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What Difference Does Gender Make

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1 What Difference Does Gender Make
What Difference Does Gender Make? Opportunities and Responsibilities for Promoting Gender Equity in USAID Health Programs Speaker’s Name Date Photo by Antonio Perez

2 Contents What do we mean by “gender” and “gender integration?”
What is the rationale for integrating gender into USAID health programs? How can USAID better implement gender integration? The objective of this presentation is to make the case for integrating gender into USAID health programs; to explain how gendered roles, relationships, and norms affect RH; and to show that health programs can increase their effectiveness and sustainability by taking gender into account. The presentation is organized into three sections. First, we will define gender and gender integration, and outline some of the commitments the U.S. government has made in regards to promoting gender equality. Second, we will look at how gender equality (the state or condition that affords women and men equal enjoyment of human rights, socially valued goods, opportunities, and resources) can improve health. This section will present several examples of evaluated RH programs that integrated gender and achieved positive results in both health and gender equity. Finally, we will briefly discuss what a gender integrated program looks like, and share resources available to USAID staff to help programs integrate gender. Photo by Meena Kadri

3 SECTION I: What do we mean by “gender” and “gender integration” in USAID health programs? Photo by Dietmar Temps

4 What Is Gender? Gender refers to the economic, social, political, and cultural attributes, opportunities, and constraints associated with being a woman or girl, man or boy. The social definitions of what it means to be a woman or a man vary among cultures and change over time. To start, and help ensure that we are on the same page, it is important to review briefly what we mean by the term gender. There are many definitions, but almost all emphasize that: Gender refers to the social and cultural meanings of being male or female. Gender roles explain different cultural and social processes that women and men experience—including constraints, limitations, preferences, and opportunities. Gender roles and norms change over time. Gender is different from Sex, which refers to the biological differences between males and females and is concerned with physiology rather than social norms. Note to Speaker: If audience questions the binary nature of gender in the definition on the slide, acknowledge that not all people conform to the gender norms associated with their biological sex. People respond to the expectations of their sex in a multitude of ways. While many people comfortably conform to gender norms, most people behave in at least some ways that are contrary to gender-normative behaviors. Others challenge gender norms further; by identifying with gender norms of the opposite sex or by forging new identities that confound normative, binary constructions of gender. Non-conforming gender behaviors and identities are increasingly visible in mainstream society in many parts of the world. The fact that there are so many deviations from rigid roles and norms further supports the notion that gender is a social construction. Photo by Barry Pousman

5 Gender is about Women and Men
Men also benefit from more equitable gender norms Men’s support is needed to achieve health and gender equity goals Many still think that the concept of “gender” is synonymous with “women.” Yet, as the previous definition of gender highlights, gender refers to the social and cultural expectations of men and boys, as well as women and girls. Overall, gender inequality disproportionately harms women, who have less power than men under existing gender relations. However, men are also harmed by rigid notions of masculinity that tend to pressure them to be aggressive, tough, emotionally distant, and even violent. We must recognize that more equitable gender relations benefit women AND men. In particular, in relation to reproductive health: Men also have their own health priorities, concerns, and needs—and yet in many instances, gender norms equate men’s health-seeking behavior with sign of weakness—or as non-masculine. These norms may prohibit men from seeking health care and information. Men thus need to be engaged as important beneficiaries of health care, with information and opportunities to change norms and behaviors that limit their own health and well-being. Men can be gatekeepers who determine women’s ability to practice healthier behaviors and access critical resources. Their support is needed to ensure that women can adopt healthier behaviors, access health information and care, and enjoy better health outcomes. Finally, men have a critical role to play in working to transform inequitable gender relations to promote improved social status of women in their communities. Addressing men and masculinities, as well as women and their empowerment, is thus a key focus of integrating gender in health programming. Photo by Jennifer Orkis (2007)

