Why Gender?

“Gender shapes the lives of all people in all societies.  It influences all aspects of our lives, the schooling we receive, the social roles we play, and the power and authority we command.  Population processes – where women and men live, how they bear and rear children, and how they die – are shaped by gender as well” (Riley, 1997).

Discourses on gender and development (GAD) suggest that the concept of ‘gender’ can be discussed at two levels: descriptive and analytical - the  former, referring to the social differences between women and men which vary with factors such as class, caste, ethnicity, religion, age and time; the latter, pertaining to the socially constructed and constituted power relationship between men and women in which women are subordinated by men.

As a concept, it evolved from a critique of Women in Development (WID) approaches which were concerned essentially with equity, anti-poverty and efficiency measures in development programmes and processes as a way of addressing women’s subordinate status.

By emphasizing the need to define development from gender perspective and by situating the analysis of women’s subordination within a framework of social relations, the GAD approach seeks to challenge institutions, organizations and practices that subordinate women (GAD Programme, APDC, 1997).

The WID approach focuses exclusively on women to improve women’s unequal position, whereas the GAD approach recognizes that improvement in women’s status requires analysis of the relations between men and women, as well as, the cooperation of men.  Emphasis is placed on the need to understand the ways in which unequal relations between men and women have contributed to the extent and forms of exclusion that women face in the development process.

Central to the GAD approach is the empowerment of women and conscientisation  of men in bringing about change in gender relations, particularly in the balance of power between women and men.

Gender analysis allows for a more realistic assessment of the roles, needs and participation of women and men in the development process not merely as passive recipients of global, national and local interventions, but as actors with definite strategies of transformation.

A gender sensitive approach emphasizes the need to probe deeper into sectors such as health, family planning and population and identify what are women’s and men’s realities, perspectives and needs and evolve strategies to integrate these into macro and micro-planning and the implementation process.  The approach also acknowledges the need for women in particular, (especially the poor and disadvantaged) to be active participants in shaping the direction of the transformation process and in so doing, they should acquire the necessary expertise, knowledge and skills for better access to benefits and resources.

Gender sensitive planning is not merely a checklist of actions.  It  needs to critically re-examine the planning process, and the interlinking of sectors, the participation and involvement of women’s groups, academicians, practitioners, researchers, etc.  It means breaking old barriers between professionals and field workers; between bureaucrats and the common people.  Achieving gender sensitivity will begin with our own lives, the linkages we forge and the ways we work.  Gender sensitivity entails changing the mind-set, challenging our own thinking, challenging dominant thinking that decides how society is organized, how resources are allocated and how power is shared.

In the context of population programmes, gender sensitization involves willingness to re-examine concepts, assumptions and goals of current health and population policies and programmes.   It means a constructive critique of an organization’s approaches, structures and processes in conceptualizing programmes, in planning, implementing, monitoring and evaluation.

ICOMP and Gender Advocacy

ICOMP was a latecomer in giving emphasis to women’s issues and interests in its programme for it was only in 1984 that it formally established a women in development (WID) programme and referred to it as special projects.  The WID programme, however, did not try to influence the shaping of a Family Planning (FP) programme in a manner that deals with gender concerns.  Rather, it focused on:  (1)  leadership and management development programmes for NGOs; community-based and grassroots women leaders; (2)  organizational capacity development for NGOs devoted to women’s economic and social needs, and (3)  enhancement of management and employment skills of poor women.

However, from 1990, the awareness of the need for FP and population programmes to look at the concerns and situations of women in relation to men began to be raised in various international and regional conferences.

In 1990, ICOMP’s international conference focused on the theme, ‘Strategy of Quality Services Delivery in Population Programme’.  Judith Bruce (known widely for developing quality of care framework) presented a paper on “Women’s Interests:  How Can Family Planning Managers Respond?”.

In her paper, she emphasized that women’s interests serve to highlight one dimension that has been absent in much of FP, contraceptive and reproductive health literature that is, women’s individual and group power.  Specifically, Judith Bruce stressed the following situations:

  The disadvantaged position of women in terms of choice over contraception and number of children they wish to bear.
  Men’s and women’s power in family and sexual relations as an essential determinant of the acceptability and usability of contraceptive technologies and service delivery approaches.
  Gender-based differences in authority between providers at different levels (among themselves) and with their clients.

If women’s interests are to be served, therefore, women need to be empowered in three domains:

1. Scope of choice about sexual activity and child-bearing,
2. Knowledge of reproduction and their information about and access to service, and
3. Intimate negotiations about sexual and contraceptive matters.

a. To analyze the demographic, social and economic characteristics of the client in more realistic terms taking into account living arrangements, partnership status, nature of their work, work load, geographic mobility, time use, fertility; and

b. To adopt an integrated picture of women’s health, particularly as it relates to reproductive choices.

