A Manual for Integrating Gender Into Reproductive Health and HIV Programs: From Commitment to Action (2nd Edition)

Transcription

1 A Maual for Itegratig Geder Ito Reproductive Health ad HIV Programs: From Commitmet to Actio (2d Editio) August 2009

2 This Maual update was prepared with support from the BRIDGE Project (No. GPO-A ), fuded by the U.S. Agecy for Iteratioal Developmet (USAID), ad implemeted by the Populatio Referece Bureau (PRB) o behalf of the Iteragecy Geder Workig Group (IGWG), a etwork comprisig USAID Cooperatig Agecies (CAs), o-govermetal orgaizatios, (NGOs) ad the USAID Bureau for Global Health. The examples provided i this publicatio iclude experieces of orgaizatios beyod USAID. This publicatio does ot provide official USAID guidace but rather presets examples of iovative approaches for itegratig geder ito reproductive health ad HIV programs that may be helpful i respodig to the Agecy requiremets for icorporatig geder cosideratios i program plaig. For official USAID guidace o geder cosideratios, readers should refer to USAID s Automated Directive System (ADS). Copyright August 2009, Populatio Referece Bureau. All rights reserved.

3 A Maual for Itegratig Geder Ito Reproductive Health ad HIV Programs: From Commitmet to Actio (2d Editio) August 2009 By Deborah Caro of Cultural Practice, LLC, For the Iteragecy Geder Workig Group

4 Ackowledgmets The developmet of the origial Geder Maual, published i 2003, ivolved may people over several years too may to ackowledge here. This update would ot be possible without the may hours ad great diversity of ideas cotributed by those idividuals, particularly the other origial authors: Jae Schueller, Maryce Ramsey, ad Wedy Voet. Special thaks to USAID s Michal Avi ad Patty Allema, geder advisors i the Office of Populatio ad Reproductive Health of the Global Health Bureau, for their commitmet ad support i makig this publicatio a reality; to Sadra Jorda ad Lora Wetzel, also of that office, ad to Diaa Prieto, geder advisor i USAID s Office of HIV/AIDS, for their ivaluable review ad suggestios. I am grateful also to Charlotte Feldma-Jacobs ad Kari Righeim of the Populatio Referece Bureau (PRB) for their cosiderable editig, support, ad ecouragemet i movig this revised Geder Maual forward. Ad, of course, thaks to all those who field-tested this Maual over the years ad whose feedback has made this a better resource. Deborah Caro August 2009 i i

5 Table of cotets Ackowledgmets ii List of Acroyms iv Preface v Brief Overview of Chapters vi chapter 1: Itroductio chapter 2: Ratioale for Geder Itegratio ad Maistreamig chapter 3: The Geder Itegratio Cotiuum chapter 4: The Geder Aalysis Framework chapter 5: A Process for Geder Itegratio Throughout the Program Cycle Step 1. Assessmet Step 2. Strategic Plaig Step 3. Desig Step 4. Moitorig Step 5. Evaluatio Refereces Appedices Appedix I Additioal Defiitios Appedix II The Iteragecy Geder Workig Group (IGWG) Appedix III Geder Resources ad Refereces i i i

6 List of Acroyms AIIH & PH All Idia Istitute of Hygiee ad Public Health MOH Miistry of Health APS Aual Program Statemet NGO Nogovermetal Orgaizatio BLP Better Life Optios Project (Idia) NORAD Norwegia Agecy for Developmet CA CBD CEDPA CIDA CSW DFID DG DMSC FGM/C FHI FWCW GO HIV/AIDS ICPD Cooperatig Agecy (ogovermetal orgaizatios ad cosultig firms that implemet USAID fuded programs) Commuity-Based Distributio The Cetre for Developmet ad Populatio Activities Caadia Iteratioal Developmet Agecy Commercial Sex Worker Departmet for Iteratioal Developmet (Great Britai) Democracy ad Goverace Durbar Mahila Samawaya Committee (Bombay, Idia) Female Geital Mutilatio/Cuttig Family Health Iteratioal 1995 UN Fourth World Coferece o Wome (Beijig, Chia) Govermetal Orgaizatio Huma Immuodeficiecy Virus/Autoimmue Deficiecy Sydrome U.N. Iteratioal Coferece o Populatio ad Developmet (Cairo, Egypt, 1994, ad all subsequet ratificatios) OECD/DAC OVC PHN PLWHA PMTCT PRB RFA RFP RFTOP RH SIDA STI SRH TA TAG TBA UN Orgaizatio for Ecoomic Cooperatio ad Developmet/ Developmet Assistace Committee Orphas ad other vulerable childre Populatio, Health, ad Nutritio People Livig with HIV/AIDS Prevetig mother to child trasmissio of HIV Populatio Referece Bureau Request for Applicatios Request for Proposals Request for Task Order Proposal Reproductive Health, icorporatig i this Maual materal Health, Family Plaig, ad HIV ad AIDS Swedish Iteratioal Developmet Cooperatio Agecy Sexually Trasmitted Ifectio Sexual ad Reproductive Health techical Assistace Techical Advisory Group traditioal Birth Attedat uited Natios IEC iformatio, Educatio, ad Commuicatio USAID Uited States Agecy for Iteratioal Developmet IGWG Iteragecy Geder Workig Group USG Uited States Govermet INTRAH Iovative Techologies for Healthcare Delivery WHO World Health Orgaizatio JHPIEGO JHPIEGO Corporatio, a affiliate of Johs Hopkis uiversity i v

