The first hospital to offer no-scalpel vasectomy services in La Paz, Bolivia, introduced its programme in 1996.  During the first year, one procedure was performed.  The next year, there were none. 

Why were the services so underutilized?  Lack of available doctors was not a factor, since several doctors were trained in the technique before the programme began.  What was missing from the programme, however, were other critical components, such as counselling, outreach, and use of educational materials. 

The failure of this programme reflects a larger problem throughout Bolivia, one relating to gender differences in access to and use of health care services.  Though the national health and population policy mandates comprehensive reproductive health care for men and women, Bolivian men rarely seek health care services of any kind because most services are designed primarily for women and children.  The only services offered to men are urology services, which focus on screening for sexually transmitted diseases, and workplace-related services, such as for factory labour and mining. 

To help fulfill the country's health care goals, non-governmental organizations (NGOs) and health care administrators are now exploring ways to increase men's involvement in health care and family planning services. 

Raising Gender Issues

There is a need to raise Bolivian men's awareness of gender issues as they relate to reproductive and sexual health.  So says Jaime Telleria H., Executive Director of the Centro de Investigacion Social Tecnologia Apropriada y Capacitacion (CISTAC), a Bolivian NGO that focusses on reseach and training in health and social issues. 

Discussions about gender issues and "macho" behaviour are rare in Bolivia, where adherence to traditional gender roles is strong.  However, through research, training, and information dissemination, CISTAC aims ultimately to broaden the male role and identity in Bolivia, which will also affect men's access to and receipt of health care services. 

Fostering Discussion

Taking a fundamental step toward achieving this goal, CISTAC and AVSC co-sponsored a workshop to educate health care programme managers about the relationships between gender issues and men's involvement in reproductive health care. 

In the three-day workshop, which was held last fall in La Paz, 30 men and women from public and private-sector institutions discussed the effect of male socialization on men's development, the family and the community; identified how these factors affect men's and women's health; examined the availability and use of health care services for men; and developed strategies to incorporate a gender perspective into these services. 

Led by Benno de Keijzer, an educator and founder of Salud y Genero, a Mexican NGO, the training focussed on male reproductive health, mental health, alcohol abuse, domestic violence, development and exercise of male behaviour, and the delivery and use of reproductive health and family planning services. 

Action Plans

As part of the workshop, the participants developed action plans to incorporate what they learned into their programmes. 

After educating themselves further on these issues, they plan to alert policy-makers and administrators of their institutions on the need for a balanced gender perspective in health care, as well as the need to offer reproductive health services to men. 

Who Decides on Family Size? 

Men's negative attitudes often prevent wives from using contraceptives even when they are motivated to use them.  Among married female students in Nigeria who did not use a modern contraceptive, one in five gave her husband's objections as the reason.  In the northern region of the country, there is a policy that forbids women from obtaining family planning services without their husbands' consent. 

Some 88% of men and 78% of women in a Nigerian study stated that men's views are more influential than women's views in making family decisions.  Only 7% of men and 16% of women said women are more influential, while 3% of both men and women thought relatives and others are most influential in their family decisions. 

In Nigeria, children are often considered to belong to the husband and his family.  A wife who fails to have many children is sometimes seen as giving her husband a reason to marry another women, and some wives prefer to have more children rather than live in a polygamous situation. 

The researchers describe childlessness as "the most dreaded tragedy for a man or woman to experience in Nigeria's patrilineal society".  About 97% of men and 95% of women in the study said they would pity a childless man, while 80% of men and 91% of women would pity a childless woman.  Most respondents felt that a childless man, particularly without a son, will not be remembered because his branch of the family will come to an end. 

The researchers conclude that men's dominant role in family and society, coupled with wives' social and economic dependence on their husbands, means that men's views on reproduction must be taken far more seriously than in the past.  To ensure equal choice in decisions about family size, they say, efforts to improve women's status must be matched by moves to give men a greater sense of responsibility for the decisions they make that affect maternal health.

Men's negative attitudes often prevent wives from using contraceptives even when they are motivated to use them.  Among married female students in Nigeria who did not use a modern contraceptive, one in five gave her husband's objections as the reason.  In the northern region of the country, there is a policy that forbids women from obtaining family planning services without their husbands' consent. 

Some 88% of men and 78% of women in a Nigerian study stated that men's views are more influential than women's views in making family decisions.  Only 7% of men and 16% of women said women are more influential, while 3% of both men and women thought relatives and others are most influential in their family decisions. 

In Nigeria, children are often considered to belong to the husband and his family.  A wife who fails to have many children is sometimes seen as giving her husband a reason to marry another women, and some wives prefer to have more children rather than live in a polygamous situation. 