6 What is “Gender Integration”?
It is a strategy for making women's as well as men's concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated. The ultimate goal is to achieve gender equality. United Nations, 1997 When we talk about integrating gender into health-related programming, most definitions (such as this one from the United Nations) emphasize that gender integration is a strategy to ensure that programs and policies: take into account women’s and men’s “concerns and experiences,” especially the specific gender norms and inequalities experienced by women or men that present constraints to achieving desired health outcomes; and assess and take into account the implications of programs and policies for how they affect relations between women and men—and ensure that interventions do not perpetuate inequality but, instead, work to promote gender equality. Again, gender equality refers to the state or condition that affords women and men equal enjoyment of human rights, socially valued goods, opportunities, and resources. As we will discuss further in a moment, most definitions also emphasize that the strategy of gender integration should be implemented in all phases of project or programming cycles—and should occur at all levels of organizations and in their programming. Note to trainer to explain if appropriate for audience: Although the terms “gender mainstreaming” and “gender integration” are used interchangeably in many contexts, they do have distinct meanings. Gender mainstreaming usually refers to efforts to integrate gender that include an organization’s own policies and practices, as well as the programs and policies that an organization implements. Gender integration, by contrast, usually focuses on addressing gender in the context of programs and policies that an organization implements with its beneficiaries. The primary technical assistance focus of the IGWG and this presentation is gender integration.

7 U.S. Government Policy Commitments: Gender in the ADS
ADS Gender Analysis MANDATORY. Gender issues are central to the achievement of strategic plans and Assistance Objectives (AO) and USAID strives to promote gender equality... Accordingly, USAID planning in the development of strategic plans and AOs must take into account gender roles and relationships. Gender analysis can help guide long term planning and ensure desired results are achieved… USAID’s gender integration approach requires that gender analysis be applied to the range of technical issues that are considered in the development of strategic plans, AOs, and projects/activities. ADS (March 2010) (The presenter may choose to focus on any of the three policy frameworks that follow—USAID, PEPFAR, and/or international—depending on the audience.) U.S. government policy frameworks have made concrete commitments to integrate gender in development programs specifically to address gender inequities to promote better health outcomes and to improve the relative status of men and women. The USAID Automated Directive System (ADS), which sets the policy for all agency programs, in its 2010 update, states that gender considerations in planning are mandatory: READ THE PARAGRAPH ON THE SLIDE STARTING WITH ‘MANDATORY.’ Further sections of the ADS elaborate the specific areas into which USAID programs are expected to integrate gender considerations; specifically, these areas include: project-level analyses and activity approval documents, performance indicators, and evaluation criteria for RFPs and APS.

8 Gender in the ADS How will the different roles and status of women and men within the community, political sphere, workplace, and household… affect the work to be undertaken? How will the anticipated results of the work affect women and men differently? ADS (March 2010) The ADS outlines two key questions that should be addressed at these various steps of the planning/program cycle: strategic planning, activity planning/performance monitoring, and competitive solicitations. Photo by David Dennis

9 U.S. Government Policy Commitments: PEPFAR
Recognizes gender inequality as driving HIV and contributing to the devastation of HIV/AIDS Requires gender analysis as per the ADS. The President’s Emergency Plan for AIDS Response (PEPFAR) was authorized in 2003 as a five-year program to dramatically ramp up the USG’s role in the fight against HIV/AIDS. The program was reauthorized in 2008 for an additional five years (PEPFAR II). The language re-authorizing the PEPFAR further strengthens its prior commitments (from ) to integrate gender by addressing the underlying gender norms and inequities that drive the epidemic and its impact. All the policy requirements from the ADS apply to PEPFAR programs. In addition, PEPFAR programs are expected to address gender inequity in five areas. Photo by Dietmar Temps

10 Gender and PEPFAR Key Legislative Issues:
Increase gender equity in HIV/AIDS programs; Reduce sexual violence and coercion; Address male norms and behaviors; Increase women’s legal rights; and Increase women’s access to income and productive resources. Specifically, PEPFAR commits to implementing strategies that: (READ BULLETS) Photo by Gary Graves

11 International Policy Commitments
UN International Conference on Population and Development (Cairo), 1994 Fourth World Conference on Women (Beijing), 1995 UN Millennium Development Goals, Targets for 2015 (The presenter may choose whether to include this slide and, if so, which international commitments may be most appropriate for focus.) From a global policy perspective, USAID and the United States Government policy frameworks also reflect and contribute to international commitments to integrate gender in order to promote health and gender equality outcomes. The policy frameworks just reviewed (on the previous slide[s]) advance commitments made at the International Conference on Population and Development in Cairo in 1994, and the Fourth World Conference on Women in Beijing in 1995, to: Promote women’s empowerment and gender equity; Focus on the needs and rights of individual women and men and promote a comprehensive reproductive health approach; Involve women in leadership, planning, decision making, implementation, and evaluation; and Encourage men to take responsibility for their sexual and reproductive behavior and their social and family roles. The USAID and United States Government policy frameworks for integrating gender also contribute to achieving the UN Millennium Development Goals—by addressing gender-related barriers to achieving maternal health and HIV/AIDS targets, as well as contributing to outcomes for the other six MDG goals (ending poverty and hunger, universal education, gender equality [in all levels of education], child health, environmental sustainability, and global partnership). Photo by Meena Kadri

