Gender and Health Status

Health status and improvement is a function of a multiplicity of factors, as well summarized in the Alma Ata declaration (WHO-UNICEF, 1987).   One powerful determinant of health status is social class (Townsend et al, 1988; Gould and LeRoy, 1988; Ebrahim, 1982) .  Social class itself is a composite consisting frequently of occupation, education and income and has also been measured by access to various resources (Bertrand et al, 1988; Liberatos et al, 1988).

Women’s status in society is one of the most important factors which determine their access to employment, education, income, land and commodities and thus the health status that they enjoy.  Further than this, moving from the societal level to the household level, studies have looked at intra-household distribution of income, food, labour, responsibility and decision making (Charlton, 1984; Goldschmidt-Clermont, 1987).  They identify women as being responsible for food production and preparation and the nutritional status of their families.  However, women have limited decision making power over the distribution of household goods and income.  Cash income is usually controlled by men.  Women perform long hours of work in households.  In Africa as in other poor countries, a significant amount of this time is spent in fetching water and fuel, with little time for their own personal health, recreation or development.  In extreme situations, this goes as far as women being deprived of food because the men and children eat first.

Since 1976 there has been increased attention to women’s status, women’s work, women’s role in society and the relationship between development, women’s role in society and health (WHO, 1985).   What has become increasingly clear is that women’s low social status has an important impact on women’s health status.  This is clearly illustrated when considering reproductive health.  Reproductive choices, whether and when to have sex and with whom, when to have children, when not to have children and methods of preventing or terminating pregnancies are issues specific to women but are often determined by factors outside of women’s control.  At the community or national level, the degree of  control women have and the degree to which society and health services are organized to meet their health needs are determined by laws and resource allocation decisions.  At the individual level, gender roles ascribed to individuals, what gives women and men legitimacy and status, will often determine how women utilize services that are available to them.  To adequately address reproductive health, an understanding of gender is essential.  Thus, the “Transformation of Reproductive Health Services Project” undertook to ensure that an understanding of gender differences and its impact on health and health care services was included in the intervention to develop reproductive health services in three provinces in South Africa.

The Context of the Transformation Project

The Transformation of Reproductive Health Services Project (TRHSP) concept was presented to the National Director General for Health of South Africa.  She presented it to a meeting of the provincial health departments after which an intervention was agreed to between the Women’s Health Project and the health departments of three of the nine provinces in South Africa.  The timing of this intervention is not coincidental.  In 1994, the first democratic elections were held in South Africa.  This created the opportunity for a reassessment of all government policies and programmes.  The framework for this is established by the new Constitution (Constitutional Assembly 1996).  Critical components of the Bill of Rights include the right to equality – including freedom from discrimination on the basis of gender, sex, pregnancy, marital status and sexual orientation; the right to freedom and security of the person, including the right to be free from all forms of violence from either public or private sources, the right to security in and control over the body, the right to make decisions concerning reproduction; and the right to health care including the right to have access to health care services, including reproductive health care.  While this moment in South Africa’s history may be relatively unique, internationally, the International Conference on Population and Development (Cairo 1994) and the Fourth World Conference on Women (Beijing 1995) and the commitment of governments (including South Africa) to the platform and plan of action of these two international meetings offers an opportunity to begin addressing similar issues in many countries.  The desired situation which the South African health sector is trying to move into is similar to many other countries in Africa and further afield.  South Africa’s starting point is one of disorganized and fragmented services, low morale among health sector staff, poor people, low literacy levels, especially among rural women, inadequate infrastructure such as roads, transport, water and electricity supply.

Within the South African health sector, there have been significant interventions to improve access to health care by moving the country towards a district based primary health care system.  Incorporated in this is the notion that comprehensive services, including reproductive health services should be available at primary level.  South Africa has  also  demonstrated  a commitment to women’s health, for example, maternal health  has been identified as a priority.  The “Presidential Lead Projects” announced by President Mandela soon after his inauguration included free health care to all pregnant and lactating women and children under five.  South Africa, at a broad policy level, is committed to improving the health status of women.  Perhaps the most obvious example of the commitment to women’s health is the passing of the Choice on Termination of Pregnancy Act which recognizes the exclusive right of women to make decisions about their bodies.  At a policy level, there is significant change.  However, this has yet to be translated into practice on the ground.  It is within this context that the TRHSP was initiated.

The TRHSP basically adopted two strategies.  Firstly, to collect a body of information for health system development towards achieving reproductive health.  Secondly, to collect information through a process which facilitates an openness to change among health service personnel.  The TRHSP utilized various rapid appraisal tools to collect information on the state of the current health service.  The data was collected from diverse stakeholders ranging from rural women, to providers in rural clinics to the director of health policy and planning.  A summary of the tools used, the objectives of each one and target of each tool is presented in Table 1.  The details of the project and the findings are published elsewhere (Fonn et al, in press; Tint et al, forthcoming).  In order to increase people’s ability to grapple with health systems development and reproductive health issues, various interventions within the TRHSP contained an educational component which included an understanding of gender.  In this article, we describe the way in which gender was incorporated into the TRHSP.

