(Lesley Doyal)

A draft framework for designing national health policies with an integrated gender perspective

1. Background

Over the last two decades, women’s issues have moved rapidly up the policy agenda of international organisations and national governments. During the eighties there was a major increase in policies designed to prevent women from being marginalised from the mainstream of economic and social life. Though these policies did lead to significant improvements in women’s lives, their overall status in society remained very much the same. In recognition of this continuing discrimination the focus on women alone is now shifting towards a broader concern with gender relations. In health care and in other areas of public policy, the emphasis is now on identifying and removing the gender inequalities that prevent women (and sometimes men) from realising their potential.

This shift towards a gender perspective was an important step forward. However it has not yet delivered the expected results and two main reasons for this can be identified. First, there has been considerable confusion about the terms being used. What do we mean by ‘gender’ and why is it different from ‘sex’? And how is the ‘gender’ approach different from one that focuses only on women?  These are important issues that need to be properly understood by all those involved in the implementation of ‘gender sensitive’ health policies. Second, there has been a lag in the development and dissemination of appropriate techniques for the incorporation of gender issues into policy process. If gender equity is to be a major goal in the development of a health service with gender equality in health as the final objective, those involved need to be properly informed about the most effective means by which this can be achieved.

This paper provides an introduction to some of these conceptual and technical issues underlying the development of gender sensitive health policies. It begins with a clarification of the relationship between gender, health and health care and then moves on to present an introductory framework for the mainstreaming of gender issues in the health sector itself. It concludes with some brief observations about gender equity and equality and its overall significance in the public policy debate.

2. Sex, gender and health: clarifying the concepts

Despite its increasing use there is still considerable confusion surrounding the term ‘gender’. It is not simply a more modern word for ‘sex’. Rather it is a term used to distinguish those features of males and females that are socially constructed from those that are biologically determined. Thus men and women are differentiated by social (or gender) characteristics on the one hand and by biological (or sex) characteristics on the other. This means that gender issues are not just of concern to women. Men’s health too is affected by gender divisions in both positive and negative ways. These differences in ‘maleness’ and ‘femaleness’ are reflected in the patterns of health and illness found among men and women around the world.

Women in most countries tend to live longer than men of the same social status as themselves though the size of this gap between male and female life expectancy varies significantly. Yet at the same time women report more sickness and distress than men do. There are also marked variations in the rates of particular health problems between men and women. Men are more likely to die prematurely from heart disease for example, while women are more likely to suffer from autoimmune diseases or musculoskeletal disorders and also from anxiety and depression. Any attempt to explain these differences has to make sense of the impact of both biological and social influences on well being.

2.1 Biological influences on health and illness

Both biomedical and common-sense accounts of the differences between men and women have traditionally focused on their reproductive biology. This approach is clearly important since the structure and functioning of their reproductive systems can lead to particular health problems for both women and men. Only men have to worry about cancer of the prostate for example, while only women can develop cancer of the cervix. However women’s capacity to conceive and give birth means that they have reproductive health care needs additional to those of men both in sickness and in health. Unless they are able to control their fertility and to give birth safely, women can determine little else about their lives so that access to quality reproductive care is a crucial determinant of their health.

The truth of this claim is evident if we look again at male and female patterns of life expectancy. Women’s greater longevity is generally accepted to be biological in origin. Far from being the weaker sex it appears that a number of biological factors combine to give them the potential for greater life expectancy than men. However this biological potential for longer life may be significantly reduced if they are the objects of discriminatory practices such as a failure by society to provide effective and appropriate health services. In these circumstances the gap between male and female life expectancy will be much smaller. Indeed in some societies it may be men who live longer. It is here then, that the biological meets up with the social and it is these social or gender differences that are potentially amenable to change.

2.2 Gender divisions in society

All societies are divided along a male/female axis with those falling on either side of the divide being seen as fundamentally different types of beings. Most obviously, those who are defined as female are usually allocated primary responsibility for household and domestic labour while males are more closely identified with the public world - with the activities of waged work and the rights and duties of citizenship.

