Whereas the sex of an individual is a biological phenomenon, gender is a social construct, defined by societal norms that attribute different roles and values to men and women. Moreover, these sex-specific roles, rights, and obligations are not just different, they also tend to be unequal (Kishor, 1999). These factors influence many subsequent elements in the causal chain that ultimately determines health status. Women’s status influences demand for both reproductive health (RH) services and the supply environment, and through these factors, RH status.

Unequal gender relations — existing to varying degrees in most if not all countries of the world– feed directly into the status accorded to women and girls in society. Women’s status is a term that describes women’s situation in both absolute terms and in terms relative to men. The focus of women’s status measurement has typically been on women’s access to, and utilization of, information and resources (e.g., access to education, access to cash employment, access to health services). Women’s empowerment is a related term that focuses on attention to women’s degree of control over their own lives and environments and over the lives of those in their care, such as their children. “Autonomy” is a related concept that also reflects women’s control over their lives and environment, as well as status. Status and empowerment are intended to reflect the extent to which egalitarian gender relations are achieved.

Gender equality is an end in itself. Research from economics, law, demography, sociology, and other disciplines demonstrates widespread gender gaps in access and control of resources, economic opportunities, power, and political voice. Because these gender inequalities impose costs on the health and well-being of men, women, and children, they diminish a country’s prospects for development.  Societies that discriminate by gender pay a high price in terms of their ability to govern effectively, reduce poverty, and pursue economic progress (World Bank, 2001).

Consequently, in recent year many development organizations have prioritized pursuing gender equality goals as well as health and development goals.  For example, in 2012 USAID released the Women’s Equality and Female Empowerment Policy.  The policy’s three overarching goals are:

1. Reduce gender disparities in access to, control over, and benefit from resources;
2. Reduce and mitigate the effects of gender-based violence; and
3. Empower women and girls by increasing their capacity to realize their rights, determine their life outcomes, and influence decision making.

To bring about these and other gender-related goals and to improve reproductive health outcomes, many groups have challenged the societal structures granting men greater power than women, and they fight for a greater balance between the two sexes in all aspects of daily life. Because of the pervasiveness of gender differentials in societies worldwide, the task of shifting this balance of power is mammoth. Nonetheless, some programs are taking on this challenge to redress gender inequalties, such as those programs that engage communities in efforts to understand and challenge inequitable gender norms (e.g., speaking out against child marriage) or programs focused on attracting and retaining girls in primary and secondary school.

A major theme of the 1994 Cairo International Conference on Population and Development (ICPD) was that gender equality is the single greatest catalyst to fertility decline. As women gain greater control over all aspects of their lives, they will be motivated and able to control their own fertility, presumably at levels lower than the current ones in most developing countries. By the same logic, greater gender equality will allow women to break down the obstacles to receiving treatment for life-threatening complications of childbirth (e.g., lack of access to family resources, requirement of husband’s consent to seek treatment), which in turn will decrease maternal mortality and morbidity.

A parallel line of reasoning is that gender equity directly influences health outcomes, in terms of both the supply and demand for services. This perspective treats gender in relation to factors that ultimately determine health-seeking behavior, service utilization, and desirable health practices, as well as highlights the importance of gender equality as an end in itself.

For example, gender inequality diminishes the likelihood that women will seek health services or perform healthy behaviors because they:

• Lack knowledge of healthy practices and sources of service;
• Have limited access to resources, including nutrition and health care; and
• Lack control over decision-making as it relates to number of children, protection from STIs, use of services, and related topics.

The low status of women also affects the supply environment (e.g., service delivery). The lack of available emergency obstetrical care in many parts of the world has been linked to the low value placed on women’s lives (Rosenfield and Figdor, 2001). Several studies have demonstrated that women of lower status receive treatment inferior to that of their higher status counterparts, even from the same set of providers at the same facility (e.g., Schuler and Hossain, 1998). Women from ethnic minority groups often experience additional barriers when they seek services, especially if they do not speak the predominant language of that country.

