Photo by Antonio Perez

1. What Difference Does Gender Make? Opportunities and Responsibilities for Promoting Gender Equity in USAID Health ProgramsSpeaker’s NameDate Photo by Antonio Perez

2. Contents • What do we mean by “gender” and “gender integration?” • What is the rationale for integrating gender into USAID health programs? • How can USAID better implement gender integration? Photo by Meena Kadri

3. SECTION I: What do we mean by “gender” and “gender integration” in USAID health programs? Photo by Dietmar Temps

4. What Is Gender? Gender refers to the economic, social, political, and cultural attributes, opportunities, and constraints associated with being a woman or girl, man or boy. The social definitions of what it means to be a woman or a man vary among cultures and change over time. Photo by Barry Pousman

5. Gender is about Women and Men • Men also benefit from more equitable gender norms • Men’s support is needed to achieve health and gender equity goals Photo by Jennifer Orkis (2007)

6. What is “Gender Integration”? It is a strategy for making women's as well as men's concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated. The ultimate goal is to achieve gender equality. United Nations, 1997

7. U.S. Government Policy Commitments: Gender in the ADS ADS 201.3.9.3 Gender Analysis MANDATORY. Gender issues are central to the achievement of strategic plans and Assistance Objectives (AO) and USAID strives to promote gender equality... Accordingly, USAID planning in the development of strategic plans and AOs must take into account gender roles and relationships. Gender analysis can help guide long term planning and ensure desired results are achieved… USAID’s gender integration approach requires that gender analysis be applied to the range of technical issues that are considered in the development of strategic plans, AOs, and projects/activities. ADS 201.3.9.3 (March 2010)

8. Gender in the ADS • How will the different roles and status of women and men within the community, political sphere, workplace, and household… affect the work to be undertaken? • How will the anticipated results of the work affect women and men differently? ADS 201.3.9.3 (March 2010) Photo by David Dennis

9. U.S. Government Policy Commitments: PEPFAR • Recognizes gender inequality as driving HIV and contributing to the devastation of HIV/AIDS • Requires gender analysis as per the ADS. Photo by Dietmar Temps

10. Gender and PEPFAR Key Legislative Issues: • Increase gender equity in HIV/AIDS programs; • Reduce sexual violence and coercion; • Address male norms and behaviors; • Increase women’s legal rights; and • Increase women’s access to income and productive resources. Photo by Gary Graves

11. International Policy Commitments • UN International Conference on Population and Development (Cairo), 1994 • Fourth World Conference on Women (Beijing), 1995 • UN Millennium Development Goals, Targets for 2015 Photo by Meena Kadri

12. SECTION II: What is the rationale for integrating gender in USAID health programs? Photo by Dietmar Temps

13. Why Integrate Gender into Health Programs? • Integrating gender improves: • Health • Gender equity Photo by Marcel Reyners (2001)

14. Gender Inequity Impedes Health Program Success • Family planning • STIs, including HIV • Safe motherhood Photo by Michael Mistretta

15. Gender Inequity Exacerbates Poor Reproductive Health • 30-60% of women worldwide experience gender-based violence (GBV). GBV is linked with: • multiple health problems • reduced access and ability to use family planning and reproductive health services.

16. Gender Inequity Exacerbates Poor Maternal and Child Health • Early marriage increases risk of maternal death. • Among women ages 15-24, 48% are married before the age of 18 in South Asia, 42% in Africa, and 29% in Latin America and the Caribbean.

17. Gender Inequity Exacerbates HIV Vulnerability • Norms of masculinity often encourage sexual risk taking. • Global studies reveal that men have higher rates of partner change than women (UNFPA, 2008). Photo by Adam Cohn

18. Gender Equity Promotes Reproductive Health • Gateway factor influencing multiple health behaviors • Middlestadt et al. 2007 www.jhuccp.org/legacy/pubs/HCP_endofproject/3Acharya.ppt Photo by Meena Kadri

