EGM/HEALTH/1998/Report
UNITED NATIONS
Division for the Advancement of Women (DAW)
World Health Organization (WHO)
51³Ô¹Ï Population Fund (UNFPA)
Commonwealth Secretariat
Tunisian Ministry of Women and Family
REPORT
________________________________________
51³Ô¹Ï Division for the Advancement of Women
Department of Economic and Social Affairs
2 51³Ô¹Ï Plaza - DC2- 12th Floor
New York, NY 10017
Telephone: (212) 963-5086, Fax: (212) 963-3463
Web location: http://www.un.org/womenwatch/daw
E-mail: daw@un.org
TABLE OF CONTENTS
Paragraph
I .ORGANIZATION OF WORK 1-12
A. Attendance 1-2
B. Documentation 3
C. Programme of work 4
D. Election of officers 5
E. Opening statements 6-12
II. SUMMARY OF DEBATE 13-46
A. Occupational and environmental health 18-20
B. Sexual and reproductive health 21-25
C. Tuberculosis, malaria and other disease control
programmes, including HIV and AIDS 26-29D. Mental health 30-32
E. Mainstreaming the gender perspective in health care 33-35
F. Integrating the gender perspective in medical education
and research 36-37G. Health reform and financing: Introducing a gender-based
analysis 38-41H. Partnership for health: Actors and key stake holders 42-46
III. CONCLUSIONS AND RECOMMENDATIONS 47-94
A. Occupational and environmental health 47-51
B. Sexual and reproductive health 52-58
C. Tuberculosis, malaria and other disease control
programmes, including HIV and AIDS 59-66D. Mental health 67-70
E. Cross-cutting recommendations 71-77
F. Health reform and financing 78-80
G. Capacity building for health personnel 81-86
H. Partnership for health 87-90I. Quality of care 91-94
IV. A FRAMEWORK FOR DESIGNING NATIONAL HEALTH POLICIES WITH AN INTEGRATED GENDER PERSPECTIVE 95-166
A. Introduction 95-96
B. Sex, gender and health: clarifying the concepts 97-116
1. Biological influences on health and illness 99-100
2. Gender divisions in society 101-106
3. The impact of gender inequalities on women's health 107-112
4. The impact of gender inequalities on men's health. 113-116
C. Gender bias in health practice 117-123
1. Gender bias in research 117-120
2. Gender bias in the delivery of health care 121-123
D. Mainstreaming gender in health research 124-137
1. Measuring women's health 125-129
2. Including women in biomedical research 130
3. Expanding the disciplinary boundaries
in health research 131-1324. Getting the whole picture 133-137
E. Mainstreaming gender in health service delivery 138-158
1. Generating political will 141-143
2. Instituting a gender sensitive needs assessment 144-145
3. Including gender issues in the planning process 146-151
4. Developing the framework for gender planning 152-153
5. Incorporating capacity building for gender sensitive
services 154-1566. Accountability, monitoring and evaluation 157-158
F. Intersectoral collaboration for gender equality and health 159-166
Pages
I. List of participants 32
II. List of documents 39
III. Programme of work 42
i
The Fourth World Conference on Women (Beijing, 1995) defined "Women and Health" as one critical area of concern in the Platform for Action and established five strategic objectives. In doing so, it emphasized the importance of a holistic and life-cycle approach to women's health. The Programme of Action of the International Conference on Population and Development (ICPD, Cairo, 1994), adopted one year earlier had set the basis for recommendations pertaining to women's reproductive health to which the Platform for Action referred in many instances. The Platform for Action reiterated the agreements reached at the International Conference on Population and Development (ICPD), in particular with regard to women's reproductive health and rights and added new ones, addressing the right of women to control all aspects of their health, and the equal relationship between women and men in matters of sexual relations and reproduction. It also reaffirmed agreements reached at the World Conference on Human Rights (Vienna, 1993) that women's rights are human rights.
In accordance with its multi-year programme in the follow-up to the Beijing Conference, the 51³Ô¹Ï Commission on the Status of Women will consider "Women and Health" as a priority theme at its forty-third session in March 1999. To prepare for the consideration by the Commission, an Expert Group Meeting on "Women and Health - Mainstreaming the Gender Perspective into the Health Sector" was organized from 28 September to 2 October 1998 in Tunis, Tunisia.
The Platform for Action puts strong emphasis on women's sexual and reproductive health. Although reproductive health is at the centre of concern for the health of women and girls and affects the health of women beyond reproductive years, certain health problems tend to be neglected under this focus. The Platform addresses a number of specific health concerns of women such as mental health, occupational health or infectious diseases without great detail and only in terms of access or research. The Expert Group Meeting identified specific recommendations with regard to these sectoral women's health issues and problems.
One of the most important keys to successful implementation of the Platform's recommendations and to improved health for women and men, is the mainstreaming of the gender perspective, in every sector. In the field of health, a gender approach to health care and health care delivery takes full account of gender differences, and responds appropriately to such differences in the development, implementation, monitoring and evaluation of health care services. It includes the integration of gender concerns into mainstream health policies and the establishment or strengthening of institutional mechanisms that support women's participation in the health system, including at decision-making levels.
The Expert Group Meeting developed a framework for a gender-sensitive health policy which is a useful tool for mainstreaming. The framework can also assist in collecting information disaggregated by sex, setting targets, involving a variety of actors or stake holders, defining their roles and responsibilities, suggesting how to allocate resources and providing guidelines for monitoring.
ii
Since efforts have increased in recent years to consider health in the framework of human rights, the Expert Group Meeting emphasized placing respect for women's human rights at the centre of such a framework. When health is considered as a human right, and not merely a social good, rights and responsibilities need to be defined accordingly. Lack of attention and neglect of women's health issues, in particular certain aspects of sexual and reproductive health, in the legislative and regulating frameworks of countries, have been recognized as part of systematic discrimination against women. The framework should ensure that steps are taken to include women's full enjoyment of the highest attainable standard of physical and mental health, as stated in Article 12 of the International Covenant on Economic, Social and Cultural Rights (1966), and to implement Article 12 of the Convention on the Elimination of All Forms of Discrimination Against Women which refers specifically to women's access to health care and family planning.
A. Attendance
1. The Expert Group Meeting on "Women and Health - Mainstreaming the Gender Perspective into the Health Sector" was held in Tunis (Tunisia), from 28 September to 2 October 1998. It was jointly organized by the 51³Ô¹Ï Division for the Advancement of Women, Department of Economic and Social Affairs (DAW/DESA), the World Health Organization (WHO), the 51³Ô¹Ï Population Fund (UNFPA), in association with the Commonwealth Secretariat. The Tunisian Ministry of Women and Family Affairs hosted the meeting.
2. The meeting was attended by 15 experts from all regions, and 35 observers: 10 from governments, seven from non-governmental organizations and 18 from the 51³Ô¹Ï System (see annex I for the full list of participants).
B. Documentation
3. The documentation of the meeting comprised five background papers (one prepared by DAW, one by the Commonwealth Secretariat and three by consultants), thirteen papers by experts, two by observers and statements (see annex II). This report and all documentation of the meeting as well as contributions received during an Online Dialogue on Women and Health conducted by the Division for the Advancement of Women from 31 August to 21 September 1998 are available on-line at the DAW/UNIFEM/INSTRAW website: http:/www.un.org/womenwatch/daw/csw/wohealth.htm.
C. Programme of work
4.4. At its opening session on 28 September 1998, the meeting adopted the following programme of work (see annex III):
- Tuberculosis, malaria and other disease control programmes, including HIV and AIDS
- Mental health
- Occupational and environmental health
- Sexual and reproductive health
- Health sector reform and health care financing
- - Quality of care
- Partnership for health - key stake holders, possibilities for alliances and modes for working
- Capacity building for health workers
- Mainstreaming gender in medical research
- Mainstreaming gender in health service delivery
- Intersectoral collaboration for gender equality
D. Election of officers
5. At its opening session, the meeting elected the following officers:
Chairperson: Dr. Charlotte Abaka (Ghana)
Vice-Chairpersons: Dr. Mabel Bianco (Argentina)
Dr. Yut Lin Wong (Malaysia)
Rapporteur: Ms. Marianne Haslegrave (United Kingdom)
E. Opening statements
6. The Expert Group Meeting was opened by Dr. Olive Shisana, Executive Director, Family and Health Services of the World Health Organization (WHO). She highlighted the different roles and responsibilities assigned to women and men in all cultures, racial and age groups which shape the development of different skills and abilities and channel their application to specific life spheres. Those associated with masculine constructs were more valued than those associated with feminine constructs, which had direct implications for the level of access to and control of resources available to women and men to protect their health and the health of their families.
7. As Dr. Shisana explained both sexes were subjected to externally-imposed, culturally-specific gender norms that constrained what they should or should not do. However these norms placed almost all women in a subordinate position in relation to men. The norms worked insidiously to the self-imposed limits on women's own hopes and aspirations and this external locus of control was aggravated by poverty and adversely affected health. The complex construct of gender interacted with biological, genetic or immunological sex differences to create health conditions, situations and problems that were different for women and men as individuals and as population groups. She emphasized that this interaction, and how it played out across different age, racial and income groups, had to be understood by health providers and health policy makers. More effective and equitable health promotion, disease prevention and control interventions had to be fashioned on the basis of such understanding.
8. In concluding, Dr. Shisana reaffirmed the commitment of WHO to the mainstreaming of gender in all its policies and programmes and enumerated the steps WHO was taking which included sensitization workshops; development of a gender policy through a consultative process; a gender working group; and the establishment of a gender focal point reporting to an Executive Director.
9. In her message to the Expert Group Meeting, Ms. Angela King, Assistant Secretary-General and Special Adviser on Gender Issues and Advancement of Women to the Secretary-General of the 51³Ô¹Ï, noted that the Beijing Platform for Action in its detailed action plan related to the health of women was setting specific targets for access to quality health services, and for reduction of maternal mortality and iron defiency anaemia. In order to improve women's health it was necessary to move from inappropriate social and economic policies to identifying the underlying discrimination and gender inequality. She stressed that many Governments, in response to the Platform for Action, had prepared national action plans and strategies which contained concrete action-oriented proposals for the health sector. Ms. King informed the meeting about the current preparation of a General Recommendation on women and health by the Committee on the Elimination of Discrimination Against Women. She expressed her deep appreciation to the Government of Tunisia for hosting the meeting and the support provided by Her Excellency Madame Neziha Zarrouk, Minister delegate to the Prime Minister in Charge of Women's and Family Affairs and her staff.
