Gender_ reproductive health_ and reproductive rights

Gender, Reproductive Health, and Reproductive Rights Marilyn Lauglo, World Bank Institute. Paper prepared for Adapting to Change Core Course September 1999 Introduction A gender perspective is an integral part of the reproductive health approach to population activities. Fundamental to the Cairo Programme of Action (POA) is the underlying principle which places women’s needs at the centre of population and development concerns. This includes the right of women to make autonomous reproductive choices and the right to high quality services which are designed around women’s experiences and needs. This requires an understanding of women’s roles, responsibilities, and positions in their homes, communities, and other public arenas. What is Gender? Gender describes the socially constructed roles, activities, and responsibilities assigned to women and men in a given culture, location, or time. It differs from sex which describes biological and genetic differences between men and women. Gender is learned and changes over time. Gender functions at the household, community, and national levels and thus is embedded in a society's social, cultural, economic, and political systems. These systems are based within a given legal framework which includes not only laws and regulations but the institutions which enforce or fail to enforce them, Gender identities influence how women and men perceive themselves, think, and behave. Gender differences interact with other inequalities such as race, age, social class, and ethnicity. Understanding gender systems benefits from examining the relationships between men and women as well as their respective roles. The Cairo ICPD Programme of Action The 1994 Cairo Programme of Action differs from earlier population programmes in (1) its underlying values which place individual women with their needs and preferences at the centre of development, (2) its recognition that women’s health is embedded in social, cultural, economic, and political systems, (3) the identification of specific strategies especially relating to increasing women’s reproductive choices, (4) its concern over a range of health conditions covering a woman’s life cycle, and (5) its recognition of the need for a wider range of high quality integrated services. Advancing gender equality, gender equity, and the empowerment of women; eliminating violence against women; and ensuring women’s ability to control their own fertility are seen to be cornerstones of population activities and are essential components of the reproductive health approach1 . Gender awareness in reproductive health is important because one finds health inequalities which result not only from the biological and genetic differences between men and women but also from the social disadvantages to which many women are subjected. Sexual and 2 reproductive decision making is not carried out in a gender-neutral environment. Women and men make choices within the context of their homes and communities where gender roles, responsibilities, and status are defined. How women approach the health system and the response of the sector to users and the public are shaped by gender factors. The response of the health system to its own workers is also important as the sector is currently undergoing restructuring. Gender and health Patterns of health and illness in women and men show marked differences. Women as a group tend to live longer than men in nearly all countries. Part of women’s advantage in life expectancy is biological in origin. When the female potential for greater longevity is not realised, it is an indication of serious health hazards in their immediate environment2. Women suffer considerable mortality and morbidity in relation to their sexual and reproductive health. Fertility regulation, pregnancy, childbirth, sexually transmitted diseases, infertility, and diseases of the reproductive system require health services for women. Biological, social, and economic factors play a role in the impact these conditions have on women’s health as will be discussed by other presentations made during this Core Course. Biological and social factors do not function separately. In malaria, tuberculosis, schistosomiasis, and HIV/AIDS there is a dynamic interaction among these factors which often is disadvantageous for women. Exposure to malaria, for example, is slightly higher in men than women. However, women’s immunity is compromised during pregnancy making them more likely to become infected and implying differential severity of consequences. Malaria during pregnancy is an important cause of maternal mortality, spontaneous abortion, and stillbirths. Particularly during pregnancy, malaria contributes significantly to the development of chronic anemia. Lack of time, limited mobility, and other social constraints may prevent women from attending clinics3. One of the reasons the links between gender and health are not clearly understood is due to the lack of research on factors affecting women and their health seeking behaviour. Another way to improve our knowledge of the multiple effects of age and gender would be if data were disaggregated by sex. HIV/AIDS status among children (under 15s) is a good example of this. Social, economic, and political factors become more important when examining other health conditions such as malnutrition, domestic violence, harmful traditional practices, and sexual abuse in conflict situations where women are especially vulnerable. 