7 Preface The Iteragecy Geder Workig Group (IGWG), ( established i 1997, is a etwork of orgaizatios, icludig the USAID Bureau for Global Health, USAID-fuded cooperatig agecies (CAs), health ad wome s advocacy groups, o-govermetal orgaizatios (NGOs), ad idividuals. The IGWG promotes geder equity withi programs to improve reproductive ad materal health, ad HIV/AIDS outcomes ad to foster sustaiable developmet. The IGWG s specific objectives are to: Raise awareess ad commitmet to syergies betwee geder equity ad reproductive health (RH), ad HIV/AIDS outcomes; Collect empirical data ad best practices o geder issues ad the iterface with RH; Advace best practices ad ifluece the field; Develop operatioal tools for the itegratio of geder approaches ito populatio, health, ad utritio (PHN) programmig; ad Provide techical leadership ad assistace. The major activities of the IGWG are geder capacity-buildig, advocacy, ad the developmet of operatioal tools (see a complete listig of IGWG products, services, ad cotacts i Appedix 3 or at This Maual is a compaio to the Guide for Icorporatig Geder Cosideratios i USAID s Family Plaig ad Reproductive Health RFAs ad RFPs, developed chiefly for USAID program maagers. The Maual complemets the Guide by orietig program desigers, maagers, ad techical staff o how to itegrate geder issues ito program desig, implemetatio, ad evaluatio. The Maual promotes greater uderstadig of how geder relatios ad idetities affect the capacity of idividuals ad groups to make iformed choices about their sexual ad reproductive health, ad to egotiate ad obtai better RH outcomes. Users of the Maual will lear how to haress a icreased awareess of geder cosideratios for the desig, implemetatio, ad evaluatio of more effective programs. This 2009 editio icorporates updated tools ad approaches to geder itegratio i USAID programs. The IGWG offers the Maual as a tool to be used, adapted, ad improved through its applicatio i the hope that users of the Maual will move from a commitmet to itegratig geder cosideratios i the desig of programs to cocrete actios to promote geder equity i programs ad policies. Feedback o the Maual ad suggestios for stregtheig it are welcome, ad should be addressed to igwg@prb.org. v

8 Brief Overview of Chapters Chapter 1 Itroductio describes the purpose ad use of the Maual ad iteded audieces. Chapter 2 Ratioale for Geder Itegratio ad Maistreamig explores the backgroud ad the beefits of addressig geder issues i programmig ad policy formulatio, ad defies some key geder terms ad cocepts used throughout the documet. Chapter 3 The Geder Cotiuum describes a tool for idetifyig ad assessig the extet to which geder has bee appropriately ad effectively itegrated ito programs. It will help program maagers more fully uderstad how geder differeces ad uequal power relatios are treated i the cotext of health program desig ad implemetatio, ad with what results. Chapter 4 The Geder Aalysis Framework presets a tool for collectig, sythesizig, ad aalyzig cotext-specific iformatio o geder relatios ad idetities that ca assist program desigers ad evaluators resposible for coductig a geder assessmet or sythesizig iformatio from existig research ad aalyses. Chapter 5 Geder Itegratio Throughout the Program Cycle provides a series of guidig questios ad methodological tips. Case studies of actual projects illustrate geder itegratio at each stage of project developmet ad demostrate the lik betwee key elemets of a geder-itegrated approach ad project actios. The five steps to geder itegratio i the programmig cycle are: Step 1: Assessmet: Collect data o geder relatios, roles, ad idetities that pertai to the achievemet of program outcomes ad aalyze data for geder-based costraits ad opportuities that may affect, impede or facilitate program objectives. Step 2: Strategic Plaig: Develop or revise program objectives for their attetio to geder cosideratios; restate them so that they stregthe the syergy betwee geder ad health goals; idetify participats, cliets, ad stakeholders. Step 3: Desig: Idetify ad decide o key program strategies ad activities to address geder-based costraits ad opportuities. Step 4: Moitorig: develop ad moitor idicators that measure health ad geder-specific outcomes. Step 5: Evaluatio: Measure progress ad impact of program ad policies o health ad geder equity. Make recommedatios to adjust desig ad activities based o moitorig ad evaluatio results; stregthe aspects of the program that cotribute to more equitable health ad geder outcomes, ad rework aspects that do ot. v i

9 Chapter 1: Itroductio 1 Sice this Maual was first published i 2003, there has bee a ecouragig icrease i attetio to geder equity goals i reproductive health (RH) 1 ad HIV/AIDS programmig, promotig respect for the fudametal eeds ad rights of idividuals ad commuities. There has also bee improved uderstadig of how to udertake a geder aalysis that ca help programs ad policies be more resposive to the social, ecoomic, cultural, ad political realities that costrai or ehace reproductive health. Use of the Maual This Maual aims to help program implemeters: Improve the quality of RH services; More effectively meet the eeds of program participats; Improve program sustaiability; Better iform ad empower cliets; Improve couple commuicatio; Purpose of the Maual Improve utilizatio of services; ad The primary purpose of this revised Maual is to offer orgaizatios a updated resource o how to itegrate a geder equity 2 approach ito the desig ad implemetatio of RH programs. Such a approach aims to maximize access ad quality, support idividual decisiomakig about reproductive health, icrease sustaiability, ad put ito practice commitmets the U.S. govermet has made to iteratioal agreemets. Broade developmet impacts ad ehace syergies across sectors. 3 I additio, iteratioal ad atioal health specialists ca use this Maual whe shapig programs resposive to RFAs ad RFPs. Programs that use geder itegratio approaches have a strategic advatage i meetig the geder requiremets of USAID ad PEP- FAR, ad i cotributig to the Milleium Developmet Goals. 1 For simplificatio purposes, the term reproductive health (RH) will be used throughout the documet but should be uderstood to icorporate sexual health as well as family plaig (FP), HIV/ AIDS, ad materal health (MH). 2 The terms geder equity ad geder equality are ofte used iterchageably, although there are differeces. Geder equality meas equal treatmet of wome ad me i laws ad policies, ad equal access to resources ad services withi families, commuities ad society at large. Geder equity cootes fairess ad justice i the distributio of opportuities, resposibilities, ad beefits available to me ad wome, ad the strategies ad processes used to achieve geder equality. Because this Maual primarily addresses geder programmig rather tha chages to laws ad policies, the term geder equity will be used throughout. 3 For further iformatio about the impact of geder-itegrated programs o RH, see E. Rottach, S.R. Schuler, ad K. Hardee, Geder Perspectives Improve RH Outcomes: New Evidece, Washigto, DC: PRB for USAID s IGWG, forthcomig. i t r o d u c t i o 1