10. Dr. Nafis Sadik, Executive Director of the 51³Ô¹Ï Population Fund (UNFPA) in her message to the meeting underlined that UNFPA placed special importance on women's health issues. The achievements of the goals of the ICPD depended on many factors, in particular political commitment, the policy and institutional context within which any health programme was developed and implemented and the role of the various actors involved. She welcomed the discussion of such different topics as occupational health and infectious diseases which were interlinked and had an impact on reproductive and sexual health.
11. Her Excellency Madame Neziha Zarrouk, Minister delegate to the Prime Minister in Charge of Women's and Family Affairs stated that it was an honour for Tunisia to host this Expert Group Meeting and to see her country's accomplishments in advancing women's rights acknowledged. Women's health had been taken into consideration in major strategies since the 1960s, first in programmes for family planning and for reducing maternal and infant mortality, then in global concepts for family health and most recently in programmes on reproductive health, a concept which had evolved since the ICPD Conference. She reported that Tunisia's health and social policies had resulted in a qualitative leap in general health and women's health in general. Thus women's average life expectancy increased by 22 years during the period from 1966 to 1996 and maternal mortality dropped from 160 to 69 per 100,000 live births in the last 12 years only. Madame Neziha Zarrouk was pleased to report that these achievements have given her country international distinctions.
12. With regard to the objective of the meeting, the Minister expressed her support for the drafting of a framework for a gender sensitive health policy. The Tunisian experience showed the value of such health policy for improving general health and women's health in particular. Further, she highlighted the great disparities which continued to exist in access to health care in the North and South. Referring to harmful traditional practices which involved mutilation and trauma, she stressed that the international conscience could not tolerate them any longer, fifty years after the adoption of the Universal Declaration on Human Rights.
13. The Platform for Action identified "Women and Health" as one of the critical areas of concern and defined five strategic objectives: Increase women's access throughout the life cycle to appropriate, affordable and quality health care, information and related services; strengthen preventive programmes that promote women's health; undertake gender-sensitive initiatives that address sexually transmitted diseases, HIV/AIDS, and sexual and reproductive health issues; promote research and disseminate information on women's health; increase resources, and monitor follow-up for women's health. In doing so, it also emphasized the importance of a holistic and life-cycle approach to women's health.
14. The Platform also addressed, in a more fragmented way, a number of specific health causes, such as mental health, cancer, occupational health, disability issues, tropical diseases and suggested to "increase financial and other support from all sources for preventive, appropriate biomedical, behavioral, epidemiological and health service research on women's health issues and for research on the social, economic and political causes of women's health problems, and their consequences, including the impact of gender and age inequalities, especially with respect to chronic and non-communicable diseases, particularly cardiovascular diseases and conditions, cancers, reproductive tract infections and injuries, HIV/AIDS and other sexually transmitted diseases, domestic violence, occupational health, disabilities, environmentally related health problems, tropical diseases and health aspects of ageing" (para. 109d).
15. As the strategy leading to implementing the tasks set under all critical areas of concern, including health and achieving equality between women and men, the Platform recommended gender mainstreaming. The definition of gender mainstreaming has been further elaborated in the Agreed Conclusions on mainstreaming the gender perspective into all programmes and policies of the 51³Ô¹Ï ( ECOSOC 1997/2), which state that "mainstreaming a gender perspective is the process of assessing the implications for women and men of any planned action, including legislation, policies and programmes, in all area and at all levels. It is a strategy for making women's as well as men's concerns and experiences and integral dimension of the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated.
16. Women's health rights are also addressed in the Convention on the Elimination of All Forms of Discrimination against Women through its various provisions including those specifically on health care. The Convention as an international legal instrument should be used by all actors to make Governments accountable for the implementation of its provisions and the eradication of discrimination against women in all its forms including in the area of health. The Declaration and the Programme of Action of the 1993 World Conference on Human Rights stated that women's rights are human rights.
17. It is against this background that the Expert Group Meeting considered the important area of mainstreaming gender into the health sector. The following summary of the discussions looks at the impact of gender on occupational and environmental health; sexual and reproductive health; tuberculosis, malaria and other disease control programmes, including HIV and AIDS; and mental health. It also pays special attention to gender and health reform and financing; quality of care; partnerships for health and capacity building and the importance of education for girls, adolescent girls and women. These provide the background to the draft framework for designing national health policies with an integrated gender perspective which follows the summary and the recommendations of the meeting.
Human rights of women
When health is considered as a human right, and not merely a social good, rights and responsibilities need to be defined accordingly. The linkage between women's human rights and health has been pioneered through the collaborative efforts of women's health and women's rights advocates.
Women's right to health is addressed in the Convention on the Elimination of All Forms of Discrimination Against Women. Its Article 12 contains rights regarding access to health care services including family planning and appropriate services in connection with pregnancy, confinement, and the post-natal period. The Committee is currently preparing a draft General Recommendation on Article 12. Many other provisions of the Convention have implicit or indirect bearing on women's rights in relation to health and these have been taken up in previous Recommendations of the Committee.
A. Occupational and environmental health
18. Men as well as women are exposed to a variety of health hazards in the workplace. However, women are more likely to suffer from occupational stress and musculo-skeletal disorders due to their work as unskilled or semi-skilled workers in agriculture and the informal sector. Occupational stress is likely to result from their multiple overlapping roles (as housewives, mothers and workers), repetitive monotonous jobs, sexual harassment at the workplace and shift-work. Musculo-skeletal disorders in women are caused by combined manual work, household work and poorly designed tools and work stations. Exposure to chemicals in the workplace such as solvents in small-scale industries and pesticides in agriculture have been known to result in adverse reproductive outcomes both in males and females.
19. There is some evidence that a number of persistent environmental chemicals are associated with long-term health hazards in women and men. Exposure of the foetus in utero to compounds such as DDT and polychlorinated biphenyls (PCBs) may cause endocrine disruption manifesting as disease at a later stage.
20. More research needs to be carried out on the environmental and other risks posed to women's health by their occupational activities in both rural and urban settings with synergistic effects of heavy household work, malnutrition, multiple pregnancies, adverse climatic conditions as they affect millions of poor women in developing countries. There is also need for ergonomic redesigning of tools, equipment and work stations to reduce most occupational morbidity in women.
B. Sexual and reproductive health
21. Socio-economic differences between women and men are even more important than biological differences in determining the sexual and reproductive health status in women. Lack of autonomy, failure to enforce laws in women's favour, discrimination in laws such as the criminalization of abortion, inadequate allocation of health resources and failure by governments to implement remedial measures sanctioned by international agreements, all contribute to their relatively poor health status in many societies.
22. The enormous impact of gender inequality is demonstrated by the estimated 586,000 maternal deaths each year, many as the result of unsafe abortion and the millions who become infected with HIV and AIDS by their partners. For poor women who often lack support from their partners and social services, pregnancy is an additional burden. Adolescent and adult women face obstacles to fertility regulation including restricted access to information and services.
23. In most countries women are primarily valued as mothers and the interruption of pregnancy is socially censured. Gender discrimination is a determining factor in legal, political and religious barriers to women's access to safe abortion. Unsafe abortion continues to be a major public health problem, causing widespread damage to women's physical and mental health. Women with low incomes, rural woman, young women and and adolescent girls are particularly vulnerable to these risks.
24. In order to change traditional male attitudes towards women, boys should be socialized to treat girls as equals at an early age. Sex education for boys as well as girls should be provided so as to reduce the incidence of unwanted pregnancy, unsafe abortion, STDs, HIV and AIDS. Quality sexual and reproductive health information and services, including emergency contraception, should be made accessible and acceptable.
25. Women should be fully involved up to the highest level of health service planning so as to ensure that their sexual and reproductive health needs are met throughout the life cycle from infancy to old age. The same applies to decisions taken on funding research on women's health.
Women's right to life -- the neglected tragedy of maternal mortality in developing countries
Every minute, a woman dies somewhere in the developing world as a result of pregnancy and childbirth. These young women, in the prime of their lives die from causes which can be prevented or treated. But, it is a question of how much the life of a woman is considered to be worth. When societies invest less in girls and underestimate the economic contribution of women and when few women are in decision-making positions, it should be no surprise, in resource-poor settings, that a low priority is given to saving the lives of mothers.
Maternal mortality should not be ranked for priority against other disease problems. Maternity is not a disease. It is the means by which the human species is propagated. Societies have an obligation to protect women's right to life when they go through the risky process of giving us life. Safe motherhood is a human rights issue to which countries should be held accountable.
C. Tuberculosis, malaria and other disease control programmes, including HIV and AIDS
26. Communicable diseases such as tuberculosis, malaria, and to a growing extent, HIV and AIDS, are diseases of poverty. Poor women are especially vulnerable because of their low nutritional status, restricted access to education and gainful employment, and heavy workloads. The stigma attached to many communicable diseases, particularly those involving disfigurement, leads to hiding of the disease and a decrease in life opportunities, including marriage.
27. Once infected, women are more likely to self treat and to postpone seeking professional care because of gender-based constraints including domestic responsibilities, caring for others and the cost of travel and treatment. Having sought treatment they receive low priority due to their low social status. Health services thus miss an important opportunity to provide women, the main health providers within the household, with the information required to perform the role of providing effective medial care at the right time and more effectively.
28. Gender bias begins at a young age: girl children are less likely to be brought to health services for immunization and early diagnosis and treatment of communicable diseases. Hence epidemiological information based on health statistics do not reflect the true distribution of disease. Men also should be involved in health decision-making with respect to their children. Research has shown that fathers= participation in the decision to immunize their children increased the timely completion of the immunization schedule.
29. Little research has been conducted on how communicable diseases affect women and men differently, and what is known is not taken into account in planning services. There is need for gender sensitivity education of health professionals at all levels, and ensuring the necessary resources for programming. Women, health advocates and non-governmental organizations (NGOs) should also be involved from the earliest stage in planning, research and delivery of services. Such training should ensure that health professionals be sensitized to the special needs of women, particularly adolescents, so that optimal use by community members of all ages will be encouraged.
D. Mental health
30. Depression, anxiety and stress are more prevalent in women whereas disorders arising from substance abuse are more common in men. World Bank data on DALYs (Disability Adjusted Life Years) shows that 30 per cent of mental disability in women is from depression as compared with 13 per cent in men. Conversely 31 per cent of mental disability in men is caused by dependence upon alcohol or other drugs as compared with only seven per cent in women. Studies show that depression is more common among poor working-class women (who usually experience more severe adverse life events and have to cope with chronic sources of stress). It may be that men externalize their mental suffering through substance abuse, and under-report their mental distress, whereas women express depression, anxiety and psychological trauma.