3 Box 1 Women and HIV/AIDS An HIV-infected person living in sub-Saharan Africa is likely to be a female under the age of 24, infected by her only sexual partner, burdened with the care of other infected family members, and subject to gender discrimination. In Africa, AIDS is very much a woman’s story which can only be addressed by addressing existing barriers to their social, cultural, and economic empowerment. An unequal balance of sexual power makes it difficult for women to protect themselves. Most HIV ñ infected women report only one sexual partner whereas most infected men report multiple partners. Women, including schoolgirls, are vulnerable to coerced sex, including rape and other sexual abuse. The younger the age, the higher the risk. Women usually become infected 5 - 10 years earlier than men. According to UNICEF, girls aged 9 to 15 are five times more likely to be infected with HIV than boys of the same age. Biologically, women are four times more likely to contract HIV and other STDs than men. The transmission of the HIV virus appears to be 2-4 times more efficient from male to female. Young girls and older women are at greater risk. STDs are often asymptomatic in women and are thus more likely to be untreated. Women's lack of empowerment makes it difficult for them to negotiate sex. Women’s lack of choice leads to dependency on men and their lack of access to credit, land, education leaves them vulnerable to cultural obligations to marry and bear children Women and girls are left with the burden of carrying for AIDS affected households. (Taken from World Bank, 1996,’ why All The Talk About Women and AIDS,’ http://gender.worldbank.org/tools/GP-15.htm) Gender, women’s status, and reproductive choice A significant body of work analysing the basis for women’s lower status uses an economic argument. This analysis views gender inequalities as arising from the different values placed on women’s and men’ work. Men’s work is judged to be productive and markets are seen as a way to judge the value of that work. Barriers to this sphere of work often exist for women who have difficulties gaining title to land, access to credit, and access to other assets. Traditionally, women have had main responsibility for seeing to the needs of families in their homes. Responsibilities in this reproductive arena limit women from participating in so-called ‘productive’ work. Although child care, care of the elderly, obtaining fuel, preparing meals, and maintaining the home are demanding tasks, deemed to be important to households and recognised as essential for society, they are usually unpaid. 4 Another major reason for undervaluing women’s work is that households are usually viewed as sites of consumption rather than producers of goods and services4. Because women‘s work is undervalued and often invisible, insufficient attention has been given to the value of women’s time and the time costs required to protect and promote women’s health. If services are to be women - centred, a better understanding of these costs is needed. A number of gender analysis tools are available to do this. These tools share in common the following activities: (1) conducting a needs assessment from a woman’s point of view, (2) mapping out an activities profile to uncover the often neglected contributions of women’s unpaid work, (3) identifying resources are available to women, (4) identifying what women view to be benefits, and (5) establishing the links between different levels of society where women participate5. In addition to economic considerations, role expectations, gender identities, the meaning of sexual activities, meanings of health and disease, health seeking behaviour and the relationships among these and other factors impinge on reproductive health. Access to available health services may be constrained because women do not have the resources needed to attend. Women may have other responsibilities in the household which take precedence and thus do not seek out health care. Transportation to services may not be available and/or women’s mobility may be limited in other ways. Family members may not allow women to attend clinics. Stigma attached to certain illnesses may prevent a woman from seeking diagnosis and treatment. Differences in language, ethnicity, education levels, and age between health workers and users may erect further barriers to optimal service use. Thus, autonomous decision making is not simply a matter of availability of services or a wide range of service options. The Cairo POA includes a number of strategies such as improving the status of women, increasing education for girls, improving information, education, & communication, integrating and improving services, focusing on adolescents, and increasing men’s responsibility for improved reproductive health. These are aimed at increasing the ability of women to make autonomous reproductive choices As with the other aspects of the reproductive health approach, care should be taken