10 The Maual is iteded as a user-friedly referece, to be used at ay stage of the program cycle, from program desig to program evaluatio. However, it will be most effective if used to guide program decisios throughout the life of project developmet, implemetatio, ad evaluatio. As a tool for strategic program plaig rather tha for traiig, the Maual provides practical steps for geder itegratio, ad is ot iteded as a comprehesive guide to addressig geder issues. It complemets geder ad reproductive health traiig materials by offerig directio o itegratig geder ito ewly desiged or ogoig project cycles, programs, ad policy aalyses. Iteded Audieces The primary audieces for this Maual iclude RH program maagers ad techical staff of USAID ad its implemetig parters, as well as govermetal orgaizatios (GOs), ad iteratioal ad local ogovermetal orgaizatios (NGOs). 2 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

11 Chapter 2: Ratioale for Geder Itegratio ad Maistreamig 2 Why Use This Maual? The evidece is strog that geder equity cotributes to the achievemet of specific RH outcomes, 4 icludig: Reduced umet eed for cotraceptio; Reduced uwated ad uiteded fertility; Reduced HIV trasmissio ad improved access to care ad treatmet; Prevetio of mother to child trasmissio of HIV; Reduced violece agaist wome; Decreased materal mortality. Moreover, the U.S. Govermet (USG) has committed to maistreamig geder cocers i its programs, upholdig its support of iteratioal agreemets, icludig the 1994 Uited Natios Iteratioal Coferece o Populatio ad Developmet (ICPD), the 1995 Fourth World Coferece o Wome (Beijig), ad the developmet of policies to implemet these agreemets. The Beijig Platform for Actio defies geder maistreamig as: the process of assessig the implicatios for wome ad me of ay plaed actio, icludig legislatio, policies or programmes, i all areas ad at all levels. It is a strategy for makig wome s as well as me s cocers ad experieces a itegral dimesio of the desig, implemetatio, moitorig ad evaluatio of policies ad programmes i all political, ecoomic ad societal spheres so that wome ad me beefit equally ad iequality is ot perpetuated. The ultimate goal is to achieve geder equality. 5 The Milleium Developmet Goals While the ICPD, Beijig, ad other iteratioal agreemets provided a visio of geder equity, they were ot specific i articulatig how progress would be measured. I 2000, the Milleium Declaratio for the first time established goals ad measurable idicators ad targets to be achieved withi a specified timeframe. The Milleium Declaratio commits sigatory coutries, icludig the Uited States, to promote geder equality ad the empowermet of wome as effective ways to combat poverty, huger, ad disease ad to stimulate developmet that is truly sustaiable. 6 Geder equity is ot oly a cross-cuttig objective i all eight Milleium Developmet Goals (MDGs), it is also the specific focus of MDG 3, Promote Geder Equality ad Wome s Empowermet. 4 J. Clelad et al., Family Plaig: The Ufiished Ageda, i The Lacet, Platform for Actio, UN Fourth World Coferece o Wome (Beijig: UN, 1995). 6 World Bak, Geder ad Developmet Group, Geder Equality ad the Milleium Developmet Goals (Washigto, D.C.: World Bak, 2003); see also r at i o a l e f o r g e d e r i t e g r at i o a d m a i s t r e a m i g 3

12 MDG 3 calls for atios to Achieve parity i: the ratio of girls ad boys i primary, secodary ad tertiary educatio; the ratio of literate females years to males of the same age; the share of wome i wage employmet i the o-agricultural sector; as well as the proportio of seats held by wome i atioal parliamets by MDG 3 both cotributes to ad is reiforced by the achievemet of the remaiig seve goals (see box below) ad the targets most relevat to geder equity. MDG 1 Eradicate Extreme Huger ad Poverty: Halve, betwee 1990 ad 2015, the proportio of people whose icome is less tha oe dollar a day ad the proportio of people who suffer from huger; ad achieve full ad productive employmet ad decet work for all, icludig wome ad youg people. MDG 2 Achieve Uiversal Primary Educatio: Esure everywhere, boys ad girls alike will complete a full course of primary schoolig. MDG 3 Promote Geder Equality ad Wome s Empowermet: See descriptio above. MDG 4 Reduce Child Mortality: Reduce by two-thirds, betwee 1990 ad 2015, the uder-five mortality rate. MDG 5 Improve Materal Health: Reduce the Materal Mortality Ratio by three-quarters, betwee 1990 ad 2015, ad achieve uiversal access to reproductive health by MDG 6 Combat HIV/AIDS, Malaria, ad Other Diseases: Have halted by 2015 ad begu to reverse the spread of HIV/ AIDS, the icidece of malaria ad other major diseases, ad achieve, by 2010, uiversal access to treatmet for HIV/AIDS for all those who eed it. MDG 7 Esure Evirometal Sustaiability: Halve, by 2015, the proportio of people without sustaiable access to safe drikig water ad basic saitatio ad achieve by 2010, a sigificat reductio i the rate of loss to biodiversity. MDG 8 Develop a Global Partership for Developmet: Develop further a ope, rule-based, predictable, odiscrimiatory tradig ad fiacial system ad address the special eeds of the least developed coutries. 4 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

