Gender and Rights in Reproductive and Maternal Health.
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WHO Library Cataloguing in Publication Data
Gender and rights in reproductive and maternal health : a manual for a learning
workshop.
1. Maternal health. 2. Reproductive health. 3. Gender identity. 4. Women’s rights.
(NLM Classification: WA 310)
ISBN 978 92 9061 240 7
© World Health Organization 2007
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All rights reserved.
The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part ol the World Health
Organization concerning the legal status ol any country, territory, city oi aiea, oi ol its
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names of proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this
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Table of conV
Acknowledgements
Preface
Part 1. Learning modules
Objectives of the workshop
Workshop outline
Session 1:
Introduction to the cours
Session 2:
Maternal health: dimensk
Session 3:
Determinants of materna
Session 4:
Identifying gender and pc
underlying medical causes
Session 5:
A rights-based approach t
Session 6:
Engendering indicators....
Session 7:
Appling a gender and righ
functioning of a health cet
Session 8:
Health service delivery issi
Session 9:
Financing maternal health
Session 10:
Assessing policies and intci
gender and rights perspecti
Session 11:
Making change happen witl
Session 12:
Closing session
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Part 2. Hand-outs
Session 1 Hand-out:
Session 2 Hand-out:
Session 3 I land-out 1:
Session 3 Hand-out 2:
Session 3 Hand-out 3:
Session 4 Hand-out:
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Session 5 Hand-out 1:
Session 5 Hand-out 2:
Session 6 Hand-out 1:
Session 6 Hand-out 2:
Session 7 Hand-out:
Session 9 Hand-out:
Session 10 Hand-out 1:
Session 10 I land-out 2:
Session 10 Hand-out 3:
Session 11 Hand-out:
IL
The human tres
Definitions of sexual and reproductive
health and rights
Concepts for gender analy:■sis,
Gender and health analysis tool
Jasmine’s story
Gender and poverty dimensions of
medical causes of maternal mortality and
morbidity: Group exercises
Universal Declaration of Human Rights
A case study for analysing a reproductive
health intervention
Definitions of some maternal health indicators.
Developing “gendered” indicators
Guidelines for observation during visit
to health facility
Costing and financing maternal and
reproductive health services
Policy approaches to gender inequalities:
some concepts
I low different policies identify and
address gender inec|iialiiics
A framework for analysing policies
Making change happen within our own settings
57
59
62
66
67
69
74
76
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80
82
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GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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Acknowledgements
'This manual was prepared by T.K. Sundari Ravindran, with valuable contributions from
Jane Cottingham and Rashidah Shuib. The manual, developed for a 6-day workshop,
was condensed from the training curriculum for a 3-week workshop developed by
WHO Geneva, Transforming health systems: gender and rights in reproductive health, a training
curriculum for health programme managers.
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The authors gratefully acknowledge the valuable feedback on the shorter version
received from participants from 10 countries (Cambodia, China, Japan, the Republic
of Korea, the Lao Peoples’ Democratic Republic, Malaysia, MongoHa, Papua New
Guinea, the Philippines and Viet Nam) at the 5-day Regional Workshop on Gender
and Rights m Reproductive and Maternal Health from 28 November to 2 December
2005 held in Kuala Lumpur. These inputs have guided the development <)f this manual
for a 6-day workshop. The authors also express their appreciation to the Government
of Malaysia for hosting and supporting the workshop.
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Preface
Globally, more than half a million maternal deaths occur each year, the majority of
them in developing countries. Within countries, it is the poor and disadvantaged who
suffer most. The majority ol these deaths arc prcvcniablc, even where icsoiik
:irc
limited.
Reducing maternal mortality has become a public health priority. Goal 5 of the
Millennium Development Goals (MDGs) calls lor improvements in maternal h< alih.
It also calls for a reduction in the maternal mortality ratio by 75% of the 1990 level
by 2015. To achieve this goal, a comprehensive approach to reproductive health
and improvements in service delivery and accessibility are needed. However, these
measures will not be sufficient by themselves.
It
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Maternal mortality is like a litmus test on the status of women, their access to health
care, and the adequacy of health systems in responding to their needs. High maternal
mortality is a complex phenomenon, but all too often, it results from discriminatory
practices against girls and women. Women’s lack of power vis-a-vis men constrains
decision-making about their health needs. It also constrains the level of investment in
maternal health services and the quality of care women receive. Many studies indicate
that women’s low status is a major barrier to obtaining reproductive health services.
In other words, fundamental inequalities between men and women and the neglect of
women’s rights contribute to the morbidity and mortality of women. Poor women arc
doubly disadvantaged in their access to services, as well as in their access to and control
over economic resources.
It is crucially important to increase awareness of gender equality, to provide analytical
and practical tools for health programme managers and others to address gender and
reproductive rights. Moreover, it is vital to ensure both men’s and women’s participation
in these efforts.
This manual aims to achieve exactly this objective. It is based on the 3-week training
curriculum developed by WHO Geneva, Transforming health systems: gender and
rights in reproductive health, a training curriculum for health programme managers.
The longer course has been successfully conducted in various settings worldwide.
However, experience has highlighted the usefulness of a shorter workshop. The
course was thus condensed into a 5-day workshop to be conducted as a regional event.
It was hosted by the Government of Malaysia in Kuala Lumpur from 28 November
to 2 December 2005. The workshop was expanded to the 6-day format presented in
this manual on the basis of the experience and feedback from participants in the Kuala
Lumpur workshop.
The manual is intended for use in facilitating a 6-day workshop on gender and rights
in reproductive and maternal health for health managers, policy-makers and others
with responsibilities in reproductive health. Other stakeholders working on advocacy
and policy and programme change in reproductive health, such as nongovernmental
organizations (NGOs) and international partners may also find it useful. Although
designed as a stand-alone course, it could be integrated with pre- or in-service
programmes on health systems, rights and gender.
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Learning modules
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be acquainted with the underlying gender,
social, economic and political
determinants of reproductive health;
have gained conceptual clarity on a rights-based and gender-sensitive approach to
policies and programmes for maternal health;
be
DC able
auie to
uo apply
apply the
the knowledge
knowledge and
and skills
skills gained
gained to develop strategies to address
gender and rights issues in maternal health within their own settings;
be able to review national maternal-mortality-reduction efforts and identify key
issues that need greater attention from a gender and rights perspective; and
have an understanding of gender- and rights-relatcd factors within the health
system.
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Participants will:
DAY 0 (a.m.)
Session I
()fficial opening and
• be introduced to each other,
to key facilitators and to the
objectives and structure of the
course
introduction to the
I'bi inat of activities
(ifticial opening
30 mins.
Brief ice-breaking exercise
40 mins.
Hxercise on expectations
course
20 mins.
Input on course: history,
objectives and structure
DAY 1 (a.m.)
Session 2
• gain a regional overview of the
topic and develop a common
understanding of the urgency of
addressing the problem
30 mins.
Input on dimensions of the MM
problem and key issues
30 mins.
Participants to read definitions of
sexual and reproductive health and
rights, followed by a discussion,
and summary by facilitator
1 h.
• be able to identify social
determinants of maternal health
and locate gender as one of
these, and be aware that it is
affected by and interacts with
other determinants
Introduction to gender concepts
and tool for gender analysis
f
1 h.
Spider s-web exercise and
subsequent discussion
lb. 30 mins.
• be able to analyse medical
causes of maternal mortality
and morbidity to identify their
gender and poverty dimensions
Exercise to identify gender and
poverty dimensions of medical
causes of maternal mortality and
morbidity
1 h. 30
mins.
• become aware that the
promotion or violation of rights
is easily identifiable and relevant
to everyone’s life
Participants work in pairs,
followed by large group discussion
45 mins.
• understand the relationship of
reproductive rights with human
rights
• understand the impact that
the promotion of rights or
violation of rights can have on
reproductive and sexual health
• be able to use a public-healthand rights-based approach for
identifying and solving problems
Brief input on basic concepts of
human rights and rights related to
safe pregnancy
Input, individual work and group
work interspersed with plenary
discussion
30 mins.
• be introduced to the concept of
“engendering” indicators
• have some exposure to
developing “engendered”
indicators
Input by facilitator
45 mins.
Group work to develop gender
sensitive indicators followed by
presentations and discussion
2h. 15
mins.
• be introduced to concepts of
sexual and reproductive health
and rights, and locate maternal
health issues within this broader
picture
Determinants of
maternal health
DAY 1 (p.m.)
Session 4
Identifying gender and
poverty dimensions
underlying medical
causes
DAY 2 (a.m.)
Session 5
A rights-based approach
to making pregnancy
safer
DAY 2 (p.m.)
Session 6
“Engendering”
indicators
30 mins.
Participants to share with their
partners experiences of their
encounters with maternal
mortality (MM) and morbidity.
Then some will share this with the
whole group. An attempt will be
made to identify associated factors
Maternal health:
dimensions of the
problem
D/XY 1 (a.m.+p.m.)
Session 3
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DAY 3 (all day)
Session 7
Applying a gender and
rights perspective to the
functioning of a health
centre (field visit)
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DAY 4
Session 8
Health service delivery
issues
DAY 4
Session 9
Financing inaternal
health services
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• become familiar with observing
and analysing various elements
of a health facility with a gender
and rights lens
Participants to visit health facilities
in small groups and carry out
systematic observation of the
quality of care, including whether
attention was paid to gender and
rights
3-4 h.
• understand what elements are
needed to make a health facility
address gender and rights
concerns
After returning from the field
visit, participants will report back
for a detailed discussion on what
they have presented
1 h. 30
mins.
• begin to look at health service
delivery issues through a gender
and rights lens
• understand gender and rights
issues within service delivery for
specific components of maternal
and reproductive health care
• be familiar with health systems
issues related to maternal health
from MDG Task Force report
Role plays: the health system
wheel exercise (modified to focus
on the relevant maternal health
issues)
1 h. 30
mins.
Input and participant seminars
1 h. 30
mins.
Input by facilitator, followed by
discussion
1 h.
Group reading of hand-out given
as homework, and discussion in
the plenary session
2h.
Brainstorming on what is a policy,
and on “gender and rights”sensitive policies
1 h. 30
mins.
Input on framework for analysing
and influencing policy
1 h. 30
mins.
• be introduced to strategies
and good practices in reducing
maternal mortality and
morbidity
Panel presentation by selected
participants
1 h. 30
mins.
• reflect on their role as
individuals in effecting change,
and address emotional and
psychological issues related to
making changes
Sharing of individual experiences
in making change happen and
summary input by facilitator
45 mins.
• apply what they have learnt
in the course to identify one
specific intervention that they
can implement in their own
setting
Briefing for working on one
specific intervention that they can
implement in their own setting.
Start and continue as homework
(making posters)
45 mins,
plus
homework
Group poster presentations
2h.
• Input session consolidating all
the modules
15 mins.
• Evaluation questionnaires to be
completed by participants
30 mins.
• Formal closing
45 mins.
• have an understanding of
the implications of different
financing mechanisms for
equitable access to pregnancyrelated health services
• be introduced to costing safe
motherhood and to innovations
in financing pregnancy-related
health care
DAYS
Session 10
Assessing policies and
interventions from
ii gender and rights
perspective
DAYS
Session 11
(p.m.) and
DAY 6 (a.m.)
Making change happen
within our own settings
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DAY 6
Session 12
(a.m.)
•
Closing session •
• learn about the characteristics
of policies and interventions
that integrate gender and rights
concerns
• become familiar with a
framework for analysing policies
• consolidate what they have
learnt on the course
• evaluate the course from their
immediate perspective
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Participants will:
be introduced to each other and to the key facilitators;
receive a brief introduction to gender issues;
learn something about the history and background of the course; and
be informed about administration and logistics.
|time: 2 hours]
a hand-out containing statements for the ice-breaking
exercise (see Box 1 below); and
a set of cards and pens for each participant.
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There are *ree major activities to be covered in this session. The session should ideally be
toow anl t feVenffi8 b?°re
3CtUaI WOKsh°P StartS’t0
Plants to get to
know and to feel at ease with each other.
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[time: 30 minutes]
Step 1: Facilitator’s welcome
[time: 10 minutes]
Welcome participants jand introduce yourself and other facilitators.
Brief participants on
the introductory activity.
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Step 2: The human treasure hunt
[time: 30 minutes]
and talking to each other until tlJ
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sheets. The game can be stopped after about U)'
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'working woman (statement 5). Most would not h.ive h..d .. kind. ,,..
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male (statement 1), and so on. This f.n ilif.ncs the inm».|11< n. mi .(h<
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division of labour". Many women may not be engaged in acme spoils, and this < an be
used to introduce the concept of gender norms and roles. Mention that these issues will be
discussed in some detail during the next day’s sessions.
Box1. The human treasure hunt
(1) Find someone who had a male kindergarten teacher when s/he was growing up.
(2) Find one woman who is engaged in active sports.
(3) Find one man who takes an active role in his children’s school activities (for
parents).
(4) Find one person who has always had female bosses.
(5) Find two people whose grandmothers were working women.
(6) Find one person who has a woman employed as a driver or security officer in
his/her place of work.
ctivity 3: .
Step 1: Expectations
[time: 20 minutes]
Give each participant a card and a pen and ask them to write down their expectations for the
course. Pin these on to a bulletin board and go over them after mentally categorizing them.
Some of the categories of expectation that usually emerge are:
•
•
new information and skills;
group dynamics and learning processes; and
applying the information and skills gained on the course when back in the workplace.
Step 2: Introduction to the course objectives and structure
[time: 20 minutes]
This is an appropriate moment to introduce course objectives and content. These may
be presented in five minutes through a PowerPoint presentation. As you present the
content, explain at what point in the programme and how expectations about knowledge
and processes will be met. The facilitator of this session must be familiar with the course
content and methodologies as well as the timetable.
Fulfilling some expectations depends more on the participants than on die facilitators (for
example, Learning from each others’ experiences”). Some expectations are not likely to
be met. These may be about the content of the course, or extracurricular activities. It is
your responsibility to clarify which expectations the course cannot meet and to explain
that it is not usually possible to meet all the expectations of a diverse group. Bui it may
well be possible to accommodate some expectations - for example, a visit to a local
nongovernmental organization - even if these were not originally planned.
Step 3: Administrative and logistical matters
|time: 10 minutes]
Give information on logistics and administrative matters. You may include issues such as:
• who to talk to for which need: ideally, introduce the people responsible for logistics;
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the resource room: what is available there (computers, printers, photocopier, telephone,
fax, e-mail, paper, additional reading matter), where it is and how it should be used;
per diem allowances and sponsorship, where applicable;
the physical location of the course venue in relation to other amenities such as banks,
travel agencies, restaurants, entertainment, and so on; and
any special health or diet requirements of the participants.
Go over the content of the course files with participants.
assignments and homework that will be a part of the course.
Explain the various
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fromTraiisjorniing health ^sterns:gender and rights in reproductive healths Opening module, various sessions. Geneva,
World Health Organisation, 2001.
8
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Workshop
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What participai
Participants will:
gain a regional overview of the topic and develop a common understanding of the
urgency of addressing the problem; afid
g
be introduced to concepts of sexual and reproductive health and rights, and locate
maternal health issues within this broader picture.
[time: 2 hours]
Materials
•
Hand-out: “Definitions of reproductive health and reproductive rights”
owerPoint presentation: Regional overview on maternal health issues
Flipchart for writing down 1key points from participants’ sharing of ideas on maternal
mortality and morbidity
How to run the session
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level, and to become aware of the urgency of the issue. The second is an input prodding an
overview of the dimensions of maternal mortality and morbidity in the Region The third
Thfr H
tO in“OduCe C°ncePts of sexual and reproductive health and rights.
highlights the linkages between the goals of improving maternal health and promoting
sexual and reproductive health and rights.
! cavity 1
[time: 30 minutes]
Participants are requested to turn to their neighbours and share their encounters with
maternal mortality and/or morbidity. These may be their own experiences as health
providers, or as individuals, or based on what they have heard from colleagues, families or
community. This should take only about 10 minutes.
1
After 10 minutes, call upon participanls lo volunteer lo share whal lhey have discussed with
their neighbours. Write down on a Hipchart:
characteristics of the woman involved (age, socioeconomic status, parity, etc.);
cause of death — clinical as well as social;
•
place of death; and
•
whether the death could have been avoided.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manua! for a Learning Worksho.
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Take about five examples and draw on these to highlight the human tragedy that maternal
mortality and morbidity’ represent. Note down the social determinants related to mortality
or morbidity in these examples (to discuss later in Session 3).
•/
|time: 30 minutes|
(Jive a PowcrPc )iiu presentation providing an overview of:
•
•
•
•
maternal mortality reduction in the MDG;
maternal mortality and morbidity rates and causes in the Region;
inequalities and differences across geographical areas and population groups; and
an agenda for action to change the situation.
An overview paper may be prepared and circulated as a hand-out if considered useful.
[time: 1 hour]
It is important to point out the link between maternal health issues and the broader concept
of reproductive health before finishing this session.
Hand out definitions of reproductive health, sexual health, reproductive rights and sexual
rights. These must include paragraphs 7.2 and 7.3 of the International Conference on
Population and Development (ICPD) Programme of Action and paragraph 96 of the
Fourth World Conference on Women (FWCW) document from Beijing. You may note
that the language of sexual rights is not used in the FWCW document. However, people in
the field talk about paragraph 96 of the FWCW' document as “the sexual rights paragraph”
because it is about applying human rights to the area of sexuality.
Participants should read the definitions and clarify any doubts. You then make the link
between reproductive and sexual rights and health and maternal health - highlighting how
one cannot be achieved without the other. Safe pregnancy and child-bearing depend on the
woman’s ability to decide whether and when to get pregnant and how many children to have.