to ensure that these strategies are not carried out in ways which results in further entrenching patriarchal attitudes and institutions. Increased male responsibility could result in greater male control over their female partners. Greater male involvement should not foster greater control by men over women's sexuality. Indeed, Schuler cites a number of examples where campaigns encouraging men to use condoms and support family planning, appealed to male control and dominance6. Greene offers an expanded framework for looking at male involvement which includes men as reproductive health clients, men as partners, men supporting women’s reproductive health, men as fathers, and men as health care providers7. Berer points out, that since men are already involved in women’s reproductive health in 5 most ways, what is needed now is not necessarily more male involvement but constructive male involvement which is supportive of women 8. Autonomous reproductive choice requires informed decision making. Pertinent, accurate, and timely information is essential. Information, education, and communication (IEC) campaigns, policies, and practices aimed at changing behaviours and attitudes need careful attention as the intentions and impacts can either extend or narrow choice. The emphasis on IEC needs to move out of the traditional model of one directional health information to more participative methods which empower women to become more assertive and improve their negotiation skills with both service providers and their sexual partners. Skills to resist sexual coercion are especially important for adolescents. A focus on adolescents should extend beyond services targeted at them by also dealing with the complex norms which regulate their sexuality. Raising the legal age of marriage can protect girls from early childbearing. Parity of education achievement between girls and boys enables women to be more equal partners in marriage. Allowing girls to remain in the classroom during pregnancy and return to school after childbirth are other policy level interventions which goes beyond service delivery. A minimum age of marriage for boys which is higher than that for girls fosters a unbalanced relationship between husbands and wives. Reducing age differences between men and women in marriage supports more equal partnerships. Protection of young people from forced marriage requires a change of practices and legal, economic, and cultural institutions supporting such practices. Gender and the response of the health system Because gender is embedded in political, economic, and social systems, it influences the way services are selected, designed, planned, and implemented. More specifically, gender influences: • the priority given to women’s health services • decisions about which services should be offered • resource allocation (financial, human, facilities, equipment, drugs & supplies, transportation & communication) • how the quality of services is defined and monitored • the degree to which women participate in decisions about the above Since ICPD, a number of donors and international agencies have been working to operationalise the reproductive health approach. Often individual donors have focused on a particular aspect of making health systems responsive to women’s needs. IPPF, WHO, and UNFPA have developed materials relating to reproductive rights9 10 11 . The Commonwealth Secretariat, has developed tools to integrate gender into national budgetary processes12. SIDA in their work with the OECD/DAC Working Party on Gender Equality and the Commonwealth Secretariat, identified enabling factors which facilitate mainstreaming gender in health13 14 . A number of international organisations interested in gender 6 mainstreaming have identified important issues to be watched for. Listed below as questions, they can also be used to monitor gender sensitivity at different levels 15 16 17 18 19 . 7 Policy environment • What is the rationale for the provision of RH services? Is there a human rights/efficiency/demographic imperative? • Is there an explicit statement of commitment to gender equality? • What are the legal and/or regulatory barriers which would affect gender and health? Has the country taken on the Cairo POA, the Beijing Platform, signed the human rights covenants? What institutions are available (i.e. effective) to hold the government accountable for gender equality? • Does political will exist to implement a gender sensitive system? Who are the stakeholders advocating a gender sensitive system? Gender equity is one way of reducing gender inequalities. One form of equity are special efforts aimed at redressing existing inequalities. This can be monitored by examining programming and resource allocation. Another form of equity ensures that the processes by which decisions are made includes the poor and other marginalised groups. Programming • Have needs assessments been conducted from the view points of both men and women? • Have programmes and activities been analysed from a gender perspective? • Are data used for selecting programmes disaggregated? • Which women's groups have been involved in the planning process and who do they represent? Resource allocation and financing • Is the manner in which revenue