The entire project was informed by an understanding of the impact of gender inequalities on health.  To illustrate, key informant interviews with managers enquired specifically about interventions that are required to ensure appropriate utilization of health services.  Answers from senior managers included issues such as a general change in the norms relating to household chores so that women can have time to go to clinics, for example, the focus groups with both nursing tutors and students looked at how women’s health sections are taught and how maternal health is taught as a separate section. The discussions specifically noted the absence of a life cycle approach in teaching women’s health.  The issue of the role of fathers in pregnancy and childbirth was identified as a gender issue in the teaching of midwifery.

Four components of the TRHSP specifically aimed at increasing project participants' understanding of gender inequality and its impact on health are as follows:    It is these four aspects of the TRHSP that are discussed in this article.

Gender and Health Orientation

At the initiation of the project, 26 senior members of the Departments of Health in each province attended a one-day gender and health orientation course.  The majority of the participants were: directors within the department; programme managers; and regional managers but significantly participants also included senior political figures (Minister of Health from one province) and the most senior civil servant (the Director General of Health from two provinces).  Of the 26 participants, 18 were male.  During the one-day course, participants were introduced to the concept of gender as distinct from sex and then did an interactive exercise linking gender to health.  The aim of the day was to introduce senior managers to some of the ideological conceptual underpinnings and underlying principle of the TRHSP and to give legitimacy to the various processes  that were to follow.  The fact that such a large group of people occupying high-level posts and mostly men attended gave the project team confidence that the initiative was pitched correctly.  It also dispelled the myth that men are not interested in gender training.  The post-course evaluation revealed that some participants felt that it was appropriate that they, as men, were targetted as previously they understood gender issues as well as women’s issues.  They also indicated that they thought the day – which was interactive in nature and required group work, an unusual format for senior health bureaucrats – was professionally facilitated.  Overall, this intervention was a risk but worked well and, in the mind of the participants proved that gender issues had real content relevant to their work.  As one participant remarked, “The most important things that we learned from the workshop are that women’s issues can be discussed rationally and most of the gender issues are within our ability to solve it is a progressive idea.”  To some extent, this consolidated provincial support for this project at the senior level.

Health Workers For Change

The second intervention was implementing a change management tool “Health Workers for Change” (Fonn and Xaba, 1996)  which involved health workers in a set of 6 workshops in which they reflected on their work, the quality of care they provide, the situation in which they work and the circumstances in which their patients live. Exploring the relationship between providers and clients from the provider perspective needs to be approached with sensitivity.  Thus, the methodology used was not within the usual qualitative or quantitative genre.  Rather, reference was made to various management and change management tools.  The experiential method of individual and group exploration best popularized by Paulo Freire was the background for this workshop series.  This model describes conscientisation as a social process where human beings achieve increasing awareness of the socio-cultural reality that influences and shapes their lives and develops their ability to transform their society.  The growth of self awareness involves being critical of social, economic and political conditions in an effort to change existing institutions so that full humanization takes place (London, 1973).

The workshops examined the context within which women are situated.  Thus issues pertaining to decision making, women’s time, women’s biology and their role in reproduction were addressed.  The links between these and the manner in which services are organized, patients are treated and health issues are dealt with, are explored.

One workshop is devoted to developing solutions to the most important issues, as defined by the health workers themselves.  Findings from this study indicate that : many health workers take up their work due to lack of other employment opportunities; management inadequacies and inefficiencies play a significant role in influencing the provider client relationship; health care provider training lacks a gender component and this has an impact on health workers’ understanding of the position of women in society and thus their relationship with women clients.

In order to conduct these workshops in the three provinces, WHP trained 37 facilitators who are employed in the provincial health care structures.  These facilitators then ran the workshops with 820 primary health care staff.  The majority of responses to these workshops was positive.  Firstly, the intervention was recognized as contributing to overall health systems development.  It was described by a director of primary health care and systems development in one province as “the most innovative management tool around”.  It was also recognized as an intervention that dealt with the important issue of provider-client relationships.  Secondly, the manual (see Annex for more information) that was developed from the workshop was described as “the first manual to put gender into health workers’ training”.  The intervention itself invigorated people who participated in the workshops – Throughout my twenty years of professional life I was just working, it is only now that I understand why I am a health worker”.  The external evaluation of the TRHSP noted that the project enhanced provincial health staff capacity.  As expressed by one, “I have acquired problem-solving, communication and decision making skills, and now I feel confident in my work environment.  I actually feel in control of myself and my work”.  Perhaps the most positive outcome is that in one province, the Health Workers for Change workshop has been institutionalized and is being incorporated into the ongoing in-service training run by the Provincial Health Department.