13 The USG, alog with other atioal, iteratioal, ad private doors, has committed to helpig developig coutries meet their 2015 targets i the iterest of iteratioal developmet as well as geder equity. Through the MDGs ad earlier agreemets, such as the ICPD ad the Beijig Coferece, the Uited States has declared it will: Promote wome s empowermet ad geder equity; Focus o meetig the reproductive ad sexual health eeds of youth; Ivolve wome i leadership, plaig, decisiomakig, implemetatio, ad evaluatio. Promote the costructive egagemet of me ad boys to improve the health of wome ad girls ad me themselves. USAID ad Geder I 1996, USAID issued its first Geder Pla of Actio, which recogized that through attetio to geder issues, our developmet assistace programs will be more equitable, more effective ad ultimately more sustaiable. 7 Sice the, the evidece has oly grow more compellig that reducig geder iequities ca result i dramatic developmet impacts i other sectors. Improvig access to educatio for girls, for example, cotributes to improved child, materal, ad family health as well as to reduced fertility, icreased icomes, ad productivity. RH programs that address the differetial opportuities, costraits, cotributios, ad beefits that wome ad me face will improve health outcomes by more effectively icreasig access to services, improvig commuicatio, stregtheig egotiatio ad advocacy skills, ad wideig participatio ad iput ito decisiomakig. USAID policy madates itegratig geder cosideratios ito RH programs. 8 As stated i the Automated Directive System (ADS), USAID requires program maagers to icorporate geder cosideratios ito the desig of ew cotracts, grats, ad cooperative agreemets ad calls for staff to: Coduct appropriate geder aalyses i the etire rage of techical issues that are cosidered i the developmet of all projects ad activities; Itegrate geder cosideratios ito the statemet of work (SOW) for competitive cotract solicitatios (Requests for Proposals-RFPs) ad program descriptios (Requests for Applicatios-RFAs); ad itegrate geder issues ito all techical evaluatios (for RFPs ad RFTOPs) ad selectio criteria (for RFAs ad APSs); Maistream geder cosideratios ito the desig, implemetatio, ad moitorig ad evaluatio of USAID program ad policy support activities; Iclude geder idicators ad sex-disaggregated data collectio ito the program moitorig ad evaluatio pla. 7 Statemet by J. Bria Atwood, Admiistrator, USAID; Accessed olie May 1, 2009 at 8 The USAID Automated Directive System (ADS) is the operatig policy for USAID programs ad policy work. The ADS 200 ad 300 series specify requiremets for madatory itegratio of geder cosideratios ito plaig, programs implemetatio, ad evaluatio. The latest versio ca be foud at r at i o a l e f o r g e d e r i t e g r at i o a d m a i s t r e a m i g 5

14 USG ad Geder I Sprig 2009, the Uited States Govermet (USG) aouced its commitmet to promotig better health aroud the world through the Global Health Iitiative, 9 beefittig wome, families, ad commuities. I additio to fudig for global HIV/AIDS, malaria, ad tuberculosis, there will be icreased focus o child ad materal health, family plaig, eglected tropical diseases, ad health system stregtheig, thereby Prevetig millios of ew HIV ifectios; Reducig mortality of mothers ad childre uder five, savig millios of lives; Avertig millios of uiteded pregacies; ad Elimiatig some eglected tropical diseases. The Presidet s Emergecy Pla for AIDS Relief (PEPFAR) 10 is a key compoet of the Global Health Iitiative. Lauched i 2003, PEPFAR demostrated the USG s commitmet to geder equality while establishig a comprehesive, itegrated, strategy to combat the global spread of HIV ad AIDS. I 2008, PEPFAR s re-authorizatio stregtheed the program s madate to itegrate geder i all techical areas i prevetio, treatmet, ad care. Through five geder strategies tailored to meet the uique geder-specific eeds ad challeges of differet beeficiary groups, PEPFAR s aim has bee to: Icrease geder equity i HIV/AIDS activities by promotig proactive ad iovative strategies to esure that me ad wome, girls ad boys, have equitable access to prevetio, care, ad treatmet services; to address barriers selectively faced by wome ad me i accessig programs ad i ejoyig program beefits; to mitigate the burde of care o wome ad girls; ad to ecourage me s uptake of services. Reduce violece ad coercio by supportig efforts to chage social orms that perpetuate violece agaist wome; by developig screeig, couples couselig ad parter otificatio strategies; by workig with health providers, other istitutios ad commuities to provide a rage of support services ad referrals for survivors, icludig the provisio of post-exposure prophylaxis (PEP); ad by stregtheig policy ad legal frameworks that outlaw geder-based violece. Address me s orms ad behaviors by costructively egagig me i advacig geder equity, prevetig violece, ad promotig sexual ad reproductive health for themselves ad their parters, icludig couples testig ad couselig; ivolvig me i prevetio of mother-to-child trasmissio; behavior chage programs addressig alcohol ad substace abuse, cross-geeratioal sex, ad multiple cocurret parterships; ad workig with the armed services ad commuities o resposible male behavior. Icrease wome s legal rights ad protectio by elimiatig discrimiatory policies, laws, ad legal practices that dey wome eforceable legal rights ad protectios, by promotig equal rights to iheritace, lad, property ad other productive assets; ad by icreasig awareess amog judicial, legal ad health sectors, commuity leaders ad traditioal authorities o the legal rights related to HIV/AIDS. 9 From the U.S. State Departmet fact sheet o The U.S. Commitmet to Developmet, July 7, Accessed o August 1, 2009 at 10 The 5-year strategy for the secod phase of PEPFAR is forthcomig ad will be accessible at 6 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

