Placing gender at the centre of health programming: challenges and limitations

Abstract

In this paper we argue that a gender analysis is fundamental to health and health planning. We begin with a definition of gender and related concepts including equity and equality. We discuss why gender is key to understanding all dimensions of health including health care, health seeking behaviour and health status, and how a gender analysis can contribute to improved health policies and programming. Despite the many reasons for incorporating gender issues in health policies and programmes many obstacles remain, including the lack of attention to gender in the training of health professionals and the lack of awareness and sensitivity to gender concerns and disparities in the biomedical community. We argue that the key to placing gender values firmly in place in Health for All renewal is a change in philosophy at all levels of the health sector and suggest ways in which such a change can be implemented in the areas of policy, research, training and practical programmes and interventions.

Introduction

Gender refers to those characteristics of men and women that are socially constructed. Sex refers to biologically determined characteristics. While biologically determined difference are universal, social differences between women and men are learned, changeable over time and vary both within and between cultures. Gender interacts closely with biological differences, and other social varibale such as class, in determining health exposures and outcomes. Unfortunately, “gender” is increasingly used inappropriately as a substitute for “sex”, particularly in the biomedical literature, a tendency which has created confusion (Fischman et al., 1999).

Gender roles change over time and over an individual's life stages. They also vary according to culture, but in practically all cultures women have a lower status than men and female roles are valued less than those of men. Exceptions are found in a small number of societies which are matrilineal and matrifocal such as the Akan-speaking people of Ghana which emphasize the powerful social, political and economic roles of women, even of unschooled market women (Terborg-Penn & Benton Rushing, 1996). Even in these societies, however, matrilineality does not necessarily give more independent power to women; entitlements usually devolve through men—often uncles—of the wife or mother. Moreover, matrilineal inheritance systems are rapidly giving way to patrilineal inheritance patterns, particularly with respect to land, as a result of the formalization of customary rights such as land registration that often discriminate against women (IFPRI, 1995).

Because it pertains to the roles performed by men and women and the power relationships between them, gender affects most areas of human existence, including health. Gender interacts with both biological differences and social factors. It affects access to health care (Kutzin, 1993; Velez, Hendrickx, Roman, & Agudelo, 1997), health seeking behaviour (Vlassoff & Bonilla, 1994; Tanner & Vlassoff, 1998), health status (Santow, 1996) and the way health policies and programmes are developed and implemented (Hatcher Roberts & Vlassoff, 1995; AbouZahr, Vlassoff, & Kumar, 1996; Hatcher Roberts & Kitts, 1996). In this paper we argue that a gender analysis is fundamental to health and health planning and discuss the challenges and limitations involved in incorporating gender into the new global health policy of Health for All in the 21st century.