DEVELOPMENT AND GENDER IN BRIEF a quarterly update from BRIDGE, raising gender awareness among policy-makers and practitioners
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ISSUE 7: HEALTH AND WELL-BEING
November 1998
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In this issue:
* Beyond reproduction: changing perspectives on gender and health
* Health sector reform, poverty and gender inequality
* Stepping stones to the transformation of gender relations?
* Masculinity and men's health needs: a Jamaican perspective
* Key resources on gender and health
* Currents in development and gender
This issue of in brief tracks the shift of health policy debates from a focus on 'women's health' to a broader vision of gender and health. This reaches beyond reproductive rights to include the health needs of both men and women over their life-course. We report on innovative sexual health programmes, showing how understandings of gender relations and masculinity can be translated into effective action. Meanwhile, as health sector reform changes the policy environment for health interventions, we call for gender analysis to be integrated into health sector policy and planning. Our back-page column, Currents, previews a forthcoming issue, which will ask what participatory and gender-aware approaches to development can learn from each other.
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BEYOND REPRODUCTION: CHANGING PERSPECTIVES ON GENDER AND HEALTH
Post Cairo and Beijing, concern with reproductive rights and sexual health has transformed a policy agenda previously dominated by population control. The international women's health movement has played an important role in shifting policy debates towards a gender-aware and rights-based approach to sexual and reproductive health (Sen et al 1994). There is increasing recognition at policy level of the gender dimensions of health, including gender-specific susceptibility to particular

conditions over the life-course. This poses challenges for optimal service delivery to meet women's and men's preventive as well as curative health needs (see Paolisso and Leslie 1995, World Bank
1994, WHO 1998b).
Access to health care can be strongly gender differentiated (see, for example, World Bank 1994,
Standing 1997, WHO 1998b). Evidence suggests that men have better access to curative care, while women are more likely to benefit from preventive care during their reproductive years. Meanwhile, older women's health needs are often neglected. But gender issues arise not only in respect of access, or the mix of services available. They are also directly related to the consequences of gender inequality (Standing 1997, WHO 1998b). Men play a determining role in decisions over when and where to seek curative care in many cultural contexts. Links between women's morbidity and mortality and gendered power relations are evident in the case of maternal mortality (Oxaal with Baden 1996) and, most starkly, of gender-based violence (World Bank 1994, Panos 1998, WHO 1998b).
Only in the face of the HIV/AIDS pandemic has sexual health come onto the policy agenda. Yet even now little is being done to meet gender-specific sexual health needs beyond reproduction. The manifest lack of appropriate measures to tackle cervical cancer, the main cancer affecting younger women, is a case in point. Attitudes about sex and sexuality, including those of health workers themselves, can create potent barriers to access for women even where suitable services exist. Rates of preventable cancers and sexually transmitted infections, including HIV/AIDS, clearly demonstrate this.
Similar gender-blindspots exist in relation to men. Fashionable as it has become to talk about men's involvement in reproductive health decision-making, simply using men as a route to improve the delivery of contraceptive services does not tackle underlying gender issues and may even worsen women's situations (Rachel Jewkes, pers. comm.). An approach is needed that addresses questions of male identity and fosters male responsibility (Germain et al 1994, Sen et al 1994), as projects such as Fathers, Inc. in Jamaica attempt to do (see later article). Integrating 'gender' into work with men should equally not be limited to work in reproductive and sexual health.
There are encouraging examples of programmes that go beyond a narrow, medicalised focus on
'health' to incorporate a gender and well-being perspective in programme design and delivery. The
'beyond the womb' programme of the Women's Health Care Foundation in Quezon City, Philippines, includes services such as counselling on domestic violence and breast screening, alongside lobbying over health reforms that affect women (Jiminez-David and Tadiar 1997). PROPATER in São Paulo,
Brazil, originally established to promote vasectomy, now provides counselling for male reproductive and sexual health problems such as sexual dysfunction and infertility (Rogow 1990).
Other initiatives address the challenges of making service delivery more gender-aware by transforming health workers' attitudes and practices. The Women's Health Project in South Africa uses a process of in-service gender training to strengthen awareness amongst health providers.
Others still seek to involve the otherwise excluded and address gender, power and communication in innovative ways. ActionHealth in Nigeria uses comic strips and role plays to explore adolescent sexual health needs (Glen Williams, pers. comm.). The Stepping Stones training programme, now