15 Icrease wome s access to icome ad productive resources by stregtheig their access to vocatioal traiig, educatio, microfiace ad credit so as improve their ability to access services, support themselves ad their childre, ad avoid coercive ad high risk activities that icrease vulerability to HIV. Geder Iequity Cotributes to Poor Health Outcomes Geder equity ad health objectives are mutually reiforcig. Geder iequity is a major obstacle to reachig better family plaig, materal ad reproductive health outcomes, ad to prevetig ad treatig HIV/AIDS. Wome s cotrol over fiacial resources ad power are fudametal to their capacity to access ad use health iformatio, make iformed decisios about their health ad fertility, ad to egotiate ad isist o safe sex practices. Coversely, whe wome or me are uable to make critical decisios about their reproductive ad sexual health, there are high social ad ecoomic costs for them as idividuals, ad for their families, commuities, ad coutries. 11 May reproductive health problems are directly liked to geder iequity, icludig materal mortality, uiteded pregacies, the femiizatio of the HIV pademic, ad geder-based violece. A high materal mortality ratio is oe of the strogest idicators of geder iequity ad discrimiatio agaist wome. Extesive research has show that poverty ad the disempowermet of wome low status, lack of power, lack of access to iformatio, limited mobility, lack of decisiomakig ad choice, early age of marriage ad violece all cotribute to materal mortality ad morbidity. 12 Wome s lack of access to family plaig or lack of decisiomakig ability regardig how ofte ad whe to have childre ofte results i high fertility ad uiteded pregacies. Wome s mobility ad access to fiacial resources is limited i may parts of the world, restrictig their access to ad use RH services. Decisios about pregacy ad family size are ofte strogly iflueced or idepedetly determied by me or other family members. 13 The icreasig femiizatio of the HIV pademic is also largely attributable to uequal geder power relatios which impede wome s capacity to egotiate safer sex practices. I additio, traditioal orms of masculiity eable me to egage i sexually risky behaviors with egative health cosequeces for themselves ad their parters. 14 Ad fially, geder-based violece is a direct result of uequal geder power relatios, ad udermies wome s reproductive as well as physical ad psychological health. A WHO study of itimate parter violece i te coutries foud that violece had a sigificat egative impact o health durig pregacy ad was associated with icreased risk of HIV. I additio, wome who experieced itimate parter violece also reported more recurrig health problems tha wome who did ot experiece violece Swedish Miistry of Foreig Affairs, Gill, K., R. Pade, ad A. Malhotra, Wome Deliver for Developmet, The Lacet 370, o (2007): R. Smith et al., Family Plaig Saves Lives, Barker et al., Garcia-Moreo et al., r at i o a l e f o r g e d e r i t e g r at i o a d m a i s t r e a m i g 7

16 The flip side of this geder iequity breeds poor health coi is that geder-itegrated RH ad HIV programs ehace positive reproductive ad sexual health outcomes for wome ad me. Research evidece exists that programs that cosider geder i respose to SRH ad HIV problems ca icreasigly demostrate value added. 16 Moreover, a review of programs that have costructively egaged me has idetified may that were effective i helpig me to reduce behaviors that put themselves ad their parters at risk. 17 Program maagers ca use this Maual to replicate ad expad upo these successes, ad to lay the foudatio for documetig the impact of the process. Geder Defiitios ad Workig Cocepts Uderstadig the distictio betwee the terms sex ad geder is importat for coductig a appropriate aalysis of geder relatios, roles, ad idetities i cojuctio with the desig of geder-itegrated RH ad HIV/AIDS programs. The defiitios below clarify some of the termiology commoly used i programs that focus o geder. Additioal defiitios used i this maual or related to geder itegratio are provided i Appedix I. Sex refers to the biological ad physiological characteristics that defie me ad wome (WHO). Geder refers to the socially costructed roles, behaviors, activities, ad attributes that a give society cosiders appropriate for me ad wome (WHO). Geder idetity refers to oe s sese of oeself as a ma, a woma or trasgeder 18 (America Psychological Associatio- APA). Sexual idetity, sexual preferece, ad sexual orietatio refer to a edurig patter of emotioal, romatic, ad/or sexual attractios to me, wome, or both sexes, ad a perso s sese of idetity based o those attractios, related behaviors, ad membership i a commuity of others who share those attractios (APA) Rottach, Schuler, ad Hardee, forthcomig. 17 Barker et al., Accordig to the APA, the term trasgeder is used to describe people whose geder idetity or geder expressio differs from that usually associated with their birth sex. 19 I March, 2009, Robert Wood, the actig Departmet Spokesma for the Bureau of Public Affairs, U.S. Departmet of State, publically edorsed the UN Statemet o Huma Rights, Sexual Orietatio, ad Geder Idetity: The Uited States supports the UN Statemet o Huma Rights, Sexual Orietatio, ad Geder Idetity, ad is pleased to joi the other 66 UN member states who have declared their support of this Statemet that codems huma rights violatios based o sexual orietatio ad geder idetity wherever they occur. See 8 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