31. Research indicates that women who use substances suffer from more serious psychological, social and economic consequences than do men. In addition, factors that contribute to their use of substances differ from those experienced by men (e.g., sexual abuse, substance use by male partner or family member).
32. Poverty, domestic isolation, powerlessness (resulting from illiteracy, low education, economic dependence, and patriarchal oppression) are all associated with the higher prevalence of psychiatric morbidity in women, compounded by sexual and physical violence. Family and social abuse of women have a devastating effect on their physical and mental health. Good quality mental health services need to be integrated with other services, in particular with legal, educational and other social services and law enforcement services in order to deal with mental illness resulting from, or aggravated by, violence and other forms of abuse to women. Inappropriate medication of emotional distress and psychological illness should be avoided as it can result in silencing women and men rather than dealing with the root causes of their problems. It should not be assumed that female relatives are able to provide the full range of mental health care within the home setting to those with serious mental illness. Mental health services should be integrated into, and viewed as part of, basic health care.
E. Mainstreaming the gender perspective in health care
33. The Commonwealth has been pioneering the introduction of Gender Management Systems (GMSs), both at the level of the national government and within the health sector in member states. Adapted to the specific conditions and requirements of each country, GMSs are a potentially very effective tool for mainstreaming gender within policies and programme. In a series of multi-national, multi-sectoral workshops, frameworks have been developed for national action plans for the introduction of GMSs in the health sector, subsequently to be completed and implemented by each national group. Among the important issues that have emerged during the process, two are seen as particularly critical. Firstly, there is a great need for sensitization and training of actors at all levels of the health sector, government and public administration in gender concepts, which are generally poorly understood. Secondly, the factor that emerges as the single most important determinant of progress is the degree of political commitment at the highest levels. The process is unlikely to proceed beyond a few token steps unless the Health Minister and senior cabinet colleagues become closely involved. External actors such as international organizations and local players such as NGOs can play vital catalytic roles in helping to secure this political commitment.
34. Applying a fully comprehensive gender perspective would require that all health statistics be disaggregated by sex and that a comprehensive women's health profile be constructed. The International Council of Nurses (ICN), for example, has developed guidelines for countries to develop such a profile covering demographics, socio-economics, health status, lifestyle, environment, health care services, health service use, sexuality, and policy development. Mainstreaming of the gender perspective includes consideration of basic health care as a human right. Even in countries, where education is provided free of charge as a human right, health care is often free only for certain groups.
35. In the interests of mainstreaming the gender perspective, ICN has issued guidelines to its affiliates which include eliminating negative cultural practices such as female genital mutilation; supporting programmes to reduce violence against women; promoting women's access to comprehensive health services and education (including that of girls and elderly women) and researching women's non-reproductive health needs (e.g., protection against pesticides, solvents, occupational strain, chronic stress). International organizations and agencies should provide technical assistance for national and regional programmes to deal with gender concerns in health care systems only if they can be shown to integrate fully a gender perspective. It should be noted that for nursing, as a female dominated profession, the industrial models of management have created a lot of dissatisfaction and staff turnover. These trends can only be alleviated by mainstreaming a gender perspective into the management of human and financial resources in nursing and within the health delivery system.
Centres of Excellence for Women's Health in Canada
Health Canada (Canada's Federal Department of Health) has established five Centres of Excellence for Women's Health across the country with a mandate to conduct policy-oriented research on women's health. The goal is to improve women's health by generating knowledge, information and policy advice that can be applied to make the health system more responsive to women's health needs. Research is generated in each centre through a partnership of academics, researchers, health care providers and community-based women's and women's health organizations. The Centres examine current health system issues such as the impact of health reform on women and women's health; patterns of health service provision to women ; women's experience with the health system; and the health needs of particular groups of women.
F. Integrating the gender perspective in medical education and research
36. In most medical, health and prevention issues concerning women's health the central topic is male-female power relationship, and not merely the lack of health services. What is needed is a gender analysis of health which would reveal the biological causes and social explanations for the health differentials between women and men and demonstrate that they are so often due to unequal social relationships and not merely to the consequences of biology. However, the traditional medical teaching that has reduced women's health and ill health primarily to a matter of their biology is still retained. This view became institutionalized within scientific medicine and the new public health within the early decades of the 20th century.
37. Medical textbooks still consider the male as the norm or reference point and regard women as exceptions to the male. The approach to women's reproductive health is still predominately biomedical. For example, the side effects of various contraceptive methods is taught in medical schools, but nothing is said about the cultural and religious barriers to contraception or the underlying issues of male-female power relationships affecting sex, equality and contraception, that are so important in actual practice. The correct technique for carrying out breast or pelvic examinations is taught in order to ensure that important abnormalities are not missed, but the technique for carrying them out painlessly and with the preservation of dignity is usually omitted. This is one of the reasons why so many women postpone attending doctors in cases where such examinations are urgently needed. Integrating a gender perspective into the medical curriculum will involve drastic ideological changes. Medical students do not, or cannot conceptualize what they are learning because they have not been taught to do so, and medical teachers have not been taught how to teach.
Gender and Health Course for Medical Faculty Teachers in Bolivia
In 1998, the Bolivian Vice-Ministry of Gender, Generational and Family Issues signed an agreement with the medical faculty of La Paz State University to mainstream gender in health science education. This paved the way for research and training activities involving teachers of medicine, nursing, nutrition and medical technology. Over two months, 30 faculty teachers (25 women and 5 men) participated in a pilot course covering themes such as gender discrimination and violence within health education and services; masculine identities and the health professions; qualitative research methods and ethics in research relations. Participants produced profiles for small-scale action research projects, focussing mainly on gender issues in their own working environment. As well as building on this process in the La Paz State University, the interdisciplinary team of course organizers has been invited to repeat the experience in other regions of Bolivia. Further courses will soon commence with health science teachers in the Cochabamba and Pando State Universities.
G. Health reform and financing: Introducing a gender-based analysis
38. The adverse effects of poverty on the health of women are well established and reflected in the health services available to them under different systems of financing health care. Individually financed services based on private payment for services, and those based on third party insurance whereby health coverage is paid for by individuals and employers, leave large groups of the population, especially women (as they fall into the lower economic groups and have less resources) without coverage. Female-headed households and elderly women are characteristically impoverished and dependent on the family and the state for health care services.
39. State financed health services, in which the state pays for all health care, and social insurance systems, whereby an essential health care package is provided for the whole population with additional services provided under other schemes, can also raise gender issues by increasing the gap between rich and poor in terms of health status and access to quality care. An equitable division of coverage by the public and private sectors is required to avoid all non-profit services being automatically assumed by the public sector.
40. Currently decentralization of management is being proposed to bring health services nearer to communities and to strengthen their accountability over resources. This should be accompanied by the provision of adequate resource allocations to local levels in order to provide basic health services. Otherwise, health care providers, the majority of whom are women, carry a burden of increased workload, as do women who are required to provide home care because of limited services available.
41. Standards of care should be set through gender-sensitive programmes and based on best practices. This will need greatly improved information systems and more gender-sensitive methodologies than the currently used DALY measurement and include qualitative as well as quantitative data.
H. Partnership for health: Actors and key stake holders
42. A number of actors and stake holders have an important role to play in mainstreaming gender into the health sector. While the Ministry of Health is usually in charge of the health sector within the Government, other Ministries (e.g. Finance, Education, Labour, Environment, Youth, Planning, Women's Affairs and Social Welfare) can also have an impact on health care. Parliamentarians can play a crucial role in the establishment of gender-sensitive health policies and in introducing legislation. Relevant parliamentary commissions on human rights or budget for instance can also be involved as appropriate, in monitoring the application of policies dealing with abuses to women's right to health or preparing budgetary allocations for the health sector. Political will at the highest level is a prerequisite. For instance, the Heads of States of Government of the Southern African Development Community (SADC) in their Declaration on Gender and Development (1997) committed themselves to recognizing, protecting and promoting the reproductive and sexual rights of women and girl children.
43. District and local authorities are important in the delivery of health care services, in particular when services are decentralized. Local authorities often have a better understanding of the realities in various cities or regions and can have better access to the communities involved. The WHO "healthy cities" initiative demonstrates the leading role that can be played by local governments in improving access to and quality of care. The example of the Women's Total Health Care Programme (PAISM) in Sao Paulo (Brazil) shows that it is necessary to establish women's health advising and coordinating offices, to do epidemiological diagnosis and health planning with a gender perspective at the district level. Of particular importance is intersectoral networking and networking with women's organizations. It is also crucial that women move into decision-making positions at the district level.
44. NGOs can play an effective role in promoting a gender approach to health care by acting as advocates for the protection of women's rights as human rights, e.g., by exposing violence against women, by calling attention to the needs of the girl child and by promoting and developing a comprehensive, holistic and rights-based approach to health services for women. They should convince the key stake holders, whether they work in government, in administration, or as providers of the necessary funding, of the need to bring about the necessary changes, by ensuring that the electorate understands and supports the changes which need to be made.
45. NGOs also have extensive experience of advocacy which involves the identification of key decision-makers; preparation of position papers; lobbying; contacting the media by means of press releases and press conferences and arranging press visits and encounters. Most key government departments concerned with health care tend to be male-dominated and may be expected to include some who are resistant to the introduction of a gender approach to health care. It is particularly important to involve health professional associations in advocacy, because their members are likely to be among the first to be affected by the changes. Their officers are also likely to be in touch with members of parliament and may have influential contacts in government. A co-ordinated approach by NGOs is needed to the departments concerned, involving NGOs with different constituencies such as the health professions, women, development issues etc.
46. Many NGOs have already developed training programmes in gender sensitivity which can easily be adapted to take account of the special needs of the health sector and of departments of government that are involved in providing health services such as finance and planning and even transport such as ambulance services. Health professional associations will also need to sensitize their own members at all levels of health service activities as they play a crucial role in providing services. They should take account of the working relationships between male and female health professionals and with other health workers as women are often less well trained and less well paid. Governments should therefore invite suitably experienced NGOs to act as partners in the development of training programmes on the gender approach to health care.
III. CONCLUSIONS AND RECOMMENDATIONS
A. Occupational and environmental health
47. Governments and international development agencies should undertake gender analysis of various sectoral policies to establish health and environment risk profiles for women and men.
48. Government environmental and occupational health policies should be extended to cover informal and agricultural sector workers who are mostly women and who are not often covered by protection laws, labour laws or occupational health and safety regulations.
49. Government and international development agencies should increase their support to research, particularly in developing countries, on occupational and environmental health risks - short and long-term - of work performed by both women and men. This should include risks in the household and from environmental chemicals, and appropriate interventions, including necessary legislation, to reduce environmental and occupational health risks in both urban and rural settings.
