Integrating a gender perspective into Health Statistics

1. Regional Training Workshop to Improve Use of Existing Data for Monitoring Gender Equality and Women’s Empowerment in Africa. 26-28 September 2011, Kampala, Uganda Integrating a gender perspective into Health Statistics Presentation on issues and data requirements Opoku Manu Asare

2. Outline • Overview • Health and nutrition of children • Maternal health • Mortality and causes of death • HIV/AIDS • Health risk factors related to lifestyle • Issues of integration • Conceptual and measurements issues

4. Goal of presentation Primary : Enhance the understanding and capacity of participants to integrate gender issues into data for SDGs and monitoring and improve the quality of lives of women and men and promote gender parity • Secondary goal: To Service as advocator of gender issues into gender mainstreaming into national development agenda

5. What are Gender Perspectives on Health? • The gender perspective is not only about women in society. It is about the ways women and men interact and their ability to access resources and opportunities, in their communities depending on their being a woman or a man. • Therefore, when any type of survey or analysis of a society is undertaken, it is important to have data that reflects the situation of women in comparison to the situation of men and vice versa. United Nations Human Settlements Programme (UN-HABITAT): Inclusive and Sustainable Urban Planning: A Guide for Municipalities, in: UNON Publishing Service Section, volume 1, 2007. United Nations UN Settlements Programme. Retrieved from: http://www.unhabitat.org/pmss/listItemDetails.aspx?publicationID=2662 [last access: 2011-11-01].

6. SDGs 3 Tier I Indicators

7. Gender issues What are the gender issues? –certain areas of concern where women and men may not enjoy the same opportunities or status –where women’s and men’s lives may be affected in different ways • Life style • Data sources • Quality of data • Biological vs social impact 

8. Women and Men: Health Perspectives • There are differentials in women’s and men’s health due to: • Biological factors • Social and cultural factors • Economic factors Some critical health risks for women are associated with their biological role – in reproduction; fertility, pregnancy and delivery

9. Health and nutrition of childrenGender issues • In most countries in the world, systematic neglect of girls in terms of nutrition, immunization and curative health care is uncommon (United Nations, 1998, 2010a; UNICEF, Division of Policy and Practice, 2011). • Yet in many cultures, sons are preferred to daughters. • Boys have a greater biological vulnerability than girls to most causes of infant death. Based on biological factors alone, male mortality before the age of 1 is expected to exceed female mortality before the age of 1 by 10 to 30 per cent (United Nations, 1998). However, in countries with a strong preference for sons, the expected excess of male infant deaths may be lower, suggesting gender-based discrimination against girls. • Girls’ disadvantage in health is revealed in – infant mortality, child mortality, nutrition, immunization and access to curative health care – as well as the overall cultural context of the country or of the population groups

10. Health and nutrition of childrenGender issues • Child mortality is usually higher among boys, except in a small number of countries, mostly located in Asia (United Nations, 1998; UNICEF, Division of Policy and Practice, 2011) • In countries with excess female child mortality, sex differences may also be observed with regard to immunization against measles and curative health care, owing to a strong preference for sons (United Nations, 1998) • Parents of a son are more likely to discontinue childbearing or to postpone the next birth. By comparison, parents of a daughter are more likely to have the next birth after a small interval, thereby increasing the risk of death for the older sibling (United Nations, 1998).

11. Data required Data on health and nutrition of children refer to • Infant deaths by sex and age (1-5 yrs) in months by sex • Children ever born and children surviving by sex of the child and age of the mother; • Distribution of children under the age of 5 by sex, age, weight and height; • Children aged 12 to 23 months by sex and type of vaccines received; • Children under the age of 5 with diarrhea in the past two weeks by sex and type of treatment received; • Children under the age of 5 with a fever in the past two weeks by sex and type of treatment received; • Children under the age of 5 with a cough or breathing difficulties in the past two weeks by sex and type of treatment received; • Household expenditure on health for each child by sex and age of the child. Additional breakdowns, such as urban/rural areas, educational attainment of the mother and wealth status of the household, should be considered