17 Chapter 3: The Geder Itegratio Cotiuum 3 To guide various projects o how to itegrate geder, the IGWG has developed a coceptual framework kow as the Geder Itegratio Cotiuum. This framework 20 categorizes approaches by how they treat geder orms ad iequities i the desig, implemetatio, ad evaluatio of program/policy. The term geder blid refers to the absece of ay proactive cosideratio of the larger geder eviromet ad specific geder roles affectig program/policy beeficiaries. Geder blid programs/policies give o prior cosideratio for how geder orms ad uequal power relatios affect the achievemet of objectives, or how objectives impact o geder. I cotrast, geder aware programs/policies deliberately examie ad address the aticipated geder-related outcomes durig both desig ad implemetatio. A importat prerequisite for all geder-itegrated itervetios is to be geder aware. FIGURE 1. The Geder Itegratio Cotiuum 20 This framework draws from a rage of efforts that have used a cotiuum of approaches to uderstadig geder, especially as they relate to HIV/AIDS. See Geeta Rao Gupta, Geder, Sexuality ad HIV/AIDS: The What, The Why ad The How (Pleary Address at the XIII Iteratioal AIDS Coferece), Durba, South Africa: 2000; G.R. Gupta, D. Whela, ad K. Alledorf., Itegratig Geder ito HIV/AIDS Programs: Review Paper for Expert Cosultatio, 3 5 Jue 2002, Geeva: World Health Orgaizatio 2002; ad WHO/ICRW, Guidelies for Itegratig Geder ito HIV/AIDS Programmes, forthcomig. t h e g e d e r i t e g r at i o c o t i u u m 9

18 I the geder itegratio cotiuum graphic (see page 9), the circle depicts a specific program eviromet. Sice programs are expected to take geder ito cosideratio, the term geder aware is eclosed i a ubroke lie, while the geder blid box is defied by a broke, weak lie. Awareess of the geder cotext is ofte a result of a pre-program/policy geder aalysis. Geder aware cotexts allow program staff to cosciously address geder costraits ad opportuities, ad pla their geder objectives. The geder itegratio cotiuum is a tool for desigers ad implemeters to use i plaig how to itegrate geder ito their programs/policies. Uder o circumstaces should programs take advatage of existig geder iequalities i pursuit of health outcomes ( do o harm! ), which is why, whe prited i color, the area surroudig geder exploitative is red, ad the arrow is broke. Geder aware programs/policies are expected to be desiged with geder accommodatig or trasformative itetios, or at other poits alog that ed of the cotiuum. Programs/policies may have multiple compoets that fall at various poits alog the cotiuum, which is why there are multiple arrows i the graphic. The ultimate goal of developmet programs/policies is to achieve health outcomes while trasformig geder orms toward greater equality; therefore, the area aroud geder trasformative is gree ( proceed forward ), ad the arrow exteds idefiitely toward greater equality. Geder exploitative approaches, o the left of the cotiuum, take advatage of rigid geder orms ad existig imbalaces i power to achieve the health program objectives. While usig a geder exploitative approach may seem expeditious i the short ru, it is ulikely to be sustaiable ad ca, i the log ru, result i harmful cosequeces ad udermie the program s iteded objective. It is a uacceptable approach for itegratig geder. Geder accommodatig approaches, i the middle of the cotiuum, ackowledge the role of geder orms ad iequities ad seek to develop actios that adjust to ad ofte compesate for them. While such projects do ot actively seek to chage the orms ad iequities, they strive to limit ay harmful impact o geder relatios. A geder accommodatig approach may be cosidered a missed opportuity because it does ot deliberately cotribute to icreased geder equity, or does it address the uderlyig structures ad orms that perpetuate geder iequities. However, i situatios where geder iequities are deeply etreched ad pervasive i a society, geder accommodatig approaches ofte provide a sesible first step to geder itegratio. As uequal power dyamics ad rigid geder orms are recogized ad addressed through programs, a gradual shift toward challegig such iequities may take place. Geder trasformative approaches, at the right ed of the cotiuum, actively strive to examie, questio, ad chage rigid geder orms ad imbalace of power as a meas of reachig health as well as geder equity objectives. Geder trasformative approaches ecourage critical awareess amog me ad wome of geder roles ad orms; promote the positio of wome; challege the distributio of resources ad allocatio of duties betwee me ad wome; ad/or address the power relatioships betwee wome ad others i the commuity, such as service providers ad traditioal leaders. Program/policy plaers should keep i mid that a particular project may ot fall eatly uder oe type of approach, ad may iclude, for example, both accommodatig ad trasformative elemets. It is also importat to ote that while the cotiuum focuses o geder itegratio goals i the desig/plaig phase, it ca also be used to moitor ad evaluate geder ad health outcomes, with the 1 0 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

19 uderstadig that sometimes programs result i uiteded cosequeces. For istace, a accommodatig approach may cotribute to a trasformative outcome, eve if that was ot the explicit objective. Coversely, a trasformative approach may produce a reactio that, at least temporarily, exacerbates geder iequities. Moitorig ad evaluatig geder outcomes agaist the cotiuum allows for revisio of itervetios where eeded. Most importatly, program/policy plaers ad maagers should follow two geder itegratio priciples: First, uder o circumstaces should programs/policies adopt a exploitative approach sice oe of the fudametal priciples of developmet is to do o harm. Secod, the overall objective of geder itegratio is to move toward geder trasformative programs/ policies, thus gradually challegig existig geder iequities ad promotig positive chages i geder roles, orms, ad power dyamics. Geder Cotiuum Cocepts Geder Blid refers to little or o recogitio of local geder differeces, orms, ad relatios i program/policy desig, implemetatio, ad evaluatio. Geder Aware refers to explicit recogitio of local geder differeces, orms, ad relatios ad their importace to health outcomes i program/policy desig, implemetatio ad evaluatio. This recogitio derives from aalysis or assessmet of geder differeces, orms, ad relatios i order to address geder equity i health outcomes. Geder Exploitative refers to approaches to program/policy desig, implemetatio, ad evaluatio that take advatage of existig geder iequalities, behaviors, ad stereotypes i pursuit of health ad demographic outcomes. The approach reiforces uequal power i the relatios betwee wome ad me, ad potetially deepes existig iequalities. Geder Accommodatig refers to approaches to project desig, implemetatio, ad evaluatio that adjust to or compesate for geder differeces, orms, ad iequities. These approaches respod to the differet roles ad idetities of wome ad me. They do ot deliberately challege uequal relatios of power or address uderlyig structures that perpetuate geder iequalities. Geder Trasformative refers to approaches that explicitly egage wome ad me to examie, questio, ad chage istitutios ad orms that reiforce geder iequalities, ad as a result achieve both health ad geder equality objectives. t h e g e d e r i t e g r at i o c o t i u u m 1 1