The researchers describe childlessness as "the most dreaded tragedy for a man or woman to experience in Nigeria's patrilineal society".  About 97% of men and 95% of women in the study said they would pity a childless man, while 80% of men and 91% of women would pity a childless woman.  Most respondents felt that a childless man, particularly without a son, will not be remembered because his branch of the family will come to an end. 

The researchers conclude that men's dominant role in family and society, coupled with wives' social and economic dependence on their husbands, means that men's views on reproduction must be taken far more seriously than in the past.  To ensure equal choice in decisions about family size, they say, efforts to improve women's status must be matched by moves to give men a greater sense of responsibility for the decisions they make that affect maternal health.

Through a long two-fold process of reflection and action, poor urban women in the settlement of El Guasco, in the south of Guayaquil (main port city in Ecuador), came to understand the reality of their lives.  Such lives are characterized by the burden of double or triple workloads, of ill health constituting severe varicose veins, back pain, renal problem, urinary tract infections, and of physical, sexual, and psychological violence.  Ultimately, the women tend to have very low self-esteem and value. 

The process was initiated by CEPAM (Centro Ecuatoriano para la Promocion y Accion de la Mujer) an NGO which started work with urban women through issues of health and adopted organizing and training strategies. 

The training courses carried out had two components.  First, training on issues such as nutrition, breast feeding, women's health, first aid, women's rights, and violence against women; and second, helping women to reflect on their lives as poor urban women. 

The training and reflection courses led to the formation of other women's grassroots organizations and the organization of women for community activities and strengthening their participation in health. 

The second result was the realization that determining factors to women’s health and ill-health lay in their status as poor urban women.  “This involved women’s understanding of the gender roles they are expected to play as women and as mothers; their self-value and self-esteem; their potentials, their needs and their problems”. 

Women were involved in the organization, implementation and evaluation of these training workshops.  They reflected on their experiences and began to understand the root causes of ill-health and out of this process, arose a proposal for the setting up of a health centre for women. 

The centre became a place for the women to share their experiences, to find out about their health and ill-health, and inform themselves about ways to improve their health and thus develop their self-esteem.   The health centre essentially was an integrated health centre for women responding to various concerns in their lives, that is, understanding women’s health in the wider context of their lives, forging a holistic view of women’s health. 

What this meant was that other external factors affecting ill-health were taken into account.  For example, a woman’s repeated vaginal infection is seen not merely a health problem resolved by a course of medical treatment, rather it is viewed within the context of her relationship with the partner and/or his relationship with other women.  Therefore, part of dealing with the problem constituted counselling and advice. 

The second aspect of integration involved undertaking the following: 

1. Health services (doctor’s appointments, ante-natal clinic, pharmacy and counselling).
2. Training of community women on health and health-related issues.
3. Research into gender and health of poor urban women.
4. Dissemination of the experiences of the health centre. 

The women themselves actively participated in running the health centre.  Individually and collectively, they were  involved in various facets of management such as planning, implementation, monitoring and evaluation tasks.  This greatly contributed toward building their self-esteem and developing positive attitudes toward their bodies and concern for their health. 

Organized by the Ministry of Health and Family Welfare, Dhaka, Bangladesh 27-28 August 1996, Sponsored by Sida, UNFPA, UNICEF, WHO and World Bank. 

The national workshop on RH with a gender perspective was participated by professionals, policy-makers, implementors, gender experts, women leaders and researchers representing multi-sectoral agencies including the government, NGOs, the private sector and donor agencies.  Its objectives were to:  a) arrive at a consensus on the definition of reproductive health in Bangladesh; b) highlight gender dimensions in relation to RH programmes and c) develop guidelines for a National Plan of Action on RH with a Gender Perspective. 

The definition of RH adopted by the ICPD Programme of Action, was unanimously accepted by the workshop and at the same time emphasized that it was important to identify and prioritize RH care interventions in the socio-economic, cultural and programmatic context of Bangladesh. 

In several plenary and group sessions, the participants designed policies, strategies and a plan of action to initiate the process of implementing RH programmes.  Essentially, the plan constituted two sections:  1) broad perspectives and 2) life cycle specific perspectives. 

Section 1:  Broad Perspective of the National Plan of Action

 Goals

• To adopt RH policies, which prioritize the reproductive rights of women and men to achieve a better quality of life.

• Reduce MMR, IMR and U5MR; and increase life expectancy.

