Placing gender at the centre of health programming: challenges and limitations
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.
Section snippets
Gender and its relationship to health
Primary health care (PHC), while concerned with socio-economic inequalities, was promoted without adequate consideration of gender. While PHC advocated for “community participation” as one of its central tenets, it tended to assume a homogenous grouping of society members with shared interests, which is usually not the case (Garcia-Moreno & Piza, 1991). Furthermore, gender roles, in particular women's roles, although central to virtually all components of PHC, were largely ignored (Leslie, 1989
How gender contributes to health policies and programmes
Inclusion of a gender analysis can improve health planning and programming in at least five ways. In this section we briefly illustrate these contributions with examples from recent research. The examples are not exhaustive of all health problems or all situations: we focus on gender issues in stable health care settings. However, many of these issues are even more pronounced in emergency and humanitarian crises (Byrne, 1996; Palmer & Zwi, 1998). For example, reproductive health services are
A gender analysis improves understanding of the epidemiology of health problems
Several recent studies have shown that a gender analysis provides a more comprehensive understanding of the epidemiology of disease and other health problems than is otherwise available. Several examples are presented below.
Injuries and violence are increasingly receiving attention as major public health problems. There are important differences in the nature and experience of violence between women and men. There also are important differences in the types of injury which affect women and men
Challenges of incorporating gender in health planning and programming
Despite the many arguments in favour of incorporating gender issues into health policies and programmes, many obstacles remain. Some of these are briefly discussed below, as well as opportunities for placing gender at the centre of health programming.
Conclusion
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. This change in philosophy requires, firstly, a recognition that “gender” is not synonymous with “women” or with sex—it is a concept that sees men and women within the context of their culturally defined roles, constraints and potentialities. This context itself often needs to be challenged, such as when gender stereotypes place women in an inferior position or
Disclaimer
The views expressed in this paper are those of the authors and do not necessarily reflect the views of their respective Organizations.
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