Through a Gender Lens: Resources for Population, Health and Nutrition Projects

This paper reviews existing models and methodologies for incorporating a gender perspective into U.S. Agency for International Development (USAID) development initiatives. Its purpose is to make preliminary recommendations and to initiate discussion among those working in the Population, Health and Nutrition (PHN) sector about their specific gender needs and how best to adapt current models and methodologies to meet them. The paper illustrates the key ideas necessary for understanding how gender might affect PHN projects and leads the reader to key documents that may be most useful and most relevant to PHN work.

Table of Contents

Section I: An Introduction to Gender Issues in the PHN Sector

Introduction
The Importance of Integrating Gender Issues into PHN Projects and Programs
Understanding and Addressing Gender Issues

Frameworks/Methodologies
Gender Training
Gender Analysis
Tools

Recommendations
Other Gender Training/Gender Analysis Manuals
Tool Kits
Supporting Texts for Gender Analysis Training

Section II: Food for Thought

Food for Thought
Project Policy Orientation and Project Staffing

Country Context
Management Issues
Commitment to Gender Equity

Project Design

Gender Roles and Power
Definition of Key Population
Current Levels of Knowledge about PHN Issues and Services
Deciding on Project Priorities
Constraints on Participation

Project Implementation/Monitoring

Participation/Service Utilization Rates
Project Decision-Making
Service Quality

Project Evaluation

Process Evaluation
Impact on Gender Equity
Impact on Health
Impact on Policy

Section III: Next Steps

Next Steps

Acknowledgments

Bibliography

Section I: An Introduction to Gender Issues in the PHN Sector

Introduction

A common refrain in development circles is that gender principles are often discussed, but seldom applied. A key factor in this failure to integrate gender issues into our work is an absence of concrete tools designed to meet the particular needs of population, health and nutrition (PHN) programs. In response, this paper reviews existing models and methodologies for incorporating a gender perspective into USAID development initiatives. Its purpose is to make preliminary recommendations and especially to initiate discussion among those working in the PHN sector about their specific needs and how best to adapt current models and methodologies to meet them.

Although women have long been the targets and intended beneficiaries of PHN programming, numerous sociocultural factors influence the extent to which women are able to influence decisions affecting their health and the quality of their lives. Given women's subordinate status and the absence of conscious development efforts directed at meeting their particular needs, women remain on the sidelines in development planning and are less likely to actualize its benefits.0 Nonetheless, programs directed primarily toward women may risk poor outcomes by neglecting the needs and perspectives of men. Gender planning takes into account the needs and perspectives of both women and men in the development process and identifies appropriate strategies for addressing the power imbalance that prevents many women from becoming full partners and beneficiaries of development. The PHN sector faces a great challenge because addressing gender invariably is complicated and difficult, and to date there is relatively little specific gender planning experience in our sector. Nevertheless, we can no longer debate the urgent need to rise to this challenge.

Attention to gender issues in development assistance has been USAID policy since 1982.1 When USAID issued its "Women in Development Policy Paper," the Agency became one of the first development donor agencies to formalize a public commitment to gender equity in its programs and projects, and to encourage its staff to approach projects from a gender perspective. In March 1996, USAID Director J. Brian Atwood announced a "Gender Plan of Action" for USAID that calls for a renewed commitment to gender-sensitive programming.2

The Plan of Action includes requirements that USAID modify each objective in its strategic framework to better address gender concerns, appoint a Senior Policy Advisor on Women in Development to the Bureau of Policy Planning Coordination and establish a fellows program to promote the integration of gender principles into USAID programs. The Gender Plan of Action also calls for guidelines that would define the technical qualifications, authority and mandate of WID officers and coordinators throughout USAID. Gender principles are meant to be incorporated into USAID re-engineering and training efforts, and a Performance Fund was to be established to award additional funds to USAID programs that successfully integrate gender strategies in their overall work.

These policies have far-reaching implications. Yet, while USAID staff clearly have the support of agency policy and the Administrator's commitment to gender issues, many questions remain about how to implement gender-aware programs in specific technical areas. As a first, practical step in addressing "gender issues as key development issues,"3 we have reviewed a broad selection of relevant models, frameworks, guidelines, training manuals, and other materials. This review focuses on approaches that are applicable or adaptable to PHN work. It is clear that PHN-customized materials are rare. It is very likely that PHN-specific materials will need to be developed as a next step in this process.

A few caveats are in order: This paper is not intended to replace more comprehensive training or texts on gender issues, gender training and gender analysis. It was beyond the scope of this working paper to explore in depth the history, concepts and debates involved in gender integration. Nor is this paper intended to be a gender analysis guide. Rather, we illustrate key ideas necessary for understanding how gender might affect PHN projects, and lead the reader to key documents that we hope will be most useful and most relevant to PHN work.