12 SECTION II: What is the rationale for integrating gender in USAID health programs? Photo by Dietmar Temps

13 Why Integrate Gender into Health Programs?
Integrating gender improves: Health Gender equity U.S. government and international commitments to integrate gender came about because of the firm belief—and emerging evidence—that integrating gender improves outcomes in health and gender. Integrating gender facilitates reaching health goals, and can contribute to achieving gender equality. In concrete terms: When women are empowered to seek better healthcare and are in control of their sexual and reproductive lives, their health improves. When men care for their own bodies and respect their partners’ health and desires, both men and women can be healthier. By addressing gender, we can improve the health of women and men, girls and boys. Working to improve the health status of all individuals through integrating gender fosters real change in the way people live and relate to each other. Ultimately, improved health and gender equity work together to support each other. They also enable more sustainable development outcomes. There is now a growing body of data that backs up these beliefs with firm evidence. The next few slides share some highlights of what the evidence demonstrates. Photo by Marcel Reyners (2001)

14 Gender Inequity Impedes Health Program Success
Family planning STIs, including HIV Safe motherhood To make visible how gender inequities between women and men limit the effectiveness of health promoting behaviors, technologies and interventions, we can consider several key areas of health programming: Family planning—As many program experiences and evaluations have documented, unequal gender roles present powerful obstacles to use of voluntary family planning. Family planning efforts are often less successful when women do not have the power to decide when and how many children to have. When women are unable to use family funds for their healthcare or are discouraged from leaving home without permission, they face difficulties in learning about and obtaining family planning services. Furthermore, gender norms about female subservience and male virility may discourage couples from limiting the number of children they have. STIs/HIV—As recent efforts highlight (such as the law reauthorizing PEPFAR, among others), gender norms around women’s and men’s sexuality can increase the risk of STIs/HIV. These norms include, for instance, men being expected to have multiple partners and women being expected to be passive and ignorant about sex. Such norms increase vulnerability to STIs, including HIV. Safe motherhood—Gender norms and the low status of women play a large role in shaping vulnerabilities associated with pregnancy and delivery. For instance, women’s overall status—especially when it comes to level of education and decision making—can affect women’s access to maternal health care; such lack of access to and control over resources often prevent women from recognizing danger signs in pregnancy, or being able to actively seek emergency care on their own. Men are more likely to control household expenditures and other household decisions, yet often know little about pregnancy. Although changing, many cultures have norms that exclude men’s involvement in pregnancy, postpartum care, or child rearing. Facilitator’s note: You may want to acknowledge the health implications for non-normative gender and sexual identities and practices by saying that some cultures are more accepting than others of non-binary gender constructs. However, in many contexts, those who challenge normative ideas about gender experience severe stigma, discrimination, and even violence. It is thus important to consider, in RH programming, that both gender conformance and non-conformance can influence health behaviors, vulnerability, and access to information and services. Photo by Michael Mistretta

15 Gender Inequity Exacerbates Poor Reproductive Health
30-60% of women worldwide experience gender-based violence (GBV). GBV is linked with: multiple health problems reduced access and ability to use family planning and reproductive health services. To further elaborate on the link between gender inequality and poor RH, here are a few illustrative statistics. Facilitator’s note: You may want to include a few data points specific to your program area or region of focus. GBV, a form of violence derived from gender norms and roles as well as from unequal power relations that disproportionately affects women, is linked with multiple health problems, including fractures; depression and anxiety; post-traumatic stress disorder; permanent disability; traumatic fistula; unwanted pregnancy; unsafe abortion; pregnancy complications; maternal mortality; transmission of STIs, including HIV/AIDS; among others. (Bott, Morrison, and Ellsberg, 2005) Recent research in Bolivia, analyzing DHS data, found that “experience of GBV” reduced the demand for family planning (defined as “current use of contraceptive methods”) and reproductive health services (“use of prenatal care” and “pap smears”) by an estimated 30% (Pinto, Kincaid, and Murillo, 2010).

