Global Health Initiative Supplemental Guidance on Women, Girls, and Gender Equality Principle

Through the Global Health Initiative (GHI), the United States is helping partner countries improve health outcomes through strengthened health systems and integrated services, with a particular focus on improving the health of women, newborns and children. Programs aim to achieve sustainable health impact by addressing infectious disease, nutrition, maternal and child health, family planning, HIV/AIDS and safe water. The first principle of the GHI is a “focus on women, girls and gender equality.” This guidance provides clarification on the goals and programming options related to women, girls and gender equality while acknowledging the critical synergies with other GHI principles such as country ownership, integration, health systems strengthening, and monitoring and evaluation.
 

Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women. - WHO

Gender-related inequalities and disparities disproportionately compromise the health of women and girls and, in turn, affect families and communities. The GHI will focus on women and girls—including adolescent and pre-adolescent girls—in the planning, implementation, and monitoring and evaluation of health and development programs and policies.
 

Gender equality in health means that women and men have equal conditions for realizing their full rights and potential to be healthy, contribute to health development, and benefit from the results. Achieving gender equality will require specific measures designed to eliminate gender inequities. - PAHO Gender Equality Policy

Requirements for Country Strategies on Women, Girls and Gender Equality

A. Gender Analysis: Each country team -- with the input of local civil society organizations, donors, government counterparts and other partners -- should conduct gender analysis, which includes an assessment of the priority needs of women and girls at the community level, to inform the design of projects and activities. The analysis should identify age-specific gender roles and norms that affect access to and control over resources and that create differences in power among and between women and men, girls and boys, all of which are relevant to health objectives. This analysis should go beyond the health sector to describe broad structural issues within a country as well as related USG investments in other sectors. Teams should note that the USAID Automated Directives System (ADS) requires gender analysis for all project design. [1]

B. Women, Girls and Gender Equality Narrative: Each country team should provide a short narrative in the GHI strategy document describing how they are implementing and will implement the principle of Women, Girls and Gender Equality. The narrative should highlight key gender issues and needs, and priority actions and key elements of implementation planned by the country team in coordination with the host government to address these. Full details on implementation of this principle will be expected in the corresponding country plans (such as the COP, MOP, OP, partner work-plans, or where deemed appropriate). These plans should include a description of how the analysis described above was used in determining priority actions; corresponding metrics and evaluation plan; and plans for how teams will systematically integrate women, girls and gender equality throughout the GHI country strategy. The narrative should specify existing activities that already support the principle. Plans should also describe the capacity of the country team to address gender equality in its programming (i.e., established gender points of contact or gender working groups).

C. Measurement and Evaluation: GHI will collect sex- and age-disaggregated data as well as health statistics to monitor progress and evaluate effectiveness of programs on women, girls and gender equality and health. Programs will report on indicators that are included and/or support national information systems. Where possible, country teams will work with host country government to incorporate gender-related outcomes into national reporting systems. GHI will support formative and operations research to develop the evidence-base for key programming recommendations.

D. Key Elements of Implementation: Below is a menu of key program elements to help improve the health of women and girls and increase gender equality. These are not listed in order of priority. The implementation of multiple elements as part of an overall country strategy, carried out through the programs that make up GHI, is more likely to promote effective programming and desired results. For example, a large, national behavior change campaign that is not supported by policy or individual and community level work will likely have limited effectiveness. These elements should be integrated into broader health projects but could also be implemented as stand-alone activities, as appropriate. The elements to include in a given country strategy should be selected based on the findings of the gender analysis and in collaboration with host country counterparts.

GHI country teams are requested to implement the items below in support of the women, girls, and gender equality principle. In doing so, teams should (1) be vigilant about unintended programmatic consequences that could exacerbate gender inequality; (2) ensure that human rights are embedded in programs; (3) apply culturally-sensitive approaches that acknowledge the significance of traditions and reaffirm positive and protective norms; and (4) look for opportunities to improve gender relations.

As GHI teams implement the GHI principles through their programs, they should identify opportunities to carry out gender-related activities as highlighted below:

1. Ensure equitable access to essential health services at facility and community levels. The best stocked facility or most highly trained health worker cannot improve health outcomes if clients with the greatest need are not able to access services. A range of social, legal, economic and cultural barriers prevent women and adolescent girls from accessing essential health services, e.g. MCH, FP and HIV. Men, boys and marginalized groups are also often dissuaded from seeking health services due to provider and community stigma, cultural norms, and structure of services. Disaggregating data by sex and age in all health service programs is essential to track access and use. Improved access can also be achieved through thoughtful integration of a range of health services that increase efficiency and convenience, and meet the multiple needs of women and girls.