The first section of this document is meant to be a brief introduction to gender issues in population, health and nutrition project, including frameworks for understanding them and a discussion of tools for their application. The second section includes questions project managers might use to begin thinking about how gender influences their particular project. The final section discusses next steps for USAID on integrating gender principles into development work. The reader is encouraged to explore this document in the order that seems most useful to him or her.

In addition, we encourage the reader to take advantage of the knowledge, wisdom and contacts available to them through gender experts in the PHN Center Gender Working Group, the WID Office and elsewhere, and to explore the accompanying bibliography for leads on other resources. The bibliography contains the documents cited in this paper as well as others on related topics that might be of interest to PHN officers.

The Importance of Integrating Gender Issues into PHN Projects and Programs

We all would like to live in a world in which women and men talk freely to each other about their sexual and reproductive health, in which contraceptive and other services are of high quality and easily accessible to all, in which women do not die from pregnancy-related causes, in which all children are wanted children, and in which individuals and couples have the resources and autonomy to decide their own destinies. However, such is not yet our world and there are many ways in which the different and unequal positions of women and men contribute to the persistence of major problems in the PHN sector.

Women and men are defined differently within and across cultures, and in almost all ways, women are at a disadvantage relative to men, including in their access to the means of attaining good health. There are practical as well as moral and ethical reasons why proper attention should be paid to how gender relations influence population, health and nutrition programs. Programmatic experience and research demonstrate that attention to gender issues has myriad substantive implications for the character, quality and success of PHN programs. Notably:

• Women and men are born equal in human rights and dignity,4 and it is our obligation as responsible reproductive health professionals to uphold and advance these rights in our work.5 ,6 ,7 ,8 ,9 Indeed, USAID as an international donor agency and U.S. Government body has formally committed itself to a number of UN Platforms and human rights conventions, including the Fourth World Congress on Women Declaration and Platform for Action (Beijing, 1995) and the International Conference on Population and Development Programme of Action (Cairo, 1994), which assign specific tasks and responsibilities to donor agencies under international law for the provision of various reproductive and sexual health programs and services.

   

• Pursuing gender equity and women's empowerment are valuable goals in themselves, and are also essential to achieving political, social, economic, cultural, environmental and health goals in development.10 ,11 As the Prime Minister of Norway stated in her keynote address to the ICPD in Cairo:12 "It cannot be repeated often enough that there are few investments that bring greater rewards than investment in women." In the population, health and nutrition sectors these "rewards" are seen in improved maternal health, child health, STD/HIV prevention, and fertility outcomes, namely, the four PHNC program outcomes.

   

• Gender, along with class, age and caste, has a major impact on the way providers behave and how clients are treated within health systems.13 ,14 Physicians are less likely to answer women's questions, less likely to give them technical information, less likely to offer them alternatives for treatment, less likely to diagnose and treat certain diseases in women than in men and more likely to attribute their complaints to psychosomatic factors.

   

• One of the most intimate and complex aspects of human behavior, human sexuality, is expressed primarily through gender roles and culturally defined "scripts."15 Sexuality is not a universal phenomenon, but a local one that is the product of particular cultural-historical contexts. Those contexts are characterized by extant gender roles that provide a means through which individuals learn what makes up the appropriate and acceptable repertoire of sexual behavior in their own culture. We know from the experience of Northern countries over the last four decades that sexual "scripts" can and do change over time in parallel with other social change, such as changes in gender roles.

   

• Women often have been systematically excluded from key policy and decision-making roles in the allocation of resources and implementation of programs affecting their reproductive health.16 ,17 Failure to directly include the beneficiaries of PHN initiatives in the decision making process impedes their ability to meet their own felt needs. It also can lead to inefficient funding allocation and ineffectual project design by not benefiting from the unique knowledge women have of the best means of encouraging and assisting their participation in those programs.

   

• Family planning programs cannot help women to achieve equal status with men simply by providing contraceptive services in isolation from the contexts in which women live and from other reproductive health services.18 Indeed, with no other intervention but greater access to the means of fertility control, women risk losing the social status conferred in some countries upon women with higher parity (and/or more sons), without balancing this loss with any gain in autonomy or power associated directly or indirectly with education or remuneration for their services.

   

• Many women and girls are put at risk of acquiring HIV/AIDS and other STDs by the sexual behavior of their male partners.19 ,20 Nowhere are the consequences of gender inequity more vividly illustrated than in the area of HIV/AIDS prevention. Schoepf21 asserts that "[b]ecause social structures circumscribe the choices people make, eradicating AIDS requires the elimination of the barriers that deny women control over their own sexual decisions." The present incidence of HIV infection among women in sub-Saharan Africa nearly equals that of men, and an estimated 90 percent of new infections occur through heterosexual sex. Responses to the AIDS epidemic, therefore, that address gender dynamics should have greater success.