In the regional seminar on ‘NGO Management and Family Planning from Women’s Perspectives’ (November 1991, ICOMP/Danish FPA/Bangladesh FPA) the various roles of women as service providers, operational workers and administrators and at the same time recipients of contraceptive services, contributing to FP were underscored.  However, it was also noted that women as decision makers or planners in FP programmes and women’s autonomy in making decisions about FP and reproductive behaviour is lacking or absent.  Moreover poor, marginalized women lack information/knowledge on FP and have less access to contraceptive services.

Other concerns expressed at the seminar pointed to the lack of men’s responsibility for fertility regulation, emphasis on family planning alone rather than the totality of women’s health and inadequate attention to quality of care.

Similar concerns were raised at subsequent international conferences organized by ICOMP.  During the 13th international conference in 1993 on ‘Managing a New Generation of Population Programmes – Challenges of the Nineties’, one of the major themes was ‘Managing Gender Sensitive FP Programmes’.  The issue paper presented underscored that gender sensitivity and responsiveness would entail the following (Dairiam, 1993):

1.  A clear understanding of women’s situation, that is, low social and economic status, frequently pregnant, disempowered, unable to make a choice of the number and spacing of children.
2. Locate contraceptive services within a reproductive health approach.
3. Broaden the concept of unmet needs so that women and men of  reproductive age regardless of marital status have access to contraceptive service.
4. Facilitate reproductive choice and access to quality services for women.
5. Programme concerns should focus not only to help women control their pregnancy within existing gender relations but also to change these relations through the following:

   help women cope with men’s resistance to FP,
   encourage men’s responsibility for fertility control, and
   direct efforts towards empowering women and reducing  gender inequality.

At ICOMP’s 14th international seminar (in December 1996, Addis Ababa, Ethiopia) on Managing Quality Reproductive Health Programmes:  After Cairo and Beyond, one major theme discussed was Addressing Gender Sensitivity and Enhancing Male Involvement in Quality Reproductive Health (RH) Programmes.  Based on the deliberations, one could discern a general understanding by the participants of what the gender concerns are.  However, there were still a few who openly expressed the sentiment that women’s empowerment would lead to men’s subordination; that gender is ‘new’ and therefore one is not sure of how to respond to it or that yes, we understand your (women’s) point, but it’s difficult to put ‘gender into practice’.

What emerges from current discourses on gender is that there is still a lack of conceptual understanding of what is gender and gender equality, what are the gender issues in reproductive health, how can programmes respond to these concerns, and perhaps, the more important question is how does one achieve the mental shift that is so required in becoming gender sensitive.

The Promises of Cairo

One needs to look back to the Cairo conference, reiterate the gains made and be guided by the Programme of Action (POA).

The Cairo conference achieved consensus in its recognition of women’s empowerment as the key to improving the quality of life for all.  An entire chapter, Chapter 4 of the Programme of Action is devoted to “gender equality, equity and empowerment of women.”  This recognizes the principle that women can exercise their reproductive rights only when they are empowered to do so.  Women’s economic rights, political rights, and reproductive rights must thus be addressed as an integrated whole. (Heyzer, 1996).   The chapter emphasized the need for the full participation and partnership of both women and men in productive and reproductive life, involving shared responsibilities for the care and monitoring of children and maintenance of the household. It also underscores the fact that “In all parts of the world, women are facing threats to their lives, health and well-being as a result of being overburdened with work and their lack of power and influence.”  Change is therefore required to improve the status of women by providing access to secure livelihood and economic resources as well as by raising social awareness through an effective programme of education and training.  Improving the status of women also enhances their decision-making capacity at all levels in all spheres of life, especially in matters of sexuality and reproduction.  Experience shows that population and development programmes are most effective when steps are taken to improve the status of women.

Cairo placed women at the centre of population policies and called for investments in improving the reproductive health of women, in girls’ and women’s education, in infrastructure to lighten women’s work loads and in widening employment opportunities for women, among other accomplishments.  The Conference emphasized the need for countries to invest in human development (Danguilan, 1997).

The POA is a very progressive document which recognizes that eliminating gender inequality is the key to improving health, reducing poverty and empowering women and is the main factor influencing fertility and population growth.  It is time to take on the challenge of reorienting health, population and family planning organizations, government, NGOs and donors, by including women’s and gender perspectives in their policies and programmes and implementing the recommendations of the ICPD in Cairo (ARROW, 1996).

The Cairo document has made bold and broad, far-reaching recommendations regarding RH of women and gender equality in the context of population and sustainable development.  At the conceptual level, the POA presents a new, and dynamic perception of RH which encompasses a range of services. RH is to be seen and delivered as part of  primary health care and the primary health care system.

