maternal and reproductive health; and drew attention to the ways in which gender-based inequalities affected all dimensions of women s health. Women s health policies evolved through participatory process with all stake-holders, and women s health services put people at the centre of their service-delivery models. Gender-mainstreaming in health would extend this approach to all dimensions of health affecting both women and men; as well as to men and women-specific conditions. However, as in the case of mainstreaming in any sector, gender mainstreaming in health has a dual focus. One, addressing gender-based differences and inequalities in all health initiatives; and two, implementing initiatives addressing women s specific health needs that are a result either of biological differences between women and men (e.g. maternal health) or of gender-based discrimination in society (e.g. gender-based violence; poor access to health services). Both 16

17 these are essential for achieving health equity, which is the ultimate goal of gender mainstreaming. While gender mainstreaming is a difficult undertaking in any sector, mainstreaming gender in health has to contend with some specific challenges. One, because there are biological differences between women and men in health needs and experiences, there is a tendency to attribute all male-female differences to biology. The consequence is that maternal health programmes are seen as an adequate response to addressing differences in health between sexes. The need for examining gender issues in all health problems as well as in delivery of health care services remains unrecognised. Two, while the disadvantages experienced by women in sectors like education, employment or political participation are evident from available data; the case of health is more complex. Women outlive men in most countries of the world, and for many health conditions, male mortality exceeds female mortality. Many policy makers and programme managers therefore remain unconvinced of any gender-based inequalities in health, and of the need for gender mainstreaming. Other dimensions of gender inequality in health -such as in morbidity, access to health care and in social and economic consequences of ill health are seldom examined. Three, health sectors in many countries are informed by a bio-medical approach to health and disease under the leadership of health professionals who may not see the relevance of understanding the social dimensions and determinants of health. Health care providers tend to see themselves as technical persons who solve a problem presented to them, and may believe themselves to be free from any gender (or other social) biases. Gender mainstreaming, in their view, may represent a diversion of valuable time and resources away from the far more important task of saving lives. 17

18 2. Enabling factors for mainstreaming gender in health When planning for gender mainstreaming in health (or in any other sector), it is useful to examine whether enabling conditions are present, and if not, spade work will have to be done to create these conditions even while work is being initiated for mainstreaming gender. Enabling conditions for gender mainstreaming include: presence of international, national and regional mandates for the activities to be initiated; presence of political will establishment of legal and constitutional frameworks that support gender equality; and availability of resources [10,11]. Presence of a strong women s health and/or human rights movement, and a culture of active civil society participation 2.1. International and regional mandates International and regional mandates, such as the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), Beijing Platform for Action or the Regional Human Rights Declarations which national governments are called upon to ratify, often initiate paradigm shifts in thinking, as for example, the CEDAW did for women s rights and Cairo Programme of Action did for reproductive health and rights. Governments who ratify these agreements are called upon to report on progress made at regular intervals, which can influence government-level action in the relevant area. International and regional mandates are important also because they influence availability of donor funding for gender mainstreaming, without which implementation will be constrained Presence of political will and a politically conducive environment Political will is a very important and essential element that can influence any gender mainstreaming initiative. However, what can be construed as political will is not always clear. Government ratification of international or regional conventions or Conference documents that support equality among women is often equated to the existence of political will. However, government ratification of conventions is not always followed-up with national policy and legislative changes. 18

19 More tangible expressions of political will are usually national and sub-national policies and legislations supporting gender equality, and especially those addressing the issue of domestic violence against women; more so when these are supported by appropriate allocation of resources and translated into tangible programmes on the ground. In addition, structures and mechanisms need to be created to ensure that all national policies and programmes integrate gender considerations; that sex-disaggregated and gender-sensitive data and information are collected and analysed by concerned national institutions; and that governments are held accountable for gender mainstreaming. Structures and mechanisms set up for gender mainstreaming should have teeth : they should be adequately funded and staffed. Drawing on the experience of putting in place women s health policies, it is possible to influence and generate political will through international and national advocacy and mobilisation of public opinion. The election of a new government often presents a window of opportunity to make a commitment to gender mainstreaming and allocate resources for the same. Influencing political will to support gender mainstreaming makes sense only within a democratic mode of governance; a political environment that upholds equality and rights, and where the state is not contributing to violation of people s rights through policies that directly discriminate certain sections of the populations, or do so indirectly through development policies privileging a minority. Whether to advocate for and implement gender mainstreaming in environments that do not satisfy these conditions - for example, within military dictatorships - remains an issue that needs serious consideration Equality legislation Another important requirement for gender mainstreaming is the existence and successful implementation of legislation that upholds and promotes gender equality in access to resources and opportunities, and in marriage laws, among others. But the enactment of laws and putting in place structures for their implementation will not be sufficient if the people in whose interests these laws are made remain unaware of the laws, do not know how to use them, or remain unable to use them because of resource constraints. Much work has to be done to widely popularise laws supporting gender equality and to create mechanisms that will enable their effective implementation; and use by those whom the laws are intended to benefit Availability of resources 19