   

• Over half a million women die unnecessarily each year from unsafe abortions and other obstetric emergencies for social rather than medical reasons.22 ,23 "Maternal mortality...deserves the designation of the health scandal of our time. ... The tragedy of maternal mortality is a question of how much societies consider the life of a woman to be worth. ... Maternal mortality should be seen in the broader social context of women's social rights. Continuing gaps between women and men dictate the need for explicit initiatives to advance women's interests."24

   

• Many culturally-bound practices, such as female genital mutilation, child marriage and childbearing, and nutritional strictures have a disproportionately negative effect the health of girls and women.25 ,26 ,27 ,28 ,29 The negative health outcomes associated with female genital mutilation are well documented, as is the tendency for boys and men to receive proportionally more, higher-quality food than do girls and women. The lack of self-determination inherent in child marriage is obvious and a clear contravention of the human right to marry and found a family with free and full consent.30 The dangerous consequences of associated early childbearing likewise are widely recognized.

   

• The estimated 80 percent of refugees who are women and children are at extreme reproductive health risk.31,32 We are only beginning to understand the magnitude of the reproductive health risks which these populations face. They include large numbers of pregnancies at closely spaced intervals, extremely poor nutritional status, lack of pre- and post-natal and inter-partum care, high incidence of rape and other forms of violence, limited or no access to emergency and interval contraceptives, and limited, if any, means to prevent or treat STDs including HIV.

   

• Determinants of violence and patterns of victimization differ markedly by gender, notably women's experience of physical and sexual abuse, and evidence is mounting that violence against women has very serious health implications.33 ,34 ,35 Available data indicate that from one-quarter to one-half of women in any given country have been physically abused by an intimate partner, and even more are subjected to ongoing emotional and psychological abuse. Rates of rape and child sexual abuse are alarming. The reproductive health consequences range from low birth weight and pregnancy loss due to battering during pregnancy, to chronic pelvic pain, STD/HIV acquisition, unwanted pregnancy, inhibition of effective contraceptive use and STD/HIV prevention, and early sex and sexual risk-taking behavior. "Traditionally, family planning and reproductive health programs have been built upon the false assumption that all sex is voluntary and that the terms of sexual encounters (such as whether to use birth control) are subject to "negotiation" among partners.... [This] assumption...is a dangerous misconception that can undermine the success of programs and potentially lead them down dangerous paths."36

   

• Men and boys very often are invisible in terms of service provision and information, which may make it difficult for them to have their own reproductive health needs served as well as to support the needs of their wives, girlfriends, daughters and sisters.37 ,38 ,39 In many contexts men serve as gatekeepers to women's reproductive health. Through lack of information, as well as gender and cultural norms men may prevent women from using family planning, accessing essential obstetric care, and protecting themselves against sexually transmitted diseases.

   

• Women's ability to breastfeed successfully is determined by the support they receive from families, communities and institutions, which is in turn determined by perceptions of women's competing obligations to productive and reproductive work.40 ,41 ,42 Mothers can be supported in their efforts to breastfeed through on-site day care and/or refrigeration facilities, breaks during the work day and/or flexible work schedules, and information, education and communication campaigns for women, their partners, employers and the larger community (including youth).

   

• Many of the special reproductive health problems that young men and women face result from their emerging sexuality, which is a function of evolving gender identity.43 ,44 ,45 As children grow into adults they are faced with sexual relationships, the risk of pregnancy and disease, as well as possible coercion and violence, all of which are influenced heavily by societal norms dictating what it means to be a man or a woman and how to behave like one. Their ability to negotiate this transition safely and in good health will be strongly affected by the support and resources that they are given to challenge negative gender stereotypes.

   

• Adequate attention to gender roles and responsibilities is elemental to the participatory, customer-focused principles of re-engineering and an essential determinant to attain development goals and "results."46 USAID Administrator Brian Atwood was quoted in a recent WID Office newsletter as saying, "Through attention to gender issues, our development assistance will be more equitable, more effective, and, ultimately, more sustainable."47

Understanding and Addressing Gender Issues

How can we address gender issues in PHN programs? There are a number of aspects to consciously applying gender principles to our work. From the ground up, these include understanding the reasons why it is important to look at the gender variable, understanding the theoretical frameworks for how gender influences development work in general, and understanding how gender influences our programs and projects in particular. Concrete means for gaining this understanding include exposure to gender concerns through such venues as training and reading, and the direct exploration of gender within a particular context through the application of tools for gender analysis. In the previous section we provided a rationale for why attention to gender issues is a crucial component of PHN work. In this section, we begin a discussion of how to carry out gender-sensitive projects by first discussing the theoretical underpinnings, then the issue of training and the process of gender analysis and finally, specific tools to assist in these tasks.