The incorporation of the life-cycle approach to RH is another important conceptual advance.  Thus, the POA lays down objectives which are aimed at meeting the changing RH needs of women, men, adolescents, older men and women (keeping in mind that older women generally have a lower socio-economic status than elderly men).

The POA also reaffirms universally recognized human rights standards in all aspects of population programmes.  Paragraph 7.3 states that reproductive health embraces certain guiding principles of human rights such as the freedom from coercion and violence that should be guaranteed to both men and women when making decisions regarding reproduction.

The Beijing Declaration adopted at the Fourth World Conference on Women in 1995 stressed that “the explicit recognition and reaffirmation of the right of all women to control all aspects of their health, in particular, their own fertility, is basic to empowerment”.  The Platform of Action calls upon governments and other actors to promote an active and visible policy of mainstreaming a gender perspective in all policies and programmes.

In the section Actions to be taken of the above document, it states “Design and implement, in co-operation with women and community-based organizations, gender sensitive health programmes…..that address the needs of women throughout their lives and take into account their multiple roles and responsibilities, the demands of their time, the special needs of rural women and women with disabilities and the diversity of women’s needs arising from age and socio-economic and cultural differences, among others.

Summing up, one therefore needs to bring together the new perspectives on sexual and reproductive health and women’s empowerment obtained at Cairo and Beijing, and the commitments made by national governments in the declarations of both conferences and based on these, rethink and reorient health sector strategies (Sida, 1997).

Operationalizing Gender Perspective in Reproductive Health

The Handbook for Mainstreaming : A Gender Perspective in the Health Sector produced by Sida offers possible themes of a health strategy with a gender perspective:

   clear recognition that gender-based discrimination and inequality are contributing factors to women’s health needs and problems and that an  effective and equitable health strategy must therefore respond to the manifestations and consequences of these social patterns and support women’s empowerment;
   better gender-disaggregated data and research to provide a more accurate assessment for planning purposes of health problems, needs and use of health services;
   strategies for health care delivery that respond to gender-based differences in health problems and access to health services, and that consider women’s concerns and needs as individuals as well as in relation to children and childbirth;
   strategies that target men as well as women for activities related to child health, fertility regulation and safe sexual practices, and that recognize men’s rights and responsibilities in these areas;
   recognition that women provide most of the paid and unpaid health care in society by expanding women’s role in decision making about policies and priorities at national level and within communities;
   health sector policies that result in an equitable distribution of the costs and benefits of investments and approaches to health care provision at both national and community levels;
   identification of ways in which the health authorities can support the initiatives of other agencies that create the conditions for health, with particular benefit to women : such as investments in water and sanitation; food security policies that target women’s food crops for extension services and productivity enhancement etc.

UNFPA has embarked in a process of assisting countries to institutionalize the concept of reproductive health through implementation of programmes integrated in primary health care systems.  In a meeting held to bring together experts involved in such a process, issues pertinent to operationalizing the concept of reproductive health were deliberated.

One issue was incorporating gender concerns in the design and implementation of reproductive health programmes.  Translated into more concrete terms, this would mean responsiveness to client needs and reproductive health conditions, women's empowerment, gender-specific data collection, institutionalizing the role of women's organizations and understanding of attitudes and practices concerning reproductive health as well as gender roles (UNFPA, 1996).

Empowerment of Women	Empowers women to understand factors and forces that shape women’s health status.  Empowers women to control their fertility.  Enables women to make reproductive choice.
Holistic Approach to Health Needs	Views women in the totality of their health needs,  particularly reproductive health, arising from their multiple roles in society.
Enhancement of Men’s  Responsibility	Encourages men to assume responsibility on birth  control and unwanted pregnancies.  Encourages men to assume responsible sexual  behaviour.  Encourages men to support women’s contraceptive use.  Encourages men to share responsibility in child rearing and care and housework.  Facilitates promotion of gender equality and mutual  respect.
Quality of Care	High-quality, comprehensive, women-centered services based on women’s needs and choices to improve their health.  No targets, incentives, or disincentives.  Set up an effective information system for individual client identification, follow-up and remotivation to enable sustained contraceptive use and to obtain client feedback.
Wide and Comprehensive	Range of services to include – contraception, infertility, breast-feeding, STDs, RTIs, HIV/AIDs, cancer screening, violence against women.  Service provision to women throughout their life cycle – married women, unmarried women, adolescents, older women, menopausal women.
Information  and Education  for Empowerment	nformation and education to women so that they are able to exert control of their bodies (e.g. control over the risk of STDs, able to negotiate with men to use condoms to avoid pregnancy, prevent the risk of STD/HIV.)  Information and education to enable women to understand the changes within themselves and their bodies as they pass through various phases of the reproductive cycle.  Education for men to instill joint responsibility for  reproductive functions including care of children.
Reaching Out to Men	Package of interventions to reach out to men (e.g. FP for men, STDs, HIV/AIDs education, infertility.)  IEC programme tailored to men (e.g. on reproduction and sexuality, male involvement and gender equality.)  Train health providers on counselling male clients and couples in RH.  Male FP motivators, providers, counsellors, community-based health workers.  Education and services for young men.  Research on male knowledge, attitudes and practices, male contraceptive methods and effective interventions.