is raised fair to women? • How much money is allocated for what? What proportion of expenditures are targeted specifically at women to help redress past inequality and neglect? What share of expenditure is devoted to public services which have been identified as reducing the burdens of women (especially poor women) and gender inequalities in health, education, income, and leisure? Participation • What are the methods of consultation with stakeholders? • Have the costs of participation been identified? Have individuals, groups been remunerated for the costs of their participation? • Which groups have been represented? Service quality is what determines whether users and non-users decide to avail themselves of existing services. Because reproductive health relates to personal and intimate aspects of sexuality, respect for personal integrity, privacy and confidentiality are crucial to good service quality. Gender interacts with social class, age, and ethnicity for both the user and 8 health personnel. These impact on how women are treated by providers. Interpersonal communication is critical to women's encounters with the health system. This has only recently come under systematic examination and mainly in connection with family planning services. Hardon et al have summarised the indicators of a number quality of care frameworks20 . PATH has recently developed guidelines on client - provider interaction for providers21 . In addition to respect for users and interpersonal communication, the technical quality of services is also essential. Gender and the response of the health sector to its workers Health sector reforms are affecting a system which employs a large number of women who are often at the bottom of the occupational hierarchy. Little attention has been given to the effect of reforms on leadership & management styles, personnel & work policies, who benefits from the changes, who is loses out, and how are decisions made. • Are women and men represented equally at all levels of the system? Is there at least a 'critical mass' of women at all levels (not just token representation)? • Have health personnel been actively involved planning in the changes? • Are staff trained, informed, and given the necessary competence to deal with the reforms? • Has a gender analysis been conducted to measure the impact of the reforms on health personnel? Gender, reproductive health, and reproductive rights Reproductive health as a spectrum of conditions is covered in detail by other presentations in this course. Reproductive health as a constellation of health services is the focus of Module 2. Reproductive health can also be seen as an approach to population activities. Arising out of the human rights and the women’s movements, the reproductive health approach is founded on a commitment to a core set of values embodied in universal human rights covenants. As noted by a number of other presenters during the first week of the Core Course, ICPD represents a shift from a population concern to a women centred approach to population and development. Details of differences between these two approaches are given in Annex 1. Reproductive Rights The ICPD POA states that implementation efforts will be guided by, among others, the following principle: ‘All human beings are born free and equal in dignity and rights. Everyone is entitled to all the rights and freedoms set forth in the Universal Declaration of Human Rights, 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. Everyone has the right to life, liberty and security of person’22 . A basic set of reproductive rights, including rights to sexual and reproductive health is implied by the rights recognised in international human rights instruments23 . 9 Promoting women’s human rights are an essential part of improving women health. Personal freedoms such as the rights to liberty & security of person, to be free from all forms of discrimination, to privacy, to be free from torture and ill treatment, to information, opinion, & expression, and to marry & found a family seek to protect all people from interference from other individuals, communities, and governments. Some of these have particular relevance to coercive practices which have arisen under some population programmes. Human rights to survival, to education, to health and health care, and to benefits of scientific progress can be seen as entitlements which can apply to safe motherhood, abortion, and STI treatment. Table 1 shows how a selected number of human rights can be used to promote women’s health. WHO, UNFPA, and the International Planned Parenthood Federation (IPPF) have published resource materials which show in detail the links between human rights and reproductive health24 . These materials give a framework for monitoring reproductive rights and can be used for reporting to the human rights monitoring machinery. Annex 2 shows the UN human rights machinery. Reproductive health strategies and services are part of systems which often are structured in disadvantageous ways for women. Since reproductive rights are fundamental to reproductive health, they are relevant at the policy, programme, and service delivery levels. Table 1 shows how human rights could be used at policy and programming