20 This is perhaps one of the most important enabling factors following political will that can be very helpful in taking the mainstreaming agenda forward. Mobilising resources for gender mainstreaming in an era when the health sector is experiencing a serious resource crunch can be a challenge. Health sector reform initiatives that are being implemented to address the resource crunch do offer some opportunities for gender mainstreaming. For example, Sector-Wide approaches in health have been introduced in some developing countries, under which all funding for health is pooled together in one basket and resource allocation is done after setting priorities for the entire sector. This has facilitated the integration of gender considerations in countries such as Bangladesh and Ghana [12]. Also, certain areas in health do get adequate funding even if the sector as a whole may remain under-funded. For example, HIV is an area with considerable international as well as national funding (at least relative to other areas). In this context, gender mainstreaming could probably begin within HIV programmes and this may influence the functioning of other health programmes eventually Presence of a strong women s health and/or human rights movement, and a culture of active civil society participation Countries, which have a history of mobilisation by the women s health movement, a track record of civil society demand for adherence to human rights, and a culture of civil society participation in policy advocacy, are better placed to initiate gender mainstreaming in health. In such settings, there exists a critical core group of stakeholders who are informed by a rights framework, knowledgeable about gender issues in health, and about the policy-making and policy implementation processes. This would make possible involvement of stakeholders in initiating and sustaining the gender mainstreaming process. There would be the added advantage of having experts who can assist with gender training of health sector personnel and for influencing larger public opinion in favour of gender mainstreaming. 3. Operational gender mainstreaming in health Operational gender mainstreaming refers to the integration of gender considerations in policy and programme interventions in (preventive, promotive and curative) health, including service delivery research and training. In this section, we first present some commonly used steps and tools to ensure that gender considerations are integrated. We then summarise available 20

21 literature on experiences with gender mainstreaming in policies, programmes, in research and in training of health providers Steps and tools used for operational gender mainstreaming in health Carrying out gender analysis of the issue being addressed by the policy or programme intervention The first step is to carry out gender analysis of the issue being addressed by the policy or programme intervention. Gender analysis involves analysing whether and in what ways biological differences between men and women and/or differences in their roles and responsibilities, access to resources and power make a difference to: risks and vulnerability to a health problem health seeking behaviour ability to access health services preventive and treatment options experiences with health services and health providers health outcomes social and economic consequences of illness [14] Annex 1 presents one example of application of a gender-and-health analysis matrix. Filling in the matrix helps identify areas where gender-based differences exist, which need to be addressed by policies or interventions. The matrix also helps identify information gaps that call for further research. In order to fill in answers in the relevant cells of the matrix, one may have to gather all available data from secondary and published sources; conduct rapid appraisals, such as pooling health service data or interviewing major stakeholders; conduct participatory datagathering and analysis exercises in relevant sites. 4 4 Examples of methods already used by WHO include: Vlassoff C, Hardy R, and Rathgeber E. Towards the Healthy Women Counselling Guide: Ideas from the Gender and Health Research Group, World Health Organisation, UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), 1996; and Fonn S and Xaba M. 21

22 Integrating gender considerations within policy / programme interventions Once gender analysis has been carried out and the gender dimensions of the policy or programme intervention have been identified, the next step is to ensure that these are addressed in policy and programme formulation. The goal is to move from gender-unequal or gender-blind policy and programme interventions to gender-specific, and gender-redistributive ones (See Box 1 for definitions). Health Workers for Change: a Manual to Improve Quality of Care, The Women s Health Project and UNDP/ World Bank/ WHO Special Programme for Research and Training in Tropical Diseases (TDR), Geneva,

23 Box 1. Assessing gender-sensitivity of policy and programme interventions Gender and policy analysts distinguish between different approaches to addressing gender in policy and programming. These approaches range from ignoring it, to trying to work within the limits imposed by gender discrimination, to challenging it. Over time a common language has developed for describing these approaches [14, 15]. 1. Gender-unequal: privileges men over women. For example, A policy which denies a married woman the right to medical insurance in her own name makes her dependent on her husband for access to medical insurance. In a context where her husband is unemployed, then she (and her husband) is denied access to medical insurance. A practice where service providers require a man s consent before a woman can be sterilised is also genderunequal in that it deliberately gives men power over women and denies women's right to self-determination Gender-blind: ignores gender norms; is blind to differences in the allocation of gender roles and resources; is not intentionally discriminatory, but reinforces gender discrimination nevertheless. Senior management recruitment policy in a department of health: requires all managers to have a PhD Community-based AIDS care programme: says that health care system cannot take responsibility for caring for people with AIDS so that home-based care must be instituted, without finding ways of involving men in homebased care so, however unintentionally, the programme puts the burden of care on women 3. Gender-specific: recognises differences in gender roles, responsibilities and access to resources, and takes account of these differentials, in an instrumental sense, but does not try to change them. Occupational health policy: protects women from working in places that are hazardous to their reproductive health. However, such a policy may in fact be gender-unequal if it does not take into account damage to male reproductive functions from similar or other workplace exposures, and offers them protection as well. Water supply policy establishes a mechanism to provide taps close to villages so that woman will not have to walk as far to fetch water. Workplace provides a child care facility for women with babies. This acknowledges women s role as primary carers AND makes it easier for mothers to work. It does not necessarily encourage men to share in childcare responsibilities. A redistributive policy would provide a childcare facility for men as well as women with babies. 4. Gender-redistributive: recognises differences in gender roles, norms and access to resources and supports changes in these so as to promote gender equality. Land policy: removes restrictions on women s right to inherit land Information, Education and Communication programme advocates to women and men about mutual respect and equal rights in sexual decision-making as a means of promoting safer sex practices. 5 Even if this practice were to be altered, to require women to give permission for sterilisation by their male partners, this may not address the problem, because women in many settings do not have the power to disagree with decisions made by their male partners 23