20 Examples Alog the Geder Cotiuum The project examples below, while based o oe or more actual cases, are fictioalized to demostrate how projects might fall at various poits alog the cotiuum. The projects are categorized accordig to their perceived itet at desig. Sometimes projects are desiged with oe approach ad result i a outcome that differs from the origial itet. This is oted i the commets uder explaatio of categorizatio. Project Descriptio Category Explaatio of Categorizatio Campaig to Icrease Male Ivolvemet i Zimbabwe I a effort to icrease cotraceptive use ad male ivolvemet i Zimbabwe, a family plaig project iitiated a commuicatio campaig promotig the importace of me s participatio i family plaig decisiomakig. Messages relied o sports images ad metaphors, such as Play the game right; oce you are i cotrol, it s easy to be a wier; ad It is your choice. The campaig icreased the use of cotraceptive methods. Whe evaluatig impact, the project asked male respodets whether ideally they, their parters, or both members of the couple should be resposible for makig family plaig decisios. The evaluatio foud that while me were more likely to believe that they should take a active role i family plaig as a result of the campaig, they did ot ecessarily see this as a topic for joit decisiomakig. Me iterpreted the campaig as promotig the otio that family plaig decisios should be made by me aloe. Exploitative The project s itetio was to covey to me that FP is a topic about which they should be cocered. However, the messages used emphasized those aspects of masculiity that speak to me s power: wiig i sports, beig i cotrol, ad makig decisios. Me came away from the campaig with the uiteded message that they should be i cotrol of FP decisios, which further limited wome s participatio i FP/RH decisiomakig ad couple commuicatio, ad udermied the objective of icreasig me s role as supportive parters. 1 2 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

21 Project Descriptio Category Explaatio of Categorizatio A Female Geital Mutilatio/Cuttig (FGM/C) itervetio i Keya sought to ecourage abadomet of the practice. Project staff realized that simply eactig a law prohibitig the practice would ot address the cultural ad social motivatios supportig the practice withi the commuity, ad would likely result i drivig the practice udergroud. A medical athropologist, hired to coduct qualitative research with wome, me, ad religious leaders, coveyed to project leaders the symbolic ature of the ritual to the commuity. Together with commuity members, the project staff desiged a ritual for girls that maitaied meaigful cultural elemets, such as a week-log seclusio, life-skills educatio, dace ad storytellig, ad gift-givig. The ew ritual retaied the celebratory ature while elimiatig the cuttig. The ew rite-of-passage ritual has bee accepted by the etire commuity. Trasformative The project egaged wome ad me, girls ad boys, i a process of critical reflectio, leadig to a uderstadig that the log-accepted cultural practice of FGM/C violated the rights of girls to health ad bodily itegrity. By workig with commuities to idetify a alterative, culturally acceptable ritual, the project staff were also able to icorporate RH iformatio to eable youg girls to make more iformed decisios. By challegig geder orms ad elimiatig a harmful cultural practice, the project ultimately aimed for a trasformative impact o participat commuities. t h e g e d e r i t e g r at i o c o t i u u m 1 3

22 Project Descriptio Category Explaatio of Categorizatio Cultural Resources ad Materal Health i Mali I order to reduce materal morbidity ad mortality, this Mali project used idigeous kowledge ad cultural resources i a attempt to icrease ad improve couple commuicatio ad health-seekig behavior durig pregacy. Research showed that oe of the most importat obstacles to wome s materal health care-seekig behavior was their lack of commuicatio with other household members, particularly husbads, about pregacy ad the eed for care. Wome said they were uable to iitiate coversatios with their husbads to solicit their coset ad fiacial support (as head of household) for materal health services. I desigig a health campaig, the project staff recruited a traditioal musical story teller (a griot) to compose a sog that would educate the commuity about the importace of materal health care. The campaig also used a traditioal article of wome s clothig (the pedelu) as a symbol of pregacy ad couple commuicatio. As a result of this campaig, the level of commuicatio betwee wives ad husbads cocerig materal health icreased dramatically. More positive attitudes ad behaviors related to pregacy emerged at the household level, icludig husbads support for reduced workloads ad improved utritio for their wives, ad approval for seekig medical attetio ad materal health services. Trasformative This project was desiged to address wome s lack of power to commuicate with their husbads about pregacy, ad to icrease their access to ad use of materal health services. Employig culturally appropriate ad sigificat symbols ad messages, the project succeeded i improvig couple commuicatio, me s willigess to assume resposibility durig pregacy for tasks that were typically performed by wome, ad me s ecouragemet for their wives to seek medical attetio. While the desig ad itet of the project were trasformative, uless the project demostrated that the project actually icreased decisiomakig o the part of wome, the outcome would be accommodatig rather tha trasformative. 1 4 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