50. Government and international development agencies should support interested NGOs in strengthening the role of women as key agents of change in occupational and environmental health and protection.
51. Household work should be recognized as an occupation.
B. Sexual and reproductive health
52. All adolescents should have access to sexual and reproductive health education starting at an early age. They should also have access to confidential rather than judgemental sexual and reproductive health services.
53. Governments and international organizations should ensure that sexual and reproductive health services are extended to men to encourage their full participation in sexual and reproductive health and child rearing.
54. Governments and international organizations should give priority to the following areas of research:
(i) Development of female controlled methods, including microbicides, post-coital/emergency contraception and dual methods that protect both against STDs and HIV and unwanted pregnancy; and methods of male contraception.
(ii) Encouragement of social and anthropological research in order to evaluate the real needs of women, the factors influencing their behaviour, and their degree of satisfaction as to the services provided.
55. Governments should, where appropriate, integrate sexual and reproductive health services, including screening of genital cancers and treatment for menopause, to respond to the broad health needs of users.
56. Governments should develop policies and formulate legal tools to support activities aimed at eliminating the practice of female genital mutilation (FGM) and other harmful practices and prevent their medicalization. Governments should provide appropriate training and support to ensure a gender-sensitive and socially conscious attitude among health care workers. This should include sex education, which is particularly relevant in countries where FGM is prevalent. The number of female service providers should be increased and their responsibilities expanded. More women should be appointed to the health sector including to managerial positions.
57. Governments and the international community should ensure the implementation of the Beijing Platform for Action with respect to the problem of unsafe abortion. Governments and legislators should address the reality and consequences of unsafe abortion by revising and modifying laws and policies which perpetuate damage to women's health, loss of life and violation of gender equality in health care.
58. Health education and services should include gender-sensitive abortion counselling and care (in all circumstances where it is allowed by law) and post abortion care in all contexts. Quantitative and qualitative research with a gender perspective can show the magnitude and impact of problems caused by unsafe abortion in specific settings. It can also demonstrate the potential for improving women's quality of life, health and survival where safe, legal abortion and post abortion care are freely available.
C. Tuberculosis, malaria and other disease control programmes, including HIV and AIDS
59. Governments and international organizations should promote research on how communicable diseases, particularly malaria, tuberculosis, and HIV and AIDS, affect women and men differently and take these differences into account in planning and delivering services.
60. Governments should ensure that stigmatization (in leprosy, filariasis, HIV and STDs infections) does not lead to under-detection and lack of treatment, especially for women.
61. In case of HIV infection, health workers should encourage their patients to inform their partners so as to protect them from infection and counsel them as to ways of doing so.
62. Governments should recognize and provide financial resources to the physically and psychologically demanding role carried by women in community based care as family mentors and care providers to relatives living with HIV, AIDS and other health problems.
63. Governments should avoid all forms of compulsory testing for HIV on women, including those related to prevention of mother to child transmission.
64. Governments should improve sexual and reproductive health services available to women with HIV and AIDS.
65. Governments, when applying prevention programmes for mother to child transmission, should improve accessibility to antenatal care and its quality of care for all women, including pre- and post-counselling services associated to HIV testing and avoid all forms of discrimination to women living with HIV in the health services.
66. Health professionals should encourage families to ensure that all girls and boys are fully immunized and monitored and treated for childhood diseases.
D. Mental health
67. Governments should invest in educating communities about the effectiveness of mental health interventions and make available the necessary services tailored to the different needs of women and men (e.g., treatment for civil and domestic trauma and injury, psychiatric illness, substance use). Priority should be given to mental health care as an integral part of primary health care.
68. Systematic efforts should be encouraged to improve the amount and quality of mental health training for workers at all levels, from medical students to graduate physicians, from nurses to community health workers.
69. Efforts should be encouraged to document the use of psychoactive substances by both women and men and the relative different causes and effects. These should lead into parallel efforts in developing effective approaches to prevent and treat such use.
70. Governments should invest in preventive actions including national gender policies to eradicate domestic and community violence against women, ensure legal and educational equality and promote economic empowerment.
E. Cross-cutting recommendations
71. Governments and international organizations should increase support to programmes targeting poverty alleviation in order to uplift the health, social well-being and quality of life for women and youths.
72. Comprehensive health and environment information, education and communication strategies should be developed. These should be gender-specific and aimed at the general public, including media and the schools, with active support from the medical, legal, policy and NGO communities.
73. Governments should ensure that research data and service statistics should be disaggregated by sex and age, and appropriate conclusions drawn for improvement of gender-sensitive health services. Government statistics should be made freely available to the public.
74. Governments should monitor not only data gathering but also the availability of services and how they are used. New indicators should be developed to provide more accurate measurement of women's health in the medical and social context.
75. Health policies and programmes should be founded on evidence-based research that supports, enlightens and strengthens health policy, programmes and service delivery. The recognition of gender as a variable in research adds validity to overall finding and encourages policy makers to conduct gender analysis and address women's health needs.
76. Good governance recognizes women's health as a human right and upholds parity democracy should be the guiding principle for effective intersectoral collaboration and gender mainstreaming.
77. The international consensus expressed in the Platform for Action, and the standards set by the Convention on the Elimination of All Forms of Discrimination Against Women and other international human rights instruments provide strategies and recommendations relevant to women's health that should be implemented and respected. All critical areas of concern of the Platform for Action need to be linked across sectors to women's health.
F. Health reform and financing
78. Gender analysis should be applied to all reforms contemplated in the health sector, including reforms in financing, to examine their potential differential impact on women and men and to ensure that priority setting is carried out with gender sensitivity and is based on rational principles and existing evidence. Gender Management Systems can provide an effective approach to ensuring the explicit inclusion of gender concerns in all areas of the health sector.
79. Governments should secure funds to protect the health of most vulnerable population groups, particularly poor women. In any case, a social pact should be established between the state and all interested parties to guarantee a minimum package of services to cover the health care of those vulnerable groups.
80. Health reform should ensure the accessibility of more vulnerable population particularly poor women to health services throughout their life span. Governments should ensure that health reform be based on the human right to health and not only on economic criteria.
G. Capacity building for health personnel
81. Education of health professionals, from those in planning and reform to service delivery, should include gender training with the intention to formulate health policies that are equitable and based on the principle of gender equality.
82. Health professionals should be educated in human rights as part of training in health care ethics to ensure that clients are treated with respect, dignity, privacy and confidentiality.
83. Training of health professionals should include the promotion of team work and the importance of providing opportunities to all health providers, particularly women at lower levels, to realize their full potential as care givers.
84. Continuing education courses should be promoted, including recertification and refresher training for health personnel. These should include participatory methods based on partnership principles and effective communication with a focus on gender-sensitivity.
85. Health personnel with the requisite skills should be strongly encouraged to enter the speciality of their choice irrespective of their gender, even though it could require support in the form of child care or a scholarship.
86. Both public and private health enterprises should be required, where necessary, to provide appropriate support services, such as child care for workers irrespective of their sex.
H. Partnership for health
87. Government and international development agencies should ensure active community participation and input into the design, implementation and monitoring of disease control programmes.
88. The community should be involved as a major partner in health programmes in order to ensure that the voice of all, in particular, women and youth, is heard in designing health services.
89. The private sector including pharmaceutical companies and private clinical services should collaborate in ensuring quality of care, access to and provision of services, particularly for poor women.
90. Practitioners in all health systems B biomedical, complementary and traditional B should be prevented from carrying out practices which violate human rights and especially the rights of women and children.
I. Quality of care
91. Women should be given information about the choices available to them, for example, with respect to breast feeding or contraceptives, the risks and benefits involved, and the freedom to decide which action to take.
92. Women should not be deprived of their right to health services on the basis of conscience clauses cited by health providers. Health services should implement referral systems promptly for women requiring services which certain health professionals were unwilling to provide such as contraception (including voluntary surgical contraception) and abortion (in all circumstances where it is allowed by law).
93. Women's time spent in visiting health services should be respected and kept to the minimum necessary, with opening hours convenient to their needs. Services for female users should be linked and placed under one managerial responsibility ("one stop care").
94. Family support should be recognized as an important determinant of health outcomes, requiring active collaboration from health and social services. When women are stigmatized by conditions such as leprosy or AIDS, family members should be especially encouraged by health workers to accompany them in consultations.
IV. A FRAMEWORK FOR DESIGNING NATIONAL
HEALTH POLICIES
WITH AN INTEGRATED GENDER PERSPECTIVE
A. Introduction
95. Over the last two decades, women's issues have moved rapidly up the policy agenda of national governments and international organizations. During the 1980s there was a major increase in policies designed to prevent women from being marginalized from the mainstream of economic, political 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 realizing their potential.
96. 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 is meant 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 equality is to be a major goal in the development of a health service, those involved need to be properly informed about the most effective means by which this can be achieved.
B. Sex, gender and health: clarifying the concepts
97. 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 females and males that are socially constructed from those that are biologically determined. Thus women and men are differentiated by social characteristics, on the one hand, and by biological 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 "femaleness" and "maleness" are reflected in the patterns of health and illness found among women and men around the world.
98. There are marked variations in the prevalence rates of particular health problems between women and men. Any attempt to explain these differences has to make sense of the impact of both biological and social influences on well being. Existing research reveals that some diseases strike women and men at different ages. For example, cardiovascular diseases are diagnosed at a later age in women than men; some diseases such as anaemia, eating and musculoskeletal disorder are more prevalent in women than in men, while other diseases or conditions affect only women, such as pregnancy-related health problems.
1. Biological influences on health and illness
99. Biomedical and social research on the differences between women and men 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. Women need to be able to control their fertility and to give birth safely so that access to quality sexual health and reproductive health care through the lifespan is crucial to their well-being.
100. The truth of this claim is evident when looking again at female and male patterns of life expectancy. Women's greater longevity is generally accepted to be biological in origin. This biological potential for longer life may be significantly reduced, and the quality of life affected, if women are subjected to discriminatory practices such as a failure by society to provide effective and appropriate health services. It is here then, that the biological meets with the social and it is these social or gender differences that are potentially amenable to change.
2. Gender divisions in society
101. The complex construct of gender interacts with biological and genetic differences to create health conditions, situations and problems that are different for women and men as individuals and as population groups. This interaction, and how it plays out across different age, ethnic and income groups, should be understood by health providers and health policy makers.
102. All societies are divided along a female/male 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.
103. In most societies these are not just differences but inequalities. What is defined as "male" are usually valued more highly than what is defined as "female" and women and men 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.