I Ik y also depend on her ability to terminate unwanted pregnancies safelv, her access to care
following a miscarriage, and so on. A woman’s reproductive and sexual health throughout
her lifetime influences and is influenced by maternal health and overall health status.
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Participants will:
•
•
be introduced to gender concepts and to a gender-analysis tool; and
identify social determinants of maternal health and locate gender as one of these, and
be aware that it is affected by and interacts with other determinants.
[time: 2 hours 30 minutes]
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Hand-out 1: Concepts for gender analysis
Hand-out 2: Gender-analysis tool
PowerPoint: Introduction to gender concepts and gender-analysis tool
Word document to project (overhead or LCD): Case study of a woman experiencing
maternal mortality or serious morbidity
a ball of twine or wool and a pair of scissors
This session consists of three activities. The first is an interactive discussion with inputs
from the facilitator on gender concepts and the gender-analysis tool. The second is a
participatory exercise known as “the spider’s web”. It involves reading out a case study of
a woman suffering from ill-health, and unravelling the factors that contributed to it. The
activity illustrates how so many factors are intertwined, using the analogy of the spider’s
web. The third activity is a whole-group discussion to help participants understand both the
links and the differences between sex, gender and other social determinants of health.
[time: 1 hour]
Step 1: Definitions
[time: 30 minutes]
Start with a brainstorming session on what participants understand by “gender” and write
their responses on a flipchart. Ask participants whether they know how “gender” differs
from “sex”, and elicit a few examples of such differences.
Distribute Hand-out 1 to participants and allow them about 10 minutes to read it individually.
It contains definitions of commonly used gender concepts: the gender based division of
' labour, gender roles and norms, access to and control over resources, and power. Clarify
any doubts or questions that participants may have.
Conclude this step wilh a summary I’owcrPoinl prcscnlafion wilh dclinilions of sex and
gender and of gender concepts given in Hand-out 1.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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Step 2: Gender-analysis tool
|iimc: 30 minuics|
I )isliil)iiic I land out 2, which contains one gender analysis tool and also an example of how
the tool is applied to make a gender analysis of one health condition: malaria.
I ul up an overhead or PowerPoint slide ol the gender analysis tool (matrix) and take
participants through the matrix, (live enough time for questions and clarifications.
[time: 1 hour 30 minutes]
Step 1: Divide up the room before the session begins
The floor of the room is divided into five large squares or rectangles. One-half of the
room is assigned to three factors that women have in common with men of the same
social group: economic, sociocultural and political factors. These are marked on the three
squares or rectangles on the floor. The other half of the room is divided into two squares
or rectangles, marked “sex” and “gender”.
Floor plan:
SOCIOCULTURAL
ECONOMIC
POLITICAL
GENDER
SEX
Step 2: Briefing
[time: 10 minutes]
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I'.xplatn that this session builds on the earlier session in which the various social determinants
of maternal health were identified after participants shared their personal experiences.
Explain also that it aims to show the interlinkages between different determinants of
maternal health, including gender. Get participants to stand in a wide circle around the
floor plan. As facilitator, you will be standing at the centre of the floor plan. You should be
facing the screen on which the case study will be projected.
i
Step 3: Case study
[time: 20 minutes]
Project the case study, which has the potential to provoke discussions on sex and gender and
social, cultural, economic and political determinants of maternal health. One example of a
< asc Sludv ispiv.-n in Hox
used here as an illustration.
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Box 2: Jasmine’s story
Jasmine was only 20 years old when she died. The first of three daughters of a
poor agricultural labourerjasmine had studied only up to second standard. Her
father could not afford it. The school was two kilometres away from her street
and it was not considered appropriate for her to go unescorted. Her father also
thought that educating a daughter was like “watering the neighbour’s garden”.
When she was 16 years old, Jasmine was married to a rich man of the peasant
caste. She was his second wife. Jasmine’s father was only too pleased at his
daughter’s good fortune.
Jasmine bore two children in quick succession. The first was a girl and the second,
the much awaited male heir. This she did even before her nineteenth birthday.
Both the children were born at home. When her son was just eight months old,
Jasmine discovered that she had missed her periods for more than two months.
She did not want to be pregnant again because her son was sickly, so she talked to
a traditional midwife.
The traditional midwife suggested going to a private practitioner 10 kilometres
away for an abortion. Jasmine had never gone anywhere outside unescorted, and
she had to wait for a day when the midwife was able to come. Jasmine went there
under the pretext of having her son immunized. The private practitioner was
willing to perform the abortion, but her charges were unaffordable for Jasmine.
i
,
Jasmine returned home desperate. She attempted an abortion on her own,
inserting a sharp object into her vagina. Within a week, Jasmine became very
sick. When the pain started to become severe, Jasmine knew that she would need
medical assistance. However, she hesitated to ask her husband to take her to
the town hospital, because she did not know what explanation to give him. Her
relationship with him was strained; she had heard that he was “seeing” another
woman because Jasmine had become “sickly”. So Jasmine took some medicine
for fever bought from a local store, and kept quiet. A couple of days later, Jasmine
died of high fever without receiving any medical help.
J.
Demonstrate how the spider’s web exercise works with one or two examples. Stand at the
centre of the room with a ball of wool or twine. The participants take turns to read the
case study in parts, and after each sentence or each couple of sentences, you call out, “But
why?”
For example:
i
\'(icililalor:
Participant 1:
jasmine slopped schooling alter her second grade. Bui why?
Her school was three kilometres away from the village.
Facilitator:
Participant 2:
But why?
The village was a poor one, far away from the capital city.
'I’hc person giving this last answer has identified a reason that could be classified as economic
— the backwardness of the village, or as political — the village’s lack of bargaining power to
secure resources.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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As soon as the participant identifies that the reason is that the village is powerless, the
facilitaU >r asks, “Sc > he >w wc mid yc m classify this I a ch >r?” The participant may say “economic”.
As s< >< m ns he < >r she says I his, l he perse m goes and siai ids in I he square marked “cconc >mic”.
I he lac 1111; 11 < >i, si a nd 11 ig al 11 ic cenl re wil 11 I Ik* ball < >1 I wine, he >kls < >nc end ol l he I wine,
and I brows I he ball lo I he participant standing in the “economic” square. You may probe
further, and ask “Can you classify it as any other factor?” Another participant may say
political . She or he should go and stand in the “political” square, and the person standing
in lhe “economic ’ square throws lhe bail lo her or him, while holding on lo the twine. Now
all ihrce arc linked b\' lhe (wine.
There is another reason why Jasmine stopped schooling - her father did not think educa tion
was necessary for girls. This would be classified as “gender” and the ball would pass on
from the person in the “political” square to the person identifying this factor and occupying
the “gender” square.
!
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Tliis continues, until by the end we are left with a complex spider’s web of factors underlying
Jasmine’s death.
The activity should be conducted at a brisk pace, with each “But why?” following in quick
succession, the factors classified and a new participant coming into the web.
You should decide before the activity at which points you will be stopping to probe “But
why?” Restrict this to no more than 10 or 12 questions.
Step 4: Cutting the web
[time: 20 minutes]
\X hen the spider’s web is complete, challenge participants to find points at which they can
cut the web. What intervention could they make that would make a difference to Jasmine’s
situation? This could happen while the participants are still standing entangled in the web.
Facilitator:
Participant:
If you were a local activist, where would you cut the web?
Facilitator:
Participant:
If you were the nurse at the local clinic, where would you cut the web?
I would be sensitive to the ways in which gender influences women’s ability to
I would intervene to help Jasmine become economically independent.
prevent unwanted pregnancies. I would do all I could to ensure that women
seeking abortion services were not sent back home without receiving the
service.
/ 'iitiliLiloi
I'.n lit if ><1111
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II you were from ihc Dcparimcm of I Icalih of the national government,
when- would you cui the web?
I • would :idvo< ai<- lor liberalizing lhe laws on abortion.
I .
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;||||< ||>
;,|1| answers, cut
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cm her or him free.
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After three
remrii io their senls for <lei.riefing and discussion.
a;
or four such examples,
Activity 3: Whole- r<
;i I 4
[time: 40 minutes]
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Step 1: Participants give feedback
[time: 15 minutes]
i
Encourage participants to start by sharing their feelings about the <exercise. I low did they
feel when they were entangled? I low did it feel to cut the web atI specific points? What
lessons do they draw from the exercise? What do they think the erntanglement signified?
Participants usually share their feeling of being hopelessly trapped as the spider’s web
was being constructed, and feeling that they would never be able to unravel the problems.
Cutting through some parts of the web gives insights into possible actions that individuals
or groups can take - no matter how complicated a situation appears or at which level a
person is able to intervene: individual, community or national.
Step 2: Facilitator summarizes
[time: 25 minutes]
Where to start
I
Point out that the key to cutting the complex web may lie in starting with the woman herself.
This would create greater space for her to reflect on her situation, interact with others and
facilitate her empowerment, helping her see that change was possible.
Draw attention to the fact that in the spider’s-web exercise, many gender factors were also
classified as sociocultural: for example, the reason for Jasmine’s early marriage. This point
should be raised for discussion - that culture and tradition are not gender-neutral and may
become tools for discrimination against women. They are likely to be the parts of the
spider’s web that are the most difficult to cut through.
Economic, sociocultural and political factors that affect women’s health are so intertwined
with factors related to gender and sex that they seem to mesh into one. While it is important
to see these links, it is equally important to separate them out analytically so that we can
identify where it is most feasible and appropriate to cut the web.
• social
■■■•• r
Draw participants attention to the links between a social-determinants perspective and a
rights framework (introduced in the next module) in relation to health. Understanding the
social causes underlying ill-health also helps us identify the economic, sociocultural, civil
or political rights involved. Violating or neglecting these may underlie the health problem.
Addressing these violations or neglecl would create conditions to enable good health.
i
Adapted from Transforming health systems: gender and rights in reproditctivc health. Mod/de 2, Session 4 Geneva IT'f-fO
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Participants will:
•
be able to analyse medical causes of maternal mortality and morbidity to identify their
gender and poverty dimensions.
[time: 1 hour 30 minutes]
•
Hand-outs 1-4, each describing one situation of maternal morbidity
Flipcharts
Phis session starts with a small group activity in which participants explore a health problem
and identify gender and poverty factors underlying many medical causes of maternal
mortalin’ or morbidity.
|time: 50 minutes]
Step 1: Instructions for the activity
[time: 10 minutes]
Divide participants into four groups. Distribute I land-outs 1-4 with instructions for group
work. Each group does the same exercise but for different maternal health problems Their
main tasks are:
to analyse the reasons underlying a negative maternal health outcome; and
to identify and circle in red factors that are related to poverty; and circle in blue factors
that arc related to gender.
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Step 2: “But why?”
[time: 40 minutes]
Starting with the statement written at the bottom left corner of a 1'arge sheet of paper
groups ask “But why?” They write the reason in a bubble next to the statement.
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They keep asking “But why?” until the line of argument is exhausted. Each reason has to
flow directly from the one before, to be written in a bubble and to be clustered next to the
others. Then participants begin with the original statement and explore another reason why
the woman experienced a negative maternal health outcome.
Participants must give as many reasons as possible in as much detail as possible. Each circle
should contain a single specific issue. For example, “culture” is not acceptable as a reason:
the group must define what it is about the culture that is the reason in this specific instance.
For example, it could be that women arc expected to have sex whenever their husbands
want to.
The following is an illustration of how this exercise is done for a problem related to
infertility.
av -<
Afraid of
asking
husband
!
No
clinic in
the area
No money
Did not tell
health worker,
her symptoms
J
Did not go to
the clinic
1
Health workers
judgemental
Went to the
clinic, but
got no
treatment
Woman infertile
because of untreated
STI
No privacy
Health worker
could not diag<
nose
No drugs
Did not know
she had an STI
STI was
asympto, matic
No resources
Poor
ordering
system
[time: 40 minutes]
Each group in turn presents one problem and the chain of events. Ask questions after
each presentation, challenging participants to clarify their line of reasoning. Explain how
gender and poverty influence the health conditions. Each report and related discussion
should be completed within 10 minutes or so. The facilitator summarizes at the end of each
presentation and discussion.
New activity based on an exercise from WHO. Transforming health systems: gender and rights in reproductive health.
Module 6, Session 3. Geneva, WHO, 2901.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual fora Learning Workshop
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Participants will:
•
•
become aware that the promotion or violation of rights is easily identifiable and relevant
to everyone’s life;
understand the relationship of reproductive rights with human rights;
understand the impact that the promotion of rights or violation of rights can have on
reproductive and sexual health; and
be able to use a public health- and rights-based approach for identifying and solving
problems.
I
|timc: 3 hours|
Hand-out 1 of the Universal declaration of human rights — this can be downloaded
from www.unhchr.ch/html/intlinst.htm
Hand-out 2: “A case study for analysing a reproductive health intervention”
Overhead or Word file for projection: Four quadrants
Flipchart or board to write on
PowerPoint presentation on the Right to Health and its application to maternal health
Essential reading as homework on the day before the session:
(a) Freedman I ,.P. Shifting visions: “delegation” policies and the building of a “rightsbased” approach to maternal mortality. Journal of the American Medical Women’s
Association, 2002, 57(3): 154-158 (enclosed)
(b) UNICEF. Saving women’s lives: a call to rights based action. UN Regional Office
for South Asia, 2000: 9-19
This session consists of three activities. The first is conducted in pairs to identify rights
violations, foDowed by a discussion with the whole group. The second activity is an
interactive input by the facilitator on the “Right to health and rights related to safe pregnancy
and delivery . In the third activity, participants work individually and in groups, interspersed
with facilitator inputs.
|liinc: 'IS ininulcs|
Slop 1: Working in pairs
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OBNOE. Aro RIGHTS m REPROOUCTM ARD ETERNAL KEALTR,
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reproductive right was violated. These may be based on their own personal experiences or
on the experiences of others.
Ask each participant to spend two minutes alone recalling one incident when s/he felt
that a right was violated, and to share this with his/her neighbour. The person sharing the
recollection should try to name which rights she or he thinks were relevant to the story and
in what ways.
Step 2: Whole-group feedback
[time: 15 minutes]
Ask participants to volunteer to share stories about what they consider to be violations of
rights that impact on sexual and reproductive health, or about the violation of reproductive
and sexual rights. Some examples that have previously come up include:
the right to choose one's marriage partner, and not be forced into an arranged
marriage;
the right to use a contraceptive method of one's own choice without overt or covert
coercion from the health system;
the right not to be discriminated against in the labour market because of having
children;
the right to be informed when one's partner tests positive for 11IV; and
the right of health workers to be protected from HIV infection.
•
•
•
•
•
Step 3: The Universal declaration of human rights
[time: 15 minutes]
Hand out copies of the Universal declaration of human rights (UDHR). Participants take
five to seven minutes to read it individually. Tell them to skip the preamble and to begin
reading at Article 1.
Go over each of the rights listed on the board or flipchart and ask participants to identify
which article in the UDHR most closely addresses it.
[time: about 30 minutes]
Prepare a PowerPoint presentation on the right to health and rights related to safe pregnancy
and motherhood. The main points to be covered in this presentation include:
•
•
•
•
I
the meaning of the right to health;
the state’s obligation to respect, protect and fulfil individuals’ right to health;
application of human rights principles to maternal and reproductive health: some
examples of rights involved; and
an explanation of what the “value-added” is when a rights-based approach is adopted
. to sexual and reproductive health programming, with illustrative examples.
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[time: 1 hour 45 niinutes]
Step 1: A methodology for maximizing the public health and human rights
elements of policies and programmes
|time: 20 minutes]
Introduce participants to the following methodology.1 It attempts to maximize both the
public health and human rights quality of policies and programmes. There are four steps:
(1) Considering the extent to which a policy or programme represents good public
health.
(2) Considering the extent to which it is respectful of and promotes rights.
(3) Considering how to get the best balance between health and rights.
(4) Considering whether this is the best approach for dealing with the public health goal
that the policy or programme seeks to address.
This [overhead] chart helps you go through the steps:
Four quadrants: The quality of human rights and public health in a
programme
Excellent
c
A
D
B
Poor
0
Poor
Excellent
Sector explanations:
A: best case
B: need to improve HR quality
C: need to improve PH quality
D: worst case: need to improve both PH and
HR quality
vertical axis: human rights quality
horizontal axis: public health quality
quadrant A: optimal human rights and optimal public health
quadrant B: excellent public health, but human rights aspect needs to be improved
quadrant C: human rights aspect is fine, but public health suffers
quadrant D: bad public health and bad human rights
rh/s methodology is adaptedfrom: International Federation ofRed Cross and Red Crescent Societies and the Francois-Xavier
Ragnond Centrefor Health and Human Rights. The public health-human rights dialogue. In: Mann J.M., Gruskin S.,
(,rodin I. I., \nnas (>f. eds. I lea/fh and human rights: a reader. Xew ) brk, Routledge, 1999:46-53.
20
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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The assumption is, generally, that in designing and implementing a health policy or
programme, quadrant A is where one would prefer to be. A programme or policy that is
respectful of rights, while still achieving its public health goal, is going to be better than one
that limits or restricts rights.
How do we use the chart to work through a policy or programme in order to maximize both
the public health and human rights aspects?
The first step: What makes a good public health intervention?
Mark the extent to which the policy promotes and is good for public health as i.a point 7
P
along the horizontal axis (see Figure 1 below). If the point lies within quadrant^, this
indicates good public health quality, and the further right the point, the better it is. If the
point lies within quadrant D, this indicates p<
poor public health quality, and the further left the
point, the poorer the quality.