widely used in Africa and Asia, takes a whole-community approach to reducing women's vulnerability to HIV infection (Welbourn 1995) (see later article).
Scaling up small-scale local initiatives like these raises a number of challenges, not least those posed by current health sector reform (see below). The move towards decentralisation and participation has the potential to democratise priority setting in health care. The shift to a rights-based agenda and towards the integration of sexual and reproductive health services offers important opportunities to address the gendered dimensions of health. But for real change, health policy must take on board women's and men's well-being beyond reproduction and the implications of gendered identities and power relations for health.
Andrea Cornwall, Research Fellow,
Institute of Development Studies
Thanks to Hilary Standing and Rachel Jewkes for their helpful comments on an earlier draft of this piece.
Additional sources to those at the end of the bulletin:
Germain, A., Nowrojee, S., and Pyrne, H.H., 1994, 'Setting a new agenda: sexual and reproductive health rights', in Sen, G., Germain, A., and Chen, L. (eds.), 1994
Jiminez-David, R., and Tadiar, F.M., 1997, Case Study of the Women's Health Care Foundation,
Quezon City, Philippines, Family Health International, North Carolina
Paolisso, M., and Leslie, J., 1995, 'Meeting the changing health needs of women in developing countries', Social Science and Medicine, Vol. 40, No. 1, Pergamon
Rogow, D., 1990, 'Man/hombre/homme: meeting male reproductive health care needs in Latin
Ameri ca', Quality/Calidad/Qualité, Population Council, New York
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HEALTH SECTOR REFORM, POVERTY AND GENDER INEQUALITY
Policies to improve the health status of the poor have been an important focus of development policy over the past 25 years. Despite this 'The gaps between the health status of rich and poor are at least as wide as they were half a century ago, and are becoming wider still' (WHO 1998a). Gender gaps in health status, in access to health services and in health outcomes are also persistent, signalling that gender inequality, as well as poverty, needs to be addressed in health sector reform.

The health impact of gender inequality and poverty are clearly seen in poor nutrition, overwork and hazardous work. Poverty and gender are also interrelated in women's vulnerability to mental illness, to violence, and to stigmatisation due to health problems, which can lead to social exclusion. However, the prevalence of violence against women across all social groups and its health consequences, dramatically illustrate that a focus on poverty alone is insufficient.
Health and well-being are also dependent on health-seeking behaviour and it is poor women and girls who are least likely to have access to appropriate care or to seek adequate treatment. A number of studies have reported that parents, including mothers, are more likely to seek medical services for sick boys than girls, and that men spend more money on higher level services than women.
A key aim of health sector reform is to improve equity in access to health care, as well as quality of care. New emphasis has been placed on prioritising selected basic services, cost-recovery, restructuring of human resources, decentralisation and community participation. There is little concrete evidence so far of the impact of these reforms by gender and income level, due to the absence of systematic monitoring. Nevertheless, it is clear that issues of health policy, financing and service delivery have important gender implications.
Redirecting services to primary-level care is likely to mean more resources targeted at women but other vital services such as emergency obstetric care, critical to prevent maternal death, may suffer.
Evidence from Benin, Nigeria and China shows that introduction of fees for maternal health care has discouraged women from using services.
Changes in health financing procedures have led to the introduction of health insurance and credit schemes specifically targeting women. A traditional credit initiative by the Country Women's
Association of Nigeria gives members access to immediate health care regardless of their ability to pay. This has ensured the survival of women in obstetric emergencies who otherwise may have died.
However, women may be struggling alone to repay the credit long after the health care is over.
Health sector support programmes often overlook the fact that an estimated 75 percent of health care takes place at household or community level, and is predominantly supplied by women. Factoring household and community-based health care into health policy and planning suggests a need for educational or infrastructure investments to support improved health practices in the home, rather than for new clinics.
Health sector reforms prioritise stakeholder participation in health planning. However, often poor women are not represented in village health committees but are active in other women's organisations, which should therefore be consulted. Innovative methods may be required. The
Yunnan Women's Health and Development programme in rural China used photography to empower rural women to reflect on their health needs. Through public exhibitions of their photographs, illiterate women were able to get their voices heard in the policy arena.