19. Gender Integration Improves Health Program Outcomes • Greater contraceptive knowledge and use • Increase in joint-decision making about family planning • Greater condom use • Decreased incidence of GBV. Sources: Rotach et al., 2010: http://www.igwg.org/Publications.aspx Barker et al. 2007: http://www.who.int/gender/documents/Engaging_men_boys.pdf

20. Gender Integration Leads to Equity and Healthy Behaviors: RH • Bolivia: PROCOSI • 2001 – 2003 • Program to integrate gender into clinical practices. Photo by Pedro Szekely

21. Program Evaluation: PROCOSI • Evaluation of seven organizational areas: • institutional policies and practices; • practices of providers; • client satisfaction; • client comfort; • use of gendered language; • information, communication, and training; and • monitoring and evaluation. • This intervention resulted in both increased gender equity and improved health outcomes.

22. Gender Equity Results: PROCOSI Percentage of Women and Men who Agree with the Following Statements Percent

23. Health Results: PROCOSI Percent

24. Gender Integration Leads to Equity and Healthy Behaviors: Safe Motherhood India: FRHS and ICRW 2001-2006 • Social mobilization • Improvement of government health services Photo by Steve Evans

25. Evaluation: Social Mobilization and Government Services • Baseline, midpoint, and endline surveys: married girls and women • Mid-intervention survey included husbands and mothers in-law • The intervention produced significant improvement in safe motherhood and gender equity results Photo by Jerry Dohnal

26. Gender Equity Results: Social Mobilization and Government Services in India The site that employed both strategies found that: • Mothers-in-law were more supportive of daughters-in-law’s health seeking than those in other intervention sites. • Husbands were more aware of basic maternal care issues and more willing to seek treatment for problems than pre-intervention.

27. Health Results: Social Mobilization and Government Services in India Women were more likely post-intervention than pre-intervention to: • Use FP for birth spacing (12.4% more likely) • Have delivery care for high-risk births (29.8% more likely) • Receive treatment for reproductive tract infection symptoms (98.2% more likely) The site that employed both strategies found that:

28. Gender Integration Leads to Equity and Healthy Behaviors: HIV/STIs South Africa: Stepping Stones (MRC) 2003-2005 • BCC intervention that employs participatory learning approaches in single-sex groups led by trained peer educators. Photo by Samuel Cavadini

29. Evaluation: Stepping Stones • 70 clusters • HIV and herpes tests • Pre- and post-intervention interviews • Stepping Stones in South Africa is shown to increase health and gender equity results.

30. Gender Equity Results: Stepping Stones • Increased couple communication. • Less perpetration of partner violence. • “I think [beating] is not a right thing because you couldn’t say you are rectifying things through beating in your relationship…I think that we are supposed to sit together and tell one another the way that is supposed to be.”

31. Health Results: Stepping Stones • 15% fewer new HIV infections among women • 31% fewer herpes infections among women • Among men: • Fewer partners • Higher condom use • Less transactional sex • Less substance abuse

32. Gender Transformative Projects Promote Lasting Change • The overall objective of • gender integration is to • move toward gender • transformative projects Photo by Anne Eckman (2006)

33. SECTION III: How can USAID health programming better implement gender integration? Photo by Dietmar Temps

34. Gender Integration Can Begin Anywhere in the Program Cycle ASSESSMENT Collect and analyze data to identify gender-based constraints and opportunities relevant to program objectives. 1 EVALUATION Measure impact of program on health and gender equity outcomes; adjust design accordingly to enhance successful strategies. STRATEGIC PLANNING Develop program objectives that strengthen synergy between gender equity and health goals; identify participants, clients, and stakeholders. PROGRAM CYCLE 2 5 3 4 DESIGN Identify key program strategies to address gender-based constraints and opportunities. MONITORING Develop indicators that measure gender-specific outcomes; monitor implementation and effectiveness in addressing program objectives.