Programming recommendations:

• Recognize and address barriers to access, including: transportation to services/or financial resources where necessary; flexible hours of operation with access to multiple integrated services; confidentiality and privacy; appropriate facilities (e.g., separate entrances or waiting areas for women and girls when needed, childcare services, access for people with disabilities);support of family members; cultural competence; and assistance with language barriers.
• Train providers on the importance of relevant and respectful care to all clients, including women, girls and marginalized groups.
• Provide alternative service delivery options (e.g., home visits and mobile units) for clients unable to reach or unlikely to use facility-based services.
• Consider clients’ preferences for either male or female health care providers.
• Integrate services where feasible and build meaningful and robust referral systems between facilities and between the community and facility levels.
• Ensure the availability and access to the full range of commodities, including female-initiated methods.
• Mobilize communities to support essential health services for all.
• Develop an accountability mechanism that captures the clients’ perspectives on quality and access of care, provider bias, and guarantees confidentiality and informed consent.

2. Increase the meaningful participation of women and girls in the planning, design, implementation, monitoring and evaluation of health programs. Women and girls need to participate in the design, management, monitoring and evaluation of health programs to effectively address their health needs. In order for women and girls to become agents of their own health and overall empowerment, programs must move beyond viewing them only as end-users and beneficiaries and acknowledge and support their roles as principal actors and decision-makers.

Programming recommendations:

• Consult program beneficiaries and those impacted by the activity on the program design and markers of success. In many cases, this will involve reaching remote areas and finding innovative ways to solicit feedback from marginalized groups as well as addressing barriers that may impact on beneficiaries’ ability to speak candidly.
• Consult civil society organizations, including women’s and human rights groups, and both public (i.e. government-run) and private organizations (i.e., local business, associations of health care workers)in program design, implementation, and monitoring and evaluation activities. Provide small grants to civil society organizations working on gender equality and health. Support models of health care provision in which women build social support and social capital, such as support groups through pregnancy and child’s first year of life, and among HIV-positive women.
• Build capacity of women and girls to communicate their needs and advocate effectively in the context of policies and programs.
• Support community feedback mechanisms through which women, girls, men and boys, including those from marginalized groups, are able to voice concerns and opinions about health services and community-based activities through a confidential and responsive mechanism.
• Involve women in the process of commodity development, such as new contraceptives, microbicides and other devices, to ensure the appropriateness and uptake of products.
• Ensure the results of evaluations are shared with men and women in the community and facilitate discussion on the implications of the findings.

Gender-based violence is violence involving men and women, in which the female is usually the victim; and which is derived from unequal power relationships between men and women. Violence is directed specifically against a woman because she is a woman, or affects women disproportionately. It includes, but is not limited to, physical, sexual, and psychological harm… It includes violence that is perpetuated or condoned by the state. - UNFPA Gender Theme Group

3. Monitor, prevent and respond to gender-based violence. Gender-based violence (GBV) has implications for almost every aspect of health. Women and girls experience substantial morbidity and mortality as a result of physical and sexual violence.[2] Men and boys are also affected by GBV are much less likely to access services because of stigma and shame. GBV increases vulnerability to HIV and other reproductive health and obstetric conditions, including unintended pregnancy and fistula, and negatively affects women’s and girl’s ability to cope with disease. While GBV encompasses a wide range of behaviors, the GHI is most likely to address intimate partner physical and sexual violence, including marital rape, sexual assault or rape, female genital cutting/mutilation, sexual violence against minors, and “honor” crimes.

Programming recommendations:

• Advocate for development and implementation of laws and policies to monitor, prevent and respond to GBV.
• Support community-level and mass media programs to change behaviors and attitudes about violence and to facilitate discussion among families, community organizations, religious and traditional leaders and other community leaders about human rights and GBV and ways to address it (e.g., supporting a zero tolerance campaign).
• Integrate screening and response of GBV into health service delivery programs, including the provision of post-exposure prophylaxis (PEP) and emergency contraception (EC) as well as follow-on psycho-social support, where feasible.
• Build capacity of health providers to recognize and address GBV as a significant factor contributing to negative health status and affecting client’s adherence to health regimens.
• Require all reproductive health and life skills programming for adolescent and pre-adolescent girls and boys to address sexual coercion and abuse and promote elements of healthy relationships.
• Support programs to empower women and girls to improve self-esteem and negotiation skills.
• Link with multisectoral programs to increase GBV prevention and response, with particular attention to the legal/judicial system and the economic sector.
• Promote and fund research on the incidence and impact of GBV, including on men and boys.