 Given the wide range of possibilities of incorporating or integrating gender in reproductive health, the tables below attempt to illustrate how a gender sensitive RH programme may be conceptualized.

Four Cases of Innovations

In this issue of Innovations, we feature four cases which describe efforts toward making reproductive health programmes and services gender sensitive and responsive.  The South African experience involves essentially a transformation of the country's reproductive health services within a setting where profound political changes are taking place.  The project, referred to as the Transformation of Reproductive Health Services Project, (TRHSP) which started in December 1995, was a "process of transforming, strengthening, and improving the system for providing comprehensive reproductive health care services, integrated into primary health care as appropriate, and for enhancing the capacity of the health workers to be able to operationalise the system.  It was based upon five underlying principles, namely: 1) research-based implementation; 2) participatory approach in research and implementation aspects, 3) change management approach; 4) capacity-building in health services and 5) mainstreaming gender for identification of and development of strategies to address the impact of inequality between women and men on health services and users.

The outcomes of these interventions included a clearer definition of reproductive health, a renewed commitment to the health system, a provider voice within the system, creation of an environment for hearing clients' views, and incorporation of gender.

The Women's Health Project, a non-government organization under the Department of Community Health, University of Witwatersrand Medical School, served as the executive agency of the TRHSP.  In October 1997, it was awarded the Commonwealth Award for Excellence in Women's Health, for being a model of good practice relevant to women's health.  The award seeks to highlight the development of approaches which address the health disadvantages of women.

In a conservative society where social and cultural taboos prevent an open discussion of topics related to sexuality and sexual behaviour, the Karachi Reproductive Health Project, sought to break new grounds.  The project has trained women in urban poor communities to provide awareness, referral and counselling services within the communities.  Named community focal persons, they serve as a bridge between the local women and local health practitioners and the health system as a whole.  It also seeks to support the local health system so that it is better  able to respond to the sexual needs of the local women by training them on topics such as HIV/AIDS, STDs, psycho-sexual issues, vaginal discharge, and other related topics.

The pilot project in the Philippines sought to enhance the gender sensitivity and gender responsiveness of family planning and other health services of a government rural health unit and a community-based health and development programme of an non-government organization.  Through a process of sensitizing programme heads, field managers and front line workers to the concerns and issues of a gender responsive family planning programme, needed changes and interventions in  programmes, were brought about, carried through and sustained.  Hence, action plans were formulated which essentially mainstreamed gender in the respective projects, activities and services.  Much can be learned from this pilot project in terms of the dimension, strategy, approach and process of promoting gender responsiveness of family planning and health programmes.  The pilot project was selected as one success story in the area of Gender and Development by the Commission on Population in the Philippines for its effectiveness in promoting gender equity, sustainability and a participatory approach.

Women's Health Committees were established in villages served by a primary health centre in India in an effort to enhance the involvement of women in government health programmes and their participation in decision making at the local level.  A major strategy adopted was the sensitization and education of committee members. 

Bruce, Judith, "Women's Interests:  How Can Family Planning Managers Respond", in Anrudh K Jain (ed), Managing Quality of Care in Population Programs, Kumarian Press,1992.

Dairiam, Shanti, "Managing Gender Sensitive Family Planning Services", in Jay Satia, Carl Schonmeyr and Sharifah Tahir (eds).  Managing a New Generation of Population Programmes:  Challenges of the Nineties, Report from ICOMP's 13th International Seminar, Nanjing, China, 3-7 August 1992.

Danguilan, Marilen J MD, Women in Brackets, The Philippines Center for Investigative Journalism, Manila, Philippines, 1997.

Gender Training in the Asian and Pacific Region, Issues in Gender and Development, Gender and Development Programme, APDC, No 9, August 1997.

Heyzer, Noeleen, The Balancing Act:  Population, Development, and Women in an Era of Globalization, International Lecture Series on Population Issues, The John D and Catherine T MacArthur Foundation, August 29, 1996, New Delhi, India.

"Monitoring Concrete Changes after ICPD", ARROWS For Change,  December 1996 Vol. 2, 20.3.

Riley, Nancy E "Gender, Power, and Population Change", Population Bulletin, Vol. 52, No 1, May 1997.

Swedish International Development Cooperation Agency (Sida), Handbook for Mainstreaming.  A Gender Perspective in the Health Sector, Department for Democracy and Social Development, Health Division, 1997.

UNFPA, Technical Report No 37, "Expert Consultation on Operationalizing Reproductive Health Programmes", December 1996.