What Difference Does Gender Make? Opportunities and Responsibilities for Promoting Gender Equity in USAID Health Programs

Speaker’s NameDate

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Contents• What do we mean by “gender”

and “gender integration?”

• What is the rationale for integrating gender into USAID health programs?

• How can USAID better implement gender integration?

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SECTION I:What do we mean by “gender” and “gender integration” in USAID health programs?

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What Is Gender?Gender refers to the economic, social, political, and cultural attributes, opportunities, and constraints associated with being a woman or girl, man or boy.

The social definitions of what it means to be a woman or a man vary among cultures and change over time.

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Gender is about Women and Men

• Men also benefit from more equitable gender norms

• Men’s support is needed to achieve health and gender equity goals

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What is “Gender Integration”?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 programs in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated.

The ultimate goal is to achieve gender equality.

United Nations, 1997

ADS 201.3.9.3 Gender AnalysisMANDATORY. Gender issues are central to the achievement of strategic plans and

Assistance Objectives (AO) and USAID strives to promote gender equality... Accordingly, USAID planning in the development of strategic plans and AOs must take into account gender roles and relationships. Gender analysis can help guide long term planning and ensure desired results are achieved… USAID’s gender integration approach requires that gender analysis be applied to the range of technical issues that are considered in the development of strategic plans, AOs, and projects/activities.

ADS 201.3.9.3 (March 2010)

U.S. Government Policy Commitments: Gender in the ADS

Gender in the ADS1. How will the different roles and status

of women and men within the community, political sphere, workplace, and household… affect the work to be undertaken?

2. How will the anticipated results of the work affect women and men differently?

ADS 201.3.9.3 (March 2010)

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• Recognizes gender inequality as driving HIV and contributing to the devastation of HIV/AIDS

• Requires gender analysis as per the ADS.

U.S. Government Policy Commitments: PEPFAR

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Gender and PEPFARKey Legislative Issues:

Increase gender equity in HIV/AIDS programs;

Reduce sexual violence and coercion; Address male norms and behaviors; Increase women’s legal rights; and Increase women’s access to income and

productive resources.

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International Policy Commitments• UN International Conference on

Population and Development (Cairo), 1994

• Fourth World Conference on Women (Beijing), 1995

• UN Millennium Development Goals, Targets for 2015

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SECTION II:What is the rationale for integrating gender in USAID health programs?

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Why Integrate Gender into Health Programs?

Integrating gender improves:

Health Gender equity

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Gender Inequity Impedes Health Program Success• Family planning • STIs, including HIV• Safe motherhood

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Gender Inequity Exacerbates Poor Reproductive Health

• 30-60% of women worldwide experience gender-based violence (GBV). GBV is linked with: multiple health problems

reduced access and ability to use family planning and reproductive health services.

• Early marriage increases risk of maternal death.

Among women ages 15-24, 48% are married before the age of 18 in South Asia, 42% in Africa, and 29% in Latin America and the Caribbean.

Gender Inequity Exacerbates Poor Maternal and Child Health

• Norms of masculinity often encourage sexual risk taking. Global studies reveal that men have

higher rates of partner change than women (UNFPA, 2008).

Gender Inequity Exacerbates HIV Vulnerability

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• Gateway factor influencing multiple health behaviors Middlestadt et al. 2007

www.jhuccp.org/legacy/pubs/HCP_endofproject/3Acharya.ppt

Gender Equity Promotes Reproductive Health

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• Greater contraceptive knowledge and use

• Increase in joint-decision making about family planning

• Greater condom use

• Decreased incidence of GBV.

Gender Integration Improves Health Program Outcomes

Sources: Rotach et al., 2010: http://www.igwg.org/Publications.aspx Barker et al. 2007: http://www.who.int/gender/documents/Engaging_men_boys.pdf

Gender Integration Leads to Equity and Healthy Behaviors: RH Bolivia: PROCOSI

2001 – 2003

•Program to integrate gender into clinical practices.