In most societies these are not just differences but inequalities. Those things defined as ‘male’ are usually valued more highly than those things defined as ‘female’ and men and women are rewarded accordingly. The work women do at home for instance is unpaid and usually of low status compared with waged work. Thus most women have access to fewer resources than males in the same social situation than themselves. These inequalities clearly have a major impact on the health of both women and men but so far it is only their effect on women that has been spelled out in detail.

2.3 The impact of gender inequalities on women’s health

Economic inequalities mean that in many countries women have difficulty in acquiring the basic necessities for a healthy life. Of course the degree of their deprivation will vary depending on the community in which they live but the ‘feminisation’ of poverty remains a constant theme. ‘Cultural devaluation’ is also important though is difficult to measure or even to define. Because they belong to a group that is seen by society to be less worthwhile, many women find it difficult to develop positive mental health. This process begins in childhood with girls in many cultures being less valued than boys and continues into later life where ‘caring work’ is given lower status and less rewards. These gender inequalities are further reinforced by women’s lack of power and the obstacles they face in trying to effect social change.

At the same time, the nature of female labour itself may affect women’s health. Household work can be exhausting and debilitating especially if it is done with inadequate resources and combined (as it is for many women) with pregnancy and subsistence agriculture. It can also damage mental health when it is given little recognition and is carried out in isolation. For some women, domestic life and labour may also carry the threat of violence since the home is the arena in which they are most likely to be abused. Even in the context of paid work, ‘female’ jobs often pose particular hazards that receive little attention.

 

2.4 But what about men?

Thus far it is women and their advocates who have paid most attention to the impact of gender divisions on health. This is not, of course surprising, since as we have seen, the damaging effects of these inequalities on their health are very evident. However new questions are now being raised about the possible health hazards of being a man and these may also need to be addressed in the development of gender sensitive policies.

On the face of it, ‘maleness’ can only be health promoting since as we have seen it is likely to give a man greater power, wealth and status than a woman in the equivalent social situation. However certain disadvantages have also been identified. In the context of waged work for instance, the idea of the ‘male breadwinner’ has meant that in many societies men have felt compelled to take on the most dangerous jobs. As a result male rates of industrial accidents and diseases have historically been higher than female rates and deaths from occupational causes more common among men than among women.

Men in the majority of societies are also more likely than women to adopt a variety of unhealthy habits- smoking and heavy drinking for instance, as well as dangerous sports. These activities are linked in most cultures to ideas about masculinity so that young men in particular may feel pressure to indulge in risk taking behaviour in order to show that they are ‘real men’. Similar concepts have been used to explain the high rates of male on male violence found in many parts of the world. In the area of mental health too, some men are now arguing that gender stereotyping narrows the range of emotions they are allowed to express, making it difficult for them to admit weakness for example or other feelings regarded as ‘feminine’.

It is clear then, that the health status of both women and men is affected by their biological characteristics but also by the influence of gender divisions on their social, cultural and economic circumstances. The impact on men is especially difficult to assess since as we have seen male status involves a complex mixture of risks and benefits. Not surprisingly, access to health care and the quality of care provided also shows marked gender differences. And again the available evidence suggests that it is women who are most disadvantaged by the way medical knowledge is generated and medical resources are allocated.

3. Gender bias in medical practice

This section will summarise the ways in which both the generation of knowledge in health care and also the delivery of services demonstrates gender bias. The status of medicine as a science has not rendered it immune from wider social and economic forces as the evidence below demonstrates.

3.1 Gender bias in research

Most health -related research continues to be carried out within the biomedical tradition. Though social factors are beginning to be taken more seriously, by far the largest proportion of resources is still spent on projects falling within the formal domain of biomedicine. This applies not just to clinical and epidemiological research but also to the routine collection of morbidity and mortality statistics which continue to be framed within standard medical categories. As a result the information collected and the findings generated are often inadequate for the implementation of gender sensitive policies.