Increasingly, many in the development world, particularly those working in sexual and RHh, have come to realize that men and boys also are negatively affected by rigid gender norms and inequalities.  Gender norms, for example, provide a narrow definition of masculinity and directly associate manhood with being brave, controlling, aggressive, and invulnerable.  As a result, various behaviors such as health-seeking, information-seeking, care-giving and emotional intimacy are perceived as ‘feminine’ and weak.  Other harmful behaviors such as violence, control, substance abuse, and unsafe sexual practices, are celebrated and reinforced as particularly ‘masculine’.  In addition to being harmful to men, this notion of masculinity negatively affects how men relate to and treat women.  Men are often disadvantaged, relative to women, in access to sexual and RH services.  Few family planning services, for example, see male clients or are prepared to address male client needs.  Likewise, men are often not allowed to be with their wives during labor or delivery in many developing countries.

Recognizing this, programs are beginning to take a “synchronized” approach — working with men and women in an intentional and mutually reinforcing way that recognizes that gender norms and inequalities are reinforced by both men and women.  Gender synchronized approaches, whether in community (e.g., behavior change communication) or service settings, challenge gender norms, catalyze the achievement of gender equality, empower women and improve the health and well-being of both men and women.  Synchronized programs can begin working with one sex and incorporate activities to work with the other sex, or work with both sexes from the beginning.  Although synchronized approaches may be done by one organization, they may rely on multiple organizations working in coordination with each other.

Methodological Challenges of Evaluating Women and Girls’ Status and Empowerment

•  Health professionals generally acknowledge the role of women’s status and empowerment in health outcomes, but they may consider such equality “beyond their manageable control.”

Given the wide-ranging nature of gender differentials in society, program managers may feel they have neither the mandate nor the means to directly change this deeply entrenched set of values. However, while in the past those who attempted to develop programs to influence power relations in sexual relationships frequently faced the viewpoint that gender relations are a component of “culture,” seen as nebulous, static, and impermeable to intervention (Helzner, 1996; Clark, 1998), significant gains have been made by designing programs that combine coordinated behavior change communication and service use (e.g., training providers, expanding services to include men as supportive partners or clients).

• The traditional public health approach differs significantly from the women’s rights/gender empowerment perspective.

Applying a human rights framework to RH programs means, among other things, focusing as much on the process as the outcome, incorporating efforts to address the gender and power dimensions of reproductive and sexual decision-making into every level of program implementation, and building a sense of entitlement among the seekers and the providers of services (Jacobson, 2000). When faced with competing demands for a very limited cache of resources, many program managers are simply not ready to “take on” a human rights-based approach to gender. Instead, they prefer to focus on providing conditions that will circumvent or negate the ill effects of gender inequities (e.g., providing contraceptive methods that women can take without their husbands’ knowledge). But with gender equality becoming more central to international RH programming, managers feel a greater urgency to track progress in this area.  Indicators on gender equality, female empowerment, and gender-based violence have been developed by USAID/State Department, UNDP, and the MEASURE Evaluation project.

• Some individuals perceive gender as an amorphous concept that does not lend itself to measurement.

Concepts central to gender inequity  “such as value systems, decision-making, and control of resources” seem abstract; they elude measurement. Indeed, the groups assembled to develop indicators of women’s status and empowerment in various contexts experienced difficulty in deciding which elements to measure (Yinger et al., 2001). Blanc (2001) cites the lack of useful and practical measures of power relations in her comprehensive review of the balance of power in sexual relationships. Although certain measures have been linked to specific outcomes in some settings, such relationships may not hold in other settings (e.g., whether they would be cross-culturally valid). As Blanc observes, power relations themselves are rarely measured; thus, if a desirable outcome occurs, assigning it to a change in power relations may be impossible.  However, with the development of the Gender Equitable Men (GEM) Scale and measurements for women’s education, women’s paid employment, decision-making in household scales, and acceptability of violence scales, several tools are available for quantifying gender equity and equality.

• To measure gender inequity, one must have comparisons, not just a single number.

Documenting gender inequities (for example, in access to resources) with a single number (e.g., percent, mean/ median) is difficult, because gender is relational. Gender inequality reflects that women have lower access to power and resources than men. Higher status women (e.g., service providers) may also discriminate against lower status women clients on the basis of gender, and thereby limit their access to services. Exceptions include selected indicators related to discrimination in the workplace. Thus, documenting disparities in gender equity often requires disaggregation and comparisons of data by sex (e.g., males versus females). Indeed, disaggregation is a requirement for all USAID-funded programs when it makes sense.  Improvement in female education (e.g., percent of girls enrolled in school) over time is generally accepted as a sign of progress contributing to the empowerment of women.