Health sector reform needs to be rethought, taking gender inequality, as well as poverty, into account.
Gender-sensitive health indicators are needed to monitor and evaluate health outcomes effectively and to assess the impact of new financing mechanisms on poor women, as well as men. Efforts must be made to ensure that health sector reforms do not put extra-heavy burdens on women through increased demands on their time or income. Moves towards decentralisation and increased participation must question whose voices are missing from decision-making, at all levels.
Hazel Reeves, BRIDGE
Sources:
See key resources at the end of the bulletin for Elson and Evers 1997; Oxaal with Baden 1996; Oxaal and Cook 1998; Standing 1997; WHOa and b 1998
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STEPPING STONES TO THE TRANSFORMATION OF GENDER RELATIONS?
HIV/AIDS prevention efforts are often predicated on a naive insistence that teaching people the facts will miraculously change behaviour. Top-down education programmes remain locked into the ABC message of 'Abstain! Be faithful! Use Condoms!' Where mainstream HIV/AIDS prevention packages are notoriously weak, the innovative Stepping Stones training programme has facilitated behaviour as well as attitude change. This grassroots intervention has important lessons to teach policy-makers.
The Stepping Stones approach was launched in 1995 as part of ActionAid's 'Strategies for Hope' programme, designed to address the vulnerability of women and young people in decision-making about sexual behaviour. It enables women and men of all ages to explore their social, sexual and psychological needs, analyse the communication blocks they face and make changes in their relationships. The programme is intended for settings where on-going AIDS support programmes are already in place.
Peer groups, formed of 10 to 20 members of the same sex and similar age, explore gender roles, money, attitudes to sex and sexuality, and attitudes to death. Participants work towards behaviour change through 18 'stepping stone' sessions over a period of three months. Peer work has been found to be particularly effective in this sensitive area of sexual health. A detailed training manual gives guidance to less experienced facilitators on video usage, role-plays, drawing exercises and other participatory learning methods. Everyone can be involved regardless of literacy.
Since its introduction, the Stepping Stones training package has been enthusiastically received not only in Africa - the context for which it was originally designed - but also in Asia, the Pacific and Latin
America. 'Stepping Stones opens the minds of people ... gives them the opportunity to explore their

needs, to become more critical in finding solutions' (Dominic Dinko, ActionAid, Ghana). In all, it has been distributed to over 1000 organisations in more than 90 countries. A Stepping Stones Training and Adaptation Project has also been developed to support trainers and to help them adapt the package to their local cultural and linguistic circumstances.
The workshop was first used in the village of Buwenda in Uganda. An impact assessment showed that condom usage increased, but also that interpersonal communications in relationships improved and domestic violence and alcohol abuse declined. Young women reported rising levels of selfesteem and assertiveness, along with a determination to be economically independent and more involved in political life. Sexual matters were more easily discussed and there was more care and support given to those suffering from HIV/AIDS.
This positive experience of mobilising the potent resource of community self-support has lessons for policy on HIV/AIDS prevention and sexual health. In particular, there is a need to address the psychological well-being of women and men in relationship to each other, rather than just their physical and material needs. 'I believe this is powerful in any intervention to influence social change, not just HIV/AIDS or gender, but in other development issues as well.' (Helen Amdemichael,
ActionAid, Ethiopia). In the words of a participant, Elizabeth Ungam, 'Go for those stones and step on them please.'
Hazel Reeves, BRIDGE
Stepping Stones materials are distributed by: TALC PO Box 49, St Albans, Herts, AL1 5TX. Contact
Kate Newman for more information on the Stepping Stones Training and Adaptation Project: knewman@actionaid.org.uk
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MASCULINITY AND MEN'S HEALTH NEEDS: A JAMAICAN PERSPECTIVE
In Jamaica, the dominant idea of masculinity values virility, strength and control in heterosexual relationships. Men are expected to be the economic providers for the family. Local norms, together with the legacy of slavery and colonial rule, have shaped these ideas of what it is to be a man.
However, with increasing male unemployment, the ideal of men supporting families is increasingly hard to meet.
This gap between cultural expectations and men's ability to fulfil them has health implications for both women and men. In Jamaica and elsewhere, domestic violence has increased as men feel the loss of economic and political power and seek to reassert their hold within the home. This can lead to alcohol