35. Examples of Gender-Integrated Projects: HIV/STIs • Incorporating safe sex negotiation and communication skills training for women • Preventing gender-based violence, a risk factor for HIV • Introducing BCC campaigns that reduce male sexual risk-taking • Supporting economic empowerment activities for women as an alternative to transactional sex

36. Examples of Gender-Integrated Projects: Safe Motherhood • Engaging men in recognizing and supporting the health needs of their pregnant partners • Providing income- generating activities for women to increase their ability to care for themselves during childbearing years • Supporting forums for women to voice their maternal health needs

37. Examples of Gender-Integrated Projects: Family Planning • Offering free or low-cost services for women without the means, control, or resources to access to family planning • Supporting women’s education and empowerment so that they can better advocate for their rights • Including male partners in reproductive health and family planning counseling or training sessions

38. Key Elements of a Gender-Integrated Project Photo by Sara Anderson • Make an institutional commitment to gender integration • Implement a system to ensure accountability • Ensure equitable participation of women and men at all levels • Foster equitable relationships

39. Lessons Learned in Gender Integration Gender integration can begin in any part of the program cycle, but is most effective when begun in the design phase. • Changing gender norms takes time, but can show notable change in relatively short periods • Do no harm! Photo by Bangladesh Center for Communication Programs (2004)

40. Getting Started: Available Resources • USAID Interagency Gender Working Group: http://www.igwg.org • USAID Global Health: http://www.usaid.gov/our_work/global_health/ • USAID Women in Development Office http://www.usaid.gov/ our_work/cross-cutting_programs/wid/ • PEPFAR Gender Technical Working Group Photo by Elizabeth Neason (2006)

41. References Barker G., C. Ricardo, and M. Nascimento. 2007. Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence from Programme Interventions. Geneva: World Health Organization. Boender, Carol, Diana Santana, Diana Santillan, Karen Hardee, Margaret E. Greene, and Sidney Schuler. 2004. The ‘So What?’ Report: A Look at Whether Integrating a Gender Focus Makes a Difference to Outcomes. Washington, DC: USAID Interagency Gender Working Group. Bott, Sarah, Andrew Morrison, and Mary Ellsberg. 2005. “Preventing and Responding to Gender-based Violence in Middle and Low-income Countries: A Global Review and Analysis.” World Bank Working Paper Series 3618. Washington, DC: World Bank. Middlestadt, Susan E.,Julie Pulerwitz, Karabi Acharya, Geeta Nanda, Bridget Lombardo. 2007. “Evidence of Gender as a Gateway Factor to Other Behaviors—Ethiopia. The Health Communication Partnership’s End of Project Meeting.” Washington, DC: USAID Health Communication Partnership. Available at: www.jhuccp.org/legacy/pubs/HCP_endofproject/3Acharya.ppt. Pinto, Guido, Mary Kincaid and Beatriz Murillo. 2010. “The Relationship between Domestic Violence and Reproductive Health and Family Planning Services in Bolivia, 2003.” Población y Salud en Mesoamérica 7(2).(electronic journal: http://ccp.ucr.ac.cr/revista/).

42. References, continued Rottach, Elizabeth, Sidney Ruth Schuler, and Karen Hardee. 2010. Gender Perspectives Improve Reproductive Health Outcomes: New Evidence. Washington, DC: Population Reference Bureau for the IGWG. UNFPA. 2008. State of the World’s Population 2008: Reaching Common Ground: Culture, Gender and Human Rights. Geneva: UNFPA. Accessed November 10, 2009 at: http://www.unfpa.org/swp/2008/en/04_reproductive_health.html#3. UNICEF. 2005. Early Marriage: A Harmful Traditional Practice. A Statistical Exploration. NY: UNICEF. UNICEF. 2001. Early Marriage: Child Spouses. Florence: UNICEF Innocenti Research Centre. United Nations. 1997. Gender Mainstreaming, Extract from the Report of the Economic and Social Council for 1997. A/52/3. Geneva: United Nations.

43. Acknowledgements Thanks to Michal Avni, Patty Alleman, and Diana Prieto for their technical review. This presentation was prepared by Elizabeth Doggett, Myra Betron, Anne Eckman, Elizabeth Neason, and Mary Kincaid for the USAID | Health Policy Initiative, Task Order 1. The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Futures Group International, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace.

44. What Difference Does Gender Make? Opportunities and Responsibilities for Promoting Gender Equity in USAID Health Programs Photo by Dietmar Temps