Frameworks/Methodologies

There are three main theoretical frameworks for integration of gender issues into development work that tend to underpin all subsequent writing on the topic: The Harvard Framework was the first developed and it underscores the importance of examining, among other things, who does what, who owns what and who controls what within a community; the Moser Methodology, which breaks gender-specific needs into practical needs and strategic interests -- providing a means of determining whether gender-specific needs will have a material benefit alone or will have a strategic, equity enhancing impact -- and defines the concept of women's triple role in relation to men's dual role; and the Longwe Framework, which outlines a conceptual continuum of women's empowerment.

These three frameworks build upon and complement one another. Therefore, most development organizations work with a combination of the key concepts from the three frameworks, rather than any one alone. Although the frameworks provide the reader with an orientation concerning gender issues in development, none has been specifically adapted to PHN work.

For more information on these frameworks, please refer to the following publications:

• Harvard: Overholt, Catherine, Kathleen Cloud, Mary Baughman Anderson, James Austin (1985). Women in Development: A Framework for Project Analysis. Harvard Institute for International Development Case Study and Training Project. In Overholt, Catherine A., Mary B. Anderson, Kathleen Cloud and James E. Austin (1985). Gender Roles in Development Projects. West Hartford, Connecticut: Kumarian Press.
• Moser: Moser, Caroline O.N. (1993). Gender Planning and Development: Theory, Practice and Training. London: Routledge.
• Longwe: Longwe, Sara Hlupekile (1991). Gender Awareness: The Missing Element in the Third World Development Project. In Wallace, Tina and Candida March (eds.) (1991). Changing Perceptions: Writings on Gender and Development. Oxford, England: OXFAM.

Gender Training

Gender training workshops differ in content, depending on their audiences and purposes. Training can contain one or a combination of three interrelated components identified by Moser as: the political, introducing gender concepts and analysis; the professional, providing workers with "how-to" skills, and the personal, challenging an individual's gender attitudes and stereotypes and exploring individuals' gender-based experience in their work and in the greater world. It has been argued that gender training must address the personal dimension in order to be effective, and that currently, traditional gender training programs fail to adequately address this dimension.48 A number of the tools discussed later in this paper give specific guidance on carrying out gender training.

Gender Analysis

Gender analysis is the systematic study of the differences in condition (material welfare) and position (status) of women and girls versus men and boys in a given population. Gender analysis provides important contextual information that can be used as a community based needs assessment to plan projects or to evaluate their progress or impact.

Since women and men have different roles in society, they will have different needs for fulfilling those roles as well as for challenging them. The knowledge and insight gained through gender analysis allows projects to assess and address the practical needs and strategic interests of men and women more accurately. Practical gender needs are those whose fulfillment assists men or women in carrying out the roles they currently have, and therefore might be said to ease their burdens. Strategic gender interests, on the other hand help a society achieve gender equity. In the short term, strategic gender needs may increase, rather than lessen, women's burdens, but in the long term will improve their status in relation to men's. Arguably one of the highest goals of development work is to promote gender equity.

Gender Equity Versus Equality Equality between the sexes is by definition impossible. Were the two sexes equal, strictly speaking, there would not be two sexes, but rather one. Equity, however, is possible. Equality means being the same, while equity means being fair. For example, some literacy programs may target more women than men, based on the observation that society at large benefits men, with men typically having had more opportunity for formal education. Certainly this is not equal treatment of women and men, but it can be argued that it is equitable because it is working toward equality of opportunity, which is often limited by one's gender.

Gender analysis provides one means for understanding these differences so that we can better design and implement projects in population, health and nutrition. One description of the utility of gender analysis comes from the Government of Finland:49

Tools

Recommendations

Since gender is context-specific, training to increase sensitivity to gender issues in a given area must reflect the circumstances of that situation. We therefore endeavored to choose the most applicable tools for PHN staff at USAID and in Cooperating Agencies as well as those that could be used in the field.

Little discussion and few case studies on PHN issues were included in the majority of the manuals we reviewed. Rather, most manuals were written from a general development perspective. Recently, however, two manuals have been published specifically to address gender training in the health sector. These are the Pan American Health Organization's gender training manual50 and a manual for gender training for top-level management working in HIV/AIDS prevention, published by Family Health International's AIDSCAP Women's Initiative.51 An upcoming publication by AVSC International also shows promise.52

The PAHO manual could be adapted for use with USAID, CA, Mission and field program staff. However, we have also recommended Power, Process and Participation (Slocum et al., eds., 1995) for field use because of its creative approach and ability to be used with less literate populations.

Note: We provide contact information for each tool cited following the annotation. At the end of this section, contact information is given for Women, Ink, an organization specializing in the distribution of publications related to gender issues in development. Many of the tools cited below can be ordered through Women, Ink, which also is the exclusive distributor of UNIFEM publications.