4. Empower adolescent and pre-adolescent girls by fostering and strengthening their social networks, educational opportunities, and economic assets. Pre-adolescent and adolescent girls face systematic disadvantages, including in health, education, nutrition, labor force participation, and the burden of household tasks. Because of social isolation, deprivation, economic disadvantage, and discriminatory cultural norms, many girls are forced to marry at very young ages and are extraordinarily vulnerable to unintended pregnancy, HIV, sexual violence, and physical exploitation. Lacking a full range of opportunities and devalued because of gender bias, many girls are seen as unworthy of investment or protection by their families, communities and governments.[3]

Programming recommendations:

• Support positive youth development through peer networks and mentorship programs in elementary and secondary schools and out of schools, where many of the most vulnerable adolescents can be found.
• Develop specific programming for out-of-school adolescent and pre-adolescents who often the most vulnerable, especially married adolescent girls.
• Promote youth-friendly “safe spaces” for health information and service delivery activities.
• Involve youth, parents, schools, communities and religious leaders when designing programs.
• Provide age-appropriate sexual and reproductive health and HIV/AIDS education and interventions.
• Foster positive adult-child communication.
• Link health activities to education and viable livelihoods programs.
• Work with communities to change behavior and attitudes towards child marriage and support community programs that implement specific interventions to increase age at marriage.
• Support interventions to prevent and respond to sexual abuse of minors.

5. Engage men and boys as clients, supportive partners, and role models for gender equality. The social expectations of how men and boys should act and the values that define masculinity directly affect attitudes and behavior related to a range of health issues. Research with men and boys has shown that inequitable gender norms influence how men interact with their partners, families and children on a wide range of issues, including preventing HIV and other sexually transmitted infections, contraceptive use, use of violence (both against women and between men), domestic chores, parenting and health-seeking behavior.[4]

Programming recommendations:

• Incorporate group education activities for men and boys into health programs (in community, workplace, etc.) including: discussion sessions and awareness-raising sessions with men and boys in group settings. Sessions, run by trained facilitators, should incorporate methodologies that promote individual self-reflection and peer support for positive changes in attitudes and behaviors towards human rights, gender equality and health.
• Incorporate community outreach and mobilization efforts focused on men and boys. These can include: community meetings, training or sensitization activities, theater and other cultural activities; marches; and mass-media campaigns using radio, television, billboards, etc.
• Use affirming messages underscoring the positive roles men and boys can play to improve their own health and in support of the health and rights of women, girls and communities at large.
• Incorporate facility-based programs which involve health services for men, or individual and couples counseling. Ensure that appropriate service structures as well as adequate provider skills and attitudes that facilitate men’s access and participation.
• Seek male religious and other community leaders and well-known role models (sports or popular culture figures) to publicly speak out in support of gender equality, human rights, and women and girls’ well-being, to act as agents of change.
• Provide safe spaces for communication between men and women/boys and girls.
• Link with workplace programs and uniformed services outside of the health sector.

6. Promote policies and laws that will improve gender equality, and health status, and/or increase access to health and social services. Supportive national and operational policies, along with sustained political commitment and resources, provide an environment that promotes gender equality and safeguards women’s and girls’ health.

Programming recommendations:

• Partner with host country governments and collaborate with multilaterals to promote women and girls' health and gender equality through, for example, explicitly including gender in the Ministry of Health's national strategy or national development plans.
• Support advocacy activities of civil society organizations, marginalized populations, and human rights groups that promote gender equality and serve a citizen monitoring function for the government's treatment of women, girls and marginalized groups in the health care sector.
• Develop operational policies that respond to gender inequities including: a country's health insurance plan which covers priority health interventions for both men and women; or policies mandating equal treatment of men and women in hiring, training and retention of health care workers.
• Promote development and enforcement of laws and policies to increase gender equality and empowerment of women and girls, including laws against discrimination in the workforce, child marriage, gender-based violence, and trafficking in persons; and for the protection of inheritance and property rights.
• Support the use of champions, such as Parliamentarians, provincial and district level leaders and other policymakers who are willing to lead efforts, to promote gender equality and safeguard women and girls health.

7. Address social, economic, legal and cultural determinants of health through a multisectoral approach. The conditions in which women and men are born, grow, live, work and age determine health status.[5] The intended health outcomes are more attainable and their impact is better sustained when the myriad structural determinants are addressed in programming.