12. Maternal healthGender issues • Women in developing countries face a high risk of dying while pregnant, during delivery, in the period immediately following delivery or from an unsafe termination of pregnancy. • Women suffers from anaemia, especially during pregnancy and after delivery • HIV or other infections. HIV-positive mothers may receive help in preventing the transmission of the virus to their babies • Unsafe abortions and sepsis • Female genital mutilation or cutting, increases the risk of complications at delivery skilled health personnel, improved access to emergency obstetric care pregnant women receiving antenatal • Women using contraceptives-education, access and cost

13. Maternal healthGender issues • Pregnant women receiving adequate/inadequate prenatal care • Nutritional deficiencies when they start their pregnancy, e.g., Iron deficiency, anaemia and deficiencies of vitamin A and iodine • Use of contraceptives and lack of access to contraceptives reduces women’s ability to plan the number and timing of their births and increases the health risks associated with pregnancy. • Unintended pregnancies followed by unsafe abortions cause a significant proportion of maternal deaths. • In developing countries, many of the women at risk of maternal death are adolescents lacking access to contraceptives. • Abortions performed in an illegal context

14. Data required Data needed to analyse maternal health are: • Availability of health facilities • Travelling time to the nearest health facility • Maternal deaths by age • Live births by age of the mother • Women of reproductive age by age • Deaths of women of reproductive age

15. Data required • Abortions: Safe and unsafe abortions • Contraceptive use by contraceptive method, age and marital status; • Pregnant women receiving prenatal care by number of visits to a health facility; • Live births by type of attendance (skilled or not) at delivery; • Deliveries in health facilities • Cost of delivery

16. Mortality and causes of deathGender issues • Women tend to live longer than men, and sex differences in life expectancy, almost always in favour of women. • The female advantage is lower in countries with high mortality overall a high prevalence of HIV/AIDS (United Nations, 2000, 2010). • By comparison, in countries with low levels of mortality, women have a considerable biological advantage, with women’s life expectancy exceeding that of men by many years (United Nations, 2000, 2010). • Status: A smaller difference in life expectancy may also be observed in countries where girls and women have a lower status and suffer from discrimination and abuse.

17. Mortality and causes of deathGender issues • In many countries, the advantage of women is not only biological rather lifestyle factors such as harmful use of alcohol, smoking and injuries considerably reduce the lifespan of men (United Nations, 2010). • At the global level, for women and men of all ages, cardiovascular diseases are the leading cause of death, followed by infectious and parasitic diseases (including diarrhoea and HIV/AIDS) and cancers (WHO, 2011). • However, the ranking of causes of death for women and men varies by region and country (WHO, 2011). For example, in sub-Saharan Africa, HIV/AIDS alone has a similar death toll as cardiovascular diseases, ranking number one for women of all ages and number three for men of all ages. The contribution of respiratory infections to total deaths is also high, ranking number one for men and number three for women. • For adults (persons aged 15 to 59) and at the global level, the top causes of death are different for women than for men (WHO, 2011). The three top causes of death for adult women are infectious and parasitic diseases, cancers and cardiovascular diseases. The three top causes

18. Data required Data needed to analyse mortality and causes of death are: • Deaths by sex and age; • Deaths by sex, age and cause of death; • Distribution of population by sex and age (for the calculation of rates and other • indicators).