24 As a minimum, one should ensure that no harm is done through gender-unequal or genderblind health policies and programming. In some situations, gender-specific policies may be more appropriate and relevant than gender-redistributive policies, as for example, when designing subsidised maternity services for women. The following guidelines have been widely used to assist in the process of moving from gender-blind to gender-specific and gender redistributive policy and programme interventions [13]: Make an assessment of the potential impact of the project on women and on men, and ensure that the project does not result in worsening women's position in relation to men or vice-versa. Make gender equity an explicit part of the project vision, goals or principles. Build in mechanisms for stakeholder participation in the design, monitoring and evaluation of the project, and women's participation equally with men. Use gender analysis to take into account in programme design and planning differences between women and men in: Roles and responsibilities Norms and values Access to and control over resources 6 Decision making power Plan for monitoring and evaluation from a gender perspective Plans as well as effective mechanisms have to be in place for monitoring progress towards achievement of the objectives of gender-mainstreamed policy and programme interventions. It would be important to evolve not only outcome indicators, but also input indicators regarding the resources allocated and process indicators tracking the implementation of the project: for example, whether activities went on as planned, whether both women and men benefited from these equitably, and so on. 6 Note that this may arise from gender discrimination in laws and policies, or be a consequence of gender-based differences between women and men in roles and responsibilities or norms and values. 24

25 There exist a number of publications on gender-indicators. Most of these have identified indicators that would help assess the situation with respect to gender-equity within a country or region. One of the bigger challenges has been the development of engendered indicators relevant to specific policy or programme interventions. Collection of sex-disaggregated information is only the first step; developing gender indicators calls for capturing the gender dimensions of the concerned issue (See Box 2). Box 2. Gender Indicators for Health Sex disaggregated vs. gender indicators for health The two are often used interchangeably, but are in fact not the same. Sex disaggregated information tells us whether there is a difference by sex, but not whether this is a consequence of gender-differences or inequalities. Gender indicators for health have a number of functions. a) They provide evidence on whether or not an observed difference between males and females in a health indicator (e.g. morbidity or mortality) is a result of gender inequality. In the case of sex-specific health conditions such as pregnancy and delivery, they help identify whether gender inequality may be contributing to avoidable morbidity, disability or mortality. Gender indicators thus form the basis for planning policies and programmes promoting health equity. Gender indicators are also necessary to track progress towards gender equity in health status and outcomes. Another genre of gender indicators are those that specifically measure progress made towards gender mainstreaming within the health sector of a country, and within institutions and health facilities. Globally, work on developing gender indicators for health is still in its early stages. Attempts have been made to identify a set of core indicators at national and global levels that indicate progress made towards gender equity in health. Indicators have also been developed to assess progress made towards gender mainstreaming within institutions, but not specifically for the health sector. A bigger challenge is to construct gender-sensitive indicators at a programme or project level. This involves ensuring that indicators constructed to measure whether specific project objectives have been met are also able to capture whether the programme or project has differently affected women and men (girls and boys). How can indicators be engendered? The first step is to have data on all indicators disaggregated by sex. Construct new indicators on those dimensions of health where gender differentials occur (or are likely to occur) most often. Example: Indicators on social and economic consequences of a health condition, on access to appropriate and timely treatment Additional variables, across which data on the indicator would be disaggregated, need to be included. Choice of variable will be based on analysis of gender factors likely to impact on the health dimension. Example: IMR by sex analysed by cause of death (was it an avoidable cause?); place of death (was medical help more often unavailable to females?) Asking questions pertaining to an indicator from both sexes. Example: Contraceptive prevalence rate in men and women, children ever born to women and men (in place of only women) Developing new indicators to be used concurrently with others already in use, based on the same sources of information: Example 1: Indicator: Proportion of pregnant women who are seropositive for syphilis. Additional indicator: Of pregnant women who are syphilis seropositive, proportion who report that their partners have symptoms. Example 2: 25