Most medical research continues to be based on the unstated assumption that men and women are physiologically similar in all respects apart from their reproductive systems. Other biological differences are ignored as are the social differences which have such a major impact on health. The consequence of this approach is the generation of biased knowledge. In the context of routine data collection, statistics are not always disaggregated by sex, making it difficult to plan for the specific needs of men and women. Similarly many clinical studies leave women out altogether or fail to treat sex and gender as important variables in the analysis.

As a result both preventive and curative strategies are often applied to women when they have only been tested on men. Particular concern has been expressed about this in relation to coronary heart disease and also HIV/AIDS. There is also is growing evidence that sex and gender differences may be important in a range of infectious and parasitic diseases including tuberculosis and malaria. Sex related biological differences may affect both susceptibility and immunity while gender differences in patterns of behaviour and access to resources may influence the degree of exposure to infection. However without more information it is difficult to translate these observations into more effective policy making or clinical practice.

3.2 Gender bias in the delivery of health care

Similar concerns have been raised about gender bias in access to medical care and in the quality of care received. There is considerable evidence to show that women experience gender-related constraints on their access to health services and that this affects the poorest women in particular. The obstacles they face include lack of culturally appropriate care, inadequate resources, lack of transport, absence of alternative care for their families and sometimes the refusal of their husband to give permission. Of course limited public expenditure on health care will affect men as well as women but in conditions of scarcity it is often the females in the family whose needs are given the least priority.

If they do gain access to health care, there is also evidence that the quality of care women receive is inferior to that of men. Too many women report that their experiences are distressing and demeaning. Medical knowledge is too often presented as inevitably superior, giving women little opportunity to speak for themselves or to participate actively in decision making about their own bodies. These problems are reflected particularly in the context of reproductive services where dehumanising and insensitive treatment can affect women’s willingness to return.

Previous sections have clarified some of the concepts relating to gender and health, and explored the empirical evidence relating to gender differences in health status and the gender bias in health care resources. These form the basis for the next two sections where a framework will be outlined for mainstreaming sex and gender issues in all aspects of health care. Section four examines the area of health -related research while section five examines the delivery of health care itself.

4. Mainstreaming gender in medical research

As we have seen, gender inequalities in the wider society are also reflected in the way medical research is carried out. If this is to be changed, women’s needs and desires must have a more prominent place in the research process. This will not happen by accident. Rather, a formal set of policies will be needed to ensure that their interests are represented. Only then will health related research reflect the interests of all its potential users equally.

4.1 Measuring women’s health

One of the most basic problems facing many policy makers is lack of specific information on the situation of women. The failure to separate women from men in national and regional statistics can make it difficult to plan effectively to meet the particular needs of either group. It is essential therefore that data is collected about both sex and gender differences in health status and that the results are clearly presented for easy use. The conceptual framework for this data collection process must be appropriate to the setting in which it is being used and must also recognise the diversity of women’s experiences over the lifespan.

Older women and young girls for example, may have particular health problems, making it essential that factors such as their nutritional status, or their access to health care are routinely monitored. This will require the development of appropriate indicators for measuring different aspects of their health and quality of life. Other groups of women whose vulnerability may require special attention include those who are refugees or migrants, those who are bringing up children alone and those who are coping with chronic disease or long term disabilities.

In many developing countries, the lack of data on women’s health reflects in part the very limited nature of the vital registration system, which affects both sexes. However this is often compounded by a failure on the part of the relevant authorities to recognise the importance of gender issues and a lack of understanding of the complex social pressures that may render women’s health problems invisible. In the case of maternal mortality for instance, a wide range of religious, cultural and social factors can contribute to serious under-reporting. New methods have now been developed for identifying those cases that are missed and these need to be used routinely by those responsible for monitoring community health.

Similar problems are evident in relation to the identification and measurement of domestic violence. This represents a huge public health problem which has not yet been adequately documented. If this knowledge gap is to be filled individual countries need to move forward with the development of ethical and culturally appropriate methods for the collection of relevant data in their own particular settings. This can be facilitated by cooperation with international organisations such as WHO who have already developed a range of resources for work in this area.