• Build capacity and design interventions sensitive to individual needs and rights.
• Decentralize the planning process, emphasizing participation of the beneficiaries:  adolescents/youth, women and the hard core poor. Integrate RH programmes within the broader context of health and population through a life cycle approach.
• Enhance linkages between population and development, focussing  on the empowerment of women.

•    high maternal mortality rate (5 /1,000 live births )
•    iron and protein deficiency
•    lack of proper medical services
•    high number of unsafe abortions
•    threat of STDs to health and well-being of women
•    violence against women

Social:  Problems of son preference, violence against women, discrimination against the girl child. 

Structural:  Problems of gender equity, law of inheritance and particularly the inadequacy of the legal system in controlling child and women abuse/trafficking. 

Programmatic:  Constraints of the programme in disseminating information rendering gender friendly services and alleviating providers' insensitivity to gender concerns. 

Overall Interventions 

The following are broad areas of interventions under which activities have been designed:

• Social and institutional interventions to empower women, raise their self-esteem, and reduce discrimination and violence against women.
• Create awareness and demand for services.
• Improve access to and efficiency of services, enhance providers' skills and improve quality of care.
• Improve stakeholders' participation, sustainability and beneficiary ownership.

Following the ICPD recommendations, the workshop designed a specific plan of action by the stages of Life Cycle Approach:  Group 1:  Before Sexual Maturation; Group 2:  Sexually Matured and Unmarried; Group 3:  Sexually Matured and Married; and Group 4:  After Fertile Period. 

Before Sexual Maturation

Objective:  To ensure the newborn an enabling environment free from gender discrimination. 

Strategies:  Design interventions focussing on parents of newborns and children prior to reaching puberty:  Intrauterine life to birth; Birth to 2 and 5 years; and 5 years to puberty. 

Specific interventions include:  i) care of iodine deficient children; ii) include hepatitis B vaccine in EPI; iii) enforce breast milk supplementation (BMS) code; iv) strengthen nutrition education; v) ensure vitamin A supplementation; vi) make secondary education compulsory; vii) integrate RH in school curricula, especially in personal hygiene; viii) involve parents and teachers in RH education; ix) train and educate providers on RH; and x) mobilize society to engender community support and awareness of gender equity and RH. 

Sexually Matured and Unmarried

Objective:  To raise consciousness of the youth on their health needs. Strategies:  Integrate the health needs of youth and adolescents in the broader context of health. 

Specific interventions include:  i) educate youth on RH/hygiene/nutrition/STDs/RTI/AIDS; ii) launch a campaign in the mass media on RH, and violence against women/abuse of children and women; iii) strengthen outreach counselling and services on RH including FP for youth and adolescents; iv) integrate services for treatment of STDs/RTI with RH services; v) enforce existing laws to protect women's rights; vi) educate and inform women of their rights; and vii) review and reform laws on marriage/violence/abuse to ensure protection of women and children. 

Sexually Matured and Married

Objective:  To increase access to, use of and quality of information and services. 

Strategies:  Accelerate women's development through inter-sectoral, community and institutional interventions. 

Specific interventions include: i) sensitize community on safe delivery, danger signs and complications of pregnancies; ii) organize community funds/insurance for safe delivery care services; iii) upgrade THC for EOC services; iv) extend and improve services on MR; v) meet unmet demands of FP; vi) encourage use of condoms for STD/RTI/AIDS; vii) organize community level counselling on the importance of medically safe abortions; and viii) classify all violence related maternal mortality in official reports. 

After Fertile:  "After Fertility" Applies to Women and Men 

Objective:  To sensitize after fertile group on their reproductive health needs. 

Strategies:  Integrate RH care services for the after fertile and old age group with health services.

Specific interventions include:  i) screen for cervical/uterus and breast cancer; ii) provide calcium supplements; iii) integrate after fertility RH services into the existing health care system; iv) raise awareness of after fertility RH care; v) disseminate effective information about the factors contributing to infertility; and vi) sensitize family about the role and responsibility of both men and women in infertility.

Recommendations

Recognizing that RH is fundamental in improving human welfare, each country should promote RH and Rights through national policies and programmes.  Investment in RH has multiple benefits for families, communities and for the next generations. 

The critical recommendations of the workshop in finalizing the National Plan of Action were to:

• Overcome constraints of resources prioritizing interventions and integrating the plan of action into the on-going programme;
• Coordinate training programmes and select competent personnel ensuring gender equity to perform tasks that commensurate with skills and experience;
• Integrate messages relevant to the Life Cycle Approach in all IEC campaigns;
• Encourage males to support RH measures and improve their use of contraception;
• Design RH programmes that focus on human sexuality and gender concerns with an understanding of the socio-cultural context;
• Pursue inter-sectoral involvement to recognize the importance of the gender dimension in RH; and
• Include single adults who are divorced or widowed within the focus of RH programmes.