levels. In the clinic and other care settings, users’ human rights can be protected through the provision of good quality of care. Standards relating to (1) technical quality (e.g. safety, competence, appropriate and essential drugs, equipment, supplies, and facilities), (2) protection of users’ autonomy and dignity, and (3) interpersonal communication can be established to ensure users’ human rights. Many aspects of service delivery fall within the overlapping spheres of gender, human rights, quality of care. 10 Table 1 Uses of human rights for improving women’s health25 Human Right Right to life Can be used to campaign for Safe motherhood Can be used to campaign against Maternal mortality and morbidity Infanticide Genocide Violence Female genital mutilation Sexual harassment Sexual abuse Forced pregnancy Forced sterilisation Forced abortion Discrimination with regard to access to sexual and reproductive health services based on sex, marital status, and/or age Discrimination which denies access to nutrition and care Discrimination which denies legal protection against violence Forced pregnancy or continuation thereof Breach of confidentiality Laws/regulations requiring spousal or parental consent for contraception or abortion Programmes which do not give full information on the relative benefits, risks, and effectiveness of all methods of fertility regulation Prohibition of access to sex education and information for youth Education systems which discriminate against pregnant students and/or young mothers Trafficking in women Degrading treatment especially during times of armed conflict Domestic violence Legislation which prohibits abortion on the grounds of rape Right to Liberty & Security of the Person Protection of women and children from sexual abuse Protection from medical intervention carried out without the informed consent of the person Right to be Free from all forms of discrimination Laws which prohibit discrimination against women and their effective enforcement Freedom from practices which are based on the idea of the inferiority of women Right to Privacy Service guidelines ensuring women’s privacy Right to Information & Education Youth access to information and education Programmes which enable service users to make decisions on the basis of full, free, and informed consent Right to be Free from Torture and Ill Treatment Protection of women and children from sexual exploitation, prostitution, sexual abuse, coercion in any sexual activity, domestic violence 11 Right to Health and Health Care Sexual and reproductive health services which are comprehensive, accessible, private & confidential, respectful of the dignity and comfort of the service user, provide choice, are safe, and allow service user to express views and preferences. Traditional practices which are harmful to health Restrictive abortion laws Working conditions which do not protect health and safety. Gender in the Context of Health Sector Reform Implementing the Cairo ICPD POA has occurred at a time when most countries are facing substantial reforms in their health systems in terms of organisation and financing. The changing role of the State, civil service reform, enhanced roles for the private non-profit and for-profit sectors, decentralisation, cost recovery, client involvement, and provider accountability & transparency are all parts of the changing environment in which the reproductive health approach is being carried out. Regardless of which reforms are selected in a given setting, the ultimate purpose of the health system is to improve health outcomes and thus gender equalities in health. Other criteria for judging the reforms are the extent to which they have improved equity, quality, efficiency, and sustainability. A major concern in health policy has been equity and this is especially important for reproductive health. As discussed in another WBI course on health sector reform, equity relates to a fair distribution in the health system i.e. equal access according to need and a fair sharing of the burden of providing health. Decisions about equitable distribution need to be made through fair procedures. The needs of poor people are often overlooked and their voices often go unheard. Poor women are the most likely to be unseen and unheard in the system. One of the main pressures for reforms has been to make more efficient use of available resources. Gilson maintains that the efficiency imperative is leading to equity oversights and discusses problems arising from this26. Establishing a package of essential services is part of the effort to make more efficient use of limited resources. Three of the five clusters of interventions identified by the World Bank 27 as belonging in the essential package are reproductive health related: prenatal and delivery care, family planning, and STD treatment. Nevertheless, caution must be exercised not to over-focus on an essential package. Given the underlying principle of a women–centred approach, a life cycle approach to reproductive health conditions is more in keeping with the Cairo POA. A package of essential services should include those services which (1) aim to serve women’s health conditions, (2) are most effective in reducing health inequalities between men