Gaps in the availability of information on women’s lives are now beginning to be filled, providing new sources of accessible data. For instance, the recent development by UNDP of a number of new gender -related indicators, offers important tools with which individual countries can assess the levels of gender equality in their own society. However there is still a need for national governments and international agencies to work together to develop more specific health related measures combining both biomedical and socio-economic data to monitor the changing state of women’s and men’s health around the world.

4.2 Including women in biomedical research

Few women are currently involved in what has been the male dominated arena of medical research but strategies for change are beginning to emerge. In the United States for instance the Office of Research on Women’s Health has been created to ensure that women’s needs are adequately represented on the medical research agenda, and that women themselves are included in relevant studies as well as taking their place as active researchers. Both the US and Australian governments have also funded long term studies to investigate the particular problems of women as they move through the life cycle. Other attempts to involve women in the determination of research priorities have included the organisation of formal dialogues between researchers and women’s health advocates, particularly in the area of reproductive health.

4.3 Expanding the disciplinary boundaries in health research

These examples can provide valuable models for those (relatively few) governments involved in the funding and the regulation of biomedical research. However they represent only a partial strategy for extending our understanding of sex and gender inequalities in health and illness. Social scientific research is also needed if the full range of influences on human health is to be understood. In particular governments need to support health-related research by anthropologists, sociologists and psychologists and to use their findings alongside those of biomedical scientists to develop more comprehensive health promotion policies.

This work will sometimes require the use of quantitative methods to document the more structural aspects of gender inequalities. However more qualitative strategies are also needed. These will involve the use of a variety of observational techniques and informal or semi-formal interviews as well as more collective methods such as focus groups. Good examples of this kind of work can now be found in the area of reproductive health in particular, where new techniques have been developed to explore the intimate concerns of women who have little or no experience of putting themselves or their interests in the public arena.

4.4 Getting the whole picture

Finally it is essential that strategies to improve the health of women (or men) are grounded in a rigorous analysis of the whole range of reproductive and productive activities undertaken across the lifespan. In the case of women this is especially problematic because of the invisibility of so many of their activities. Femaleness can no longer be equated with motherhood and the scope of health research needs to shift accordingly. Hence planners need to acquire much more information on the risks women face both in the home and in the workplace and a combination of biomedical and social research will be needed to make that possible.

Until recently, few researchers had examined the risks associated with domestic work. This is now beginning to change as new techniques are being developed to explore the ‘black box’ of the family. This has revealed a number of hazards that are especially dangerous for the poorest women. Analysis of the relationship between patterns of energy consumption and the volume of household work for instance suggests that some women‘s responsibilities impose long term damage on their health. A range of environmental risks have also been identified including lung damage caused by pollution from cooking stoves as well as a range of unregulated but toxic substances.

Women’s work outside the home also needs much more attention from both researchers and policy makers. Though male workers die more often than females from work-related causes there are many parts of the world in which women’s work related disease and disability is rapidly increasing. Evidence is only now beginning to emerge that traditionally ‘female’ jobs such as nursing and clerical work can pose both physical and psychological risks. The millions of women now taking on traditionally ‘male ‘ jobs may also be facing serious risks especially if they are forced to combine heavy physical labour with domestic work and with reproduction.

If these issues are to be taken seriously, occupational health researchers need to develop greater gender sensitivity in their methods of investigation Their findings need to reflect both the different jobs done by women and men and also the biological and social differences that mediate the impact of waged work on health and well-being. Only then will regulatory bodies have accurate information on which to base health and safety at work policies that can benefit men and women equally.

We have identified a number of strategies that can be adopted to ensure that health reset carried our under the auspices of local, national and international organisations is gender sensitive, and provides an appropriate base for policy making. However it is also important to recognise that a great deal of information on gender issues is already available. Hence is essential that health planners and policy makers use the most up to date and gender sensitive resources as the basis for developing their services.