16 Gender Inequity Exacerbates Poor Maternal and Child Health
Early marriage increases risk of maternal death. Among women ages 15-24, 48% are married before the age of 18 in South Asia, 42% in Africa, and 29% in Latin America and the Caribbean. Gender inequity also impacts safe motherhood. For example, the practice of early marriage is linked with maternal and infant mortality and morbidity. While both girls and boys may be married at very young ages in some areas, on average girls are married earlier, and are more likely to be married to someone much older. In some cases, girls are married under very coercive conditions, while others may simply be too young to give their fully informed consent. The consequences of early marriage for girls are also more severe: marriage usually means premature childbearing, and early marriage increases a girl’s chances of experiencing domestic abuse (UNICEF, 2005; UNICEF, 2001). Girls ages are five times more likely to die in pregnancy or childbirth than women aged 20-24, while girls ages are twice as likely to die.

17 Gender Inequity Exacerbates HIV Vulnerability
Norms of masculinity often encourage sexual risk taking. Global studies reveal that men have higher rates of partner change than women (UNFPA, 2008). Finally, gender inequity plays an important role in the transmission of STIs, including HIV/AIDS. And, as noted before, men suffer health consequences as a result of gender inequality, too. Gender norms around sexuality encourage men, and especially young men, to be aggressive sexually, and to have multiple partners. Women, on the other hand, are often expected to be sexually innocent and passive, giving them less control over decisions about safer sex practices. Global studies reveal that men (regardless of marital status and sexual orientation) have higher rates of partner change than women (UNFPA, 2008). Multiple partners increases risk of STIs and HIV. These norms are linked with the transmission of STIs and HIV. Photo by Adam Cohn

18 Gender Equity Promotes Reproductive Health
Gateway factor influencing multiple health behaviors Middlestadt et al oject/3Acharya.ppt Increasingly, data exist that identify not only the barriers that gender norms and inequalities present to improved health outcomes, but also the positive outcomes that programs have achieved in both health and equality as a result of explicitly addressing these gender-related barriers. A study in Ethiopia measured the effect of men’s attitudes toward gender norms (using the Gender-Equitable Male (GEM) Scale) on their reproductive health behaviors (as measured using the Intimate Partner Behavior Index). The results confirm that men who report gender equitable attitudes are more likely to enact all 34 healthy RH behaviors, such as using family planning methods or discussing condom use with their wives (with an average of .22 correlation across all 34 behaviors). In this regard, gender-equitable attitudes are thought to be a gateway factor, with the potential to influence multiple health behaviors and outcomes. (Middlestadt et al., 2007) Photo by Meena Kadri

19 Gender Integration Improves Health Program Outcomes
Greater contraceptive knowledge and use Increase in joint-decision making about family planning Greater condom use Decreased incidence of GBV. The USAID Interagency Gender Working Group conducted two detailed reviews of evaluation data from dozens of program interventions to examine “what difference it makes when a gender focus is incorporated into RH programs” (Boender et al., 2004 p.1). Both “So What” reports (Boender et al., 2004 and Rottach et al., 2010) concluded that addressing gender norms can result in improved outcomes. The 2010 report found that gender integrated programs resulted in health outcomes ranging from greater contraceptive knowledge, greater contraceptive use, and increase in joint-decision making about family planning; to greater condom use and decreased incidence of GBV. A recent evaluation for the World Health Organization (WHO) and Instituto Promundo also provides important evidence about the effectiveness of interventions that integrate gender norms and inequalities related to men and boys. Of 58 programs reviewed, about 2/3 (67%) had effective or promising results in changing men’s and boys’ behavior and attitudes related to reproductive health and gender equity outcomes (Barker, Ricardo, and Nascimento, 2007). A number of projects have successfully integrated gender into health programs in order to attain both increased gender equity and improved health outcomes. We present three examples drawn from the “So What” reports in this presentation: one for RH/FP, one for safe motherhood, and one for HIV/AIDS. Sources: Rotach et al., 2010: Barker et al. 2007:

20 Gender Integration Leads to Equity and Healthy Behaviors: RH
Bolivia: PROCOSI 2001 – 2003 Program to integrate gender into clinical practices. Speaker’s note: You may want to tailor the examples highlighted in this section of the presentation to the audience’s priorities, such as their particular program focus area or geographical region. In Bolivia, PROCOSI is a network of NGOs that coordinates and implements health programs. The PROCOSI network implemented a program in among 17 of its partner organizations using a framework developed by International Planned Parenthood Federation (Manual to Evaluate Quality of Care from a Gender Perspective) to operationalize a gender perspective into clinical services Photo by Pedro Szekely