and drug abuse and, in turn, family breakdown and increasing numbers of woman-headed households.
Men can feel compelled to father children to demonstrate that they are 'real men'. This has significant implications for the reproductive health of both women and men. It is in this arena that ideas of masculinity have directly influenced health policy and delivery.
The Jamaican National Family Planning Board researched men's sexual behaviour and attitudes, incorporating the findings into a programme to foster male responsibility in reproductive health.
Trained counsellors go into the community to encourage men to approach clinics for information, counselling and condoms. On the same basis, a community-based organisation, Fathers, Inc. was founded. It addresses specific men's sexual health issues by training male teenagers to deliver peercounselling on topics including prostate cancer, relationships, fatherhood and safer sex behaviour.
Whilst these programmes are of value they do not provide space for the needs of gay and bisexual men, or 'men who have sex with men'. With the dominant idea of masculinity being centred on heterosexuality, these alternative models of masculinity are taboo.
In Jamaica, the GLABCOM (Gay, Lesbian and Bisexual Community) programme run by Jamaica
AIDS Support provides a forum for the input of this community's health priorities into health service design and delivery. In Britain, the London-based Big Up agency focuses on the sexual health of
Caribbean 'men who have sex with men'. Volunteers are of the same cultural background and innovative methods of outreach target male gathering places such as barbershops.
Since Cairo, there has been much rhetoric over the 'involvement' of men in reproductive health programmes. In fact, men are already very much involved as partners and in the design of health service policy, not always to the benefit of women. For a truly gendered approach to health, a more nuanced analysis of the interdependencies of men and women is needed. In Jamaica, innovative health programmes have recognised the importance of understanding men's specific health needs and that there are important differences between men as well as between women and men.
Steven Lize, Roehampton Institute, London
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KEY RESOURCES ON GENDER AND HEALTH
Visit the ELDIS Hot Topic guide on Gender and Health for a comprehensive list of electronic resources available.

Elson, D., and Evers, B., 1997, 'Sector programme support. The health sector: a gender aware analysis', Mimeo, Genecon Unit, University of Manchester
Oxaal, Z., with Baden, S., 1996, 'Challenges to women's reproductive health: maternal mortality.'
BRIDGE Report No. 38, IDS, Brighton
Oxaal, Z. and Cook, S., 1998, 'Health and poverty: a gender analysis.' BRIDGE Report No. 46, prepared for the Swedish International Development Agency. IDS, Brighton
Panos Institute, 1998, 'The intimate enemy: gender violence and reproductive health', Panos Briefing
No. 27, Panos, London
Sen, G., Germain, A., and Chen. L., 1994, Population Policies Reconsidered: Health, Empowerment and Rights, International Women's Health Coalition and Harvard Centre for Population and
Development Studies, Harvard University Press, Boston
Standing, H., 1997, 'Gender and equity in health sector reform programmes: a review', Health Policy and Planning: a Journal on Health in Development, Vol. 12, No. 1, Oxford University Press, Oxford
Welbourn, A., 1995, Stepping Stones: a Training Package on HIV/AIDS, Communication and
Relationship Skills, ActionAid, London
WHO, 1998a, The World Health Report, WHO, Geneva
WHO, 1998b, Gender and Health: Technical Paper, Family and Reproductive Health, WHO, Geneva
World Bank, 1994, 'A new agenda for women's health and nutrition', Development in Practice series,
World Bank, Washington DC
For more information about these sources, please contact BRIDGE.
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**CURRENTS IN DEVELOPMENT AND GENDER**
Participation has become a 'buzzword' of development in the 1990s. Participatory approaches are increasingly used by advocates of gender-redistributive change and gender-sensitive programme development as tools for unlocking the voices and perspectives of relatively powerless groups. But to what extent has a gendered understanding of social relations been integrated into participatory approaches? Has the use of participatory approaches contributed to a better understanding of the divergent needs and interests among men and women in different communities? And has this translated into more gender-aware programme design or policy? A forthcoming issue of in brief explores the relationship and synergies between gender analysis and participatory approaches to development.
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BRIDGE (briefings on development and gender) is an information analysis service specialising in gender and development issues. BRIDGE's aim is to assist development professionals in government and non-government organisations to integrate gender concerns into their work. Based at the Institute of Development Studies, in the UK, BRIDGE was set up with financial assistance from OECD-DAC agencies. development and gender in brief is produced with financial support from the Netherlands
Ministry of Foreign Affairs (DGIS).
Editor: Hazel Reeves, BRIDGE Research and Information Officer
Institute of Development Studies, University of Sussex, Brighton BN1 9RE
Tel: (01273) 678243 Fax: 621202 or 691647 (INTL +44 1273)
E-mail: bridge@ids.ac.uk http://www.ids.ac.uk/ids/research/bridge
(c) Copyright: Institute of Development Studies 1998 ISSN: 1358-0612
Access online versions of BRIDGE Reports and Bibliographies at: http://www.ids.ac.uk/bridge/reports.html
For further information contact:
Hazel Reeves, Manager

BRIDGE Institute of Development Studies
University of Sussex, Brighton BN1 9RE, United Kingdom
Tel: + 44 (0) 1273 606261, Fax: + 44 (0) 1273 621202
Email: bridge@ids.ac.uk