5. Mainstreaming gender in health service delivery

The mainstreaming of gender concerns into the planning, delivery and monitoring and evaluation of health services is a complex process. Lack of awareness or ‘gender blindness’ on the part of policy makers and planners frequently leads to gender bias and to the prioritisation of male interests in decision making. If this is to be avoided those involved need to have not only a clear understanding of the relevant issues but also the political will to reduce the inequalities between men and women.

This does not, of course, mean that both sexes should be treated in exactly the same way. Despite their commonalities, men and women will also have their own particular needs. Hence adherence to the principle of equity is required to ensure that these different needs are met, with equality in health as the desired outcome. Nor does it mean that all women (or all men) should receive the same treatment. Their varying circumstances will mean that here too a range of strategies will be needed if equality is to be achieved between women and between men.

5.1 Identifying gender concerns in the policy environment

If the goal of developing gender-sensitive policies is to be achieved, this needs to be built explicitly into the original objective of the programme in a way that can be used later for evaluation purposes. This will require a preliminary analysis of the context in which the policy will be operating and a clear understanding of the gender issues involved. This may be a relatively simple operation comparing the numbers of males and females in the target population and assessing the gender patterns in current service use. However the analysis will usually need to be taken a stage further to make sense of the gender relations between individuals and groups being counted.

The questions to be asked will vary depending on the type of policy being developed but in most health care contexts they should include some of the following

do gender differences in daily life expose women and men to different kinds of health risks?

how are existing gender differences in the use of services to be explained?

can any differences be observed in the quality of care women and men currently receive?

who currently controls access to health related resources and do the allocation criteria take into account the different needs of men and women?

These broader contextual issues may sometimes be difficult to map but unless they are woven into the implementation process at all stages the resulting policies will not be sensitive to women or men in their approach and inequitable in their effects. This can be illustrated by reference to some of the gender-related problems that have arisen in the process of health sector reform.

5.2 Health sector reform: a case study

Many countries are now going through a process of health sector reform. Though some attention has been focused on the implications of these developments for the poorest people, few policy makers have taken gender issues into consideration. There is now increasing evidence that as a result, health sector reform may be increasing rather than reducing gender inequality.

Although information on these effects is still sparse, it is clear that gender issues should be a central concern in health sector reform for several reasons. First, women are found disproportionately among the most vulnerable population groups. Hence economic and financial changes in service delivery may have a disproportionate effect on them. Second, access to and utilisation of, health services are heavily influenced by cultural and ideological factors such as low valuation of the health of women and girls and this needs to be recognised in the way services are planned. And third, women make up the majority of health workers. Unless attention is paid to gender issues of this kind, health sector reforms may only worsen women’s overall position by comparison with that of men. The following illustrate the sorts of questions that need answering before equitable policies can be enacted.

What would be the impact on male and female health workers of reforms in health care bureaucracies?

Would decentralisation improve access to health care or further marginalise the most vulnerable groups?

How would improvements in the functioning of national ministries of health affect male and female workers?

What are the implications of different financing options for gender inequalities in access to care ?

How would managed competition affect equality and access?

Are women’s health needs more or less likely to be met in a mixed economy of care operated in collaboration with the private sector?

 

5.3 Putting gender issues into the planning process

If gender inequalities in health and health care are to be properly identified and tackled women themselves will need to be more involved in the design, implementation and evaluation of services. Because of the relative absence of women from most of the important arenas of decision making, special care may have to be taken to ensure that their views are heard. The most appropriate forms of consultation will vary with the circumstances but may include either discussion with representative groups or direct consultation with potential users.

If the planning process is to be as participatory as possible and the goal of greater equality is to be realised in practice there must be a serious commitment to these aims at the highest levels of government. This is best demonstrated through the creation of a national or regional policy framework within which both the planning process itself and delivery of services can be located. Though there is no single model for such a framework, a range of options already exist in countries with varying political and legal structures. Experience shows that little is likely to be achieved unless responsibility for the achievement of greater gender equality (both in health and elsewhere) is clearly allocated and the goal itself is given a high priority.