Excellent
I,
I
c
A
D
B
Poor
0
Poor
Excellent
The second step: Consider the rights aspect of the policy
Consider the rights aspect of the policy and mark this as a jpoint Q
~ along
*
the vertical axis
(see Figure 2 below). If the point lies within quadrant C, this indicates good human rights
quality, and the further north the point, the better the human rights quality is. If the point
lies within quadrant D, this indicates poor human rights quality, and the further south the
point, the poorer it is.
Excellent
c
A
D
B
Poor
0
Poor
Excellent
Suggest that determining the human rights value of a policy or programme can be done
by considering each of the rights in the UDHR and determining for each right whether
it is positively or negatively impacted upon, or irrelevant. Ask participants to remember
government obligations as well as the Siracusa principles. Make it clear that sex-based
discrimination in the UDHR should be integrated across rhe various relevant rights in the
UDHR.
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GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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The third step: Where public health and human rights intersect
I haw a vcriical line from P on the horizonial axis and a I
horizontal line from O on the
vertical axis. 1 he point of intersection of these two lines, R, gi
ivcs the quadrant in which the
policy lies for its public health and human rights quality (sec 1‘igure 3 below).
Excellent
I
e
A
D
B
Poor
0
Poor
Excellent
i
The goal is to be tn quadrant A or move towards it by working through the various aspects
or the policy.
d'JCtive
[time: 1 hour 25 minutes]
‘f
Step 1: Assessing the quality of public health
[time: 10 minutes]
G.VC each pamapant a copy of a case study of a health intervention with instructions for
analysmg its public health and human rights quality. The hand-out given here is an example
WMe the steps for analysis stay the same, you may wish to substitute this case study with
another.
]
Parac^ants complete the public health analysis of the intervention. They may discuss this
vnth their neighbours before reaching a decision.
Step 2: Whole-group discussion on public health quality
[time: 20 minutes]
After participants have analysed th<ie public health quality of the intervention, they move
into a whole-group discussion.
mtervend<C>nP‘mtS
qUeSti°nS’ Which are Iinked to the Pubhc health quality of the
What arc the reasons for focusing on this population?
22
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presumption that they are at a higher risk of being infected;
large number of sex partners from whom and to whom they could presumably
receive or transmit infection;
real or perceived lack of power to negotiate condom use with clients;
increased likelihood of having other STIs: assumption that they are more likely
than other people to contract HIV and spread it to others (their clients); and
politically expedient: looks like something is being done.
•
Why not focus on testing clients?
•
•
Is there likely to be pre- and*post-test counselling?
What test is likely to be used? How accurate is the test given at six-monthly intervals
likely to be?
Will all sex workers be tested? Which sex workers arc likely to be identified?
What happens to sex workers once they are found to be infected?
•
•
If their sex workers’ cards are removed, are these women likely to find other
sources of financial support immediately? Why do women generally engage in sex
work? Will this need go away if they are found to be infected? Will revoking their
cards impact on sex workers’ ability to use health and other services?
Does this approach in any way control the clients’ rate of transmission to these
women?
Given the health commissioner's concerns, is this approach likely to be effective in
preventing heterosexual transmission?
Put up your [overhead] transparency of ‘Tour quadrants: The quality of human rights and
public health in a programme”. What is the level of consensus among participants on the
public health quality of the intervention? Call out at each point beginning with O along the
horizontal axis of the chart, running your pen along the axis. Ask participants to raise their
hands when they think you have reached the quality of the intervention. Mark this point on
the horizontal axis. Let this point be P.
Step 3: A rights analysis using the UDHR
[time: 10 minutes]
Now ask participants to carry out a rights analysis of the intervention using the UDHR.
Are any of the rights being restricted? If yes, are these restrictions valid under the Siracusa
principles? Participants work individually, consulting with their neighbours if they want to.
Make it clear that sex-based discrimination, which a gender analysis would reveal, is included
in this analysis.
I
Step 4: Whole-group discussion on human rights quality
[time: 20 minutes]
Facilitate a discussion in the large group on the human rights quality of the intervention.
I
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Rights to be considered and discussed include Articles 1, 2, 3, 5, 6, 7, 8, 9, 12, 13, 20, 21,
2.2, 23, 25, 27 and 29. While many of these rights may not be immediately relevant to the
example provided, a discussion will allow consideration of the proposed intervention from
a rights framework.
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[time: 10 minutes]
and T.
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he co
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P -w marked on it. Deterge
the consensus for the human rights quality of the intervention. Call out at each point
beginning with O, along the vertical axis of the chart, running your pen along the axis’
Ask parents to ntise their hands when they think you have rcLhed the quality ofThe
intervention. Mark this point Q on the vertical axis.
*
Draw a vertical line through point P and a horizontal line through point Q. Mark the
quadLt “L" WR°' rdS
!? ’^htheCaSe
ln thC hand'°Ut> thiS P°int R is
to “
mterV£ntiOn iS °f P°Or Pubhc heal* - weU as poor human
Lhl quX
Step 6: Discussion: How to move towards quadrant A
fume: 15 minutes]
Focus the discussion on 1what specific changes would be needed for this intervention to
move towards quadrant A.
*
How can we make the public health objective re:
spond to the problem in a manner that
is as targeted, precise and gender-sensitive as possible?
How can we make the response to the problem more effective?
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I articipants may propose a number of different options. You can discuss each of these
in relation to whether they are of a better public health and human rights quality *an
*e “ample. Anonymous voluntary testing and counselling sites available to the generd
p pulaaon, including sex workers, and the promotion of condom use are usually ten as
£“””sh“ ”d p“Mc
H“^ *” -Ib'
*»
Policies and programmes that respect rights are ;
actually better and more effective. Human
nghls and public health concerns arc not incompatible.
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Considering human rights in the design, implementation or evaluation of health policies and
programmes is a useful way to determine whether existing health policies and programmes
promote or violate rights (especially gender equality) and to judge their effectiveness.
Public health decisions are often made for political expediency, without consideration of
their effects on human rights, and even to some degree their effect on public health.
U)h!>
•
People working in public health have a responsibility to look at whether human rights
are promoted, neglected or violated by actions taken in the name of public health.
•
The links to the government that exist for anyone working in public health, whether
as an agent of the state or because they receive government funding, impose a dual
obligation to promote and protect health, as well as to promote and protect human
rights.
•
People working in public health have the power to decide to restrict rights, so this
responsibility has to be taken seriously.
Health policies or programmes that violate rights have long-term negative
consequences in that they make it harder for people and communities to trust any policies
or programmes.
J.
Adaptedfrom Transforming health systems: gender and rights in reprod/tcfire health. Module 5. Sessions I, 2 and I Genera,
U'/HO, 2001.
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Participants will:
•
•
be introduced to the concept of “engendering” indicators; and
have some experience with developing “engendered” indicators.
|time: 3 hours]
•
•
Hand-out 1: “Definitions of some maternal health indicators”
Hand-out 2: Instruction for group work on “engendering” reproductive health
indicators
PowerPoint presentation on “engendering” indicators
Indicators to monitor maternal health goals: report of a technical working group, Geneva,
8-12 November 1993. Geneva, World Health Organization, 1997
1 hete ate thtee activities. 1 he first is a brief discussion in the large group to identify
definitions of some commonly used maternal health indicators. The second activity is
an input session by the facilitator. The third is a group activity to evolve “engendered”
indicators to monitor some reproductive health programmes.
[time: 45 minutes]
Step 1: What is a health indicator?
[time: 15 minutes]
Begin by defining what health indicators are, and give some examples. A health indicator is
usually a numerical measure that provides information about a complex situation or event.
\Xlien you want to know about a situation or event and cannot study each of the many
factors that contribute to it, you use an indicator that best summarizes the situation. For
example, to understand the general health status of infants in a country,
country, the
the key
key indicators
indicators
are infant mortality rates and the proportion of infants of low birth weight.
Ask participants to tell you the difference between rates and ratios, and explain these
conccpis if ncccssarv.
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An indicator is a rate or proportion when the numerator is included in (he population
defined by the denominator.2 For example, the literacy rate in a population has literate
persons in the numerator and total population in the denominator.
An indicator is a ratio when it is an expression of a relationship between a numerator and a
denominator in which the two are usually two separate and distinct quantities.3 For example,
the population sex ratio has as numerator the number of males in the population, and in the
denominator the number of females in the population.
Elicit from participants the definitions of some commonly used maternal health indicators.
You may choose so'me from Hand-out 1.
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[time: 30 minutes]
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Provide an input on the meaning of “engendered” indicators and ways in which indicators
may be developed or modified to capture the gender dimensions of maternal and
reproductive health.
[time: 2 hours 15 minutes]
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Step 1: Group work
[time: 45 minutes]
Divide participants into four groups. Each group is given a hypothetical reproductive health
project for which they must develop indicators (Hand-out 2).
Step 2: Reporting back
[time: 1 hour 30 minutes]
One person from each group reports back to the whole group on:
•
•
•
•
•
the reproductive health project under consideration;
indicators to be used and their definitions;
the attempt made to bring gender and rights dimensions into one or more of the
indicators;
mode of collection of information on these indicators; and
how often the information will be collected (for example, census inft )rmati< >n is collected
‘once in a decade).
Each presentation should last no more than 10 minutes and may be followed by a
l()-minute discussion. Some of the indicators that may emerge from each of the groups
are outlined below.
2 LastJ.M. et al. A dictionary ofepidemiology. New } ork, Oxford University Press, 1995.
1 Ibid.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workahop
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propoi l ion ol Icmale adolescents reporting condom use (this may be further relined,
for example, to specify regularity of condom use, .access to condoms, or whether a
condom was used in their most recent sexual encounter);
15-1 y-year-olds as a proportion of all abortion-related obstetric and gynaecology
admissions; and
proportion of women in the 15-19 age group who have had one or more children or
are currently pregnant.
•
percentage distribution of maternal deaths by place of death;
proportion of women who died at home or on their way to’ the hospital because the
hospital” was too far away;
•
percentage distribution of maternal deaths in hospital, by time between admission and
death; and
proportion of women reporting a delivery complication who delivered in a health
facility.
•
percentage distribution of all women using contraceptives, by method used;
proportion of women and men ireporting that they were given adequate information
on the various contraceptive options available;
proportion of contraceptive users who are men;
proportion of contraceptive users reporting at least one follow-up contact with the
health facility or health worker; and
proportion of satisfied users at the end of X months following acceptance.
proportion of clinic users who are aware of the symptoms of one or more RTIs/
STIs;
f
number (and/or proportion) of clients seeking treatment for RTI/STI;
•
proportion of clients (by sex) whose partners have also sought treatmentproportion of those diagnosed with an RTI/STI who completed treatment (reasons
for not completing treatment: cost? access? quality?); and
proportion of those who completed treatment who are cured of the problem. '
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Which of the indicators addressed above had the potential to address the gender/rights
dimensions of the issue? For example, in the Adolescent Reproductive Health project
"Hormauon on condom use should be collected from both girls and boys. In addition to’
finding out the proportion of girls aged 15-19 who are currently pregnant or have had a
I..Id, the proportton of boys aged 15-19 who have either fathered a child or arc responsible
lor a current pregnancy could also be an indicator. This information may be collected by
I
rccofosHn'lW Id
CUrrCntIy P'68”3" ab°Ut
agE °f
father' Antenatal
rccotds tn health centres could routinely collect data on the age of the father.
In the Safe Motherhood project, a gender/rights dimension may be added to the indicator
.Ik dtstrtbutton of maternal deaths in hospital by time duration between admission and
28
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death This can be done by asking about reasons for delay. Similarly, reasons for non-use
o a health facility by women reporting a deliver}' complication would give insights into
whether gender-based discrimination, through the lack of access to resources and power or
through roles and norms, played a role in this delay.
To add a gender dimension to indicators for the Family-Planning and RTI/STI programmes
indicators should be analysed by the sex of the respondent. Finding out reasons for nonuse of any contraceptive method, or non-use of health services for RTI/STI from both
women and men could also help bring out the role of gender in this.
I
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Adapted from Transforming health systems: gender and rights in reproductive health. Module 4, Session 6 Geneva, WHO,
2001.
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Participants will:
•
•
become familiar with observing and analysing various elements of a health facility with
a gender and rights lens; and
understand what elements are needed to make a health facility address gender and
rights concerns.
[time: 4 hours 30 minutes]
Hand-out: "Guidelines for observation during visit to health facility"
Tliis session consists of two parts. The first activity is a visit to a health facility The second
is a whole-group discussion and a detailed summary by the facilitator.
|time: 3 hours|
Step 1: Preparation
Before the session begins, give participants instructions as described in Step 2. If available,
distribute brochures about the health facility and the services offered so that participants
begin to familiarize themselves with the services offered by the clinic.
Step 2: Instructions for the activity
[time: 10 minutes]
Divide participants into four groups and distribute the hand-out. The hand-out will give
clear instructions on what to observe and how to present the information when reporting
back.
Explain that each group will visit one specific health facility. The group’s task consists
of observing, and when needed, interacting with clients/patients and health providers to
gal her details about the quality of health services, and the extent to which gender and rights
issues have been taken into account when planning for the delivery of health services. In
particular, rhev must observe the following elements of quality of care:
30
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual lor a Learning Workshop
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client—provider interaction;
information/counselling for client; and
essential supplies, equipment and medication needed, plus norms and standards.
•
Tell them they have approximately two-and-a-half hours for the visit and then they must
write up a group report for presentation to the class the next morning [30 minutes].
I
Step 3: Reporting back and discussion
[time: 1 hour 30 minutcs|
The reporting-back session takes place on the same afternoon as the visit. I -ach group in turn
has approximately 10 minutes to present its findings. The presentation should highlight:
a general description of what the group observed about the health facility and its internal
and external environment, staff presence, workload, and so on;
what was present and what was missing in terms of quality-of-care elements listed below;
and
what needs to be done to make the clinic and the health facility address gender and rights
concerns.
•
I
•
After each presentation, make sure you allocate sufficient time for discussing gender
and rights issues.
What are the gender- and rights-relared aspects you identified in the service/clinic you
•
visited?
•
•
•
•
How do gender and rights impact on the internal and external environment, staff
presence, workload, and so on? For instance, are there separate toilets for men and
women? Are there any separate rooms for consultation and counselling? Are the
women accompanied by their husbands? If yes, does this mean there is gender equality?
In terms of service providers, are there more female than male workers? If yes, whv?
What does this show? Usually reproductive health (RH) services are dominated by
female workers. Could this also influence men’s access to these services?
It is also important to raise issues related to rights, such as privacy and confidentiality
and whether these are maintained during the consultation. If the consultations take
place in separate rooms, we may assume there is privacy, but what if the personal
medical dossiers are not kept locked and anyone who walks in can easily read them?
Another issue is informed consent and whether people arc informed about the health
examination or the treatment they may undergo. This is also linked to a person's right to
information and self-determination. People should obtain sufficient information about
the medical examination they are undergoing or a treatment they may have to follow in
order to make an informed choice. Information, education and communication (IEC)
materials in the waiting rooms and consultation rooms can also help raise people's
knowledge and information about specific health issues.
Time may also be a constraint for people to access services. For instance, different
opening times for specific services may be an extra burden for women who may have
to come back several times to the clinic to obtain different services.
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It is important to highlight that gender and rights aspects are not obstacles, but that they
help improve (he quality ol health services. Summarize some of (he main gender and
rights points brought up during the discussion. In particular, mention that quality-of-care
problems are often not just due to technical details or medical causes, but they are also
related to ignoring gender and rights issues within a health service setting.
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Participants will:
begin to look at health service delivery issues through a gender and rights lens;
understand gender and rights issues within service delivery for specific components of
maternal and reproductive health care; and
be familiar with health systems issues related to maternal health from the MDG Task
Force report.
[time: 3 hours]
Jr:paratio!1
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Prepare the role-plays based on instructions in the Notes for the facilitator.
•
Notes for the facilitator: “Descriptions of role-plays and questions for discussion”
Role-play characters, each individual character on a separate piece of paper, taken from
• Notes for the facilitator
Essential reading 1: Summary report of MDG Task Force 4: Who has got the power?
Transforming health systems for maternal and child health care (2005) - to be read the
previous evening as homework
r
Thii, session consists of two activities. The first is a participatory activity, which should take
place in a large room (desks should be moved to the edges to i__.
' a large empty space
make
in the middle of the room). Volunteers are recruited to take part in a series of role-plays
while others observe. At the end of each role-play, the facilitator asks a set of questions,
the answers to which bring out an aspect of health care delivery system functioning and the
gender and rights issues that the role-play illustrates.
The second activity is a presentation by participants of the key health system issues pertaining
to maternal health care. This should be based on the Summary report of MDG Task Force
4. The facilitator pulls the session together with concluding remarks highlighting the need
to have a “health systems” approach to improving maternal health care?
[time: 1 hour 30 minutes]
Step 1: Prepare the role-plays
Type oul each character from the “Noles for the facilitator” on to a separate piece of paper.
The role-plays arc numbered 1 to 5 and the characters have letters assigned to them. Label
each envelope so that it indicates which role-play and which character it corresponds to. In
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this way, the people acting in a particular role-play know who their fellow actors are.
It isusclul lohavea lcwprops:a lelcphonc, some shawls, a doctors coat, etc. I xiok through
the characters and bring appropriate props. This helps people get into their characters and
adds a touch of realism and humour. For example, if you bring a small cushion, an actor
can stuff it under his/her shirt to pretend Io be pregnant.