21 Program Evaluation: PROCOSI
Evaluation of seven organizational areas: institutional policies and practices; practices of providers; client satisfaction; client comfort; use of gendered language; information, communication, and training; and monitoring and evaluation. This intervention resulted in both increased gender equity and improved health outcomes. The evaluation of the program included household surveys of health service users and their partners (pre- and post-intervention). Evaluation at the clinic level included: 1) exit interviews with clients after their visits to the clinics, before and after the gender interventions; 2) follow-up interviews with the same women in their households three months after the exit interviews; 3) a survey with a sample of the women’s partners; 4) service statistics; 5) estimation of the costs of incorporating a gender perspective into service delivery; and 6) monthly clinic visits to qualitatively assess changes that took place in the participating organizations.

22 Gender Equity Results: PROCOSI
Percentage of Women and Men who Agree with the Following Statements Percent The evaluation measured positive changes in partner communication, couple decision-making, and attitudes toward gender roles and gender-based violence. The chart above shows women’s and men’s changed attitudes, which were found to be statistically significant. For instance, women were 4 percentage points less likely after the intervention to agree that women should not initiate sexual relations; 3 percentage points less likely to agree that sometimes men have the right to beat their partners; and 19 percentage points less likely after the intervention than before the intervention to agree that women’s work should mainly be in the home. Men’s attitudes changed, too: men were 14 percentage points less likely after the intervention to agree that women should work mostly in the home.

23 Health Results: PROCOSI
Percent The evaluation also found significant decreases in unmet need and significant improvements in quality of care. All results reported on the slide are statistically significant. First, unmet need for planning and spacing births, with desire to use family planning decreased by 34%—from 17% to 11% of women having unmet need. Providers were 19% more likely to call a woman by name and 94% more likely to use visual aids when communicating with patients. Women were 9% more likely to ask questions post-intervention than pre-intervention. While the health results may not be caused directly by the measured gender results, it is likely that they are related. For instance, if women and men share wage and household labor more equally, women may be more likely to have the means and the bargaining power within their relationships to seek contraception to limit and space their births.

24 Gender Integration Leads to Equity and Healthy Behaviors: Safe Motherhood
India: FRHS and ICRW Social mobilization Improvement of government health services The Foundation for Research in Health Systems (FRHS) and the International Center for Research on Women (ICRW) conducted a randomized controlled intervention study targeting newly-married adolescents in two comparable blocks of Ahmednagar district in Maharashtra. The intervention had two components: A social mobilization strategy that held forums, or interactive health education sessions for married adolescent girls. Young girls’ husbands participated in male group forums. A government health service improvement strategy that trained local health officials. Government health providers were also sensitized to adolescents’ health needs and trained to provide couple counseling to married adolescent girls and their husbands. Photo by Steve Evans

25 Evaluation: Social Mobilization and Government Services
Baseline, midpoint, and endline surveys: married girls and women Mid-intervention survey included husbands and mothers in-law The intervention produced significant improvement in safe motherhood and gender equity results Each cell of the design was implemented in one primary health center (PHC) area: One PHC had only social mobilization strategies, a second only improving government health services, a third had both strategies concurrently (SM+GS) and a fourth, the control area, received neither. The interventions and control PHC were assigned randomly. FRHS conducted a baseline census of 1,866 married girls and women ages across the study villages, collecting data on adolescent girls’ health needs, their constraints, and their families and communities; health-seeking patterns; and experiences and perceptions of quality of care for a number of reproductive health outcomes. Similar surveys were completed at the midpoint (N=2,100) and endline (N=2,359). Mid-intervention, 972 husbands of young women were surveyed to collect data on their knowledge of, and involvement in, their wives’ health-seeking. Similarly, 75 mothers-in-law were interviewed at midpoint to assess their attitudes toward their daughters-in-law. The evaluation demonstrated significant improvement in safe motherhood results, and qualitatively measured improvements in gender outcomes. Photo by Jerry Dohnal

26 Gender Equity Results: Social Mobilization and Government Services in India
The site that employed both strategies found that: Mothers-in-law were more supportive of daughters-in-law’s health seeking than those in other intervention sites. Husbands were more aware of basic maternal care issues and more willing to seek treatment for problems than pre-intervention. Of the four study arms, the one that had both intervention types saw the greatest increase in basic awareness of reproductive morbidities and infertility. The government-services-only site did not see significant improvements in most outcomes. The slide above presents a few key gender outcomes from the site with both interventions.