USAID/CA

PAHO's Workshop on Gender, Health and Development: Facilitator's Guide 53 is the first general-purpose gender training manual we reviewed that is written specifically for people working in the health sector.

• Advantages. This manual is clearly written, provides a vast number of health -- including reproductive health -- examples and case studies, and does a nice job of discussing key gender issues. Like UNICEF's gender training manual,54 it comes in a three-ring binder and so is flexible in its format and can be photocopied easily. It has sample flipcharts, to encourage a participatory approach; transparencies, and one sample agenda. While PAHO does not provide a participant manual per se, handouts at the back of the manual can be photocopied and used as such. The manual is available in Spanish as well as English. It draws many examples from the Americas - certainly a strength for people working in Latin America and even for training U.S.-based staff, although perhaps less relevant for those working in other areas.

   

• Drawbacks. Since this manual, like most others (and because it was designed for PAHO headquarters and field staff), is heavily based on the written word, Power, Process and Participation (see below) may work better with less literate populations. In addition, in terms of transfer of learning, UNICEF's emphasis on field observations may be preferable to the case study approach (alone) adopted by PAHO. PAHO uses Moser's rather than Longwe's policy approach analysis; however, it discusses empowerment at length. As with the other manuals reviewed, gender-sensitive indicators are not included.

Pan American Health Organization (PAHO) Women, Health and Development Program 525 Twenty-Third Street, NW Washington, D.C. 20037 Tel: (202) 974-3136 Fax: (202) 974-3671 E-mail: quirosed@paho.org (Edna Quiros) http://www.paho.org/

Missions/Field Programs

Power, Process and Participation -- Tools for Change55 from the Intermediate Technology Development Group (based largely on EcoGen work) is designed to be adapted to local conditions.56

• Advantages. This resource is only slightly more than 250 pages, making it both easily portable and approachable. Its strength lies in its creative approach to overcoming barriers, such as illiteracy, through numerous oral and visual exercises as well as its participatory approach, which can be used to level the playing field in terms of power relations. It is therefore an essential tool for collaborative work with disparate groups and less educated populations. It is an excellent resource for non-governmental agencies and others seeking to advocate for and empower women, including frank guidance regarding ethics and conflict resolution. The tools in the book are self-contained, and workshops can be designed using any combination of them.

   

• Drawbacks. This resource is clearly intended for training field-level staff and project participants, with greater emphasis on practicality than teaching theory, so those wishing to provide this background will need to bring it in from a different source. The book also lacks tools or background directly related to PHN issues.

IT Publications 103-105 Southampton Row London WC1B 4HH ENGLAND UNITED KINGDOM Tel: (44.171) 436-9761 Fax: (44.171) 436-2013

Other Gender Training/Gender Analysis Manuals

The following are additional manuals for gender training and/or analysis within a development context. While not written specifically for health projects and programs, they might have other desirable qualities that would support their use by PHN Center staff. The materials are listed alphabetically by the organizations that produced them.

AIDSCAP

AIDS Control and Prevention Project (1997). A Transformation Process: Gender Training for Top-Level Management of HIV/AIDS Prevention. Training Manual. Arlington, Virginia: AIDSCAP, Family Health International.

• Advantages. This is the first gender training manual we found that was designed specifically for a senior management audience. Even though it focuses on one particular PHN topic, this is an important and unique contribution to the literature, both because of its focus on senior management and because it takes the bold step of using the Longwe Women's Empowerment Framework with an audience that often is presented solely or mainly with efficiency based arguments. Nowhere is the need for gender equity more apparent, and more critical to human life, than in the area of HIV/AIDS, and AIDSCAP effectively maps out the social and sexual aspects of women's vulnerability, discusses strategies for overcoming bureaucratic resistance to gender equity policies, provides alternative intervention strategies for addressing gender issues and gives guidance on assessing process as well as impact.

   

• Drawbacks. The graphics tend to lessen the readability of this manual, and would make photocopying difficult. Also, its narrow focus on HIV/AIDS would need to be expanded for a wider PHN audience.

AIDSCAP 2101 Wilson Blvd., Ste. 700 Arlington, VA 22201 Tel: 703-516-9779 Voice Mail: 703-516-0460 Email:jrosengren@fhi.org http://www.fhi.org/aids/aidscap/aidscap.html

CCIC and AQOCI

Moffat, Linda, Yolande Geadah, Rieky Stuart (Translation: Micheline Laflamme, Diane Archambault, Lucie Jauvin) (1991). Two Halves Make a Whole: Balancing Gender Relations in Development. Canadian Council for International Cooperation (CCIC), Match International Centre and the Association Québécoise des Organismes de Coopération Internationale (AQOCI). Ottawa: Bonanza Press.