I
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Step 2: Assign the characters and prepare to act
|timc: 10 minutes]
This session starts with aU participants standing in a large circle around the room, with the
desks moved weU out of the way. Ask for volunteers who are willing to participate in role
plays. Give each volunteer the envelope containing a description of the role-play and of
the character they are to play. You do not have to have men playing men or women ^laying
women. Assign this at random — just give out the envelopes.
j
Explain to the actors and observers that a series of role-plays will be enacted during this
session. AU the roles are about service providers and service users in primary health care
facilities. TeU the actors that they wiU not know who the other characters are before the
role-play starts, but that this will quickly become clear.
1
Ask each actor to read about her or his character and think about how they may act as this
person. Give everyone a few moments to do this. Explain that you can help anyone who
has a question. Maintain pri\-acy when answering any questions, so that no one*else can hear.
Assist them in developing a plan for acting as their character by asking questions rather than
telling them what to do. For example, if someone acting the character of a nursing sister
wants help, read the description with him or her. Then, talk through how they imagine that
person might feel, what circumstances they might be working in, etc.
1 Explain to the actors that observers just need to get a flavour of the situation and that acting
talent is not required. Everyone should remember that the actors are playing a role, and that
what they do and say will not be seen as a reflection of their own personalities or opinions.
Actors should also remember to face the audience, and to talk so that everyone can hear.
Instruct observers to play close attention to what the characters do and how they interact.
Step 3: The role-plays and discussions
[time: 50 minutes]
Call everyone not acting in Role-play 1 to gather around the first piece of paper on the floor.
Actors with a “1” marked on the envelope should do their role-play.
Start by introducing the situation and tie characters briefly.
For example: “We
are at a clinic and we have a clinic nurse (point to the person playing the nurse) and a
patient (point to the person playing the patient). This clinic has a referral centre that is
40 km away and this is the clerk (point to the person playing the clerk) who books
appointments and does other clerical work at the referral hospital.”
Let each role play run for about five minutes, making sure that the aspect of health system
functioning to be addressed by it emerges (see below). Stop the role-play by firmly saying,
“ I hank \<mi”.
1
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For each actor: How did it feel to play the role you played?
For the observers: Describe what was going on in the role-play. In your experience, is
this a likely scenario? If not, how would the reality differ?
What are the gender issues in the health service setting depicted in this role-play? Are
any nghts violated? Which rights, if any, have been respected or promoted?
What action could be undertaken to improve service delivery in this situation?
•
•
care delivery syc (1) provider-client relations;
(2) access; and
(3) infrastructural requirements.
What to cover in the li
You will need to think on iyour feet, posing questions that will draw out the points we need
to make about the functioning o’f the health care delivery, system.
Somei examples are given
,
below.
Ibis role-play is about a pregnant woman with prc-eclampsia who does not get any
instructions or advice from her doctor about her condition.
I
One gender issue that emerges from this role-play concerns health pronders’ lack of
awareness of gender issues that may prevent the woman from taking appropriate steps to
deal with her health problem, should complications develop. There is also an issue of the
provider’s unwillingness to engage with a person of a lower class and caste who, according
to the provider, is not able to articulate her problems or understand what the provider
says.
Move the discussion on to what can be done to alter this situation. Some suggestions
that have emerged from discussions like these have been: training to communicate better
and to change attitudes, a better working atmosphere, additional human resources such as
counsellors (these could be volunteer, lay counseUors) and a performance appraisal system
that includes provider attitudes and gender biases. These would be the responsibility of the
health manager.
The discussion could also identify other attitudinal barriers that participants have encountered
or are familiar with, and how these can be dealt with.
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At the end of a very long morning, the provider is exhausted. A woman who appears to be
very sick has walked all morning to get to the health centre, and reaches it just before lunch
break. She is very poor and badly dressed, and appears to be bleeding. Her clothes arc
stained and she smells bad. This is a woman with several children, who has had a backstreet
abortion and has developed an infection. She docs not feel confident about going to the
front of the queue to talk to the nurse alxiut the urgency of the situation. She tries to catch
the nurse’s attention, but feels that she is watching her with distaste. The woman’s impulse
is to go away and never come back.
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Questions to ask include: Why might she have had a backstreet abortion? Why has she
come at such a late stage? Why is it that the woman had no money to take a ride to the
clinic?
Identify the many barriers to access this woman has encountered at various stages: access
to contraception restricted because of husband’s unwillingness and/or lack of money to
buy regular supplies; lack of access to safe abortion because of legal restrictions on the
method, and also inability to afford a private practitioner; lack of time or lack of awareness
of symptoms of infection, which led to delayed care-seeking for post-abortion infection,
etc. Almost all of these arc rooted in gender and poverty.
Encourage participants to share other barriers to access that emerge from their own personal
or work experiences. For example, absence (5f female staff, whether the staff reside in the
clinic, timings of clinics, location, etc. The focus should be on barriers on the provider’s
side.
Then, take the discussion forward to identify ways in which the situation in the clinic, as well
as the policy environment, may be altered to improve access to safe abortion.
In the health centre in this role-play, there is no doctor on night duty. There is no ambulance
and no phone, and so the lone midwife on duty has to instruct a woman in labour who
arrives with hca\-y bleeding to make her own arrangements to go to the hospital 40 km
awav.
The helplessness of the health provider emerges as an important issue for discussion
from this role-play. The community often blames and gets angry with the health provider.
\\ hat arc the solutions to this problem? I low can such a situation be avoided? Suggcstcil
solutions include:
•
There should be a notice stating that, at night, complicated deliveries cannot be handled
at the clinic, and women should go straight to the referral hospital.
Danger signals in pregnancy, delivery and postpartum that require referral should form
part of a public education campaign aimed at both women and men.
1-ncourage participants to share examples from their own <experiences
x *
'
'lack
/ of
of' when
infrastructure got in the way of effective health delivery. On some courses, lack of separate
outpatient areas for men and women, lack of separate toilets, lack of child care facilities, lack
of physical safety for clients and health providers (where clinics are located in remote areas)
have been expressed as infrastructural constraints.
It is worth pointing out that it is often women who staff remote clinics and who are midwives
and that it is a significant burden on providers in such a situation to deliver quality services.
Moreover, health care for pregnant women is not the same as rare emergencies that may also
require emergency transport. It is well known and predictable that a specific proportion of
deliveries are likely to be complicated. Despite this, emergency transport for complications
in delivery is not built into health care delivery systems. Point out that maternal mortality is
high in poor countries, specifically because emergency transport for women in labour is not
routinely available. This is one example of the low value placed on women’s lives.
36
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Step 4: Pulling it all together
[time: 30 minutes]
Pay attention toer* ■
In order for health care delivery systems to ffunction adequately, we need to focus our
attention on the generic systems issues. These include drug supply,’training and so
) on - the
various points of the wheel that were developed in the role-play.
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Good management u cru
. I
Good management, which builds health care jprovider capacity; competence and
accountability, is essential and fundamental to adequately functioning healthi care sendees.
I
fhe gendered :n.-
f-
Prescribed gender roles mean that when health care delivery systems function poorly,
(women in particular are negatively affected. Improving health care delivery systems will
thus benefit women.
It is possible to increase women’s autonomy and promote their reproductive and sexual rights
within existing health services. Examples that come up in this activity' include: encouraging
mep to take joint responsibility when women are in labour, or for child care; and fostering
woi ..ten s control over their bodies by welcoming them at contraception services, irrespective
of their age.
1
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[time: 1 hour 30 minutes]
Participants are divided into four or five groups and assigned to read specific sections of
the Summary report of MDG Task Force 4 as homework for the previous evening. Each
group has to prepare a presentation of no more than 10 minutes based on what they have
read. All presentations are first given, and then there is a discussion for 40-50 minutes.
The facilitator then concludes the sessioi
ion, highlighting the need for addressing health system
factors impeding maternal health.
I
Descriptions of the seven role-plays and questions that you may ask to bring out gender
issues are set out below.
lypc our each role-play so that each character is on a separate
each
separate piece
piece of
of paper.
paper. Put
Put each
character description in an envelope marked with the number of the role-play (1-7), and
the letter of the character (a, b, c). (character b from the role-play on technical competence
will, for example, be contained in an enveloped marked “2b”. This will help each group of
actors in a particular role-play to know who their group members arc.
'lb set the scene before this role-plav begins, you will sav:
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“Today is a busy day- at the clinic. There is a long queue and it is also the day many people
come lor family planning.”
'Today is a busy day al the clinic. 'There is
i a long queue and it is also the day many people
come tor family planning.
Yiu area woman Irom a low income household. \ou are in ihesixih month of pregnancy
and have been suflering Irom bloated lace and water retention in your feet and legs for
about 10 days now. You feel really unwell, and it has taken you an entire week to find time,
put together the money and get permission to come to the health centre. You are shy and
scared of telling the doctor about your problems.
Today is a busy day at the clinic. There is a long queue and it is also the day many people
come for family planning.
You are a female doctor at the clinic. A pregnant woman with signs of pre-eclampsia has
just come to you. Many such cases come to you, but they come at their own convenience,
many days after the problem develops. Moreover, they do not take any action despite your
spending a lot of time persuading them to seek hospital deliveries. You are in a hurry,
and you just examine her and give a prescription. There is no use wasting time with such
women: thev never listen.
•
•
:
What are the likely consequences of the woman’s and the doctor’s behaviour? .
;
What does the provider’s behaviour indicate about her sensitivity to gender and social
issues dial may a five I I he palicni?
Is there any action that could be taken that would promote a better interaction between
the provider and the patient and improve pregnancy outcome?
I
I
To set the scene before this role-play begins, you will say:
This is a busy clinic. It is almost lunch time and the queues are g
getting shorter at last. The
nurse (point her out) is keen to take her lunch break and in the distance
------------ : we see a patient
(point her out) arriving hours after the clinic has opened.”
i
This is a busy clinic. It is almost lunch time and the queues are getting shorter at last.
\ou come from a rural farming family. You have five children and your husband has been
strongly opposed to contraception. You have been bleeding for several days and it shows
no signs of stopping. During the past couple of days you have been feeling feverish and
rather sick. You had an abortion performed by a paramedic doing private practice last week
and have been waiting for the bleeding to stop. You decide that things are very bad and you
must get some help. You decide to go to the government clinic, which is a long way from
where you live. You cannot ask your husband for money to go to a private facility, because
he does not know you have had an abortion.
38
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You miss a connecting bus, have to walk a considerable distance, and get to the clinic at 12
noon. You are late, as most people arrive at 8 a.m. By the time you get there you are hardly
able to walk. You must join the queue. You wait for an opportunity to talk to the nurse
who is busy with patients. Your clothes are soiled with blood, and you know that you smell
bad. You feel that everyone is watching you. You try to catch the nurse’s attention, but she
seems to be looking at you with distaste. Your impulse is to go away and never come back
again to this clinic.
Character B
This is a busy clinic. It is almost lunch tt
time and the queues are getting shorter at last. The
nurse is keen to take her lunch break.
You are the nurse. You have been working all day and the queue is still long. You see people
still arriving even at midday. You watch one woman come and sit beside the queue. She
is trying to catch your attention. You can see how sick she is; her clothes are stained with
blood. You think she may have attempted an abortion. “Why,” you wonder to yourself, “do
women do things like this to themselves?”
Questions W bring
ui <’.■
Why might she have had a backstreet abortion? Why not prevent the pregnancy?
Why has she come at such a late stage?
Why is it that the woman had no money to take a ride to the clinic?
Why would a woman not have money to pay for transport instead of walking?
What would be the best course of action for a health centre to undertake to encourage
women to come as soon as a problem develops?
To set the scene before this role-play begins, you will say:
“It is night at the clinic. The night-call nurse (point her out) is sitting in the clinic, available
for emergency cases.”
It is night at the clinic. The night-call nurse is sitting in the clinic, available for emergency
cases.
You are the midwife on call for the clinic tonight. You arc sitting in the clinic having s< >me
tea, thinking of going t() |>ct| lls j( js |a(c Njg.|lt jll(y is a|w.,vs s(1-css< u| T|lcrc js no ()IK. t()
talk to or to help if there is a problem. You have no phone in the clinic and the ambulance
is located at the hospital 40 km away on a bad road. It is worse now that it is the rainy
season.
It is night at the clinic.
I
You are a pregnant woman who is having her third child. You have been in labour at home
for six hours and now you see that you are bleeding. Your husband has left you for another
woman and you are all by yourself with no one to help. You are verj’ scared and manage to
get a man from the village to drive you to the clinic in his car. He is only helping you because
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you have begged him. He is concerned about the cost. You arrive at the clinic scared, in
labour and bleeding.
•
•
•
•
What facilities are required in a clinic for staff to be able to respond appropriately to
this situation? What kind of systems would have to be in place to make all this happen?
What could a manager do to make this happen?
Linder what circumstances would transport for women in labour be guaranteed? What
would be required to make sure this always happened?
What kind of action would ensure that women in this situation had more control over
their own bodies and health?
As both men and women make and want babies, what kind of action would lead to
men and women both having some responsibility^ for the healthy outcome of this
pregnancy?
wf
btaltl). Module 6, Session 2. Geneva, ITIdO, 2001.
rransjo^ing h'M, system: gender and rights in repMre
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Participants will:
1
•
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be familiar with different mechanisms for financing health care;
have an understanding of the implications for different financing mechanisms for
equitable access to pregnancy-related health services; and
be introduced to costing of pregnancy-related health care.
|time: 3 hours]
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•
•
•
Hand-out: Instructions for group work
Essential reading 1: Weissman E., Sentumbwe-Mugisa ()., Mbonye A.K., Ussner
C. Costing safe motherhood in Uganda. In: Berer M. Ravindran TICS., eds. Safe
motherhood: critical issues, London, Reproductive Health Matters, 1999: 85-92
Essential reading 2: Reducing maternal and child mortality in Bolivia. Executive
Summary series, PHRplus, PHR Resource Centre, Bethedsa, MD (undated)
PowerPoint presentation: Financing maternal health care: mechanisms, implications
and innovations
This session consists of two activities. The first activity is an input from the facilitator, a
PowerPoint presentation on innovations in maternal health care financing, prepared Based
on the sample PowerPoint presentation provided.
The second is a reading exercise on costs of and innovations in the financing of maternal
health care that promote access to care for women from low-income and marginalized
groups. The groups report back to the whole group on key learning, with inputs from the
facilitator.
[time: 1 hour|
The facilitator starts a discussion on why it is important to understand how maternal health
services are financed. Policies around financing mechanisms determine resource availability
for maternal health programmes. Any attempt at improving maternal health services (for
example, based on discussion in the earlier session) and making them more gender- and
rights-sensitive has to contend with financing issues. Some financing mechanisms help
ensure access to health services for low-income and marginalized groups and can help
promote quality of care. However, others may create barriers to access and utilization, and
compromise quality of care.
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This is then followed by a PowerPoint presentation, which:
•
gives an overview of different methods of financing health care;
discusses thc consequences of different methods of health financing for maternal and
reproductive health services; and
introduces information on some innovations (to be dealt with in detail in the next
activity).
[time: 2 hours|
Step 1: Reading and summarizing
[time: 45 minutes]
Divide the participants into four groups. Assign members of two groups to read Essential
reading 1, and members of two other groups to read Essential reading 2 as homework.
The next day, in the class session, participants work in groups and share the main points
t ey gathered from the reading. The group then prepares answers to the questions given
in the hand-out.
°
Step 2: Discussion
[time: 1 hour 15 minutes]
Elicit from the groups that have read Essential reading 1, responses to the following
questions:
°
•
Describe the essential steps used in the mother-baby package costing study done in
Lganda. what was tire range of services considered? How were tire incremental costs
assessed.-'
/
\X hat were the current and incremental per capita costs for providing enhanced maternal
and newborn health services in Uganda?
What were the main components of cost?
Do you have some idea of the current cost of maternal health care in your country? If
only a small increment could be made in overall spending for maternal and newborn
health, where would you choose to put- the additional money?
,SSUeS.tO.hlghl,g,;tare: thc ^ed to carry out simple costing studies; using costing
feXies™
“
additi°nal “ ^“ts and ways J
i
Now the groups that read Essential reading 2
are called upon to respond to the following:
•
W hat was thc mechanism for financing that was used?
What potential implication did it have for increased access
and utilization of maternal
health services?
•
^aUs^no?3? Jr “T1™ ab°Ut thiS finanCing mecha“sm? What are they?
is he potenual for implementing such innovations (or modified versions of
them) within their respective country settings?
I
For more than two decades now, international economic forces have moved in the direction
of reduced resources for the health sector in developed and developing countries alike.
This trend of the health sector being severely short of resources has continued through the
1990s and into the new millennium.
The introduction of cost-sharing mechanisms, such as user charges for health services, m-y
may
have a detnmental effect on the use of services by poor women. These women do not have
ready access to cash, or do not control cash in the household and have to seek permission to
spend money. There have been few studies looking at the gender impact of cost-recovery
mechanisms, and these do not look at different subgroups of women who may be affected.
They could include, for example, different income groups, rural/urban residence, regions
of a country, age groups and race/ethnicity.
Paying through tax revenue represents the fairest mechanism for financing essential maternal
health services: antenatal care, delivery care, postpartum care, and contraceptive and
abortion services. In order to expand these services to include a wider range of sexual and
reproductive health services, vital for good maternal health, countries are experimenting with
social insurance and pre-payment schemes. There is much to learn from these experiences
and to advocate for their application within our countries.
I
In order to have some idea about the volume of revenue to be raised through various
financing mechanisms, it is important to have a basic idea of the costs involved. WHO had
developed a simple and practical methodology for costing mother-babv packages,4 which
policy-makers and planners may find useful.