Treatment of Gender in this Database

Because gender plays such a complex and pervasive role in all aspects of human life, addressing gender to improve health outcomes should be integrated into ongoing RH programming, and not just as stand-alone programming.  Further, programs should offer opportunities for women and men to participate separately and together in activities and services.  Gender indicators are relevant throughout family planning programming and thus are included in several sections of this database.  In addition to the indicators on Women’s Status and Empowerment in this section of the database, gender indicators are found in the following sections: Male Engagement in Reproductive Health Programs, Sexual and Gender-based Violence,  and Service Delivery – Gender Equity/Sensitivity.

The issue of gender is treated in four different ways in this database.

1. Population-based Indicators of Women’s Status and Empowerment

Evaluators can use selected population-based indicators of women’s status and empowerment that are available from the Demographic Health Survey and other large-scale national surveys in one of three ways. First, the simple tracking of the indicator can document progress (e.g., increasing levels of female education). Second, indicators can serve to document gender differentials in male/female comparisons. And third, indicators can serve to demonstrate the effect of women’s status on other behaviors or phenomena (e.g., women with less education have lower decision- making power).

2. Gender in Managerial Structures and in Service Delivery

Gender affects two aspects of the supply environment for RH services in measurable ways: the managerial structure and the service delivery system. For example, men generally make higher salaries than do women for comparable work; women often hold the lowest paying jobs in an organization. In terms of service delivery, women of lower status may get treatment inferior to that of their higher status counterparts, even in the same facility. Providers may inadvertently reinforce gender stereotypes through messages they communicate to clients.

3. Indicators for Gender-Relevant Programs

In the wake of the Cairo ICPD, programs worldwide have attempted to incorporate men into RH programming to a greater extent, both to support health-seeking behaviors in their partners and to participate directly by adopting practices that foster improved RH, hence the Male Engagement in RH Programs indicators. Sexual and Gender-based Violence constitutes one of the most harmful physical expressions of gender inequity and is also included in this database, pertaining to both men and women.

4. A “Gender Interpretation” of Other Indicators

Because of the far-reaching influence of gender in all aspects of service delivery, several of the indicators contain gender implications that indicate how to analyze the results from a gender perspective. Often by disaggregating data by sex (e.g., males versus females), one can identify the effects of gender inequity in a system.  This is why USAID requires sex-dissaggregated data, when appropriate.

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References

Blanc, A.K. 2001. “The Effect of Power in Sexual Relationships on Sexual and Reproductive Health: an Examination of the Evidence.” Studies in Family Planning. 32[3]: 189-213

Clark, W.H. 1998. Gender and Social Context in Population Council Operations Research: Lessons From the Past, Thoughts for the Future. New York, NY: The Population Council.

Helzner, J.F. 1996. “Men’s Involvement in Family Planning.” Reproductive Health Matters No.7, May: 146-153.

Jacobson, J. 2000. “Transforming Family Planning Programmes: Towards a Framework for Advancing the Reproductive Rights Agenda.” Reproductive Health Matters: 8, 15.

Kishor, S. 1999. A Framework for Understanding the Role of Gender and Women’s Status in Health and Population Outcomes. MEASURE DHS+ (Unpublished)

Rosenfield A. and E. Figador. 2001. “Where is the M in MTCT? The Broader Issues in Mother to Child Transmission of HIV.” American Journal of Public Health 91, 5: 703-4

Schuler, S.R. and Z. Hossain. 1998. “Family Planning Clinics Through Women’s Eyes and Voices: A Case Study from Rural Bangladesh.” International Family Planning Perspectives 24,4: 170-175, 205.

World Bank. 2001. Engendering Development: Through Gender Equality in Rights, Resources, and Voice. Policy Research Report. Washington, DC: The World Bank.

Yinger, N., A. Peterson, M. Avni, J. Gay, R. Firestone, K. Hardee, E. Murphy, B. Herstad, and C. Johnson-Welch. 2001. Mainstreaming Gender in Monitoring and Evaluation: A Practical Approach for Reproductive Health and Nutrition Programming. Interagency Gender Working Group, Subcommittee on Research and Indicators. (Unpublished)