• Advantages. Following a brief introduction to gender issues, this manual outlines the Gender and Development (GAD) approach to gender analysis, including the Harvard Analytical Framework. Critical questions for non-governmental organizations (NGOs) are provided for each aspect of project development, implementation and outcome. The manual includes instructions for developing a gender training workshop, including agendas, overheads, case studies and a discussion of recurring issues that are raised during GAD workshops. Suggestions also are included for applying GAD analysis to NGOs themselves. A final section sketches the history of gender and development.

   

• Drawbacks. Like the OXFAM manual, this manual will require considerable reading before designing and conducting the training workshop(s), especially to give it a PHN focus. Only one of the short case studies focuses on a PHN issue, and none of the three elaborate case studies does. Due to the manual's reliance on written materials, this manual would be more difficult than others to adapt to illiterate populations. Workshop facilitators wishing to address the personal level in their training will want to use another manual, as this one deals only with the professional and political levels. Also, some background material may need to be updated, as the manual was published in 1991.

Canadian Council for International Co-operation (CCIC) 1 Nicholas Street Suite 300 Ottawa, Ontario K1N 7B7 CANADA

CEDPA

Centre for Development and Population Activities (1996). Gender and Development. The CEDPA Training Manual Series, Volume III. Washington, D.C.: CEDPA.

• Advantages. The CEDPA manual provides a good introductory workshop for those unfamiliar with gender and development concepts. It presents three analytical frameworks, Harvard, Parker's Gender Analysis Matrix and Longwe, and summarizes Moser's concepts of gender roles and practical gender needs and strategic gender interests. Included in the manual is a checklist for the incorporation of Gender and Development (GAD) concerns into projects, as well as a workshop evaluation questionnaire. This manual is especially notable in that it includes a section dedicated to gender and reproductive health, with a case study. Its participatory exercises emphasize the verbal and visual, and with some redesigning, the workshop could be adapted to illiterate populations.

   

• Drawbacks. The CEDPA manual is somewhat less flexible than other manuals in format, and goes into less depth of content.

Centre for Development and Population Activities (CEDPA) 1717 Massachusetts Avenue NW, 2nd Floor Washington, DC 20036 Tel: (202) 667-1142 Fax: (202) 332-4496 Email: cmail@cedpa.org http://www.cedpa.org/

EcoGen

Thomas-Slayter, Barbara, Rachel Polestico, Andrea Lee Esser, Octavia Taylor and Elvina Mutua (1995). A Manual for Socio-economic and Gender Analysis: Responding to the Development Challenge. Ecology, Community Organization (ECOGEN), Clark University and Virginia Polytechnic Institute and State University. Worchester, Massachusetts: Clark University.

• Advantages. Based on the premise that capacity building among the most disadvantaged groups within any society is necessary for sustainable development, this manual adopts an approach called socio-economic and gender analysis (SEGA). The main elements of SEGA are sketched out in an introduction, and are followed by a conceptual framework that presents the rationale behind the manual in Part I. Forty tools and strategies are offered in Part II. These focus on organizing strategies; gathering information and raising awareness; identifying priorities; assessing needs; planning and formulating projects, and strategizing for change. Part III analyses 10 case studies of development activities using the SEGA method, and Part IV gives suggestions for clarifying goals and objections, and measuring outcomes of development initiatives. Indicators designed for sensitivity to the SEGA approach are offered.

   

• Drawbacks. In its attempt to be comprehensive in addressing factors influencing a project, the SEGA approach loses considerable clarity. It also would be highly time-consuming to implement.

OXFAM

Williams, Suzanne with Janet Seed and Adelina Mwau (1994). The OXFAM Gender Training Manual. Oxford, England: OXFAM United Kingdom & Ireland.

• Advantages. A large number of topics are covered in OXFAM's manual (including exercises and handouts), with the idea that training workshop facilitators will select those topics most appropriate to their audience, and a number appropriate to the length of time they have available for the workshop. This manual not only approaches gender at the institutional level, building skills in gender training and project planning, but at the personal level as well. An evaluation questionnaire is provided in addition to more traditional self-report training evaluations, to quantify differences in participants' perceptions and knowledge before and after the workshop.

   

• Drawbacks. Considerable time and money will need to be devoted to each workshop's design. The manual is over 600 large pages in length, and so will require some time to peruse before choosing the activities specific to the training at hand. At approximately $50 (U.S.), the manual might be too expensive for many developing country partners. One case study deals with nutrition; otherwise, PHN topics are lacking.

Save the Children

Parker, A. Rani, Itziar Lozano and Lyn A. Messner (1995). Gender Relations Analysis: A Guide for Trainers. Washington: Save the Children.