19. HIV/AIDSGender issues In sub-Saharan Africa, women are more likely than men to be infected with HIV, while in other regions of the world, men are more likely than women to be infected. At the global level, half of adults living with HIV are women. However, in sub-Saharan African countries with the highest HIV prevalence, women represent the majority of people living with HIV/AIDS (UNAIDS, 2010, 2011b). • Women face a higher risk of becoming infected with HIV during unprotected sexual intercourse than men • In addition women are more biologically vulnerable than men to infection • Women and girls may have difficulties in negotiating condom use with their partners

20. HIV/AIDSGender issues • In particular, sexual violence and abuse hampers women’s ability to protect themselves from HIV infection and/or to assert healthy sexual decision-making • Furthermore, sex outside a marital union and multiple sexual partnerships are often tolerated for men (although not for women) and, hence, a woman can be vulnerable to HIV infection because of her husband’s concurrent sexual relations. • These risks are higher where women have partners much older than themselves, have a lower status than men and are economically dependent on men owing to social or legal discrimination (United Nations, 2000; UN, Economic and Social Council, 2011; WHO, 2009; UNAIDS, 2010).

21. Data required Data needed to analyse HIV/AIDS from a gender perspective are: • People living with HIV by sex and age • HIV/AIDS deaths by sex and age • HIV testing in the past 12 months by sex and age • Access to antiretroviral drugs by sex and age • Multiple sexual partnerships and condom use during last high-risk sexual encounter (i.e., sex with a non-marital, non-cohabiting partner) by sex and age Comprehensive correct knowledge of HIV/AIDS by sex and age • Other data can contribute to an understanding of the causes and consequences of HIV/AIDS. Such data may refer to violence against women, early sex or time spent caring for household members who are living with HIV • Additional data on sexual behaviour and HIV prevention, prevalence and treatment related to special risk groups, such as sex workers, men

22. Health risk factors related to lifestyleGender issues Social and cultural factors have traditionally led men to take up health-damaging habits, such as drinking and smoking. Men tend to consume more alcohol than women in all regions of the world and at all ages (United Nations, 2010). • Obesity, often the result of sedentary lifestyles and unbalanced diets, puts an individual at increased risk for many diseases and health problems, including hypertension and diabetes (WHO, 2009). While information on sex differences in balanced nutrition are rarely available, limited information on physical activity suggests that, in some countries in Asia, girls and women tend to be engaged less often in physical exercise, often owing to cultural norms (WHO, 2009). • Unsafe sex, which can lead to sexually transmitted infections, including HIV, may be a more important health risk factor for women than for men Women may be more vulnerable to sexually transmitted infections owing to a combination of biological and social factors. Because of biological differences

23. Health risk factors related to lifestyleGender issues • In many countries, women are more exposed than men to indoor air pollution. Eg. cooking is done with solid fuels and the ventilation is poor, women are more likely than men to develop acute lower respiratory infections, chronic obstructive pulmonary disease and lung cancer (Desai, Mehta and Smith, 2004). • Unintentional injuries, including occupational injuries, are associated more often with men than with women (WHO, 2008). Unintentional injuries represent a large share of male deaths but a relatively small share of female deaths. • Similarly, adult mortality rates due to unintentional injuries, including road traffic accidents, are much higher for men than for women.

24. Data required Data on health risk factors related to lifestyle may refer to: • People currently drinking by sex and age • People currently using tobacco by sex and age • People who are obese by sex and age • People engaging regularly in physical activity by sex and age • Condom use at last high-risk sexual encounter (i.e., sex with a non-marital, non-cohabiting partner) by sex and age • Population using solid fuels for cooking on an open fire or stove • Unintentional injuries by sex, age and type of injury • Occupational injuries by sex, age and type of injury

25. Issues of integration • Mainstreaming a gender perspective in statistics • Mainstreaming a gender perspective in statistics means that gender issues and gender based biases are systematically taken into account in the production of all official statistics and at all stages of data production (Hedman, Perucci and Sundström, 1996; United Nations-, • Gender mainstreaming has been embraced internationally as a strategy towards realising gender equality. It involves the integration of a gender perspective into the preparation, design, implementation, monitoring and evaluation of policies, regulatory measures and spending programmes, with a view to promoting equality between women and men, and combating discrimination. • Policy, programme and projects issues