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Sexsion (lerc/o/u’d by T.K. S/iiithiri Wiii'iudnin.
4 For more details on how to carry out a costing exercise, refer to the "Mother-Baby Package Costing Spread Sheet "from http://
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package costings
wnwhoSntlreproductive-healthleconomics/motherJmty^
spreadshcct.pdf
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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Participants will:
°f p°td“'te8“d"“d
x
become familiar with a framework for analysing policies- and
morW^^ tO Strat£gieS
S°Od PraCtiCeS ln
maternaI
I
and
[time: 4 hours 30 minutes]
Hand-out 1: “How different policies identify and address gender inequalities” reSXe^S5
^r-spectfic and gender-
•
Hand-out 2: I ixercise on different policy approaches to gender
Hand-out 3: A framework for analysing policies
PowerPoint presentation: Gender and nghts in policies and interventions
ssennal reading as homework: Lerberghe, W Van, Brouwere, V De Of blind alleys
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Brouwere, V De, Lerberghe, W Van, eds. Safe motherhood strategies- a review of
PohcTn'^r
AnWerP’ 2001
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by the facilitator The^hM
a^definition
foUOWed by a ”ary Presentation
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legated to strategy
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[time: 1 hour 30 minutes]
Step 1: What does “policy” mean?
(time: 15 minutes]
Ask the group what the word
“policy” means to them, and write their ideas up on an
overhead chart or flipchart.
44
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^ meaning of the word “policy” differs in different countries. In general, people think
I
of it narrowly, to cover government legislation and/or government regulations. For
the purposes of this course, since it aims to encourage changes in practice wherever the
participants are situated, a broader definition of policy would be helpful. The discussion
should generate a very broad list of what policy can mean, including:
•
thegoals/aims/visions of a govcrnincnl,group <>i• organizei<.n,
the plan of action adopted in relation to those goals;
a decision;
•
•
a group of decisions;
an orientation;
the fact that policy evolves in the process of implementation, so f
___ 1
that frequently the
intention of formal policy, such as legislation, is not what is actually delivered in practice;
and
•
the fact that policy is manifested in practice (i.e. as an approach) or in writing (e.g. a
white paper, law or mission statement).
I
Encourage broad definitions of policy at various levels. If participants do not come up with
this kind of definition, ask questions such as: “What about households? Do households
have policies?” Participants may come up with ideas such as the male head of a household
allocating a set amount of money to his wife to cover domestic costs for the month. They
may come up with a household rule that children have to come home in the evenings by a
set time; or a woman doing all the cooking; or men being served food first. In this way they
can sec that ongoing practices arc a form of policy.
Ask also about policies in the workplace, such as how many days’ leave a person can take,
or grievance procedures.
Most of the examples presented in this curriculum are about government policy - whether
in legislation or in public health services. However, a broader perspective on policy is
necessary to empower not only participants who work for government, but also those in
NGOs, partner organizations or other structures. They must be enabled to develop the
skills and the recognition that they can initiate or influence policy change.
Distinguish between formal policies and informal or uns|ipoken
’
policies. For example, in
many countries urban health services have better facilities, more equipment and more staff
than rural health services. There may be no formal policy that a department of health will
give priority to urban health services over rural ones. However, in effect, the failure to insist
that equal attention is given to rural health services means that whatever the written policy,
the actual policy is to discriminate against rural health services and therefore the people
who rely on them. If the health system only employs men at management level because
that is the standard thing to do, then arguably their practice suggests an unwritten policy to
exclude women.
Ip this way, absence of a decision or failure to address a problem is also a type of “policy-inpractice”. For example, if there is no legislation or regulation or even health system practice
to ensure that the poorest people in society can afford health services, then this can be called
a de facto policy. In this way, “non-decisions” arc also policy.
!
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^me-Tho°7 d° POl'CieS 'dentify and address Sender inequalities?
In addition to having a shared understanding of the
term “policy”, participants need
to be able to work out. whether and how different
policies identify and address gender
inequalities.
Prepare a list of examj
' of-----iples
different policies. Box 3 provides some <
examples to give you
ideas. You may use these, or include other
----- ------- examples to make a new hand-out.
Participants are given Hand-outs 1 and 2. Explain briefly the three different approaches to
gender of vanous policies from Hand-out 1. P "
•
approaches to
Participants then have to allocate each policy
to one of the gender approaches to policy. They h:
^ave 10 minutes for this exercise.
In the large group, go through each policy. Tell participants that the categories help one to
chan fth
M ‘1
" 11 POliCy recognizes gender norms, and if and how it tries to
and S£
IdeaBy’
ShOUid b£ try‘ng tO deVel°P poUcies
Prom°te gender equity
nd equality or at a minimum, make women’s lives easier. TherXre, gender-specS
e tei than gender-blind or gender-unequal, and gender-redistributive is our aim.
Box 3: List of policies
1.
Materna1 health policy: trains midwives to improve their clinical skills to prevent
maternal moibidity and mortality.
2. Water supply policy: establishes a mechanism to provide taps close to villages
so that women will not have to walk as far to fetch water.
8
3. Human resource policy: includes provision for child
care facility at the
workplace.
4. Land policy: removes restrictions on women’s right to inherit land
5. °CtCUpa“°na'health P<>Iicy: Protects women and men from working in places
that are hazardous to their reproductive health.
6. Senior management recruitment policy in a department of health: requires aU
managers to have a PhD.
H
7. Community-based AIDS care ]---------programme: says that a health care system
cannot take responsibility for caring for people with AID?
, so that homebased care must be instituted.
8. meflZt"’CdUCati<,n and “unication policy: establishes messages and
cthod to advocate to women and men about mutual respect and equal nghts
sexual decision-making as a means of promoting safer sex practices.
Ask participants which policy approach they allocated to nolicv 1
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relevant experience or holds a aualifvino-
tO
that takes int:o account
D„f„Md,of,r po*-o,
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[time: 1 hour 30 minutes]
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Give a PowerPoint presentation that: introduces a basic framework for policy analysis (see
Hand-out 3 for essential contents).
. One of the commonly used frameworks for policy analysis uses “context-actors-process ”
as the three main dimensions around which to examine a policy. The purpose of policy
analysis is to identify the factors facilitating and constraining (government) action/inaction.
The intention is for participants to be able to analyse policies to understand why they were
developed at a particular time, and what shaped the policy content. This will also help them
understand whether and why the policy takes account of or tries to change gender norms.
Once they have gained confidence in retrospectively analysing policies, they will be able to
think about how to influence and shape policy content themselves.
Illustrate the framework with several real-life examples (see accompanying “Notes for
the facilitator for an example from South Africa). Make the presentation interactive by
stopping at various points and eliciting examples that participants can think of from their
countries.
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[time: 1 hour 30 minutes]
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This panel presentation should involve about four participants from diverse settings
or countries, and ideally also from diverse backgrounds. Each panellist should give a
presentation of no more than 10 minutes on:
one policy in their country that was successful in achieving a maternal or reproductive
health objective;
> ■ the context, actors and the process of policy development and implementation;
•
some reflections on factors that contributed to the success of this policy; and
•
thoughts on how this policy approached or addressed gender (gender-unequal,
-blind, -specific or -transformative?) and which rights are being promoted by the
: policy.
.•
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After all four panellists have spoken, the facilitator will take one round of questions lasting
about 20 minutes. These questions may be clarificatory or information-seeking in nature.
Next, it is the task of the facilitator to link this panel presentation with the previous activities,
by asking panellists to respond on:
•
•
the context, the actors and the process through which these strategies came into
existence; and
the extent to which the strategies have addressed gender and rights issues related to
maternal health.
This discussion could last for about 30 minutes, followed by concluding remarks by the
facilitator.
Adapted, with new activities, from Transforming health systems: gender and rights in reprod/tctii'e health. Module 5, Sessions
1-3. Geneva,
2001.
In 1996, the Choice on Termination of Pregnancy zXct was passed in South Africa. This Act
provides for abortion on request up to 12 weeks; and under a broad set of circumstances,
in consultation with a health worker, up to 20 weeks. Adolescents do not require parental
consent; trained midwives can carry out abortions.
f
Many people have asked how it was possible to bring about this law, and to what extent
the process can be followed in other countries. It is important to recognize that the same
activities will not lead to the same results in .different contexts.
These are some of the key factors in relation to the nstitutionali and political context, whicli
facilitated bringing about this law in South Africa:
•
The South African Constitution provides for equality on the basis of gender. It also
provides for security in and control over the body, and the right to make decisions
concerning reproduction. In relation to health care, it includes the right to have
access to health care services, including reproductive health care. There is a profound
commitment to human rights in the (.onstituti( >n, law and p< >licy. There is a commitment
to religious rights, but not at the expense of individual rights to equality. Thus the
context was favourable to gender-redistributive policy — to redistributing reproductive
rights so that women too would be able to exercise these rights.
There is a poor-quality and inequitable but functioning health system, so that the
provision of abortion is possible. This in turn depends on the government’s ability to
implement its general commitment to improving health services.
Key cultural factors that influenced bringing about the law in South Africa included:
South Africa s population is religious, with diverse but predominantly Christian religions.
There is a strong discourse of African patriarchal “tradition”. However, at the time of
the legislative process, the predominant discourse of civil society organizations was of
human rights, including women’s rights, and particularly the right to equality. Thus, in
the legislative process, it was possible to rilobilize around women’s right — particularly
the right of black women who had previously been disenfranchised and discriminated
against — to abortion. Previously, only white people and rich people had access to
abortions. However, given the significant role of religion and the concept of African
traditional values, it was necessary to ensure that religious leaders and people who
represented “African” values spoke in favour of the new laws.
A significant immediate contextual factor was the change of government in 1994 after years
of apartheid discrimination:
•
48
The new, democratically elected government had committed itself to immediate social
and legal change on all fronts. It wanted to be seen to be acting. In addition, its platform
of human rights included a moral imperative to end population control (whether control
of fertility or movement). This was therefore a very enabling contextual environment
in which to argue for womens right to control their fertility through access to abortion,
as part of a broader reproductive rights and health strategy.
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GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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Since South Africa had been isolated from international trends because of sanctions,
the International Conference on Population and Development (1CPD) and other
■
international agreements did not play a significant role in influencing this decision.
However, the global trend towards macroeconomic approaches that promote fiscal
restraint has meant a lack of available funds to implement the commitment to increased
access to health care, including the provision of new services, c.g. abortion services
Links between NGOs in different parts of the world did impact on'the development of
the new law, since South African NGOs accessed know-how from different countries
on how to word legislation. Lessons learnt from different countries were taken into
account and shared with legislators.
Wmen’s rights and health groups and other organizations: In South Africa at the
time of the abortion legislative process, women’s organizations and women’s advocacy
NGOs formed an alliance of NGOs (the Reproductive Rights Alliance) working in
the medical, legal, human rights and women’s health advocacy fields to gain maximum
benefit from organizational interventions.
Piofessionals: Health, human rights and medically oriented
groups mobilized for
liberalized abortion legislation.
PL).I1CY activists helped define the problem from womens perspective and develop
policy proposals (solutions). They then engaged with the formal political process by
working from the outside (giving information to the media, mobilizing mass-based
•
organizations) and from the inside (giving information directly to parliamentarians,
giving evidence at hearings).
Civil sogigt)" A consultative process initiated as part of the Women’s Health Conference
in 1994 mobilized mass-based organizations, policy activists and future government
bureaucrats from rural and urban areas. The Conference emphasized the participation
of black women because of historical discrimination on the basis of race. This process
developed a consensus on priority problems facing health system transformation and
in relation to sexual and reproductive rights and health. It developed policy proposals,
including on maternal health, contraception, access to abortion, cancer treatment, STIs,
HIV/AIDS, etc. It also developed proposals to address discrimination, including on
age>ng, lesbian health, access to water, and so on.
An abortion reform NGO developed draft legislation as the basis for lobbying. There was
some disagreement between different interest groups about the best possible solution. For
example, doctors and NGOs (with lawyers) argued that nurses should not be allowed to
perform abortions. This could be interpreted as doctors trying to hold on to their medical
preserve and being supported by other professionals such as lawvers.
In contrast, womens rights and health groups argued that nurses should be allowed to
pet form abortions in the first trimester, in order to ensure access to abortion for rural
women, since there arc few doctors in rural areas. I Utimatelv the law agreed that midwives
should be able to perform abortions, in keeping with the
? new governments commitment
to equity of access.
I he process ol solution development in South Africa paid little attention to issues related
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH; Manual for a Learning Workshop
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to implementation. Those involved in developing the new policy had never been in
government, and had little experience of health systems. I he law docs not address how it
will take account of limited health system capacity for referral, drug supply and so on.
Moreover, little consideration was given to whether or not health workers would support
the liberalized abortion law. While there was some information indicating that nurses would
not support the change in law, the new law did not indicate how it would address nurses
concerns. The process of developing the new law did not include consultation with nurses
organizations to gain their input and build their sense of ownership of the new law. ()nce
the law was implemented, many nurses became gatekeepers, not referring women who
needed abortions. No nstitutionalised system to promote health-worker support and to
require health workers to implement the law was established.
Another factor that was not considered in solution development was how to ensure that
women would be told about the law and their new rights and how to access these.
The interests of politicians became apparent in the South African political process when
the parliamentarv process was postponed. When a women’s health activist asked a
parliamentarian why this had happened, he said that the political party wanted to wait until
I
local elections were over, for fear that this legislation would make them lose votes.
In order to persuade politicians that a liberalized law was in the interests of their constituency,
activists brought poor black women who had been criminalized for having abortions to speak
at parliamentarv hearings, rather than speaking on their behalf. They mobilized religious
f igures to speak in fa\ our of the legislation on the basis of addressing women’s suffering and
meeting their health needs. They also mobilized people from diverse ethnic backgrounds to
show that (here was a groundswell of support from different constituencies.
Key pieces of technical information influenced the politicians deciding on South Africa’s
abortion law. There was historical research that showed that all South African cultures
and races had been performing abortions for centuries. Medical research showed the
costs carried by the public health sector for treatment for incomplete (illegal and unsafe)
abortions, thus providing a monetary motivation for liberalized law.
Information on how liberal abortion law looks in other parts of the world served to support
parliamentarians in shaping a new law. Information on the links of South African anti
abortion groupings to right-wing terrorist groups in the United States of America served to
i
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undercut their legitimacy.
The South African strategic planning process was weak in relation to addressing the concerns
and needs of the bureaucracy. Neither politicians nor NGO activists took adequate account
of likely barriers to implementation. Their focus was on the political process, ignoring that
once the Act had been promulgated it would have to be implemented by a bureaucracy.
Inadequate identification of health system leadership below national level was another
weakness. Health service providers were not identified as a constituency to be mobilized
before the new legislation to ensure their support for and capacity to implement it. The
legislation, or subsequent regulations, should have addressed such issues as:
<
E
time-frames, financial allocations and human resources;
50
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•
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how to implement a new service in the context of health system restructuring, with
major changes under way through decentralization and changes in financing systems;
training of midwives in the procedures;
building management support for the new legislation to ensure that it would be
implemented in the context of health system restructuring;
winning the support of health care providers so that they would not see this Act as yet
another burden, or as running against their values;
building the knowledge base of communities so that they could put pressure on the
bureaucracy to deliver services;
winning the support of health care providers in an ongoing and systematic way; and
training doctors and nurses in the procedures.
As a result, after the law was promulgated in 1996, implementation was very slow. Service
providers complained of lack of management support. Nurses at clinic level often operated
as gatekeepers instead of referring women appropriately. Communities did not know about
the rights provided by the law, and did not always support them.
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Source: Klugrnan B. In: Transforming bea/lh systems:gender and rights in reproductive health. Module 5, Session }.
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Participants will:
reflect on their role as individuals in effecting change, and address emotional and
psychological issues related to making changes; and
apply what they have learnt during the course to identify one speci'hc intervention that
they can implement in their own setting.
[time: 3 hours 30 minutes]
•f
Hand-out 1: Instructions for preparing posters describing
one intervention, which
participants can implement within their own settings for promoting gender and rights id
maternal and reproductive health care
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Acuyip- 1 starts with sharing by participants of a situation in which they have been agents
tor c ange. This is followed by Activity 2, in which participants develop interventions they
can implement within their own settings for promoting gender and rights in maternal and
reproductive health care.
[time: 45 minutes]
Start by introducing the purpose of this session, based on the objectives given. Then
request participant volunteers to share briefly their experiences of being change agents in
a professional or personal capacity. By “change agent” we mean a person who when faced
W1 a problem situation, identifies that a change or innovation is needed and takes initiative
to get this done. Keep each sharing session short (no more than three minutes). Ask for
a range of experiences, personal and professional, mainly around changing attitudes trying
something that has not been done before, and so on. After four or five petpie have’sZ
experiences, summarize, highlighting that:
many of us arc and have been change agents in our lives- I'ynge agem is no. a “comfortable” position to be in, as it involves risks such as
iridoad : . n’'” C<| gUCS ;lntd SUperi<,rS’ P°SSible failure and 1OSS of
additional
w<»iKl(>.id, siicss and so on; and
it also brings a great deal of satisfaction to be in a position to “make a difference”.
52
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Activity 2: Working x
initiated
[time: 45 minutes, plus homework]
Preparation
On Day 0, immediately after participants have been briefed on administrative and logistical
issues. Hand-out 1 is distributed to participants. They are requested to think through an
intervention that they can implement in their own contexts for promoting gender and rights
in maternal and reproductive health. They are informed that they will have to present their
phn as a poster on the afternoon of Day 5. Participants work in groups. This may be by
area of interest, by organizational affiliation, or by the geographic area in which they are
working. Some may wish to work individually, and this is also possible.