104. Gender also shapes the development of the self. The social norms that sanction acceptable male and female behaviour in different settings influence the formation of the individual's subjective identity. Research has shown how the expectations and the cognitive, emotional and social functioning of girls and boys are gender differentiated and how they evolve into the distinctive ways in which women and men perceive and act within given social contexts. These norms put almost all women in a subordinate position in relation to men, placing self-imposed limits on their hopes and aspirations. Poverty is often an aggravating factor.
105. The importance of gender should be stressed at institutional as well as individual and household levels. A complex set of values and norms permeates organizational systems, such as health care, the legal structure, the economy and religious practices. This reinforces wider patterns of gender discrimination, shaping the opportunities, resources and options available to individual women and men.
106. 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. For women the effects of gender are predominantly negative. The impact on men is more difficult to assess since male status involves a more complex mixture of risks and benefits.
3. The impact of gender inequalities on women's health
107. Social and 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 "feminization" of poverty remains a constant theme. "Cultural devaluation" is also important though it 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.
108. The prevailing tendency is to view as pathological what are normal processes in women's physical and mental health. For example, pregnancy and child birth are normal physiological processes under most circumstances. Unlike diseases affecting males, they are not diseases or surgical events. In many societies pregnancy and child birth have been medicalized excessively rather than treated as healthy processes. Gender inequalities preventing access to quality health services doubly disadvantage women already at risk because of their life-giving role.
109. The nature of female labour itself may affect women's health. Household work and child care can be exhausting and debilitating especially if they are done with inadequate resources and combined, as they are for many women, with pregnancy and subsistence agriculture. It can also damage mental health when they are given little recognition and carried out in isolation. The time consumed by caring for others leads to neglect by women of their own health. For women, domestic life and labour also carry the threat of violence since the home is the arena in which they are most likely to be abused. The emphasis on their domestic roles also means that women suffer more severe consequences than men when a family member is a substance user or if they use substances themselves. Even in the context of paid work, "female" jobs often pose particular hazards that receive little attention.
110. Gender-based violence is a risk factor for many women. Not only is it a violation of their human rights but it has wide ranging consequences for their physical and mental health and the health system. Women are victims of assault as a result of inequalities in society, and are most at risk of abuse from their partners and close relatives.
111. The sexual subordination of girls and women has increased their vulnerability to STDs, HIV and AIDS, exacerbating the burden of disease among them and greatly reducing life expectancy and quality of life. In addition girls and women with HIV and AIDS are exposed to stigma and mistreatment in most circumstances.
112. Women are under represented as policy makers, decision-makers and educators in many segments of the health sector. Inequality in access to training and education is one reason. This translates into reduced access to resources and a lack of attention to women's needs and priorities.
4. The impact of gender inequalities on men's health
113. Thus far it is women and their advocates who have paid most attention to the impact of gender divisions on health. 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.
114. On the face of it, "maleness" can only be health promoting since 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 renumerated 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.
115. Men in the majority of societies are also more likely than women to adopt a variety of unhealthy habits - using licit and illicit psychoactive substances - 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".
116. Gender inequalities affect men's behaviour and may affect relationships between women and men. They have impeded men's appreciation of their responsibility for the health hazards of violence in relationships between women and men.
C. Gender bias in health practice
1. Gender bias in research
117. 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. There is a lack of qualitative research. As a result the information collected and the findings generated are often inadequate for the implementation of gender-sensitive policies.
118. It is therefore important to develop more adequate health information systems to inform policy and programme decision-making. This should include locally collected data (both qualitative and quantitative) that is more sensitive than existing DALYs (Disability Adjusted Life Years) to both socio-economic conditions and gender issues. The data can then be used to set priorities through a process that includes a systematic gender analysis.
119. Most medical research continues to be based on the unstated assumption that women and men 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 and age, making it difficult to plan for the specific needs of women and men. Similarly many clinical studies leave women out altogether or fail to treat sex and gender as important variables in the analysis.
120. 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 and AIDS. There is also 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 and its consequences. However, without more accurate information it is difficult to translate these observations into more effective policy making or clinical practice.
2. Gender bias in the delivery of health care
121. 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, stigma and sometimes the refusal of their husband or other family members to give permission to access. 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.
122. 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. The gender bias and superiority stance of medical and health professionals of both sexes too often intimidate women, giving them no voice in decisions about their own bodies and their own health.
123. When women are excluded from the decision-making process, gender bias in staff deployment, promotion, postings and the career development of health personnel obstruct health seeking behaviour of women.
D. Mainstreaming gender in health research
124. 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 health should have a more prominent place in the research process. A formal set of policies will be needed to ensure that their interests are represented.
1. Measuring women's health
125. 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 should be appropriate to the setting in which it is being used and should also recognize the diversity of women's experiences over the lifespan.
126. 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 rural women, industrial workers, sex workers, refugee or migrant women, women bringing up children alone and women coping with chronic disease or long-term disabilities. For example, research has shown that women suffering from stigmatizing or disfiguring diseases such as tuberculosis and leprosy were more isolated than men from all activities and treated as outcasts, even within the family setting.
127. 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 recognize the importance of gender issues and a lack of understanding of the complex social pressures that may render women's health problems invisible. Health statistics are based on clinical records in which male data is more prominent and hence females are under-represented. In the case of maternal mortality also, a wide range of religious, cultural and social factors can contribute to serious underreporting. Process indicators have now been identified and these need to be used routinely by those responsible for monitoring community health.
128. Similar problems are evident in relation to the identification and measurement of rape, domestic violence and sexual abuse. This represents a huge public health problem which has not yet been adequately documented. To fill this knowledge gap, 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 co-operation with international organizations such as WHO which have already developed a range of resources for work in this area.
129. 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 elaboration by the 51³Ô¹Ï Development Programme (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. Indicators for reproductive health have been established by WHO and UNFPA. Also, a number of specialized programmes in WHO are now focusing on sex and gender differences in the impact of specific diseases such as malaria, leprosy, onchocerciasis and tuberculosis. However, there is still a need for national governments and international organizations to work together to develop more specific health-related measures combining both biomedical and socio-economic data to monitor the epidemiological profile of women's and men's health, particularly with respect to emerging epidemics such as tuberculosis, HIV, tobacco, and neglected areas such as occupational, mental health and substance use.
2. Including women in biomedical research
130. Few women are currently involved in what has been the male-dominated arena of medical research either as researchers or as subjects. However strategies for change are beginning to emerge. Concerns about bias in medical research have led to attempts in a number of countries to include women in study samples wherever appropriate. However, it is essential that this is only done with the relevant ethical safeguards, such as informed consent protocols. Long-term studies have also been initiated to investigate the particular problems of women as they move through the life cycle and more of these are needed in different socio-economic and cultural settings. Attempts to involve women in the determination of research priorities have included formal dialogues between researchers and women's health advocates, particularly in reproductive health services.
3. Expanding the disciplinary boundaries in health research
131. Reforming biomedical research can only be a partial strategy for extending understanding of sex and gender inequalities in health and illness. Social science research is also needed if the full range of influences on human health is to be understood. In particular, governments should encourage multidisciplinary research involving social, environmental and biomedical researchers as co-investigators, and use their findings to develop more comprehensive health promotion policies.
132. The most useful studies are often those that have used both quantitative and qualitative methods in which statistical data are enriched by in-depth information from people's own experiences. Good examples of this kind of work can now be found in the areas of sexual and reproductive health, tropical diseases, mental health, occupational and environmental health, where new techniques have been developed to explore the intimate concerns of women and men which would otherwise remain hidden. For example, research on onchocerciasis and lymphatic filariasis has shown that women are concerned about the impact of the disease on their physical appearance while men are troubled by sexual performance and virility.
4. Getting the whole picture
133. It is essential that strategies to improve the health of women and 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 many of their activities are invisible. Femaleness cannot 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.
134. Until recently, few researchers had examined the occupational and environmental risks associated with domestic work. This is now beginning to change as new techniques are being developed to explore the interior 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 in the household.
135. Women's work outside the home also needs much more attention from both researchers and policy makers. Though health records show that male workers die more often than females from work-related causes, women's work-related disease and disability is rapidly increasing in many parts of the world. Evidence is now emerging 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.
136. Occupational health researchers need to develop greater gender sensitivity in their methods of investigation as well as a clearer understanding of the differences between women and men. 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 women and men equally.
137. The strategies should be adopted to make health and health services research more gender-sensitive and, therefore, more appropriate as a base for national and international policy making. However, a great deal of information on gender issues is already available and it 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.
E. Mainstreaming gender in health service delivery
138. The mainstreaming of gender concerns is vital at every stage of the policy process from policy formulation, planning, delivery and implementation to monitoring and evaluation. Lack of awareness or "gender blindness" on the part of policy makers and planners frequently leads to gender bias and to the prioritization 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 women and men.
139. In mainstreaming gender into the health sector, establishing effective partnerships with women and men's groups is critically important. While the Ministry of Health usually has the mandate to deliver health services, interventions from other ministries especially Finance, Education, Women's Affairs and Social Welfare, Environment and Youth should be encouraged. Alliances between the ministries, target population, local authorities, the private sector, international organizations and donors should be formed. The private sector, in particular employers of men and women with potential occupational health concerns should be key partners in the provision of health.
140. Both sexes should not be treated in exactly the same way. Despite their commonalities, women and men will also have their own particular needs. Hence adherence to the principle of equality is required to ensure that these different needs are met. 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.
1. Generating political will
141. In order to achieve these goals, there should be a serious commitment at the highest levels of government. Experience shows that little is likely to change unless there is the necessary political will, the 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. Ministries of Health, Finance, Education and Environment should allocate special resources to mainstreaming gender in health service delivery through, for example, the creation and support of gender focal points, and by establishing the necessary budget line items.
142. Political will can be generated in different ways. One strategy should be to use examples demonstrating the cost-effectiveness of gender intervention in order to strengthen arguments based on equality and human rights considerations. The media can also be used, particularly through the publicizing of individual cases. In addition, strategic networks can be deployed to campaign for change.
143. Individuals and groups in civil society should press for public sector reforms and good governance mechanisms. These will lead to a more transparent system and to the greater availability of data that can be used to make the necessary arguments to politicians about gender priorities for action. International organizations also play a role encouraging governments to implement their commitments to gender equality.
2. Instituting a gender-sensitive needs assessment
144. If the goal of developing gender-sensitive policies is to be achieved, it 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. It will involve a comparison of the numbers of males and females in the target population and an assessment of the gender patterns in current service use.
145. In order to do this the following questions inter alia should be answered:
3. Including gender issues in the planning process
146. To make the planning process gender-sensitive the following steps should be taken:
C Tools, methods and training material should be developed to assist in conducting gender analysis in policies and programmes and in implementing gender impact assessment.