• Advantages. Save the Children's gender training has evolved from a "woman-focus" to a "woman-focus with a gender perspective." The organization's experience and those of other development agencies went into creating this guide to gender training. A framework for gender relations analysis at the personal, institutional and methodological levels is described in their manual. The guide also provides a five-day training curriculum geared toward technical and management practitioners. It uses participatory methods to intervene at the personal, institutional and methodological levels. This is the first of a three-volume series of gender relations tools. The following two volumes will provide case studies covering Save the Children's implementation of the proposed methodologies and a description of the most effective tools.

   

• Drawbacks. This manual does not provide PHN-related examples, which would need to be developed for the workshop(s), and the emphasis on the written word in Gender Relations Analysis will exclude illiterate participants.

UNICEF

United Nations Children's Fund (1994). Gender Equality and Women's Empowerment: A UNICEF Training Package. New York: UNICEF.

• Advantages. Originally written for UNICEF staff worldwide, this manual is also available in French and Spanish. It provides a lot of guidance on designing a gender analysis training workshop, and includes many working tools, such as overhead transparencies, a model invitation letter and evaluation questionnaires. Also included is a participant's manual, which can be photocopied and passed out. (The manual's three-ring binder format facilitates photocopying.) This manual teaches the Longwe women's equality and empowerment approach to gender issues, and includes reading material on the evolution of gender concerns in development. One of the most progressive characteristics about this manual is that it includes field observations, and subsequent debriefings, as part of one of its suggested agendas. While not the main emphasis of the manual, PHN topics are discussed, including case studies about contraceptive accessibility and AIDS prevention.

   

• Drawbacks. Persons uncomfortable with women's equality and empowerment as a goal in international assistance efforts, or those for whom efficiency is primary, may dislike the approach taken in this manual. Its heavy emphasis on the written word would make it unsuitable for illiterate audiences.

UNIFEM

Parker, A. Rani (1993). Another Point of View: A Manual on Gender Analysis Training for Grassroots Workers. United Nations Development Fund for Women (UNIFEM). New York: Women, Ink.

• Advantages. A step-by-step guide to facilitating a gender analysis training workshop with grassroots development workers, this publication includes exercises and handouts on the Gender Analysis Matrix (GAM), a tool for determining, at the community level, the different effects development interventions have for women and men. GAM analysis is conducted by representative groups from within the culture. An annotated bibliography provides information on gender analysis and gender training materials.

   

• Drawbacks. The manual provides very few case studies, and none on PHN topics, so PHN-specific examples would need to be drawn up for workshops. The purpose of this manual is to train project staff in GAM, which is by nature dependent on a literate audience. Those working with illiterate populations should choose another resource. Little guidance for planning a workshop is given, so those new to conducting training would need to consult with other resources as well.

Tool Kits

The following three resources are hybrids - not full training manuals, but broader in scope than the materials in the supporting texts section that follows.

ARROW

Asian-Pacific Resource and Research Centre for Women (1996). Women-Centred and Gender-Sensitive Experiences: Changing our Perspectives, Policies and Programmes on Women's Health in Asia and the Pacific. Resource Kit. Kuala Lumpur, Malaysia: ARROW.

• Advantages. The 1996 ARROW tool kit reflects the evolving work of gender issues within health and population, moving from a woman focus to encompass a gender focus as well. The five-part resource kit includes an Introduction (Part I), a Framework for Change (Part II), Perspectives for Change (Part III) , Policies for Change (Part IV), Programmes for Change (Part V) and an annotated bibliography (Part VI). It can be used for gender sensitization training, consciousness raising, program evaluation, policy making and advocacy. Numerous reproductive health and policy issues are discussed, within an Asian/Pacific context. Tools include checklists, matrixes and recommendations.

   

• Drawbacks. Written specifically for the Asian/Pacific context, this tool kit will be most appropriate for this audience. People working elsewhere should be sure to include discussion of topics and use examples from their areas and societies.

Asian-Pacific Resource and Research Centre for Women (1994). Toward Women-Centred Reproductive Health. Information Package No. 1 1994. Kuala Lumpur, Malaysia: ARROW.

• Advantages. ARROW's Information Package No. 1 comes in three parts. Part I is entitled, "Broadening the Concept:/Addressing the Needs," and discusses reproductive and population concerns within an Asian/Pacific context. Part II is entitled, "Ideas for Action," and discusses such topics as the values and principles that underlie fertility regulation programs, quality of care and government policies. It also provides a model program for women-centered reproductive health. Part III is an annotated bibliography of resources on family planning policies and programs.

   

• Drawbacks. Written specifically for the Asian/Pacific context, this tool kit will be most appropriate for this audience. People working elsewhere should be sure to include discussion of topics and use examples from their areas and societies.

GENESYS

GENESYS Project (1994). Gender Analysis Tool Kit. Washington, D.C.: Office of Women in Development, United States Agency for International Development.