The task is to identify the “what” of change first: What would they like to do within their
own settings to reduce morbidity and mortality associated with pregnancy and childbirth?
But it is equally important to think through the “how” of change:
•
•
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Who will they approach and how will they do this in order to win support for what they
propose to do?
Who is likely to support them? What is in it for them?
What are some of the barriers they may encounter? How will they work around these
or overcome them?
What financial and non-financial resources will they need? How will they raise these?
Participants are expected
(
to have thought through ideas during the course of the work,
In this session, they can start writing them down in preparation for designing the poster,
and discuss their ideas or clarify doubts with facilitators. The poster must be completed as
homework.
[time: 2 hours]
Groups/individuals take turns to put up their posters, about four to six at a time. They stand
by their posters as others walk around reading their posters and asking questions/making
comments. After about 20 minutes, another set of four posters goes up, and the process
is repeated. By the end of the session, all groups/individuals will have received comments
on their plans.
Adapted from Transforming hea/lb systems: gender and rights in reproductive health. Module 6, Session 7 Geneva U "H()
2001.
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GE_N.DEn *N.D.RIGH.T? [N REPRODUCTIVE AND MATERNAL HEALTH: Manual tor a Learning Workshop
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Participants will:
consolidate what they have learnt on t'the course; and
evaluate the course from their immediate
- perspective.
[time: 1 hour 30 minutes]
Forms for written evaluation of workshop by participants
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[time: 15 minutes]
The course co-coordinator/director presents a consolidation of the key learning from the
course, taking participants through Days 1 to 5.
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[time: 30 minutes]
Distribute the course-evaluation
forms. Explain that the form is long because it'Aims
at
finding out about the entire
course while things are still fresh in participants’ minds.:-
I
Collect the forms after 30 minutes. F2 '
File these safely and hand them over to the course
organizer or whoever is responsible for them.
i
[time: about 45 minutes]
(if relevant to the context) and time alloc
1 f av^ ta
g-
ertificates may be given out
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This is an exercise to allow participants to become better acquainted with others taking
part in the workshop. Move around the room, talk to others and find people wifth the
characteristics mentioned below. Write down their names beside the statement. You have
about 10 minutes to find all the people.
(1) Find someone who had a male kindergarten teacher when s/he was growing up..
(2) Find one woman who is engaged in active sports.
(3) rind
Find one man who takes an active role in
i his children’s school activities (for parents).
p;
(4) Find one person who has always had female bosses.
(5) bind two people whose grandmothers were working women.
(6) bind one person who has a woman employed as a driver or security officer in his/her
place of work.
56
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...reproductive rights embrace certain human rights that are already recognised in national
laws, international human rights documents and other consensus documents. These rights
rest on the recognition of the basic nght of all couples and individuals to decide freely and
responsibly the number, spacing and timing of their children and to have the information
and means to do so, and the nght to attain the highest standard of sexual and reproductive
health. It also includes their right to make decisions concerning reproduction free of
discrimination, coercion and violence, as expressed in human rights documents. In the
exerctse of this right, they should take into account the needs of their living and future
c ildrcn and their responsibilities towards the community. The promotion of the responsible
exercise of these rights for all people should be the fundamental basis for government
and community-supported policies and programmes in the area of reproductive health
including family planning. As part of their commitment, full attention should be given to rhe
promotion of mutually respeclful and equitable gender relations and particularly to meeting
the educational and service needs of adolescents to enable them to deal in a positive and
responsible way with their sexuality. Reproductive health eludes many of the world’s people
because of such factors as: inadequate levels of knowledge about human sexuality and
inappropriate or poor-quality reproductive health information and services; the prevalence
of high-nsk sexual behaviour; discriminatory social practices; negative attitudes towards
women and girls; and the limited power many women and girls have over their sexual
and reproductive lives. Adolescents are particularly vulnerable because of their lack of
information and access to relevant services in most countries. Older women and men have
distinct reproductive and sexual health issues which are often inadequately addressed ”
1995. New} ork, United Nations, 1996 (UN Doe. A/CONF.177/20).
7
“The human rights of women include thei? right to have control over and decide freely and
responsibly on matters related to their sexuality, including sexual and reproductive health,
free of coercion, discrimination and violence. I iqual relationships between women and men
in matters of sexual relations and reproduction, including full respect for the integrity of the
person, require mutual respect, consent and shared responsibility for sexual behaviour and
its consequences.”
Paragraph 96 of: United Nations. Platformfor Action ofthe I mirth World Conference on
II"omen. Bei/iny,. 4-15 September
1995. Neiv > ork, I JnitedNations, 1996 (I 'N Doc. .■ 1 /CONI '. 177/20).
a
I: Manual for a Learnii
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41 1
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Reproductive health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system
and to its functions and processes. Reproductive health therefore implies that people are
able to have a satisfying and safe sex life and that they have the capability to reproduce and
t e freedom to decide if, when and how often to do so. Implicit in this last condition are the
rights of men and women to be informed and to have access to safe, effective, affordable
and acceptable methods of family planning of their choice, as well as other methods of
i leir Choice lor rcgulalion of fertility which arc not against the law, and the right of access
health'care services that wil1 enaWe women to go safely through pregnancy
and childbirth and provide couples with the best chance of having a healthy infant. In line
with the above definition of reproductive health, reproductive health care is defined as the
constellation of methods, techniques and services that contribute to reproductive health
and well-being by preventing and solving reproductive health problems. It also includes
sexual health, the purpose of which is the enhancement of life and personal relations and
not merely counselling and care related to reproduction and sexually transmitted diseases ”
n
Poi,u,atim Fu"d- Program ofAction ofthe International Conference on Population and
Development, Ca.ro, o-13 Septend,er 1994. NenAork. United Nations, 1996 (UN Doc A/CONF1711131 „dZ 4
Action ofthe Fourth World Conference on Womens
I^O^N^"0^
^.Un^Z
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In almost all societies, women and men perform different activities, although the nature
and range of these activities vary across classes and across communities. They have also
changed over time. Women are typically responsible for child care and household work, but
they also engage in producing goods for household consumption or for the market. Men
are typically responsible for meeting the household’s needs for food and resources.
In all societies, males and females are expected to behave in ways that are very different.
They are socialized from early childhood to conform to masculine and feminine roles
and norms. They have to dress differently, play different kinds of games, be interested in
different issues and subjects, and have different emotional responses to situations. There is
a tacit perception that what males do is better and more valuable than what females do.
The impact of socially constructed gender roles is felt significantly in the area of sexuality
and sexual behaviour. Women are expected to make themselves attractive to men, but to be
more passive, guarding their virginity and never initiating sexual activity. In some societies,
this is because women are held to have less sexual drive than men. In other societies,
the ways women are controlled are based on the idea that without restrictions, women’s
kexual desires might get the better of them. Men are often expected to take the initiative in
sexual activity, and are believed to be, by nature, unable to control their sexual desires when
aroused. It is therefore considered to be the responsibility of women to protect themselves
from inappropriate male attention and desire.
J.
Women and men have unequal access to and control over resources. This inequality
disadvantages wom'en. Gender-based inequalities in relation to access to and control over
resources exist within social classes, races or castes. However, women and men of different
races, classes and castes may be differently unequal. For example, women from one social
class could have more power than men from a lower social class.
f
Access is the ability to use a resource.
Control is the ability to define and make decisions about the use of a resource.
I
>
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For example, women may have access to health services, but no control over what sendees
are available and when. Another common example is women having access to an income or
owning property, but having no control over how the income is spent or how the property
is used. There arc many different types of resources that women have less access to, and
less control over. These include:
I
work
food
credit
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workahop
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money
social security, health insurance
child care facilities
housing
facilities to carry out domestic tasks
transport
equipment
health services
technology and scientific developments
positions of leadership and access to decision-makers
opportunities for communication, negotiation and consensus building
resources that help vindicate rights, such as legal resources
‘f
communin' resources
social networks
membership in social organizations
•
•
•
I
inputs to be able to make decisions to modify or change a situation
formal education
non-formal education
opportunities to exchange information and opinions
houis of the day available to use as they choose
flexible, paid work hours
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•
self-esteem
self-confidence
ability’ to express one’s own interests
I
Alen often
I
Ma'e P<>wer and control over resources and decisions is nstitutionalised through the laws
I policies (>
. 1 h,"'sX;:: I
l)i liiajjy
.,ht rulcs :ind rcKUladons ,>f formal social
>1 <r < gn c men greater control over wealth and greater rights
I
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in marriage and over children. For centuries, religious institutions have denied women the
right to priesthood, and schools often insist that it is the father of the child who is her or his
legal guardian, not the mother.
ACCESS TO AND CONTROL
OVER
ECONOMIC
AND
SOCIAL
INTERNAL
RESOURCES
POLITICAL
RESOURCES
INFORMATION
/EDUCATION
TIME
POWER AND
DECISION-MAKING
D
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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lit
Gender analysis of a health problem: the impact of different characteristics of gender on
men’s and women’s health'1
Relation to x health
problem:
Arc
f low do
there sex
biological
differences
differences
between
women "
and men
influence
their:
women*
affect their:
in:
How
do the
How do
How do
gender
access to and
different
norms/
control over
roles and
activities of
men and
values affect
men’s and
women’s:
resources
affect
men and
women’s:
Vulnerability"
Incidence/
prevalence
Healtfi-seeking.
behaviour
Ability to access
health services
[may
not be
applicable]
Preventive and
treatment options,
responses to
treatment or
rehabilitation
I'.xpcricncc with
| may
health services and
health providers
not be
applicable]
Outcome of health
problem, e.g.
recovery, disability,
death
Consequences
(economic &
social, including
attitudinal)
t)/ (l/JIcrciil t/f/xxcs, c/lmic iirti/tpx, f/ni-x or other relevant (Inferences between men and women
i
1 Adaptedfrom: Cender and Health Croup, Uverpool School of TropicalMedicine, Guidelinesfor the Analysis ofGender and
Z'/,y7W
y Vropica! Medicine and Departmentfor International Development, United Kingdom, 1999:26r
Id; I lartigan. I>, (iomc- Ida Silra,J, de Srhntter, M, Module 3: The origin ofhealth needs'. Workshop on
Geiidei, Health and Development: facilitator's Guide, Pan American Health Organisation, Washington DC., 1997:35-66;
Kauindran, IKS and Mishra US. Information needsforgenderanalysis in health Paperpresented at the meeting on Gender and
'
Organisation, 2000 (unpublished); Kingman, B, Fonn, S, and Tint, KS. Reproductive Health
]/ : \aknw \mmnt of Power Dynamics lietween Men and Women, Johannesburg: EC/UNFPA Initiative for Repivduc-
lireWeallhni la,el-‘ame.
w
Ill)()\ .md \l omen\ I faith Project, 200!.
1
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3
The matrix below uses the example of malaria to illustrate how to use the Gender
and health analysis tool as a basis for analysing health and health-seeking behaviour. This
immediately alerts you to potential gender biases and issues that may need attention in policy
or programming. I he matrix has been filled in using one review article on gender and
malana’ and includes only enough information to give you an idea of how to use the matrix.
Boxes have been left blank where information was not supplied in the article. In an actual
gender analysis, you would draw on a wider range of information sources and use the matrix
■for.summary purposes.
In relation to
malaria:
Are there sex
differences in
How do
biological
differences
between
women and
men influence
their:
How do the
different roles
and activities of
men and women
affect their:
How do gender
norms/values
affect men’s and
women’s:
No significant
sex difference
reported in
incidence or
prevalence
Pregnant
women
are more
“attractive”
to mosquitos,
and may have
an increased
infection rate
May influence
exposure, e.g.
India: men
sleeping on
farms away
from home
unlikely to use
bednets; women
harvesting maize
before daylight
in peak biting
time or running
food stall at
night
Clothes worn
can affect
proportion of
body exposed;
men may spend
more leisure
time outdoors
Asymptomatic
nature of
malaria in
pregnancy
means that
pregnant
woman not
likely to seek
care
Bednet
maintenance
and,
consequently,
re-impregnation
is generally
women’s
responsibility,
but can be
hampered
by costs or
time required
(i.e. links to
resources)
In some
communities
men are given
priority' use
of bednets to
ensure that as
breadwinners,
they have a
good night’s
sleep; in many
cases men get
priority because
of higher status
J.
Vulnerability:
1
Incidence**/
prevalence **
(male/female)
Rate of infection
increases in
pregnancy
I
Health-seeking
behaviour
Women in 2049 age group
are seriously
underrepresented
in malaria cases
reported from
health facilities
!
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How do access
to, and control
over resources
affect men’s and
women’s:
Economic
factors are major
determinants in
acquiring bednets; women
more inclined
to buy nets than
meh, but less
likely to control
household
income so have to
use own income,
which is limited;
economic factors
are also main
reason for non
use of services
<7
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Allotey PA., Ravindran T.K.S. Gender analysis in the control ofmalaria: the insecticide-treated bed net intervention. Key
Centre for Women's Health, Faculty ofMedicine, Dentishy and Health Sciences, I ■nirersity ofMelbourne, Australia, 2001.
9
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GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshoj
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In relation to
malaria:
Arc there sex
dilTcrcnccs in
I low do
biological
dilTcrcnccs
between
women and
men influence
their:
I low do the
different roles
and activities of
men and women
affect their:
I low do gender
norms/values
al feet men’s and
women’s:
Vulnerability:
No significant
sex difference
reported in
incidence or
prevalence
Pregnant
women
arc more
“attractive”
to mosquitos,
and may have
an increased
infection rate
May influence
exposure, c.g.
India: men
sleeping on
farms away
from home
unlikely to use
bednets; women
harvesting maize
before daylight
in peak biting
time or running
food stall at
Clothes worn
can affect
proportion of
body exposed;
men may spend
more leisure
time outdoors
Incidence**/
prevalence **
(male/female)
Rate of infection
increases in
pregnancy
I low do access
to, and control
over resources
affect men’s and
women’s:
night
Ability to
access health
services
Study from Papua
New Guinea
shows that the
effect of distance
on access is
different for
different age-sex
groups; the effect
of distance is
most pronounced
for adolescent
boys
[May not be
applicable)
Experience
with health
services
and health
providers
Burkina Faso
study shows
that female
patients have
more difficulty in
communicating
with health
workers
[May not be
applicable]
Routine chemoprophylaxis and
treatment of malaria in pregnancy is
hampered by the range of cultural,
social and economic factors that also
hinder antenatal care attendance.
These include: women more likely
to use traditional healers; may not
attend antenatal caVe because of
pregnancy-related taboos; where
there is a preference for the male
child, mothers may take their male
infants with malaria more often to
health centres, and be prepared to
walk further with them
I
-------------------------------- j------------------------
Women, as
mothers, are
the target of
programmes to
get children to
■ health centres,
but tendency for
women to be
blamed for the
failure of such
programmes
Cases of
women refusing
examination by
male providers;
Burkina Faso
— inadequate
histories taken
of women
but not of
men; New
York - delayed
diagnosis of
women but not
of men
In areas where
there has been
a resultant shift
from subsidized
bednets to full
payment, their
use has declined
and hence
vulnerability
increased.
Gender a critical
factor here, both
because women
have less control
over household
income and
because they are
more inclined to
give priority to
buying bednets
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In relation to
malaria:
Are there sex
differences in
How do
biological
differences
between
women and
men influence
their:
I low do the
different roles
and activities of
men and women
affect their:
I low do gender
norms/values
affect men’s and
women’s:
Vulnerability:
No significant
sex difference
reported in
incidence or
prevalence
Pregnant
women
are more
“attractive”
to mosquitos,
and may have
an increased
infection rate
May influence
exposure, e.g.
India: men
sleeping on
farms away
from home
unlikely to use
bednets; women
harvesting maize
before daylight
in peak biting
time or running
food stall at
night
Clothes worn
can affect
proportion of
body exposed;
men may spend
more leisure
time outdoors
Non
involvement
of women in
vaccine trials
may result
in vaccines
that have
unforeseen
side-effects in
women
Women, as
carers, more
likely to be
willing-to seek
care
Preventive
programmes
are usually
communi tvbased; where
social norms
mean that
women cannot
participate,
there has been
limited success
Financial
considerations
are usually the
most important
in whether a
full course of
treatment is
completed - links
to women’*- le^er
access to income
Incidence**/
prevalence **
(male/female)
Rate of infection
increases in
pregnancy
Preventive
and treatment
options,
responses to
treatment or
rehabilitation
I low do access
to, and control
over resources
affect men’s and
women’s:
Outcome of
health problem
Male mortality
higher than
female mortality
in the 0-4 and
5-14 year age
groups. From 15
years onwards,
there are more
female deaths
from malaria.
High mortality
rates reported in
pregnant women
Poor prognosis
during
pregnancy
India study
showed male
mortality rate
significantly
lower than
female for
falciparum
malaria
In societies
where there is
a preference
for the male
child, the
outcomes may
be unfavourable
to girls even
when malaria
incidence rates
are the same for
both
Poor outcomes
for pregnant
women may
be further
exacerbated bv
gender factors
within the
sociocultural
context and
economic status
of the women,
which present
barriers to health
service utilization
and good health
Consequences
(economic &
social, including
attitudinal)
Cambodia study
shows that when
men had malaria
the household
was more
severely affected
economically.