5.4 The importance of capacity building for gender sensitive services

Once plans have been drawn up, the effective operation of the service will require a strategy for educating health workers and managers so that they understand better the significance of gender issues in health. Capacity building programmes need to be designed for both male and female workers and they need to focus not just on ‘women’s issues‘ but on the wider question of gender itself. They may include broadly based ‘gender awareness‘ courses and also more detailed briefings on gender-related topics not generally included in medical, nursing or other curricula.

It is important that these programmes be culturally appropriate to the settings in which they are to be used but a number of models already exist which can be used as the foundation for their development. Courses of this kind need to be provided for health workers who already qualified but they also need to be formally built into the curriculum for all those undertaking health care education and training. Medical and nursing curricula in particular need to be very carefully shaped if gender issues are to be properly embedded in the future planning and delivery of services.

5.5 Tackling gender inequalities in the relations of caring

One of the most important goals of this capacity building must be to inculcate in all health workers a respect for the dignity and human rights of all service users. This needs to include a special commitment to the right of women to play as active a part as possible in decisions about their own care. Both their own socialisation as well as the attitudes of many doctors and nurses place particular obstacles in the way of many women seeking to give their informed consent or refusal to treatment.

Education of both health care workers and managers and also of female service users are essential if these problems are to be overcome. However education and information giving alone will rarely be enough to ensure appropriate and ethical treatment Hence a range of mechanisms need to be put in place to ensure that women have access to advocacy services when they are needed and that formal and easily accessible opportunities exist for complaint and possible redress.

5.6 Monitoring and evaluation

Finally it is essential that all policies include gender issues in their strategy for monitoring and evaluation. This will enable service providers to measure the differential impact of the policy on men and women in their roles as both users and workers. The results will then provide the basis to plan any changes needed to promote greater gender equity and equality in health. And most importantly the lessons learned can be more widely disseminated to help those at an earlier stage of innovation. Again these monitoring and evaluation strategies need to be culturally sensitive and designed to reflect (and hopefully change) existing patterns of gender relations. However a range of practical tools are now available as a starting point for this work.

6. Putting gender equity and equality in health into a broader perspective

This paper has concentrated on the differences between men and women, exploring the impact of sex and gender on health and health care. It has identified existing gender inequalities in health care and mapped out some of the methods by which they can be tackled. However this can only be a starting point if the ultimate goal is to move towards gender equality in health on a community, a national or a global scale.

Health care is only one of the influences on health itself. Hence if gender inequalities in health are to be tackled successfully the strategy also needs to include a range of other public policies in areas as diverse as education, law and order, agriculture, transport, social security and the legal system. In each of these areas gender equity needs to be a specific goal and targeted interventions need to be introduced to tackle traditional patterns of gender disadvantage. Only then will the root causes of gender inequalities in health be challenged.

In the development of macro economic policy for example, attention needs to be paid to the informal sector, to unpaid labour and to the ‘care economy’ so that the implications of any decisions for women’s work receive appropriate attention. Similarly, legislation is required to create a ‘level playing field‘ through the control of gender discrimination in access to social and economic resources. Looking at more specific areas of public policy, targeted interventions that can reduce gender inequalities in health include the development of an integrated policy to meet women’s practical energy needs, female literacy programmes, special subsidies to meet the transport needs of rural women, strategies to increase women’s management of water resources, and more provision of credit for women especially in the agricultural sector.

Finally it is essential that all policy makers recognise that gender inequalities are by no means the only determinant of health. As we have seen, the health of both sexes is also profoundly affected by issues such as class, race and socio-economic status. Thus policies to improve the health of women (or men) must also take factors such as these into account. Gender equity in health is an important goal but it is only one amongst many and broader issues of discrimination and disadvantage will have also have to be addressed if progress is to be made towards the achievement of gender equality and equal health for all.