147. Health sector reforms have failed until now to take into account gender issues that are critical if a negative impact, particularly on women, is to be avoided. The impact of user charges often negatively affect poor women who tend to be more vulnerable than men for reasons of economic dependency or limited access to paid work.
148. Institutional changes in the national health systems to address inefficiencies and to raise levels of service coverage, without consideration of the specific health risks and needs of women and men, have often resulted in maintaining or reinforcing gender roles and relations that have an adverse impact on health.
149. A health sector reform has a direct impact on staff composition, and unless it is done in a gender-sensitive way, may run the risk of reinforcing occupational segregation between women's and men's jobs. Gender disadvantages are reflected in occupational segregation between female and male health staff with women being posted to more marginal areas and rarely in senior positions.
150. In order to achieve a balance of the sexes throughout the process of health sector reform, attempts should not be restricted to improvements in managerial and administrative skills. There are a number of often unrecognized issues which adversely affect the contribution of women health providers. Examples include civil service regulations, "old-boy" networks, rigid hierarchy and seniority patterns, and failure to provide incentives for gender-sensitive performance.
151. Decentralization is perceived as an alternative policy to the centralized one and as a way of transferring resources, functions and authority to the periphery. However, due to the existing interregional inequalities within developing countries, less wealthy districts will be unable to raise funds to protect the most vulnerable population groups such as orphans, widows, unsupported elderly, landless and female-headed households.
4. Developing the framework for gender planning
152. In order to mainstream gender issues in health service, it will be necessary to create 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 exists in countries with varying political and legal structures.
153. The issue of setting targets for service delivery needs to be examined carefully on a case by case basis, particularly where there are built-in incentives for the service providers. There are many examples where human rights have been violated, gender inequalities perpetuated and priorities distorted by the application of incentive driven programmes, especially in the field of sexual and reproductive health and mass screening.
5. Incorporating capacity building for gender-sensitive services
154. The effective operation of the service will require a strategy for educating health workers to understand the full significance of gender issues in health. Capacity-building programmes should be designed for both female and male workers. They should focus not just on "women's issues" but on the wider topic of gender itself, human rights and gender identities of female and male health providers. They may include broadly based "gender awareness" courses and participatory approaches at every level.
155. 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, taught by competent gender experts and advocates need to be provided for qualified health workers at all levels and 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 so that gender issues are properly embedded in the future planning and delivery of services.
156. The attitudes of many doctors and nurses often constitute particular obstacles to women seeking informed decisions concerning their own health. Therefore, one of the most important goals of the capacity building should be to inculcate in all health workers a respect for the dignity and human rights of all service users, including the formal right to full information about their condition and available treatments. This should be expressed in an explicit charters of rights.
6. Accountability, monitoring and evaluation
157. Gender dimensions which cross all aspects of health systems should be subject to accountability as an essential part of good management practice. Access to education and information alone will rarely be enough to ensure appropriate and ethical treatment. Therefore a range of mechanisms is needed to ensure that women have access to advocacy services. The existence of formal and easily accessible opportunities for complaint and redress through an independent system is needed as well.
158. It is essential that all policies include gender issues in their strategies for monitoring and evaluation. This will enable service providers to measure the differential impact of the policy on women and men in their roles as both users and workers. The results will then provide the basis to plan any changes needed to promote greater gender equality and equity in health. The lessons learned can be more widely disseminated to help those at an earlier stage of innovation. These monitoring and evaluation strategies need to be culturally sensitive and designed to reflect and change existing patterns of gender relations. However, a range of practical tools from different countries are now available as a starting point for this work.
F. Intersectoral collaboration for gender equality and health
159. While intersectoral coordination is important, it does not, in itself, solve women's health problems because of the gender inequality in decision-making within and between sectors and financial allocation. Good governance to ensure women's participation in health decision-making is essential. The first principle is that health is a human right and that includes women's human rights. The second is a gendered democracy or parity democracy that ensures women's equal political participation. Accountability and transparency are also vital.
160. The framework for intersectoral coordination should be based on the agreements made in the Beijing Platform for Action in which twelve critical areas of concern were identified. This document, combined with the Convention on the Elimination of All Forms of Discrimination Against Women and other international human rights instruments, provides strategies and recommendations to improve the political, economic, social and cultural well-being of women. However, these need to be more systematically integrated and linked across sectors to women's health.
161. Health care is only one of the influences on health itself. If, therefore, 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, industry, transport, social security and the legal system. In each of these areas gender equality 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.
162. In the development of macro-economic policies 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 agrochemicals, water resources and more provision of credit for women especially in the agricultural sector.
163. It is essential that all policy makers recognize that gender inequalities cross all determinants of health, such as class, ethnicity and socio-economic status. Policies to improve the health of women and men should also take factors such as these into account.
164. Intersectoral coordination should, furthermore, be implemented across sectors and at all levels, from the local to the global level, by a variety of actors.
165. Recognizing that countries vary according to their infrastructure, capability and history of intersectoral planning, the main focus should be to ensure gender mainstreaming in all policies and programmes.
166. The following examples illustrate the challenges and some best practices of intersectoral coordination that include a gender perspective:
(i) Gender-based violence, trafficking of women and child prostitution: The Pan American Health Organization (PAHO) coordinates a prevention programme on gender violence in seven Central American and three Andean countries that involves criminal justice, law enforcement, health, employment and a broad group of actors including women's NGOs;
(ii) Environmental health: Sweden has adopted Agenda 21 of the Earth Summit and applied it on a national and municipal level with ombudsmen to ensure integration of gender equality into environment programmes. Examples in Asia are found in water and sanitation programmes in which women's participation combined with good intersectoral coordination were key in achieving success;
(iii) Occupational health and women worker's access to health services: In the l970s, women's unions in Hong Kong improved occupational health in the free trade zones by educating women on the labour laws. This included more than maternity leave and covered safety and environmental conditions. In Botswana, Cuba and the Netherlands, national policies striving for universal access to health helped to ensure unpaid household working women and those in the informal sector access to health services;
(iv) Promotion and prevention: In Zimbabwe, the HIV and AIDS programme uses a wide intersectoral approach involving women's NGOs, the media, schools and various governmental agencies. Some anti-smoking programmes in the USA, including those which reach out to young women have been successful in reducing smoking through intersectoral cooperation;
(v) Community health: In the Women's Total Health Care Programme (PAISM) in Sao Paulo, women and their organizations played a key role in setting up community based health systems with a strong gender component. In collaboration with the Municipal Government's Women's Health Office and its local health centres, women participated in designing and applying epidemiological surveys, based on their needs, establishing priorities and monitoring their application. Outcomes of this programme include free access to family planning including emergency contraception, abortion and counselling services for women in special situations and establishment of Maternal Mortality Prevention and Survey Committees;
(vi) Sexual and reproductive health: The initiative to eradicate FGM in the Sabini community in Uganda demonstrates effective horizontal collaboration at the local level. These efforts involve health workers, NGOs, community-based organizations and traditional leaders who provide information, education and communication on the dangers of FGM. These efforts are supported vertically by women parliamentarians, educators, the media and health activists who provide strong advocacy at the policy level;
(vii) Tropical diseases: The positive role of the private sector, combined with community involvement of women, is illustrated in the partnership of the African Programme for Onchocerciasis Control (APOC) in which a pharmaceutical company provides free medication (Ivermectin) for prevention to many countries in Africa and the Americas.
References
See Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995 (51³Ô¹Ï publication, Sales No. 96.IV.13), Strategic objectives under the critical areas of concern
"C. Women and health".General Assembly, Report of the Economic and Social Council for 1997, A/52/3 of 18 September 1998.