27 Health Results: Social Mobilization and Government Services in India
The site that employed both strategies found that: Women were more likely post-intervention than pre-intervention to: Use FP for birth spacing (12.4% more likely) Have delivery care for high-risk births (29.8% more likely) Receive treatment for reproductive tract infection symptoms (98.2% more likely) Of the four study arms, the two arms that included social mobilization strategies saw the greatest improvement in the reproductive health outcomes. This slide presents some key health outcomes from the site with both social mobilization and government services improvement interventions.

28 Gender Integration Leads to Equity and Healthy Behaviors: HIV/STIs
South Africa: Stepping Stones (MRC) BCC intervention that employs participatory learning approaches in single-sex groups led by trained peer educators. Stepping Stones is a gender-integrated BCC intervention that employs participatory learning approaches in single-sex groups led by trained peer educators. The Stepping Stones program aims to improve sexual health through building stronger, more gender-equitable relationships with better communication between partners. Groups reflect on issues like love, sexual health joys and problems, menstruation, contraception and conception, HIV, STIs, safer sex, gender-based violence, and dealing with grief and loss. Though Stepping Stones has been used in 40 countries, and the curriculum is available in at least 13 languages, we present here the results from a rigorous evaluation of the program carried out in South Africa from Photo by Samuel Cavadini

29 Evaluation: Stepping Stones
70 clusters HIV and herpes tests Pre- and post-intervention interviews Stepping Stones in South Africa is shown to increase health and gender equity results. The program was evaluated by the Medical Research Council (MRC) in South Africa from in 70 clusters (usually, each cluster was a village) at least 10 kilometers apart. 1,360 men and 1,416 women, aged 15 – 26 years, participated in the study. Study villages were assigned to receive either the Stepping Stones intervention, or a single 2-3 hour session based on the Stepping Stones curriculum. Participants were interviewed prior to the implementation and gave blood for an HIV and herpes test. Participants were re-interviewed and re-tested 12 and 24 months after the first interview. Additionally, qualitative research was completed in two of the clusters prior to and after participating in Stepping Stones. The South Africa evaluation showed evidence that the program has increased gender equity and improved health outcomes.

30 Gender Equity Results: Stepping Stones
Increased couple communication. Less perpetration of partner violence. “I think [beating] is not a right thing because you couldn’t say you are rectifying things through beating in your relationship…I think that we are supposed to sit together and tell one another the way that is supposed to be.” The evaluation measured gender results using qualitative methods, and found that the intervention increased couple communication, and increased awareness of gender violence and its harmful results. The study also found that men in the intervention committed less intimate partner violence.

31 Health Results: Stepping Stones
15% fewer new HIV infections among women 31% fewer herpes infections among women Among men: Fewer partners Higher condom use Less transactional sex Less substance abuse First, the intervention decreased incidence of HIV and herpes among women: women in the intervention arm had 15% fewer new HIV infections than those in the control arm, and 31% fewer herpes infections. Men also reported improvements in health behaviors, including significantly fewer partners, decreased substance use, and increased correct condom use after the intervention. Again, the intervention demonstrated both gender and health results as meaningful outcomes, but it is likely that the gender results are inextricably linked to improved health outcomes. (Rottach, Elizabeth, Sidney Ruth Schuler, and Karen Hardee Gender Perspectives Improve Reproductive Health Outcomes: New Evidence. Washington, DC: USAID IGWG and Population Action International.)