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• Evaluation of seven organizational areas: institutional policies and practices; practices of providers; client satisfaction; client comfort; use of gendered language; information, communication, and training; and monitoring and evaluation.

• This intervention resulted in both increased gender equity and improved health outcomes.

Program Evaluation: PROCOSI

Gender Equity Results: PROCOSIPercentage of Women and Men who Agree with the Following Statements

Health Results: PROCOSI

India: FRHS and ICRW

2001-2006

•Social mobilization

•Improvement of government health services

Gender Integration Leads to Equity and Healthy Behaviors: Safe Motherhood

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• Baseline, midpoint, and endline surveys: married girls and women

• Mid-intervention survey included husbands and mothers in-law

• The intervention produced significant improvement in safe motherhood and gender equity results

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Evaluation: Social Mobilization and Government Services

• Mothers-in-law were more supportive of daughters-in-law’s health seeking than those in other intervention sites.

• Husbands were more aware of basic maternal care issues and more willing to seek treatment for problems than pre-intervention.

The site that employed both strategies found that:

Gender Equity Results: Social Mobilization and Government Services in India

Women were more likely post-intervention than pre-intervention to:

• Use FP for birth spacing (12.4% more likely)

• Have delivery care for high-risk births (29.8% more likely)

• Receive treatment for reproductive tract infection symptoms (98.2% more likely)

Health Results: Social Mobilization and Government Services in India

The site that employed both strategies found that:

Gender Integration Leads to Equity and Healthy Behaviors: HIV/STIsSouth Africa: Stepping Stones (MRC)2003-2005

•BCC intervention that employs participatory learning approaches in single-sex groups led by trained peer educators.

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• 70 clusters HIV and herpes tests Pre- and post-intervention interviews

• Stepping Stones in South Africa is shown to increase health and gender equity results.

Evaluation: Stepping Stones

• Increased couple communication.

• Less perpetration of partner violence.

“I think [beating] is not a right thing because you couldn’t say you are rectifying things through beating in your relationship…I think that we are supposed to sit together and tell one another the way that is supposed to be.”

Gender Equity Results: Stepping Stones

• 15% fewer new HIV infections among women

• 31% fewer herpes infections among women

• Among men:

• Fewer partners

• Higher condom use

• Less transactional sex

• Less substance abuse

Health Results: Stepping Stones

Gender Transformative Projects Promote Lasting Change

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The overall objective of gender integration is to move toward gender transformative projects

SECTION III:How can USAID health programming better implement gender integration?

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Gender Integration Can Begin Anywhere in the Program Cycle

PROGRAM CYCLE

1

3

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4

ASSESSMENTCollect and analyze data to identifygender-based constraints and opportunitiesrelevant to program objectives.

STRATEGIC PLANNINGDevelop program objectives that strengthen synergy between gender equity and health goals; identify participants, clients, and stakeholders.

DESIGNIdentify key program strategies to address gender-based constraints and opportunities.

MONITORINGDevelop indicators that measure

gender-specific outcomes; monitorimplementation and effectiveness in

addressing program objectives.

EVALUATIONMeasure impact of

program on health and gender equity outcomes; adjust design accordingly

to enhance successful strategies.

Examples of Gender-Integrated Projects: HIV/STIs• Incorporating safe sex negotiation and communication skills training

for women

• Preventing gender-based violence, a risk factor for HIV

• Introducing BCC campaigns that reduce male sexual risk-taking

• Supporting economic empowerment activities for women as an alternative to transactional sex

• Engaging men in recognizing and supporting the health needs of their pregnant partners

• Providing income- generating activities for women to increase their ability to care for themselves during childbearing years

• Supporting forums for women to voice their maternal health needs

Examples of Gender-Integrated Projects: Safe Motherhood

• Offering free or low-cost services for women without the means, control, or resources to access to family planning

• Supporting women’s education and empowerment so that they can better advocate for their rights

• Including male partners in reproductive health and family planning counseling or training sessions

Examples of Gender-Integrated Projects: Family Planning

Key Elements of a Gender-Integrated Project• Make an institutional commitment to

gender integration

• Implement a system to ensure accountability

• Ensure equitable participation of women and men at all levels

• Foster equitable relationships

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Lessons Learned in Gender IntegrationGender integration can begin in any part of the program cycle, but is most effective when begun in the design phase.