I. LIST OF PARTICIPANTS
CONSULTANTS
Ms. Mercedes Juarez de Robert (Mexico) Platanenlaan 77 2061 TS Bloemendaal Holland, The Netherlands Tel: 31 23 5259782 Fax: 31 23 5256110 E-mail: mjuarez@stance.nl
Professor Lesley Doyal
Professor of Health and Social Care
School for Policy Studies
Rodney Lodge
Grange Road
Clifton, Bristol, UK
BS8 8EA
Tel: 44-117-974 1117
44-117-16380232 (private)
Fax: 44-117-973 7308
E-mail: L.Doyal@bristol.ac.uk
Dr. Suniti Solomon (UNAIDS consultant) Director, YRG Care 1 Raman Street Chennai - 600017, India Tel: 91-44-8264242 Fax: 91-44 -8256900, or 91-44-8256842 E-mail: yrgcare@giasmd01.vsnl.net.in
EXPERTS
Dr. Charlotte Abaka
CEDAW expert and Vice-Chairperson
U. S. T. Box 68
Kumasi, Ghana
Tel: 233-51-26016 (residence)
233-51-26232 (clinic)
National Council on Women and Development
P.O. Box M 53 Accra, Ghana
Tel: (233-21) 776-470
Fax: (233-21) 503865
Dr. Uche Amazigo OCP/APOC B.P. 549, Ouagadougou, BF Tel: 226 30 23 12/13 or 34 36 46 Fax: 226 30 21 47 E-mail: amazigo@ocp.oms.bf
Dr. Mabel Bianco Coordinator LACASO (Latin American Council of AIDS Service Organizations) President of Fundacion Para Estudio e Investigacion de la Mujer Parana 135, Piso 3? A13" 1017 Buenos Aires, Argentina Tel : 541-372-2763 Fax: 541-375 59 77 E-mail: feim@feim.wamani.apc.org. E-mail: feim@ciudad.com.ar
Dr. Mary-Jo Del Vecchio Good Professor of Social Medicine at Havard Medical School Havard Medical School 641 Huntington Avenue Boston, MA 02115, USA Tel: 617- 432 2557 Fax: 617- 432 2565 E-mail: mjdgood@warren.med.harvard.edu
Dr. Aruna Dewan
Deputy Director
National Institute of Occupational Health
Ahmedabad, India
Tel: 91-79 286 7351,52,59
Fax: 91-79 286 6630
E-mail: dewan@ad1.vsnl.net.in
Dr. Mahmoud Fathalla
Professor of Obstectrics and Gynecology
Assuit University
P.O.Box 30
Assuit, Egypt
Tel: 20-88-33 48 20
Fax: 20-88-33 73 33
E-mail: mfathall@intouch.com
Dr. Nébiha Gueddana
Directeur General
Office National de la Famille et de la Population
(ONFP)
42, Avenue de Madrid
1002 Tunis, Tunisia
Tel. 216-1-34 10 88
Fax. 216-1-35 49 67
216-1-34 03 35
216-1-35 45 07
E-mail: n.gueddana@rns.tn
Ms. Marianne Haslegrave Commonwealth Medical Association (CMA), BMA House Tavistock Square London, WC1H 9JP, UK Tel: 44-1-71-383 6095 Fax: 44-1-71-383 6195 E-mail: com_med_assn@compuserve.com
Ms. Wanda Nowicka Executive Director Federation for Women and Family Planning ul. Rabsztynska 8 01-140 Warsaw, Poland Tel/Fax: 48-22-6320882/631 0817 E-mail: polfedwo@waw.pdi.net
Ms. Susanna Rance Direccion postal Casilla 10640 Calle Francisco Suarez No 205 Zona Bajo Tacagua La Paz, Bolivia Tel: 591-2-51634 Fax: 591-2-313867 E-mail: srance@lpz.rds.org.bo
Dr. Sheila Dinotshe Tlou Senior Lecturer Faculty of Education, University of Botswana Private Bag 0022 Gaborone Botswana Tel: 355-2369 ( work) 351-681 (home) Fax: 356-591 E-mail: tlousd@noka.ub.bw
Dr. Yut Lin Wong Senior Lecturer, Health Research Development Unit, Faculty of Medicine University of Malaya 50603 Kuala Lumpur, Malaysia Tel: 603-750-2342 / 750-2570 Fax: 603-755-7740 E-mail: wongyl@medicine.med.um.edu.my
OBSERVERS
Governments
Canada
Dr. Carol Vlassoff Senior Specialis Population and Reproductive Health Canadian International Development Agency (CIDA) 200 Promenade du Potage Hull, Quebec, K1A OG4, Canada Tel: 819-994-079/ 997 70 91 Fax: 819-997-049 E-mail: CAROL_VLASSOFF@acdi-cida.gc.ca
Ms. Gloria Wiseman Senior Adviser International Affairs Directorate Health Canada Brooke Claxton Building - 8th Floor Tunney's Pasture Ottawa, Ontario K1A OK9, Canada Tel: 613-941-1969 Fax: 613-952-3496 E-mail: Gloria_Wiseman@hc-sc.gc.ca
France
Ms. Caroline Mechin Chargée de Mission du Secteur International Service des Droits des Femmes 31, rue Le Peletier 75009 Paris, France Tel: 01-47-70-41-58 Fax: 01-42-46-99-69 E-mail:SEDF-EUROPE-INTERNATIONAL@sante.gouv.fr
Germany
Ms. Angelika Diggins-Rösner Bundesminsterium für Familie, Senioren, Frauen und Jugend Referat 404 - FR. B 53107 Bonn, Germany Tel: 49-228-930-2312 Fax: 49-228-930-49-15/930-2221
Nigeria
Mr. S.A. Mohammed Counsellor Embassy of Nigeria 56, Avenue Tahar Ben Achour Mutuelleville Tunis, Tunisia Tel: 216-1-84 62 55
Sweden
Ms. Katarina Lindahl Executive Director International Unit of RFSU Swedish Association for Sexual Education Box 121 28 10224 Stockholm, Sweden Tel: 46 8 6534744 Fax: 46 8 65 30 823 E-mail: katarina.lindahl@rfsu-se Tunisia
Ms. Habiba Ben Romdhane Professeur Universitaire en médicine Chercheur, Institut National de Santé Publique (INSP) 5-6 Rue Khartoum Diplomat, Le Belvedère Tunis 1002, Tunisia Tel: 216-1- 87414, 881250 Fax: 216-1-795889 E-mail:habiba ben roumdhane@rns.tu
Ms. Munira Garbouj Soins de la Santé de Base (DSSB) 31, Rue El Kharoum Le Belvedère, Tunis, Tunisia Tel: 216-1- 798657
Ms. Sihem Najar CREDIF Avenue du Roi Abdelaziz El-Saoud, Rue 7131 El Manar II 2092 Tunis, Tunisia Tel: 216-1- 885322 Fax: 216-1- 882893 E-mail: Zakia.Bouaziz@CREDIF.rnrt.tn
Dr. Hajri Selma Endocrinologue Consultant ONFP -SCPM - Ettaoufik Boulevard 7 Novembre El Menzah 1002 Tunis, Tunisia Tel/Fax: 216-1- 845212
Ms. Arfa Samia SF
Association Tunisienne des Mères ATM
El Menzeh 6 Tunis, Tunisia
MSP rue Tanit No. 7 Nord Hilton
Tel: 216-1- 784043 (Private)
216-1- 620123 (Office)
51³Ô¹Ï System
Department of Public Information
Ms. Lena Yacoumopoulou (Radio Producer for the Women's Weekly Programme) UN Radio Department of Public Information New York, USA Tel: 963-5270 Fax: 963-3410
51³Ô¹Ï Development Programme
Dr. Catherine Hankins
Associate Professor of Epidemiology
McGill AIDS Center
Group for Action Research
1616 Rene-Levesque Blvd. West, 3rd Floor
Montreal, Quebec HGH 1P8, Canada
Tel: 514-932-3055
513-527-4962 (home)
Fax: 514-528-2452 (office)
514-527-4928 (home)
E-mail: MD77@MUSICA.MCGILL.CA
51³Ô¹Ï Drug Control Programme
Ms. Giovanna Campello Focal Point on Gender UNDCP, P.O.B 500 A-1400 Vienna, Austria Tel: 43 1 26060-5551 Fax:43-1-26060-5866 E-mail: gcampello@undcp.un.or.at
51³Ô¹Ï High Commissioner for Refugees
Ms. Yasmina Chourfi Senior Regional AdvisEr for Refugee Women 13 AL Falah Street - Cairo, Egypt Tel: 30-31-751/2 Fax: 30-31-753 E-mail: chourfi@unhcr.ch
51³Ô¹Ï Children's Fund
Ms. France Donnay Senior Adviser, Health Health Section, Programme Division Three UN Plaza New York, NY 10017, USA Tel: 212- 824-6325 Fax: 212-824-6460 E-mail:fdonnay@unicef.org
International Research and Training Institute for the Advancement of Women
Ms. Zakia Amara Bouaziz
Board member INSTRAW
President
Directeur General CREDIF
Avenue du roi Abdelaziz Al Saoud
2092 Tunis, Tunisia
Tel: 216-1-885-322
Fax.: 216-1- 882-893
216-1- 887-436
E-mail: Zakia Bouaziz@CREDIF.rnrt.tn
World Health Organization
Ms. Annemieke Brands Technical Officer Women, Health and Development 20 Avenue Appia CH-1211 Geneva 27, Switzerland Tel: 41-22-791-4214 E-mail: Brandsa @who.ch
Ms. Marianne S. Jensen, Division of Analysis, Research and Assessment 20 Avenue Appia CH-1211 Geneva 27, Switzerland Tel: 41-22-791-2860 E-mail: Jensenm@who.ch
Ms. Jacqueline Sims Technical Officer Office of Global and Integrated Environmental Health 20 Avenue Appia CH-1211 Geneva 27, Switzerland Tel: 41-22-791-3755 E-mail: simsj@who.ch
Dr. Sally Bisch
Regional Adviser Women, Health and Development WHO Regional Office for South-East Asia I.P. Estate, Ring Rd New Delhi, India 110002 Tel: 91-11-331-7804 Fax: 91-11-331-8607 E-mail: bisch@who.ernet.in
Dr Ileana C. Herrell Senior Adviser Health Policy in Development WHO/Geneva 20 Avenue Appia CH-1211 Geneva 21, Switzerland Tel: 41-22-791-2524 Fax: 41-22-791-4726 E-mail: Herrelli@who.ch
Ms. Joyce Kadandara Chief and Regional Adviser, Women=s Adolescent Health WHO Regional Office for Africa P.O. Box cy 348 Causeway Harare, Zimbabwe Tel: 263-04-728991-7 Fax: 263-04-728998
Ms. Mirvet Abou Shabanah Women in Health and Development WHO/EMRO P.O.Box 1517 Alexandria (21511), Egypt Tel: 483-0090 Fax: 483-8916 E-mail: Ashbana M@who.sci.eg
Dr. Samia Galal Saad
Expert on Gender and Environment
Adviser to the Minister of Environment
18 El Fawakeh Street
El Mohandesseeen
Cairo, Egypt
Tel: 202-525 64 61
Tel: 202-360-7892 (home)
012-215 0261 (mobile)
Fax: 202-360 7892
E-mail: sam_gal@hotmail.com
WHO/Pan American Health Organization Dr. Marijke Velzeboer-Salcedo Coordinator Women, Health and Development Program Pan American Health Organization 525 Twenty-Third Street N.W., Washington, D.C. 20037-2895, USA Tel: 202-974-4305 Fax: 202-974-3671 E-mail: velzebom@paho.org
World Bank
Ms. Anne Tinker Principal Health SASHP MC-11-830 1818 H Street, N.W. Washington, DC 20433, USA Tel: 202-473-3683 Fax:202-522-2955 E-mail: atinker@worldbank.org
International Atomic Energy Agency (IAEA)
Ms. Baldip Khan Nuclear Medicine Section Division of Human Health IAEA P.O.B 100 A-1400 Vienna, Austria Tel: 43-1-2600 Fax: 43-1-26007 E-mail: b.khan@iaea.org
Committee on the Elimination of Discrimination Against Women (CEDAW)
Ms. Emna Aouij Député à la Chambre des Députés 7, Avenue Haroun Errachid Mutuelleville 1002 Tunis, Belvédére, Tunisia Fax: 216-1- 797-285
Non-Governmental Organizations
Dr. Beth Bowen Health for Humanity Bahai International Community Office for the Advancement of Women 866 51³Ô¹Ï Plaza, Suite 120 New York, NY 10017, USA Tel: 212-803-2500 Fax: 212-803-2566 E-mail: oaw-nyc@bic.org
Dr. Joyce E. Braak, M.D., President Institute for Research on Women's Health 145 Green Acres Rd. Elizaville, NY 12523, USA Tel: 518-537-5979 Fax: 518-537-5989 E-mail: braak@epix.net
Mr. John Harvard Commonwealth Medical Association (CMA) BMA House Tavistock Square London, WC1H 9JP, UK Tel: 44-71-383-6095 Fax: 44-71-383-6195 E-mail: com-med-assn@composerve.com