Gender and Health Sensitization

The third intervention, Gender and Health Sensitization Workshops, followed a similar format of training 37 provincial facilitators and running workshops throughout the provinces with 779 primary care staff.  The point of running the  workshops was to look at issues around quality of care and for health workers to identify interventions which would lead to creating an improved work environment both for providers and users of the service.  During the intervention, health workers were taken through an interactive process whereby the concept of gender was explored and reference was made to several manuals (Williams et al, 1994; Hope and Timmel,1984).  Participants were asked to look at the influence of gender differentials in their own lives and link these to gender, health and health service provision.  The complex issue of culture was raised, in that gender roles are culturally determined and a common belief that culture cannot be tampered with.  Examples that people gave emerged during an exercise to remember when they first became conscious of being a boy or a girl.  A report from one of the workshops  cites – “… at a young age when his sisters wanted him to help them with dishes, their mother told them that he was a boy and  boys don’t wash dishes.  When his sisters grumbled the mother responded ‘you must not grumble, he is your brother and the heir to this family.  One day you will come running to him when your husbands beat you’.  He said he felt superior, happy and satisfied”.  Yet people did make changes.  The facilitators, who had more training and ran the workshops many times were more steeped in the process.  They said that understanding gender empowered them to change their lives.  Numerous examples were given – “I always came back from work to cook even when I left work at seven in the evening. Then after the gender training, I felt that this had to change.  To my surprise, my husband did not resist.  He now cooks supper for the family some evenings, and now I have even joined a local choir because I have time to do all that.  I realize that I tried to do everything because I thought that was what I was supposed to do as a woman”.

In linking gender to health services, a common issue identified in many if not all of the workshops was the positioning of male nurses in the health system.  They are perceived as having more value and are given positions of greater power than female nurses although the majority of nurses are female.  In general, these workshops enabled people to discuss issues which previously were not tackled.   Participants felt that they were valuable and that they should be run for all health workers.  Health workers reported that the workshop gave them space to talk about gender and reflect on their lives. They were limited, however, in that few of the solutions that were generated related to clients and provider client interactions as was the case with the Health Workers for Change workshops.

Woman to Women Peer Education

The fourth intervention was the Woman-to-Women peer education initiative using health workshop packages on : the body; cancer of the cervix; AIDS; sexually transmitted diseases; (in production now is a contraception workshop package) which were researched, tested and published by WHP.  In this initiative, lay women are trained using these packages to run information dissemination workshops on topics identified as important by women themselves.  The format has interactive components which try to take account of gender issues.  For example, in the session on sexually transmitted diseases, account is taken of the difficulty women may have in engaging in a discussion about condoms and we include role plays to assist people in working out ways in which they may be able to deal with this.  Responses from some of the women who were trained gives some indication of the success of the intervention.
 

Concluding Notes

The transformation process occurring in South Africa has given focus on the impact of social conditions on the lives of people.  The TRHSP thus incorporated gender in the intervention.  The TRHSP was about getting information on health system functioning, on the state of facilities, what in-service training was taking place, how clinics are organized, patient waiting time etc.  Yet embedded in it was the gender content.  It was not an 'add on'.  We presented the composite findings of all the research tools to provincial staff at dissemination workshops.  Commenting on these workshops, one manager said,
 

Because gender consciousness was integrated within the overall project and was related to health and health services, it took on a form which people could relate to.  Gender, like social class or apartheid has an impact on health and is a factor in health systems planning and delivery.  This link was made clear by including gender as one of the components through which health and health services was understood.

The project was to a large extent successful and indication of this is that provincial plans following findings from this project have been incorporated into the provincial planning process.  Among these plans are interventions which include a gender focus, indicating that incorporating gender within the overall project did not mean that it got lost or did not get prioritized. 

This manual is based on research in five countries in Africa where workshops have been piloted, tested and modified.  The methodology has been found to be effective, realistic and practical to implement.  It has a positive impact on how workers see their jobs and their interactions with clients, especially women.

In the workshop series, health workers undergo a process of identifying their problems and solutions to these problems.  They explore the quality of care that women receive and the reasons for the frequently poor quality of this care.

The workshop series focuses on women because women have special problems and because they use health services more than men, especially for their children.

The workshops are presented in the form of a manual so that these can be run in one's own health centre and clinics.

The six workshops described help health workers to examine the manner they relate to women clients and the factors that influence these relationships.  The workshops also identify ways and means to improve both health services and job satisfaction for health care providers, which can lead to better worker-client relations.

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