Programming recommendations:

• Promote linkages to programs outside of the health sector, including programs for: girls’ education, safe schools, and women’s literacy; economic opportunity for young women; safe housing, fair and safe employment, and social safety nets; legal services; access to land and other productive resources; and address environmental factors such as environmental degradation of natural resources.
• Coordinate with host country and multilateral entities supporting efforts for women, girls and gender equality outside the health sector.
• Increase efforts to raise-awareness among families, communities and government decision-makers about the range of determinants influencing the health of men and women, girls and boys.
• Address and respond to harmful traditional practices, including child marriage, forced marriage, abduction, FGM/C, and “honor” crimes.
• Identify and support positive traditional practices that promote gender equality.
• Address the resource and health needs of women and girls in the lowest economic quintiles.

8. Utilize multiple community-based programmatic approaches, such as behavior change communication, community mobilization, advocacy, and engagement of community leaders/role models to improve health for women and girls. A community-based approach allows community members to use their skills and resources to expand the reach of health messages and services through culturally accepted venues. This approach can help communities work to prevent and respond to social and health problems, instead of having external actors step in and assume these responsibilities.

Programming recommendations:

• Incorporate behavior change communication (BCC) activities that are focused on gender into health programs. Use BCC to increase awareness and knowledge; change harmful attitudes and behaviors; and influence social norms and policies.
• Engage community leaders, role models, and gatekeepers, including religious/tribal leaders, school teachers, mothers-in-law and grandmothers, etc. to increase knowledge about the health consequences of specific behaviors, and encourage them to serve as advocates for change in the community.
• Work with local actors to identify cultural norms and practices that support women’s and girls’ health and gender equality, and to develop actions to reinforce them.
• Employ community members in the provision of information and services, such as trained peer educators, community-based distributors, and community caregivers.

9. Build the capacity of individuals, with a deliberate emphasis on women, as health care providers, caregivers, and decision-makers throughout the health systems, from the community to national level. Women and men should have equal opportunities to pursue a health occupation, develop the requisite skills and knowledge, be fairly paid, and enjoy equal treatment and advancement in a career. When gender inequalities and discrimination affect health care providers, health policy-makers, educators and managers it can impede entry into health occupations or contribute to attrition, absences from work, lower productivity, poor health and low morale of health workers. The result is a limited pool of formal and informal health workers.[6]

Programming recommendations:

• Support efforts to recruit and retain women health care workers and decision-makers to increase the overall number of qualified female health care providers.
• Strengthen pre-service and in-service clinical training for both men and women.
• Provide trainings to strengthen the capacity of both men and women to serve as decision-makers and administrators in the health system.
• Strengthen the capacity of informal health personnel, community health workers, and other care givers.

10. Strengthen the capacity of institutions -- which set policies, guidelines, norms and standards that impact access to, and quality of, health-related outreach and services -- to improve health outcomes for women and girls and promote gender equality. Multiple organizations including government and military facilities (national, state and district levels), health institutions, and community based organizations can play a significant role in enabling or limiting gender equality.

Programming recommendations:

• Recognize and address discrimination in the healthcare workforce, including discrimination based on gender, and promote equal opportunities for men and women in health professions. [6]
• Monitor, prevent and respond to sexual harassment and assault in health facilities, hospitals and other health centers.
• Promote pre-service and in-service training in gender and promotion of gender equality in health centers and health-related institutions.
• Support development of civil society organizations through building advocacy, administrative and technical skills to deliver and monitor high quality health and social services.
• Provide training and mentoring to community-based workers, informal health workers and public sector health personnel, at all administrative levels on promotion of gender equality and unique health needs of women and youth.
• Build capacity of host-country governments to develop and enforce policies benefitting women, girls and gender equality.
• Develop and implement policies and programs to eliminate workplace violence and gender discrimination.
• Build capacity of government to collect, track and evaluate gender-related indicators.

[1] USAID Guide to Gender Integration and Analysis, http://www.usaid.gov/policy/ads/200/201sab.pdf

[2] Addressing Gender-Based Violence through USAID’s Health Programs: A Guide for Health Sector Program Officers, Interagency Gender Working Group of USAID, http://www.prb.org/pdf05/GBVReportfinal.pdf

[3] Start with a Girl: A New Agenda for Global Health, Center for Global Development, http://www.cgdev.org/content/publications/detail/1422899/

[4] Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence from Programme Interventions, World Health Organization, http://www.who.int/gender/documents/Engaging_men_boys.pdf

[5]Social determinants of health, World Health Organization, http://www.who.int/social_determinants/en/

[6] Gender Equality in Human Resources for Health: What Does this Mean and What Can We Do?, IntraHealth International, http://www.intrahealth.org/files/media/gender-equality-in-human-resources-for-health/gender_equality_hrh.pdf