Background

Gender Management System (GMS) is an integrated package of principles, procedures, structures and mechanisms which provide a framework for integrating gender into all government policies, programmes and activities.  It is designed to assist governments toward achieving Gender Equality and Equity. 

A Gender Management System may be implemented at different levels:

1. National level
2. Provincial level
3. Local level
4. Institutional level (university, NGO, IGO) 

The Commonwealth Secretariat in collaboration with the Commonwealth Medical Association, organized a workshop in Cape Town, South Africa from 2-6 June 1997 which was designed to strengthen the capacity of countries to mainstream gender at all levels of the health system.  Participants were senior policy-makers and officials from health, women's affairs, finance and planning ministries, parliamentary representatives as well as NGOs from Botswana, Lesotho, Mozambique, Namibia, South Africa, Swaziland and Zimbabwe. 

At this workshop, participants developed the framework for Gender Management Systems in the health sector which included the following: vision, mission, and goals, outlines of objectives; strategies/activities; responsible agencies/actors; resources; time-frame; indicators, evaluation and monitoring. 

Towards the end of the workshop, each group produced a document designed to introduce a GMS into the health sector.  The document consisted of the following: 

The Vision

A health sector in which all women and men have equal rights and both are respected as equal partners at all levels of the health system.  Within this framework, women and men will work in collaboration and partnership utilizing their full potential to ensure that the specific health needs of all are adequately met.  This is possible only where policies, programmes and procedures are gender sensitive.  A prosperous society is envisaged, characterized by equal participation of men and women in the utilization of health services at all levels. 

The Mission

To achieve gender equity and equality through strategic action such as:

•    promoting political will
•    changing negative cultural values
•    strengthening partnerships among stakeholders
•    building capacity to introduce reform
•    promoting good professional practices in the provision of health for all.

To achieve integration of gender into all national policies, programmes and activities which impact upon health. 

Objectives

Policy and Structural Reform

• To establish a gender desk (appoint an officer, identify a structure).
• To provide health planners, service providers and other stakeholders with appropriate knowledge, skills and attitudes to ensure gender sensitivity at all levels.
• To develop gender desegregated data base by sex, age, and location for planning and programme implementation.
• To include gender equity into all programme design and strategies.
• To create an enabling environment for effective implementation monitoring and evaluation of gender integration in health policies and programmes.
• To strengthen essential national health systems research, and the use of gender sensitive research results in the formulation of health policies and programmes.
• To build capacity for introducing gender awareness in development policies, relevant ministries, monitoring and evaluation, of the complete health environment.

• To include gender and development in impact training of all on-going education.
• To use health professionals to facilitate partnership-building among all stakeholders, including health and all other ministries, NGOs and IGOs to foster intra and inter-sectoral networking.
• To support the use of gender equity in recruitment, training and promotion and encourage the use of gender concepts among providers and users of health services.

To increase resources for women's health including:

 a)  expanding women's access to appropriate health care
 b)  consolidating preventive health care for women
 c)  undertaking gender sensitive initiatives towards   reproductive health
 d)  reviewing and strengthening all reproductive   health programmes.


• Components based on desegregated data in order to ensure accessibility of services.
• To publicize information about the health of men and women.
• To identify psycho-social problems that impinge on the health of men, women and children and develop programmes that meet these needs.
• To promote primary prevention of cancers of the cervix, uterus, breast, prostate and lungs.
• To review data available on malnutrition and address gender-related feeding practices and micro-nutrient efficiencies.
• To develop programmes that address health needs of adolescents, taking into account the aged, and developing programmes to address those needs.
• To formulate and implement primary, secondary as well as tertiary preventive programmes to reduce diseases of affluence.

Specific Programmes (some examples)

• Establish mechanisms to prevent the practice of private and traditional medicine which damages the quality of care for women and children.
• Disseminate information on labour rights and occupational health of  women.
• Ensure the involvement of women in the process of programme development and policy-making particularly by those infected with HIV/ AIDS, to 50% without neglecting the importance of men.
• Conduct surveys on abortion in order to identify the current situation, causes, complications and measures to be adopted to minimize unplanned pregnancies and to provide safe services.
• Subsidize non-governmental projects, encourage and support women's groups.
• Introduce gender sensitivity at all levels of education, primary, secondary and tertiary (including language-sensitive text books and curricula).

 a)  women and violence
 b) women and tobacco
 c)  women and alcohol
 d)  literacy training