Women’s
workload also
increased
[May not be
applicable]
Sec Column 1
No information
available
See Column 1
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—
** Of(lU'I'en’ii/ c/asses, e/bnic t!ro/if)S, d^cs or other rrii'idiil (l/JIcrcnccs hclnvcn tro/t/tn dtttl bc/irecn ///cn: liridencc
shotrs thdt h/ulicr /ncowc uro/ips dre n/orc /ik-e/y to hike /d'ered/ire tielion; thodv/i ''b'o d/orc /ike/y to shoir resis/dnee
beeddse o/ ineorrect use o) (Irnas.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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Jasmine was only 20 years old when she died. The first of three daughters of a poor
agricultural labourerjasmine had studied only up to second standard. Her father could not
aTord it, the school was 2 km away from her street and it was not considered appropriate for
her to go unescorted. Her father also thought that educating a daughter was like “watering
the neighbour’s garden”.
When she was 16 years old, Jasmine was married to a rich man of the peasant caste. She was
his second wife. Jasmine’s father was only too pleased at his daughter’s good fortune.
Jasmine bore two children in quick succession: the first was a girl and the second, the much
awaited male heir. This she did even before her nineteenth birthday. Both the children
were born at home. When her son was just eight months old, Jasmine discovered that she
had missed her periods for more than two months. She did not want to be pregnant again
because her son was sickly, so she talked to a traditional midwife.
The traditional midwife suggested going to a private practitioner 10 km away for an abortion.
Jasmine had never gone anvwhere outside unescorted, and she had to wait for a day when
the midwife was able to come. Jasmine wept there under the pretext of having her son
immunized. The private practitioner was willing to perform the abortion, but her charges
were unaffordable for Jasmine.
Jasmine returned home desperate. She attempted an abortion on her own, inserting a sharp
object into her vagina. Within a week, Jasmine became very sick. When the pain started to
become severe, Jasmine knew that she would need medical assistance, but hesitated to ask
her husband to take her to the town hospital, because she did not know what explanation
to give to him. Her relationship with him was strained. She had heard that he was “seeing”
another woman because Jasmine had become “sickly”. So, Jasmine took some medicines
for fever bought from a local store, and kept quiet. A couple of days later. Jasmine died of
high fever, without receiving any medical hejp.
66
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
____ 1________ ______ _________________________ ___ ...
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Youij group has been given a flipchart with one of the following statements written in the
bottdm left corner:
1
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•
•
•
‘‘A woman with pre-eclampsia delivers at home and develops complications’’
‘ An adolescent girl dies of complications due to unsafe abortion’’
‘A woman who delivers at home has postpartum haemorrhage and is brought to the
hospital in shock”
‘A pregnant woman dies soon after arrival at the tertiary hospital due to prolonged
obstructed labour”
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You have 40 minutes in which to analyse the reasons underlying a negative health outcome
and to identify reasons that are related to gender and poverty. All charts will be put up and
discussed in the large group.
|timc: 25 minutes]
Starting with the statement (e.g. ‘A woman with pre-eclampsia delivers at home and develops
complications);, ask yourselves “But why?” Write the reason you come up with, on a bubble
drawn next to the statement on the big piece of paper. Keep asking “But why?” until
the line of argument is exhausted. Each reason has to flow directly from the one before,
and must be written directly next to the previous reason’s circle. Then begin again at the
original statement and explore another reason why the woman did not deliver in a health
facility. Each circle should contain a single specific issue. Do not use general terms such as
“culture” as a reason; articulate which aspect of culture is causing the problem.
The figure below illustrates a series of reasons why for a different problem.
Did not
know
about con
traceptives
No one will talk
about it
Did not use
contraception
Unwanted
adolescent pregnancy
We
There is no
service nearby
Health workers think it
is not correct to give
The family \ adolescents contraplanning clinic |
ceptives
will not see
adolescents
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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[time: 15 minutes]
•
•
Identity and circle in red factors that are related to.povcrty; and circle in blue factors
that arc related to gender.
Think through reasons why you have identified a reason as related to “gender” or to
“poverty’”. Write down your reasons on the chart paper.
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GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual lor a Learning Workshop
—---------- .
. . _ _____
w”
Article 1.
All human beings are born free and equal in dignity' and rights. They are endowed with
reason and conscience and should act towards one another in a spirit of brotherhood.
Article 2.
Everyone is entided to all the rights and freedoms set forth in this Declaration, without
distinction of any kind, such as race, colour, sex, language, religion, political or other opinion,
national or social origin, property, birth or other status. Furthermore, no distinction shall
be made on the basis of the political, jurisdictional or international status of the country or
terntory to which a person belongs, whether it be independent, trust, non-self-governing or
under any other limitation of sovereignty.
Article 3.
Everyone has the right to life, liberty and security’ of person.
Article 4.
No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited
in all their forms.
Article 5.
No one shall be subjected to torture or to cruel, inhuman or degrading treatment or
punishment.
Article 6.
Everyone has the right to recognition everywhere as a person before the law.
Article 7.
All are equal before the law and are entided without any discrimination to equal protection
of the law. All are entitled to equal protection against any discrimination in violation of this
declaration and against any incitement to such discrimination.
Article 8.
j.
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Everyone has the right to an effective remedy by the competent national tribunals for acts
violating the fundamental rights granted him by the constitution or by law.
J
Article 9.
No one shall be subjected to arbitrary arrest, detention or exile.
II
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual tor a Learning Workahop
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Article 10.
Everyone is entitled in full equality to a lair and public hearing by an independent and
impartial tribunal, in the determination ol his rights and obligations and of any criminal
charge against him.
I
Article 11.
I
(1) Everyone charged with a penal offence has the right to be presumed innocent until
proved guilty according to law in a public trial at which he has had all the guarantees
necessary for his defence.
(2) No one shall be held guilty of any penal offence on account of any act or omission
which did not constitute a penal offence, under national or international law, at the time
when it was committed. Nor shall a heavier penalty be imposed than the one that was
applicable at the time the penal offence was committed.
I
Article 12.
No one shall be subjected to arbitrary interference with his privacy, family, home or
correspondence, nor to attacks upon his honour and reputation. Everyone has the right to
the protection of the law against such interference or attacks.
Article 13.
(1) Hvcrvonc has rhe right to freedom of movement and residence within the borders of
each state.
(2) Everyone has rhe right to leave any country, including his own, and to return to his
count rv.
Article 14.
(1) Everyone has the right to seek and to enjoy in other countries asylum from
persecution.
(2) This right may not be invoked in the case of prosecutions genuinely arising from
non-political crimes or from acts contrary to the purposes and principles of the United
Nations.
Article 15.
(1) Everyone has the right to a nationality.
(2) No one shall be arbitrarily deprived of his nationality nor denied the right to change his
nationality.
Article 16.
(1) Men and women of full age, without any limitation due to race, nationality or religion,
have the right to marry and to found a family. They are entitled to equal rights as to marriage,
during marriage and at its dissolution.
(2) Marriage shall be entered into only with the free and full consent of the intending
spouses.
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............ ___________ _
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(3) The family is the natural and fundamental group unit of society and is entitled to
protection by society and the State.
Article 17.
(1) Everyone has the right to own property alone as well as in association with others.
(2) No one shall be arbitrarily deprived of his property.
Article 18.
Everyone has the right to freedom of thought, conscience and religion; this right includes
freedom to change his religion or belief, and freedom, either alone or in community with
others and in public or private, to manifest his religion or belief in teaching, practice, worship
and observance.
Article 19.
Everyone has the right to freedom of opinion and expression; this right includes freedom
to hold opinions without interference and to seek, receive and impart information and ideas
through any media and regardless of frontiers.
Article 20.
•11) Everyone has the right to freedom of peaceful assembly and association.
(2) No one may be compelled to belong to an association.
Article 21.
(1) Everyone has the right to take part in the government of his country, directly or through
freely chosen representatives.
I
(2) Everyone has tbie right of equal access to public service in his country.
(3) The will of the people shall be the basis of the authority of government; this will shall
be expressed in periodic and genuine elections which shall be by universal and equal suffrage
and shall be held by secret vote or by equivalent free voting procedures.
I
Article 22.
Everyone, as a member of society, has the right to social security and is entitled to
realization, through national effort and international co-operation and in accordance with
the organization and resources of each State, of die economic, social and cultural rights
indispensable for his dignity and the free development of his personality.
Article 23.
(1) Everyone has the right to work, to free choice of employment, to just and favourable
conditions of work and to protection against unemployment.
(2) Everyone, without any discrimination, has the right to <•<|iml pay I • »l < < |i i;il ■V' >11
(3) Everyone who works has the right to just and favourable rcmuncraiion ensuring
for himself and his family an existence worthy of human dignity, and supplemented, if
necessary, by other means of social protection.
GENDER AND RIGHTS IN REPRODUCTIVE AND MATERNAL HEALTH: Manual for a Learning Workshop
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(4) Everyone has the right to form and to join trade unions for the protection of his
interests.
Article 24.
Everyone has the right to rest and leisure, including reasonable limitation of working hours
and periodic holidays with paiv.’
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Article 25.
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(1) I'.vcryone has I he nghl lo a slandard of living adequate for the health and well-being of
iimself and of his family, including food, clothing, housing and medical care and necessary
social services, and the right to security in the event of unemployment, sickness, disability
widowhood, old age or other lack of livelihood in circumstances beyond his control.
(2) Motherhood and childhood are entitled to special care and assistance. All children
and assistance. All children.
whether born tn or out of wedlock, shall enjoy the same social protection.
f
Article 26.
(1) Everyone has the nght to education. Education shall be free, at least in the elementary and
fundamental stages. Elementary education shall be compulsory. Technical and professional
education shall be made generally available and higher education shall be equally accessibly
to all on the basis of merit.
Education shall be directed to the full development
of the human personality and to
develop
the strengthening of respect for human rights and fundamental freedoms. It shall promote
understanding, tolerance and tnendship among all.nations, racial or religious groups, and
s a further the activities of the L nited Nations for the maintenance of peace.
'3 Parents have a prior right to choose the kind of education that shall be given to their
children.
Article 27.
from a600"6
right tO th£ Pr°tection Of the moral and ^eiial interests resulting
from any scientific, literary or artistic production of which he is the author.
8
Article 28.
Everyone is entitled to a social and international order in which the rights and freedoms set
forth in this Declaration can be fully realized.
rreeaoms set
Article 29.
2) In the exercise of his nghts and freedoms, everyone shall be subject only to such
i—, „ m i,™, b,
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morality, public order and the general welfare in a democratic society.
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(3) These rights and freedoms may in no case be exercised contrary to the purposes and
pnnciples of the United Nations.
i P - and
Article 30.
any right to engage in any acti^ty or to^rfol^SeTat
of any of
the rights and freedoms set forth herein.
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Read the following case study and then evaluate its public health quality using the questions
to guide your thinking.
Case study
In this particular country, the health commissioner is concerned with preventing
heterosexual transmission of HIV/AIDS. She decides to add an HIV test to the
routine testing for sexually transmitted infections (STIs) given to sex workers every
three months. Sex workers are given a card to carry, which says they are disease-free..
If they are found to be infected with an STI, their card is temporarily revoked for a
three-month period. The HIV test will be added to the STI tests at the six-month
interval. If a woman is found to be HIV-infected, the card will be permanently
revoked.
Take 10 minutes to complete the public health analysis of this intervention. You may
discuss it with your neighbours if you wish. Ignore the rights aspects for the moment. Go
through the following steps:
•
•
•
Stale (he public hcallh problem being addressed.
State the goal of the proposed action.
Determine the public health quality' of this intervention. Is this good public health?
Will ii achieve the stated goals?
Bear in mind the various elements of a good public health intervention listed earlier in
the session: effectiveness, coverage, feasibility, cost, community' involvement. You should
consider all of these when determining the quality' of any public health policy or programme.
Once you have considered them for this analysis, identify the place on the horizontal axis of
the chart, “Four quadrants: The quality^ of human rights and public health in a programme”
which you think represents the public health value of the programme. Mark this point P.
After the whole-group discussion and voting on the public health quality of the intervention,
take 20 minutes to complete the human rights analysis of this same intervention. You may
discuss ibis wiih vour neighbours ilif \<>u wish. Ignore the public health aspects of this
nut ixt iiu<>n l«>i ili, iiHHih in
Look at the UDHR (starting with Article 1) and consider every right that is being
violated or promoted by this intervention.
Think through how exacdy' the right is being impacted upon in the short term as well
as in the long term.
Remember to consider for each right, government obligations to respect, protect and
fulfil it.
Recall the rights that can never be restricted (as discussed in Session 2).
•
•
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Pay attention to the severity, scope, frequency and duration of whatever violation you
see.
;
Once you have completed the analysis, identify the place on the vertical axis of the chart that
you think represents the human rights value of the programme. Mark this point Q.
Assessing the overall quT
-
Draw a vertical line through P and a horizontal line through Q. R, the point of intersection
of these .lines, represents the overall public health and human rights qualm- of the
intervention.
[
Four quadrants: The quality of human rights and public health in a
programme
3
£-
Excellent
£
i.
c
A
D
B
Poor
1
0
Poor
Sector explanations:
A: best case
B: need to improve HR quality
Excellent
C: need to improve PH quality
D: worst case, need to improve both PH and
HR quality
After this, there will be a whole-group discussion. You will vote to arrive at the point on
the vertical axis that represents the group’s consensus on the human rights quality of the
intervention. In this way, you will identify the quadrant the intervention fits into, which will
indicate the combined quality of its health and human rights components.
—L-,__________________
GENDER AND RIGHTS IN REP
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Indicator
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
f.8
1.9
2
2.1
2.2
2.3
2.4
2.5
2.6
Data needed & equations
Family Planning_______
Average birth interval
Contraceptive prevalence rate (modern
methods)_____________
New contraceptive acceptors annually
Contraceptive acceptance rate
Annual continuation rate
Crude birth rate
Age-specific fertility rate
Average number of children (live births)
born in last three years___________
Average age at first birth for women under
25 years
Number of pregnancy-related deaths
Number of maternal deaths
Maternal mortality ratio**
Percentage of women attended at least once
_ during pregnancy by trained personnel**
Percentage of births attended by trained
_ health personnel**_________
Availability of facilities providing essential
I obstetric care per 500 000 population**
Type
P I I
Months since last live birth _________
Number of women or partners using any modern method x 100
_________ Estimated number of women of reproductive age
Number of women or partners accepting a modern method during the
________________________ reference year
Number of women/partners accepting a method x 100
Estimated number ot women of reproductive age
Acceptors during the reference year continuing at the end of a year x 100
________
Total new acceptors
________
Number of births in the reference year x 1000
_________ Estimated mid-year population
Data Source
2
3
1 !
X
X
X
X
X
X
X
X
X
X
X
X
X
Number of births during the year to women within age group x 1000
__________Estimated number of women in the age group
X
Number of live births in last 3 years
'____ Estimated number of women of reproductive age
Age at first birth for women < 25 years old
Estimated number of women < 25 years old
____ Maternal_________ _______ __________
Deaths of women during pregnancy or within 42 days of termination of
pregnancy irrespective of the cause of death
Deaths of women during pregnancy or within 42 days of termination of
pregnancy from any cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes
Number of maternal deaths x 100 000
z
Estimated number of live births
Women attended at least once during pregnancy x 100
________ Estimated number of live births
Births attended by trained health personnel x 100
______________ Esq-mated number of live births____________
Number of facilities providing essential obstetric care
________________ ■500 000 population
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
r
k-
X
I
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f
Q
m
z
o
m
x
I
2.7
2.8
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X
Q
I X
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X
m
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x
O
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4
4
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Percentage of population living within 1 hour
travel time of health centre/hospital offering
essential obstetric care** _________ ______
Percentage of complicated obstetric cases
managed at essential obstetric care health
facilities**
2.9
2.10
2.11
Case fatality rate for obstetric
complications***___________ _
Caesarean deliveries as °/o of all births in the
population
__________
Prevalence of anaemia and moderate/severe
anaemia by gestation
•
2nd trimester anaemia moderate/severe
anaemia
•
3rd trimester anaemia moderate/severe
anaemia
Data Source
Type
Data needed & equations
Indicator
P I
Population living within 1 hour travel time to health facility x 1..QQ
Total population
X
1 _____ 2
X
Complicated cases managed in essential obstetric care facilities
_______ during the reference period x 100________
Estimated number of complications in the population during the reference
____________ period_________________ ____________
Number of maternal deaths due to direct obstetric causes x 1QQ
Number of direct obstetric complications
Number of caesarean deliveries in the reference period x 1QQ
Estimated number of live births in the reference period______
X
X
X
X
X
X
Percentage of pregnant women screened for
2.12
__________ syphilis_____________ _________
P = Process indicator, 1 = Impact indicator, 1 Service data, 2
I
X
X
X
3
X
X
Number of women in 2nd trimester with
Hb <1 Ig/dl
Hb <7g/dl
in 3rd trimester with
Hb <1 Ig/dl
Hb <7g/dl_________
_________
Estimated number of live births
Number of pregnant women screened for syphilis x 100
Estimated number of live births
X
X
Surveillance/routine reporting, 3 = Surveys
**S«9InZtorS to Monitor Maternal Health Goals: Report of a Technical Working Group. Geneva, World Health Organization, 1994, WHO/FHE/MSM/94.14.
**♦ This indicator refers to a given facility and should not be aggregated at the national level.
Apart from the quantitative data mentioned above, interviews and focus group discussions with mothers (possibly led by local women’s organizations) may complement the
findings of the suggested indicators.
_______________ _________ _____________________
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V-ur or,,up Ins IS nnnutcs io w„rk on one of ,1,,. f,,||„w,n,, f(ll||. p|.;1|,|(,ns
N,)mi|1.,k.
whole group. Your snnll group discussion shonkl
come to a close hve to ten minutes before the half-hour is up to allow time for the reporters
to write up their presentations.