26. Issues of integration • Adopt gender mainstreaming as a strategy - planning, budgeting, monitoring and evaluation for gender and development, • Creation and/or strengthening of gender and development focal points, • Generation and maintenance of gender statistics and sex-disaggregated databases to aid in planning, programming and policy formulation. • National Development Planning Commission • Gender and Children Ministry? • Constitution of the country • Laws and regulatory framework • National Strategy for Development of Statistics • Adoption of the SDGs

27. Illustration • Gender mainstreaming is a method for integrating a gender perspective into policy and service delivery, and achieving gender equality in health. • It involves a process of incremental change for the organisation that enables women, men and transgender persons to benefit equally from health care policies and services. In other words, gender comes into the mainstream of health care. It seeks to give visibility to gender inequalities in health and to ensure that there is a commitment to addressing these inequalities.

28. Stages of gender mainstreaming To undertake gender mainstreaming, the following must be undertaken: • Gender Statistics • Gender Analysis • Gender Impact Assessment • Gender Stakeholders Consultation • Gender Budgeting • Gender Procurement • Gender Indicators • Gender Monitoring • Gender Evaluation • Gender Equality Training • Gender-sensitive Institutional Transformation • Gender awareness-raising

29. Stages of gender mainstreaming • Conduct of consultative meetings with data users and data producers to identify issues • Dissemination/Communication of gender statistics • Official statistics agencies to prepare papers or conduct studies on women’s contribution to the economy

30. Key Steps to Integrating Gender Perspectives into Health Statistics • Senior level commitment and leadership towards gender mainstreaming • Training and awareness raising on gender inequalities in health and the benefits of gender mainstreaming • Collection and Collation of gender and sex-disaggregated data • Consultations with women’s and men’s organisations, service users, health care unions and staff • Gender proofing: assessing gender relevance and carrying out gender impact assessments • Planning and Delivery of Services • Demonstration Projects in specific services • Monitoring and Evaluation

31. Sources of data • Population and Census • Surveys such as DHS • Integrated Biological and Behavioural Surveillance surveys can provide data on key populations at higher risk of HIV infection, such as men who have sex with men, sex workers and people who inject drugs. • Reports from health facilities, including antenatal clinics attended by pregnant women, may provide information on results from HIV-tested blood from a sample of patients and on access to antiretroviral therapy. • Time-use surveys can provide data on time spent caring for household members who are sick or disabled, including household members who are infected with HIV. However, data specific to care given to HIV-infected persons are difficult to obtain • School-based surveys, such as the Global School-based Student Health Survey

32. Sources of data • Population censuses may be used to collect data on births and deaths • Civil registration systems with complete coverage • Household surveys, such as DHS and MICS • Health administrative records (immunization, vaccinations • Demographic surveillance systems(“verbal autopsy”). • Civil registration records, health facility records, burial records and interviews with traditional birth attendants and family members. • Population registers can provide data on population distribution by sex and age.

33. Conceptual and measurement issues • Limited scope of data collection programmes • Insufficient frequency & reliability from existing programmes • Administrative data systems under-used • Lack of measurement standards and guidelines • Data are not available fast enough • Inability to produce data on vulnerable groups

34. Conceptual and measurement issues • Many countries still lack a complete and accurate civil registration system. • Some sex bias in reporting child deaths and live births may take place. • In general, data obtained from censuses and household surveys are subject to recall errors, such as omission of events, misreporting of the timing of events and age heaping • Data obtained from household surveys are affected by sampling errors.

35. Conceptual and measurement issues • Some sex-selective underreporting of deaths may occur in countries with less developed statistical systems. • Causes of death are often not reported or misreported, for both women and men. Some causes of death, such as AIDS suicide and homicide, may be intentionally misreported when there is social stigma attached to them • The type or frequency of alcohol consumption (e.g., binge drinking, hard liquor) may vary by sex and surveys may not adequately distinguish the relevant risk behaviours

36. Exercise • List two gender issues in health at your community • List two gender issues in health at your workplace • List two gender issues in health at national level • How are you mainstreaming gender issues in health into your decision making at your home • Prepare a gender responsive budget for your household

37. THANK YOU