23 Project Descriptio Category Explaatio of Categorizatio Codom Social Marketig i Bolivia The goal of a social marketig campaig i Bolivia was to icrease codom sales. The campaig televisio spot featured a youg ma who said very proudly that he used a differet color codom with each of his several girl frieds. The iteded message was that he used codoms wheever he had sex, a safe sex message. Exploitative The TV spot capitalized o social ad cultural values supportig me s virility, sexual coquest, ad cotrol. It reiforced the expectatio/stereotype that macho me have multiple female sexual parters ad udercut the otio that joit commuicatio ad decisiomakig, egotiatio, ad mutual respect are importat for safe sex behaviors. It also cotradicted other health efforts to promote safe sex practices through parter reductio. Project Descriptio Category Explaatio of Categorizatio Youth Roles i Care ad Support for Persos Livig with HIV/AIDS (PLWHA) I Zambia, a project aimig to ivolve youg people i the care ad support of PLWHA coducted formative research to assess the iterest of youg people i beig caregivers, ad to explore the geder dimesios of care. Youg people were asked what care-givig tasks male ad female youth feel more comfortable ad able to carry out, ad asked PLWHA what tasks they would prefer to have carried out by male or female youth. Based o this research, the project developed youth care ad support activities for PLWHA which icorporated tasks preferred by youg wome ad youg me. Accommodatig The program was successful i egagig both youg wome ad youg me i providig care ad support with which PLWHA are comfortable. This project divided tasks accordig to the existig gedered divisio of labor, but also accordig to the desires of PLWHA. The program accommodated existig gedered divisios of labor, but missed a opportuity to egage youg me for the first time i a care-givig role, creatig the potetial for a more trasformative outcome. t h e g e d e r i t e g r at i o c o t i u u m 1 5

24 Project Descriptio Category Explaatio of Categorizatio HIV/AIDS Prevetio i Thailad This project provided educatio, egotiatio skills, ad free codoms to female commercial sex workers (CSW) i Thailad. Although kowledge ad skills amog CSWs icreased, actual codom use remaied low. After further discussios with the CSWs, project maagers realized that CSWs were t successful i usig codoms because they did ot have the power to isist o codom use with their cliets. The project the shifted its approach ad elisted brothel owers, who had the power ad authority to isist o codom use, as propoets of a 100% codom-use policy. Sice the vast majority of brothels i the project regio participated i the project, the project resulted i a sigificat icrease i safe sex practices. Accommodatig This project accommodated to the lack of power that female sex workers had over their cliets ad istead used the power of male brothel owers to demad 100 percet codom use o their premises. While the approach did ot challege the power differetials betwee sex workers ad brothel owers, it did force more protective health behavior o the male cliets. Mass Media to Reach Youth o RH i Nicaragua A Nicaragua NGO produced a popular TV soap opera (teleovela) to itroduce a rage of social ad health issues (e.g., pregacy, HIV prevetio, geder-based violece, ad discrimiatio agaist the physically disabled) ito public debate. Sice the soap opera was particularly popular with youth, it preseted the opportuity to address ad challege traditioal geder roles. Oe storylie followed a youg couple as they fell i love, ad through their discussios about itimacy, cotraceptio, ad STIs. The male character i the couple was sesitive ad carig toward his female parter, ad they egaged i ope commuicatio about sexuality ad family plaig. I aother episode, the youg woma was raped. The teleovela the dealt with the aftermath of sexual violece, icludig wome s legal rights i Nicaragua ad the effect of rape o itimacy. Usig mass media, this program preseted alterative geder role models ad raised awareess ad public discussio about geder ad RH. Trasformative to certai segmets of the populatio This project had a trasformative itetio to model o-covetioal equitable geder roles for youg me ad wome as a way of promotig more ope commuicatio about sex, rights, ad geder-based violece. The evaluatio of the project revealed that as a commuicatio medium, soap operas reach primarily youger ad older wome, ad older me, but ot youg me. Therefore, the trasformative messages were ot commuicated to the half of the iteded audiece who were youg me. Based o the evaluatio, the project revised its commuicatio strategy, reachig out to youg me i soccer clubs. 1 6 A M a u a l f o r I t e g r at i g G e d e r : F r o m C o m m i t m e t t o A c t i o ( 2 d E d i t i o )

25 Project Descriptio Category Explaatio of Categorizatio Female Codom Promotio i South Africa A pilot program was desiged to icrease the acceptability ad use of the female codom i South Africa. Historically, female codoms have bee promoted to wome. Ackowledgig that me, i the Africa cotext, dictate the terms of heterosexual ecouters, the program decided to try a iovative approach: the promotio of the female codom to me by male peer promoters. This ivolved (1) male promoters demostratig to me the use of the female codom; (2) explaiig to me that self-protectio ad sexual pleasure are completely compatible with the use of the female codom, especially whe compared to curretly available barrier alteratives, ad (3) givig female codoms to the me to use with their female parters. Staff based their programmatic approach o research showig that me are prepoderatly cocered with retaiig cotrol over the meas of protectio agaist HIV ad STIs, while they remai ambivalet about female-cotrolled methods. They wated their wome to be protected from STIs, icludig HIV, but the threat of ifectio was see as esurig that wome remaied faithful. Exploitative This program had a explicit itetio of empowerig me to use a techology that was developed so that wome would have more cotrol over decisios about cotraceptio ad protectio from STIs ad HIV. It exploited me s greater power over decisios about sexuality ad reproductio to achieve a health outcome, ad reiforced me s cotrol over the meas of protectio as well as the orm that allows me to have multiple parters while wome are expected to remai faithful. While some may iterpret this project as accommodatig rather tha exploitative, sice it egaged me aroud the use of a method ostesibly cotrolled by wome, the program was grouded i research that me s iterest i ay method was likely to be based o maitaiig cotrol over their parters sexuality. t h e g e d e r i t e g r at i o c o t i u u m 1 7