1 •
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A new projeci
|
for the improvement of the reproductive health of adolescents is being!
initiated in your district. The project is planned for a three-year period. The objectives
are:
I
to promote condom use;
to prevent unsafe abortions; and
to promote postponement of child-bearing.
The following are some indicators routinely used for monitoring this project:
proportion of (sexually active) adolescent boys reporting condom use (this may be
hn lher refined, for example, lo specify regularity of condom use, access to condoms
or whether a condom was used in their most recent sexual encounter);
ln-19-year-olds as a proportion of all abortion-related obstetric and
gynaecology
admissions; and
ptoportiot, of women in the 15-19 age group who have had one or more children or
are current!}' pregnant.
Alter one or more of these indicators
or develop new ones so that they address gender/
rights dimensions.
Concern has been raised about the number of'maternal deaths reported in your area A
e-motherhood project aimed at reducing maternal deaths ever the next three years is to
be implemented very soon. The specific objectives are:
7
to prevent delay between the development of a serious complication in pregnanev and
reach,ng a health faeillw providing emergency obstetric care; and
'
to prevent delay within health facilities in initiating appropriate treatment.
The toJJocrjg
78
routinelr used
monitMing
I
proiecc
—
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Alter one or more of these indicators or develop new ones so that they address gender/
rights dimensions.
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In your province, more than 80% of contraceptive users have adopted female sterilization.
Your brief is to improve the quality of family-planning services offered in the five primary
health centres under your supervisioni over the next three years. You design a project that
aims to:
•
•
•
widen contraceptive choice for women and men;
improve follow-up services; and
improve client satisfaction.
The following are some indicators routinely used for monitoring this project:
•
•
•
percentage distribution of all contraceptive users, by method used;
proportion of contraceptive users reporting at least one follow-up contact with the
health facility or health worker; and
proportion of satisfied users at the end of X months following acceptance.
Alter one or more of these indicators or develop new ones so that they address gender/
rights dimensions.
i ”? work
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A new RTI/STI prevention and control project is being implemented in your health facility.
The objectives of the project are to:
•
•
•
improve awareness of the signs and symptoms of RTIs/STIs;
promote treatment seeking among those with symptoms of RTIs/STIs; and
encourage partner notification and treatment.
The following are some indicators routinely used for monitoring this project:
•
•
•
proportion of clinic users who arc aware of the symptoms of one or more RTI/STI;
number (and/or proportion) of clients seeking treatment for RTIs/STIs; and
proportion of clients (by sex) whose parmers have also sought treatment.
Alter one or more of these indicators or develop new ones so that they address gender/
rights dimensions.
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During your visit to the health facility, you will be working in four groups. Each group will
visit one specific health facility or different clinics within the same health facility.
Your task is to observe, and when needed, interact with clicnts/patients and health providers.
The aim is to gather details about the quality of health services, and the extent to which
gender and rights issues have been taken into account when planning for deliver}7 of health
services.
VCe would like each group to observe the following elements of quality of care (see table
below). You must write up a group report for presentation to the class the next morning.
This presentation should highlight:
a general description of what your group observed about the health facility and its
internal and external environment, staff presence, workload, and so on;
•
what was present and what was missing in terms of the quality-of-care elements
listed below; and
•
what needs to be done to make the clinic and the health facility addrc■css gender and
rights concerns.
I
The presentation should be no longer than 10 minutes. You can prepare a written report for
submitting to the facilitator and also transparencies or PowerPoint presentations.
Table: Elements of quality of care
Element
Definition of element: some examples
Client—provider
interaction
Takes into account the ways in which gender may cause vulnerability and risk, and
also affect treatment seeking and compliance
• Ensures privacy and confidentiality
• Respects patient’s dignity
• Treats all clients with respect, irrespective of clients’ social and economic
position
• Does not persuade or coerce client in any way
• Carries out a two-way conversation without being judgmental, and facilitates
informed decision-making
Information/
counselling for
client
80
• Information materials available
• Counsellor does not assume ignorance on the part of the client and acknowledges
the client’s own knowledge base
1 rivacy and confidentiality maintained during and after counselling
• Counsellor respects client’s culture and value systems
Counselling available to all (e.g. FP counselling not restricted only to married
women)
Counselling includes asking clients about issues related to gender roles and
norms, access to and control over resources, and decision-making power
• Topics covered in counselling include information on the nature of the problem,
ways to prevent it, treatment options available and treatment proposed by tbr
provider
T
• Sufficient time for provider to counsel client
i
Essential
supplies,
equipment and
medication
needed, plus
norms and
standards
■
Physical space well organized, with dear inslrut lions uvailal.h «.
p.ifh HI'. < >11
where to get what information
• Adequate waiting space
• Table, speculum, gloves
• Electricity, water supply, toilets (in working condition and not kicked up; lor
women and men
Consistent supply of drugs, supplies, and necessary equipment maintained
• Medications and supplies stored properly
• Proper disposal of bio-hazardous waste
Protocols for management available and prominently displayed
• Clinic organization takes into account the specific needs of women and men
because of gender and other social inequalities: e.g. clinic timings take into
account women’s workload and availability of transportation; special needs of
those without literacy skills taken care of: e.g. oral or pictorial instructions, local
language sign boards, help desk or someone available at reception to help
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You have been assigned to read, as homework, either a reading on costing a mother-baby
package in Uganda, or one on financing maternal and child health services in Bolivia.
For the reading on costing, think through and note down your responses to the following:
•
•
•
•
I
I
\X hat were the essential steps used in the mother-baby package costing study done in
I ganda? \\ hat was the range of services considered? Flow were the incremental costs
assessed?
\X hat were the current and incremental per capita costs for providing enhanced maternal
and newborn health services in Uganda?
XX hat were the main components of cost?
Do you have some idea of the current cost of maternal health care in your country^ If
only a small increment could be made in overall spending for maternal and newborn
health, where would you choose to put the additional money?
For the reading on financing maternal and child health services in Bolivia, think through and
note down your responses to the following:
•
•
•
XYhat was the mechanism for financing used?
XVhat potential implication does it have for increasing access to and utilization of
maternal health services?
Do participants have some concerns about this financing mechanism? What are they?
XXhat is the potential for implementing such innovations (or modified versions of
these) within their respective country settings?
Tomorrow you will be working in groups, and will share the main points you gathered from
the reading. [The group then prepares “group” answers to the questions above.]
You will not be required to make a formal presentation, but will be requested to contribute
to the large group discussion. The brief notes may then be submitted to the facilitator for
inclusion in the report.
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Many policies do not recognize differences between women and men. Some policies, which
we might call “gender-unequal”, actually privilege men’s well-being over women’s. These arc
policies that directly deny women’s rights or give men rights and opportunities that women
do not have. For example, a policy that denies a married woman the right to medical
insurance in her own name makes her dependent on her husband for access to medical
insurance. If her husband is unemployed, then she (in addition to her husband) is denied
access to medical insurance. A policy that requires a man’s consent before a woman can be
sterilized is also gender-unequal in that it deliberately gives men power over women. This
approach is not given in the table in the hand-out, but if there are such health policies in
your country, you could include this approach.
Gender-blind policy is blind to gender differences in the allocation of roles and resources.
Thus, what may appear to be a good policy - for example, one that brings clinics close to
peoples homes - may not impact equally on men and women. ’This is because women
may not control transport to reach the clinic, or may not have funds to pay for services. A
recruitment policy that gives both educational levels and years of experience as its criteria
may seem to be a fair policy. However, it does not recognize that, while certain women maxhave good work experience and competence, they may not have had the same opportunities
as men for formal education, and the policy will discriminate against women. I •or this
reason we can call it gender-blind — not intentionally discriminatory, but reinforcing gender
discrimination nevertheless.
Gender-specific policy is aware of the practical gender needs of women and men, and tries
to address them. For example, it could involve creating a separate outpatients area run
by women doctors for women patients so that they can discuss their reproductive health
problems freely. Alternatively, it could involve designing educational interventions to help
adolescent boys deal with peer pressure in smoking or consuming alcohol.
I
Gcndcr-rcdistributive policy tries to change the allocation of roles, resources and power
between men and women in society. I'or example, this could mean raising awareness among
men of the reproductive health consequences of women’s work burden and the problems
of repeated pregnancy. It could mean promoting male methods of coniracepiic >n, including
i'nvestment in research on male methods of contraception.
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In this table, each column represents a different policy approach to gender. Below the table,
there is a list of different policies. Decide where each policy fits in the table and fill in its
number under the appropriate column.
Gender-unequal
Gender-blind
Gender-specific
Gender-redistributive
(1) Maternal health policy: trains midwives to improve their clinical skills to prevent
maternal morbidity and mortality.
(2) Water supply policy: establishes a mechanism to provide taps close to villages so that
women will not have to walk as far to fetch water.
(3) Human resource policy: includes provision for child care facility at the workplace.
(4) Land policy: removes restrictions on women’s right to inherit land.
(5) Occupational health policy: protects women and men from working in places that are
hazardous to their reproductive health.
(6) Seni<>r management recruitment policy in a department of health: requires all managers
to have a PhD.
I
(7) (.ommuniiy-based AIDS care programme: savs that the health care system cannot
take responsibility for caring for people with AIDS so that home-based care must be
instituted.
(8) Information, education and communication (IEC) policy: establishes messages and
methods to advocate to women and men about mutual respect and equal rights in
sexual decision-making as a means of promoting safer sex practices.
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[A slightly simpler version of this framework was originally published in IClugman B. Mainstreaming gender
equality in health polity. Agenda, 1999: 48-70.]
This framework draws on some of the key conceptual developments in policy analysis
over the last decade. In particular, it draws on Walt and Gilson’s [1] recognition of the role
of context; actors and political process in influencing policy content, and on Kingdon’s
[2] conceptualization of the existence of “multiple streams” of problems, solutions and
politics and the need for “policy entrepreneurs” to create links between these streams.
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CONTEXT
i.
activists
Problem
identification
'.
ACTORS
1
Solution
development
.
/
Political and bureaucratic
preess
o
CONTENT defined in
POLICY and through “
IMPLEMENTATION
<■
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Context can be divided into:
•
social context (e.g. position of women, level of educational attainment in society, social
stratification);
•
political context (e.g. nature of political regime, role of civil society, political participation
of women);
•
economic context (e.g. nature of economy, resource base, whether equity is a priority in
resource allocation);
cultural context ( e.g. predominant values and norms on gender, reproduction and
sexuality, and extent to which inequalities including gender are institutionalized);
immediate context (e.g. recent change in government and related ideological shifts,
recent international agreements such as the Convention on the I Jimination of all forms
of Discrimination Against Women (CEDAW) or the ICPD Programme of Action);
and
•
•
•
international context (e.g. proportion of partner funds in national budget, bargaining
power within the global geopolitics).
An issue may be identified as important and as deserving attention in some specific contexts
and not in others. Also, contextual factors play a major role in influencing whether a policy
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initiative finds a great deal of support or opposition, or receives no attention at all. Any
attempt at influencing policy therefore should analyse the nature of contextual factors at
anv given point in time.
In order to develop a coherent strategy, it is essential to identify which actors or stakeholders
share your goals for policy change, and which are against them. Which of these have power
or inliuciK*e and which do not? Which are mobilized and which arc not? Could certain
groups be mobilized in support of your goal? Some examples of actors in the policy
development or implementation process include:
politicians and political parties;
government officials;
NGOs;
community groupings/“people’s organizations ;
specific constituencies (e.g. professional organizations, religious organizations),
the media; and
research institutions.
Some of these actors will support a policy or implementation goal, while others will oppose
it. Some will have more resources and power than others, and will therefore have more
influence. Some will be mobilized and others will not. An analysis^of actors is necessary
to identify potential allies and opponents, who could be mobilized in support of a specific
change process, and their resources or lack thereof. Specific strategies need to be identified
so as to work with those who support the policy and to deal with those who do not.*
brequcntly, women arc not mobilized into organizations that make their voices heard. Jt is
important to identify whether or not there are any organizations of poor or marginalized
women and how to support their participation in a change process.
The framework identifies the process of problem identification as very significant in
ensuring that the final policy and its implementation are aimed at promoting social and
gender equity. When people who do not have the interests of the majority at heart define
•,i probk ni, the problem definition may not recognize the specific interests of the majority.
Mmir.iK-nminggender in hcaltli means making sure lhat women’s perspectives, experiences
;n id pi im ii i<■.hapc problem def initions. It means focusing on equity - putting the needs of
ih< »•.< wh«» an mo-.i dr.advai 11 aged first, whet her these are children, women, men or specific
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The following box highlights issues related to the process of problem identification and
(k finiiion. These need io be taken into consideration when looking at how a policy came
about, or when attempting to plan a policy or implementation intervention. Again, it uses
the South African experience in order to show how the issue of abortion was first identified
as a problem, in order to get it on to the political agenda.
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Box 1: Problem identification: whose problems?
Who defines the problem?
• Need to ensure that ordinary people’s perspectives - women’s, men’s, adolescents’ (and
within this, marginalized groupings of men, women and adolescents) - are heard and
that legislation and programmes are designed to meet their needs, as they perceive
them.
•
Need to ensure that inequality does not silence the experience or the voices of certain
groupings, for example, poor women who are either not recognized as having the right
to input, or who do not have the confidence to express their views.
•
Need to ensure that the way the problem is defined identifies and addresses how the
issue impacts specifically on poor women’s position in society, as well as their daily life
experience. Focal issues, as raised in the Gender module, are their power, their roles,
their access to and control over resources.
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r<>’:
There are many institutions in society, such as universities, private sector bodies, and
government technical staff, whose task is to develop solutions to society’s problems. There
are often many different ways of solving a problem. It is important to look at what the
solutions tabled were, who tabled them, why, and whose interests they represent, in trying
to understand how a policy was developed.
Solutions need to address equality - to ensure that barriers to the sexual and reproductive
rights of those with the least power and resources, notably women, are addressed. Solutions
need to address equity - to ensure that the policy or programme applies to all people, and
will be implemented in such a way that the inequalities in the allocation of resources and
power between men and women and between different social groups are reversed.
It is essential to establish mechanisms during the process of advocacy to gather information
about how those who are poorest or suffer discrimination experience the issue, and what
sorts of solutions would improve their overall situation.
Frequently, neither problem identification nor solution development is carried out in a way
that involves those experiencing the problem. Rather, it often addresses the interests of
particular interest groups, such as:
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consultants wanting to do more research;
politicians wanting to maintain their political support; and
donors wanting to support a programme that fits their country’s policies or their
institution’s values: for example, a vertical programme providing only contraception
• services, or only sexually transmitted disease services, irrespective of the impact on
ordinary people.
Who is responsible for.making and implementing legislation or policy in a specific country,
arJa or workplace?
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In the context of a country, this would include:
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poliiiciuns;
goveninienl al dillcreni levels andall bodies responsible for implementing the legislation
or policy; and
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others in a “policy elite” such as powerful business people or
religious leaders.
(itindlc and I lioinas |3| have identified lour dillcreni concerns that seem to be the major
factors that influence decisions made by politicians and senior government officials. These
are:
•
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the meaning of change for political stability and political support;
the technical advice they receive;
their relationships with international actors; and
the impact of their choices on bureaucratic interactions, i.e. how policy or implementation
decisions affect their power at work, their levels of responsibility, and so on.
It is important to work out what factors influence those who arc in power, so that advocacy
activities address their concerns, in a language that they understand.
References
7.
2.
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Walt G., Gilson L. Reforming the health sector in developing countries: the centra! role ofpolicy analysis. Health Po/icx’
and Planning, 1994,9(4): 355-370.
’
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Kingdon J. Agendas, alternatives
anenicitirvs andpnldicpolicies.
andpublicpolicies. New York, HaiperCollins,
l\aiperCollins, 1995.
2.™*/'n
cho'a‘S’ ‘""lP°‘“y
>h‘ political mmmj of reform in developing
countries. Policy Sciences, 1989, 22:213-248.
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Youj need to plan an intervention to reduce morbidity and mortality related to pregnancy
and child birth, or to improve accessibility, availability, affordability and quality of health
services related to making pregnancy safer. The intervention must address gender and rights
concerns. You ma}' choose to carry out one limited activity or an intervention consisting
of several components.
(1) Think of an area of your work in which you think it will be possible for you to implement
an intervention that fulfils the objectives stated above.
(2) Define your goal. What exactly do you want to achieve/change?
(3) Mention the major steps of the intervention(s) chosen to achieve the above goal. The
time line for this intervention can be kept at one year, to begin with.
(4) Analyse the situation within your institution. Who or what will support your cause?
Develop a plan to involve these supporters in your intervention at some level. For
example, if you know of a colleague from another department who may be supportive,
make it a point to consult with this person and keep him/her informed < >f developments.
You could think of constituting an advisory group, il making (his formal would help.
Include these steps in your intervention. Who will oppose it, or what factors will act
as barriers? You may want to go back and modify the intervention accordingly. For
example, if you know that some colleagues will oppose it, you may want to think
through how this opposition can be neutralized.
(5) List also potential allies outside your institution with whom it wonk] be important
to network. Develop your alliance or network, and set up mechanisms (committees,
regular meetings or e-group forming) to keep them informed. Include these in your
major steps identified above.
(6) To summarize, your final plan should contain the following:
AREA OF WORK
GOAL
INTERVENTION STEPS PLANNED
ALLIES/POTENTIAL SOURCES OF RESISTANCE WITHIN YOUR
ORGANIZATION
I-XTI-RNAI, ALIJ ANCES/NI•T\X,( )RKS
Write these up in poster format.
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This hand-out is to be distributed during Session 1 on Day 0.
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