Ms. Peggy Maguire Director General European Institute of Women=s Health 9 Herbert Place Dublin 2, Ireland Tel: 353-1-676-6717 Fax: 353-1-676-6740 E-mail: info@eurohealth.ie
Dr. Nagwa Hassan Mohamed Soroptimist International of Europe Health Co-ordinator 9 El Aksheed St Roda Cairo, Egypt Tel: 20- 02-363-023/368-6271 Tel: 02-368-6271 (clinic) Tel: 02-363-0232 (home) Fax: 20-02-392-2236/772-944
Ms. Soon-Young Yoon The Earth Times Foundation 915 Castle Point Terrace Hoboken, NJ 07032, USA Tel: 201-653-7658 Fax: 201-792-5638 E-mail: ssyoon@aol.com
ORGANIZERS
World Health Organization
Dr. Olive Shisana Executive Director Family and Health Services 20 Avenue Appia CH-1211 Geneva 27, Switzerland Tel: 41-22-791-4353/2111
51³Ô¹Ï Population Fund
Ms. Wariara Mbugua Manager Gender Theme Group 220 East 42nd Street, 18th Floor New York, NY 10017, USA Tel: 212-297-5142 Fax: 212-297-5145 E-mail: mbugua@unfpa.org
51³Ô¹Ï, Division for the Advancement of Women
Ms. Dorota Gierycz Chief, Gender Analysis Section UN Division for the Advancement of Women 2 UN Plaza, Room 1244 New York, NY 10017, USA Tel: 212-963 5913 Fax: 212-963 3463 E-mail: gierycz@un.org Ms. Maria Hartl Social Affairs Officer Gender Analysis Section UN Division for the Advancement of Women 2 UN Plaza, Room 1238 New York, NY 10017, USA Tel: 212-963-3140 Fax: 212-963-3463 E-mail: hartl@un.org
Commonwealth Secretariat
Professor Stephen Matlin Director, Human Resource Development Division Commonwealth Secretariat Marlborough House, Pall Mall London SW1Y 5HX, UK Tel: 44-1-71-747-62 80 Fax: 44-1-71-747-62 87 e-mail: matlins@commonwealth.int
Tunisian Ministry of Women and Family Affairs
Mr. Salah Triki Head of Office of the Minister of Women and Family Affairs Officer-in-Charge of the Department of International Cooperation 1 rue d=Alger Tunis, Tunisia Tel: 216-1 332-781 Fax: 216-1-349-900
Ms. Boutheina Gribaa Director of Follow-up, Planification and Human Resources / Office of the Minister of Women and Family Affairs 1, rue d'Alger Tunis, Tunisia Tel: 216-1-352-666 Fax: 216-1-349-900 Ms. Beya Mouakhar Coordinator and Translator 61, Bab Benat 1035 Tunis, Tunisia Tel: 216-1-560-203/767 898 Fax: 216-1-568-811 E-mail: beya75@yahoo.com II. LIST OF DOCUMENTS
INFORMATION PAPERS
EGM/HEALTH/1998/INF.1 Programme of Work
EGM/HEALTH/1998/INF.2 List of Documents
EGM/HEALTH/1998/INF.3 Procedures followed in ad hoc expert group meetings Organized by the Division of the Advancement of Women
EGM/HEALTH/1998/INF.4 Information note for participants
EGM/HEALTH/1998/INF/5 List of participants
WORKING PAPERS
EGM/HEALTH/1998/WP.1 The health of women and girls : from Cairo to Beijing and beyond Prepared by the 51³Ô¹Ï Division for the Advancement of Women
EGM/HEALTH/1998/WP.2 A draft framework for designing national health policies with integrated gender perspective Prepared by Professor Lesley Doyal, DAW Consultant
EGM/HEALTH/1998/WP.3 Women and HIV/AIDS concerns B a focus on Thailand, the Philippines, India and Nepal Prepared by Dr. Suniti Solomon, UNAIDS Consultant
EGM/HEALTH 1998/WP.4 Gender Management System in the health sector Prepared by Professor Stephen A. Matlin, Commonwealth Secretariat
EGM/HEALTH/1998/WP.5 Towards a gender-sensitive reform in the health sector :Issues of concern drawn from the Bangladesh reform process. Prepared by Dr. Mercedes Juarez de Robert, WHO Consultant
EXPERTS' PAPER
EGM/HEALTH/1998/EP.1 Factors affecting women's health in Eastern and Central Europe with particular emphasis on infectious diseases, mental,environmental and reproductive health Prepared by Ms. Wanda Nowika
EGM/HEALTH/1998/EP.2 Occupational and environmental health of women Prepared by Dr. Aruna Dewan
EGM/HEALTH/1998/EP.3 Women and mental health Prepared by Dr. Mary-Jo Del Vecchio Good
EGM/HEALTH/1998/EP.4 Issues in reproductive health Prepared by Dr. Mahmoud F. Fathalla
EGM/HEALTH/1998/EP.5 Integrating the gender perspective in medical and health education and research Prepared by Dr. Yut Lin Wong
EGM/HEALTH/1998/EP.6 The role of local government implementing health care policies with the gender perspective Prepared by Dr. Maria Jose de Oliveira Araújo
EGM/HEALTH/1998/EP.7 Cost benefit and economic approach related to health care services system Prepared by Dr. Mabel Bianco
EGM/HEALTH/1998/EP.8 Women and health : Mainstreaming the gender perspective in health care, including the management of human and financial resources in nursing Prepared by Dr. Sheila Dinotshe Tlou
EGM/HEALTH/1998/EP.9 Framework for human rights approach to women's health : The work of the CEDAW Committee Prepared by Dr. Charlotte Abaka, Vice-Chairperson of CEDAW
EGM/HEALTH/1998/EP.10 The role of NGOs in promoting a gender approach to health care Prepared by Ms. Marianne Haslegrave
EGM/HEALTH/1998/EP.11/ Women's health and tropical disease : A focus on Africa Rev.1 Prepared by Dr. Uche Amazigo
EGM/HEALTH/1998/EP.12 The gender agenda: Role of parliamentarians in the establishment of gender-sensitive health policies Prepared by Ms. Susanna Rance EGM/HEALTH/1998/EP.13 Important elements and actors in the establishment of a gender specific reproductive health policy Prepared by Dr. Nébiha Gueddana
OBSERVERS' PAPER
EGM/HEALTH/1998/0P.1 Body talk : Women and health B information, education and communications Prepared by Ms. Soon-Young Yoon
EGM/HEALTH/1998/0P.2 Environmental deterioration : Gender specific health impacts Prepared by Dr. Samia Galal Saad
EGM/HEALTH/1998/0P.3 Summary - Online dialogue on women and health Prepared by Ms. Soon-Young Yoon
BACKGROUND PAPERS
EGM/HEALTH/1998/BP.1 Aide-Mémoire
EGM/HEALTH/1998/BP.2 "Women and Health" Critical area of concern (Extract From the Beijing Platform for Action)
III. PROGRAMME OF WORK
Monday, 28 September 1998
9:30 - 11:00 a.m. Opening ceremony
Opening Statement by Dr. Olive Shisana, Executive Director, Family and Health Services, World Health Organization Message from Ms. Angela E.V. King, Assistant Secretary-General, Special Adviser on Gender Issues and Advancement of Women, 51³Ô¹Ï Message from Dr. Nafis Sadik, Executive Director, 51³Ô¹Ï Population Fund Statement by Her Excellency Ms. Neziha Zarrouk, Minister for Women and Family Affairs, Tunisia
11:00 a.m. - 1:00 p.m. Election of Officers and Adoption of the Programme of Work Introduction to the Meeting Overview on gender and health
Dr. Mercedes Juarez de Robert (Consultant): Gender-sensitive reform in the health sector Professor Lesley Doyal (Consultant): A draft framework for designing national health policies with an integrated gender perspective Professor Stephen Matlin (Commonwealth Secretariat): Gender Management Systems in the Health Sector
1:00 - 2:30 p.m. Lunch
2:30 - 4:30 p.m. Gender analysis of specific health problems and policy implications
Dr. Suniti Solomon (Consultant) : HIV/AIDS Dr. Uche Amazigo (Nigeria): Tropical diseases - a focus on Africa Dr. Mary-Jo Del Vecchio Good (USA): Mental health Dr. Aruna Dewan (India): Occupational and environmental health Dr. Mahmoud Fathalla (Egypt): Issues in reproductive health Ms. Wanda Nowicka (Poland): Women's health in Eastern and Central Europe
4:30 - 5:30 p.m. General debate
Tuesday, 29 September 1998
9:30 a.m. - 12:15 p.m. Working groups on policy implications:
-Tuberculosis, malaria and other disease control programmes, including HIV/AIDS -Mental health -Occupational and environmental health -Sexual and reproductive health
12:15 - 1:00 p.m. Reports from working groups to plenary
1:00 - 2:30 p.m. Lunch
2:30 - 4:30 p.m Implications of a gender analysis for the structure and management of health systems
Dr. Nébiha Gueddana (Tunisia):Important elements and actors in the establishment of a gender specific reproductive health policy Dr. Mabel Bianco (Argentina): Cost benefit and economic approach related to health care services system Dr. Sheila Dinotshe Tlou (Botswana): Health care including management of human and financial resources in nursing Dr. Yut Lin Wong (Malaysia): Integrating the gender perspective in medical and health education and research
4:30 - 5:30 p.m. General debate
Wednesday, 30 September 1998
9:30 a.m.- 12:15 p.m. Working groups on implications of a gender analysis for the structure and management of health systems:
-Health sector reform and health care financing -Quality of care -Partnership for health - key stake holders, possibilities for alliances and modes for working -Capacity building for health workers
12:15 - 1:00 p.m. Reports from working groups to plenary
1:00 - 2:30 p.m. Lunch
2:30 - 4:30 p.m. The role of various actors in the development and implementation of a gender- sensitive framework for national health policies:
Dr. Charlotte Abaka (Expert, Member of the Committee on the Elimination of Discrimination against Women, Ghana): Framework for a human rights approach to women's health Ms. Marianne Haslegrave (United Kingdom): The role and possible contributions of NGOs Susanna Rance (Bolivia): The role of parliamentarians Introduction of the paper of Dr. Maria Jose de Oliveira Araújo (Brazil) : The role of local governments
4:30 - 5:30 p.m. Working groups on the draft recommendations for framework for national health policies -Mainstreaming gender in medical research -Mainstreaming gender in health service delivery -Intersectoral collaboration for gender equality
Thursday, 1 October 1998
9:30 a.m. - 1:00 p.m. Working groups continue
1:00 - 2:30 p.m. Lunch
2:30 - 5:30 p.m. Working groups continue, followed by meeting of the drafting committee
Friday, 2 October 1998
9:30 a.m. - 1:00 p.m. Introduction of draft recommendations and report in plenary, followed by meeting of the drafting committee
1:00 - 2:30 p.m. Lunch
2:30 - 4:00 p.m. Adoption of final report and recommendations
4:00 - 5:00 p.m. Closing session