• Changing gender norms takes time, but can show notable change in relatively short periods

• Do no harm!

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Getting Started: Available Resources• USAID Interagency Gender Working Group: http://www.igwg.org

• USAID Global Health: http://www.usaid.gov/our_work/global_health/

• USAID Women in Development Office

http://www.usaid.gov/our_work/cross-cutting_programs/wid/

• PEPFAR Gender Technical Working Group

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ReferencesBarker G., C. Ricardo, and M. Nascimento. 2007. Engaging Men and Boys in Changing

Gender-Based Inequity in Health: Evidence from Programme Interventions. Geneva: World Health Organization.

Boender, Carol, Diana Santana, Diana Santillan, Karen Hardee, Margaret E. Greene, and Sidney Schuler. 2004. The ‘So What?’ Report: A Look at Whether Integrating a Gender Focus Makes a Difference to Outcomes. Washington, DC: USAID Interagency Gender Working Group.

Bott, Sarah, Andrew Morrison, and Mary Ellsberg. 2005. “Preventing and Responding to Gender-based Violence in Middle and Low-income Countries: A Global Review and Analysis.” World Bank Working Paper Series 3618. Washington, DC: World Bank.

Middlestadt, Susan E.,Middlestadt, Susan E., Julie Pulerwitz, Karabi AcharyaJulie Pulerwitz, Karabi Acharya, , Geeta Nanda, Bridget Lombardo. Geeta Nanda, Bridget Lombardo. 2007. “Evidence of Gender as a Gateway Factor to Other Behaviors—Ethiopia. The 2007. “Evidence of Gender as a Gateway Factor to Other Behaviors—Ethiopia. The Health Communication Partnership’s End of Project Meeting.” Washington, DC: USAID Health Communication Partnership’s End of Project Meeting.” Washington, DC: USAID Health Communication Partnership. Available at: Health Communication Partnership. Available at: www.jhuccp.org/legacy/pubs/HCP_endofproject/3Acharya.ppt.

Pinto, Guido, Mary Kincaid and Beatriz Murillo. 2010. “The Relationship between Domestic Violence and Reproductive Health and Family Planning Services in Bolivia, 2003.” Población y Salud en Mesoamérica 7(2).(electronic journal: http://ccp.ucr.ac.cr/revista/).

Rottach, Elizabeth, Sidney Ruth Schuler, and Karen Hardee. 2010. Gender Perspectives Improve Reproductive Health Outcomes: New Evidence. Washington, DC: Population Reference Bureau for the IGWG.

UNFPA. 2008. State of the World’s Population 2008: Reaching Common Ground: Culture, Gender and Human Rights. Geneva: UNFPA. Accessed November 10, 2009 at: http://www.unfpa.org/swp/2008/en/04_reproductive_health.html#3.

UNICEF. 2005. Early Marriage: A Harmful Traditional Practice. A Statistical Exploration. NY: UNICEF.

UNICEF. 2001. Early Marriage: Child Spouses. Florence: UNICEF Innocenti Research Centre.United Nations. 1997. Gender Mainstreaming, Extract from the Report of the Economic and

Social Council for 1997. A/52/3. Geneva: United Nations.

References, continued

AcknowledgementsThanks to Michal Avni, Patty Alleman, and Diana Prieto for their technical review.

This presentation was prepared by Elizabeth Doggett, Myra Betron, Anne Eckman, Elizabeth Neason, and Mary Kincaid for the USAID | Health Policy Initiative, Task Order 1.

The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Futures Group International, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace.

What Difference Does Gender Make? Opportunities and Responsibilities for Promoting Gender Equity in USAID Health Programs

Photo by Dietmar Temps