32 Gender Transformative Projects Promote Lasting Change
The overall objective of gender integration is to move toward gender transformative projects Photo by Anne Eckman (2006) Gender-integrated projects can take many forms, with varying degrees of change in gender and health outcomes. Sometimes a project will accommodate inequitable gender norms; in other words these projects will adjust to or compensate for inequitable norms in order to accomplish health outcomes. On the other hand, some projects actively strive to examine, question, and transform rigid gender norms and power imbalances as a means of reaching health and gender equity objectives. Transformative projects are more likely to create sustainable change than those that accommodate gender norms. Importantly, a WHO and Instituto Promundo review of programs that engaged men in RH projects demonstrated that projects rated as being “gender transformative” had a higher rate of effectiveness at changing behaviors and attitudes towards health and gender. Among the 27 programs that were assessed as being gender transformative, 41% were assessed as effective– versus 29% of the 58 programs reviewed overall. These findings suggest that gender-integrated programming is most effective in achieving health and gender outcomes when programs adopt strategies that go beyond acknowledging and compensating for gender differences and inequalities. Rather, when programs are able to adopt strategies that challenge and transform underlying gender norms and inequalities, they may be able to achieve greater and more sustainable changes related to health and equity. While not sufficient in themselves, accommodating approaches are sometimes necessary in addition to or in preparation to conduct gender transformative interventions. The overall objective of gender integration is to move toward gender transformative projects/policies, thus gradually challenging existing gender inequities and promoting positive changes in gender roles, norms, and power dynamics.

33 SECTION III: How can USAID health programming better implement gender integration? Photo by Dietmar Temps

34 Gender Integration Can Begin Anywhere in the Program Cycle
ASSESSMENT Collect and analyze data to identify gender-based constraints and opportunities relevant to program objectives. PROGRAM CYCLE 1 3 2 5 4 EVALUATION Measure impact of program on health and gender equity outcomes; adjust design accordingly to enhance successful strategies. STRATEGIC PLANNING Develop program objectives that strengthen synergy between gender equity and health goals; identify participants, clients, and stakeholders. If you have not been addressing gender, it is not too late to start! While the optimal stage to begin integrating gender is during the project design phase, in fact, gender can be addressed starting at any stage of the cycle – it’s never too late to “jump in” and start working to address gender issues.  Because gender integration is necessary at each stage of program development, implementation, and evaluation, it is possible to revise activities to address gender at any point in the program cycle. MONITORING Develop indicators that measure gender-specific outcomes; monitor implementation and effectiveness in addressing program objectives. DESIGN Identify key program strategies to address gender-based constraints and opportunities.

35 Examples of Gender-Integrated Projects: HIV/STIs
Incorporating safe sex negotiation and communication skills training for women Preventing gender-based violence, a risk factor for HIV Introducing BCC campaigns that reduce male sexual risk-taking Supporting economic empowerment activities for women as an alternative to transactional sex Perhaps the most important piece of gender integration is ensuring that gender analysis gets translated into concrete program and activity design. These examples are drawn from “A Summary of The ‘So What’ Report: A Look at Whether Integrating a Gender Focus into Programs Makes a Difference to Outcomes.” They highlight some of the ways in which gender analysis resulted in re-design of projects to integrate gender. See:

36 Examples of Gender-Integrated Projects: Safe Motherhood
Engaging men in recognizing and supporting the health needs of their pregnant partners Providing income- generating activities for women to increase their ability to care for themselves during childbearing years Supporting forums for women to voice their maternal health needs These examples are drawn from “A Summary of The ‘So What’ Report: A Look at Whether Integrating a Gender Focus into Programs Makes a Difference to Outcomes.” They highlight some of the ways in which gender analysis resulted in re-design of projects to integrate gender. See:

37 Examples of Gender-Integrated Projects: Family Planning
Offering free or low-cost services for women without the means, control, or resources to access to family planning Supporting women’s education and empowerment so that they can better advocate for their rights Including male partners in reproductive health and family planning counseling or training sessions These examples are drawn from “A Summary of The ‘So What’ Report: A Look at Whether Integrating a Gender Focus into Programs Makes a Difference to Outcomes.” They highlight some of the ways in which gender analysis resulted in re-design of projects to integrate gender. See:

38 Key Elements of a Gender-Integrated Project
Photo by Sara Anderson Make an institutional commitment to gender integration Implement a system to ensure accountability Ensure equitable participation of women and men at all levels Foster equitable relationships There are many systematic elements that contribute to a successful process of gender integration in health projects. These elements vary according to the particular context and levels at which gender integration occurs. But some common, overarching, guiding principles of gender integration include the following: Make an institutional commitment to gender integration Provide adequate funding Foster and support gender champions Implement a system to ensure accountability Specific objectives related to gender equality Indicators for measuring success Ensure equitable participation of women and men at all levels In activities In institutions Foster equitable relationships Between women and men, institutions and individuals.