and women, (3) are services which women themselves prioritise. One of the main gender concerns under new financing mechanisms e.g. insurance and user fees is that women, who most often are in unpaid work, are not covered by insurance. Not 12 only do women lack the means to pay for services but their positions in families and households often precludes them from being able to negotiate the necessary resources for using services themselves and for their children. Adolescents also are less likely to pay for services. The increasing focus on shifts from the public to private sector for health financing and provision sometimes loses sight of the continued responsibility of governments to ensure equity in the distribution of health service resources and in who will pay for them. Ministries of health also have a role in regulation, especially regarding safety and the protection of human rights. The limitations of relying on market forces to shape the health system are well known. Caution must be taken whenever market mechanisms are used within the system. Heavy reliance on contracting with providers runs the risk that no one will provide unattractive services i.e. to the poor, the elderly, and adolescents. Remote areas and areas with poor populations, which now have difficulty recruiting and retaining health workers, may have even greater difficulty providing services if contracting out of the public sector is poorly thought out. Increased moves towards decentralisation do not necessarily decrease inter-regional or intraregional disparities. Although often promoted as a means of better responding to local needs, there is always the possibility that local elites which do not include women or representatives of their interests, will capture political power. Decentralisation requires technical competence at local levels – something which is often lacking. Again, central governments in decentralised systems continue to have responsibility for policy, regulation, standard setting, and monitoring. Health sector reforms will also be judged by whether they result in making health systems more sustainable. Sustainablilty requires the ability to mobilise the resources (i.e. political commitment, inputs by users, management capacity, financial resources, and personnel) necessary for their continued existence. Sustainability is not merely financial selfsufficiency. Sustainability requires perceived value by the user. For women, this means that the health system meets their needs, is sensitive to their roles and responsibilities, understands the constraints under which they live, and accords them the dignity and means to make autonomous choices. Marilyn Lauglo 13 September 1999 14 References 1 http://www.un.org/ecosocdev/geninfo/population/icpd.htm 2 WHO, Women’s Health and Development, Family and Reproductive Health, Gender and Health: Technical Paper, Geneva, 1998. WHO/FRD/WHD/98.16 3 WHO, p. 20 4 Budlender, D.& R. Sharp, How to do a gender-sensitive budget analysis: Contemporary research and practice, 1998 5 March, C., I Smyth, and M. Mukhopadhyay, A Guide to Gender-Analysis Frameworks, Oxfam, 1999 Schuler, S.R. , ‘Gender in Population and Reproductive Health,’ unpublished paper, 1999 6 7 Greene, M.E., ‘Male Involvement in Reproductive Health: Translating Good Intentions Into Gender Sensitive Programmes,’ 1998 8 9 Berer, Marge, ‘Men,’ Reproductive Health Matters, No. 7, 1996. IPPF, Charter on Sexual and Reproductive Rights, 1995 10 Cook, Rebecca, Women's Health and Human Rights: the Promotion and Protection of Women's Health through International Human Rights Law, WHO 11 The State of the World Population 1997, The Right to Choose: Reproductive Rights and Reproductive Health, UNFPA 12 Commonwealth Secretariat, Gender Budget Initiative, 1999 SIDA, Gender Equality in Sexual and Reproductive Rights and Health, 1998 Commonwealth Secretariat, ‘Gender Management System Handbook,’ 1998 13 14 15 DAC Working Party on Gender Equality, ' Gender Equality in Sexual and Reproductive Rights and Health,' 1998 16 Commonwealth Secretariat, 'Gender management system handbook,' 1998 Pfannenschmidt, S., a. McKay, & E. McNeill, 'Through a Gender Lens,' FHI for GWG, USAID/PHN, 1997 CIDA, Gender sensitive indicators: Guide and Project level handbook, 1997 17 18 19 Doyal, L. ‘A Framework for Designing National Health Policies with an integrated Gender Perspective,’ in Women and Health, Mainstreaming the Gender Perspective into the Health Sector, Report from Tunis,’ 1998 20 Hardon, Anita, Ann Mutua, Sandra Kabir, and Elly Elgelkes, in Monitoring Family Planning & Reproductive Rights: A manual for empowerment, 1997 21 PATH, Outlook, Vol. 17, no 2, 1999 Programme of Action adopted at the ICPD, Cairo, Ch. 2, Principle 1, p. 9 UNFPA, The State of World Population, 1997, p 13. 22 23 15 24 See WHO, Human Rights in relation to Women’s Health, 1993, UNFPA, The State of World Population, 1997, and IPPF, Charteron Sexual and Reproductive Rights, 1996 25 Modified and taken from Newman, Karen (ed.), IPPF Charter on Sexual and Reproductive Rights Guidelines 26 Gilson, Lucy, ‘In defence and pursuit of equity,’ Social Science and Medicine, Vol. 47, no. 12, 1891-1896, 1998 27 World Bank, World Development Report 1993; Investing in Health, 1993