39 Lessons Learned in Gender Integration
Gender integration can begin in any part of the program cycle, but is most effective when begun in the design phase. Changing gender norms takes time, but can show notable change in relatively short periods Do no harm! Truly transforming gender roles and norms can take a lot of time, dedication, and resources. You will not be able to achieve gender equality overnight. At the same time, many of the evaluated interventions (like those we shared) have demonstrated marked changes in both gender and health outcomes in relatively short periods of time. Thus, while it can be challenging, transforming gender relations in health programs is possible–and it does yields results. There is no perfect formula for gender integration: the process must be context specific. Gender integration must begin with recognizing varying roles, opportunities, or constraints that women or men have so that both can benefit from your program. Whatever the case, an essential principle in gender integration, as in all development work, is to “do no harm.” In other words, we must ensure that we do not exacerbate gender inequality or exploit inequalities to achieve desired health outcomes. Instead, we need to recognize that addressing gender constraints and supporting gender equity creates new opportunities to more effectively achieve improved health outcomes. Photo by Bangladesh Center for Communication Programs (2004)

40 Getting Started: Available Resources
USAID Interagency Gender Working Group: USAID Global Health: USAID Women in Development Office our_work/cross-cutting_ programs/wid/ PEPFAR Gender Technical Working Group Photo by Elizabeth Neason (2006) USAID staff have several sources of support for increasing efforts to integrate gender concerns into projects and programs: First, the IGWG is a network of USAID and cooperating agencies that promotes gender equity within USAID’s population, health, and nutrition programs. The IGWG has a collection of resources, including a virtual library of its reports and studies on gender and development, and a listserv and website available to all. The IGWG also offers training on gender and development for USAID and CA staff. USAID’s Women in Development Office works to ensure that women participate in and benefit from all of USAID’s programs (particularly those related to democracy and legal reform, girls’ education, and economic growth). It provides technical assistance to Missions to help achieve this goal, across multiple sectors. Finally, the PEPFAR Gender Technical Working Group provides country-level technical assistance to US government colleagues in the area of HIV/AIDS.

41 References Barker G., C. Ricardo, and M. Nascimento Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence from Programme Interventions. Geneva: World Health Organization. Boender, Carol, Diana Santana, Diana Santillan, Karen Hardee, Margaret E. Greene, and Sidney Schuler The ‘So What?’ Report: A Look at Whether Integrating a Gender Focus Makes a Difference to Outcomes. Washington, DC: USAID Interagency Gender Working Group. Bott, Sarah, Andrew Morrison, and Mary Ellsberg “Preventing and Responding to Gender-based Violence in Middle and Low-income Countries: A Global Review and Analysis.” World Bank Working Paper Series Washington, DC: World Bank. Middlestadt, Susan E., Julie Pulerwitz, Karabi Acharya, Geeta Nanda, Bridget Lombardo “Evidence of Gender as a Gateway Factor to Other Behaviors—Ethiopia. The Health Communication Partnership’s End of Project Meeting.” Washington, DC: USAID Health Communication Partnership. Available at: Pinto, Guido, Mary Kincaid and Beatriz Murillo “The Relationship between Domestic Violence and Reproductive Health and Family Planning Services in Bolivia, 2003.” Población y Salud en Mesoamérica 7(2).(electronic journal:

42 References, continued Rottach, Elizabeth, Sidney Ruth Schuler, and Karen Hardee Gender Perspectives Improve Reproductive Health Outcomes: New Evidence. Washington, DC: Population Reference Bureau for the IGWG. UNFPA State of the World’s Population 2008: Reaching Common Ground: Culture, Gender and Human Rights. Geneva: UNFPA. Accessed November 10, 2009 at: UNICEF Early Marriage: A Harmful Traditional Practice. A Statistical Exploration. NY: UNICEF. UNICEF Early Marriage: Child Spouses. Florence: UNICEF Innocenti Research Centre. United Nations Gender Mainstreaming, Extract from the Report of the Economic and Social Council for A/52/3. Geneva: United Nations.

43 Acknowledgements Thanks to Michal Avni, Patty Alleman, and Diana Prieto for their technical review. This presentation was prepared by Elizabeth Doggett, Myra Betron, Anne Eckman, Elizabeth Neason, and Mary Kincaid for the USAID | Health Policy Initiative, Task Order 1. The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I , beginning September 30, Task Order 1 is implemented by Futures Group International, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace.

44 What Difference Does Gender Make
What Difference Does Gender Make? Opportunities and Responsibilities for Promoting Gender Equity in USAID Health Programs Thank you for your attention. Photo by Dietmar Temps

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