• Advantages. Commissioned by USAID, the Gender Analysis Tool Kit provides a "Gender Considerations in Development (GCID)" framework for assessing the extent to which a partner organization has institutionalized gender issues, as well as quantitative tools; diagnostic tools, planning, monitoring and evaluation tools, and a review of methods for incorporating gender issues into agricultural and environmental/natural resource management sectors.

   

• Drawbacks. Built for a strictly USAID audience, this tool kit will have little relevance to field-level staff. Some PHN topics are used illustratively but little depth of background on gender or PHN issues is given in this tool kit.

Supporting Texts for Gender Analysis Training

The following resources should prove useful to USAID and Cooperating Agency staff interested in gender analysis. Although not designed for conducting gender training workshops, they include important tools that will help clarify and simplify the work of gender analysis.

CIDA

Canadian International Development Agency (1995). Guide to Gender-Sensitive Indicators. Hull, Québec: CIDA.

This guide was developed to help CIDA staff use both quantitative and qualitative gender-sensitive indicators as one instrument of results-based management. It discusses why and how they should be used, especially in projects with an end-user focus. Five major categories of indicators (and their limitations) are discussed: risk/enabling indicators, input indicators, process indicators, output indicators and outcome indicators. A bibliography (with an emphasis on CIDA's work) follows the text. (French- and English-language text.)

Canadian International Development Agency (1996). The Why and How of Gender-Sensitive Indicators: A Project-Level Handbook. Hull, Québec: CIDA.

"This handbook concentrates on gender-integrated and WID-specific projects with an end-user/local stakeholder focus. The Handbook is a brief introduction to a complex subject. It should be used in tandem with its companion volume, the more comprehensive Guide to Gender-Sensitive Indicators (CIDA, 1995), which contains fuller discussions of concepts, methods and case studies..." (French- and English-language text.)

CEDPA

Centre for Development and Population Activities (1996). Gender Equity: Concepts and Tools for Development. Washington, D.C.: CEDPA.

A companion book to CEDPA's Gender and Development training manual, this concise volume provides key concepts and background information for the understanding of gender issues within the development context.

Finland Ministry of Foreign Affairs

Ministry of Foreign Affairs, Finland (1995). Guidelines on Gender Analysis. Helsinki, Finland: Department for International Development Cooperation, Ministry of Foreign Affairs, Finland.

The Finnish government presents guidelines and guiding questions to its development workers in this concise publication. Only 28 pages long, this tool covers two main themes: the why and how of gender analysis, and means for building gender equity into projects and programs.

ICRW

International Center for Research on Women (1995). Taking Women into Account: Lessons Learned from NGO Project Experiences. Washington, D.C.: ICRW.

Prepared for the United Nations 1995 conference in Beijing, this document details U.S. NGOs' experiences in integrating gender concerns into development work. Four case studies illustrate this work: The Regional OILS Project of ATI in Tanzania and Zimbabwe; the WARMI and WCI projects of Save the Children in Bolivia; WID Initiatives in Agroforestry and Integrated Aquaculture programs of CARE in Guatemala, and the Northwest Thailand HIV/AIDS Prevention and Women's Empowerment projects of CNE and LLI in Thailand. Case studies were chosen in which women were both participants and beneficiaries; the needs, contributions and constraints of women were taken into account, and the lessons gleaned from the projects were replicable and/or had widespread impact.

InterAction

InterAction Commission on the Advancement of Women (1996). Best Practices for Gender Integration in Organizations and Programs from the InterAction Community: Findings from a Survey of Member Agencies. Washington, D.C.: InterAction.

Survey results from 30 of InterAction's member agencies revealed a number of key issues regarding gender integration in development work. These "best practices" included the existence of a gender policy statement and consultation with NGO partners; integration of gender issues into program planning through sex-disaggregated data, gender analysis and consultation with local women's NGOs; a centralized gender department, unit or other focal point within the organization; gender training; evaluation of gender impact; gender equitable recruitment, hiring and retention, and family-friendly work policies, including parental leave, flexible work arrangements and child and dependent care. A short annotated bibliography of practical gender resources follows the text and includes "thumbs up" for "essential" tools.

Intermediate Technology Development Group

Gianotten, Vera, Verona Groverman, Edith van Walsum and Lida Zuidberg (1994). Assessing the Gender Impact of Development Projects: Case Studies from Bolivia, Burkina Faso and India. London: Intermediate Technology Development Group.

In 1990, the Directorate General for International Cooperation (DGIS) of the Netherlands' Ministry of Foreign Affairs issued a policy document called A World of Difference that emphasized the need for the collection of baseline data prior to project implementation as well as a screening assessment regarding the potential effects a project might expect to have. During this time, DGIS also updated its criteria for incorporation of gender and assurance of women's unconstrained involvement in its projects. These two events led to the Ministry's desire for a new methodology to help in the planning and evaluation of development projects as they relate to gender. DGIS' experience in developing such guidelines is illustrated through the publication of three case studies used to test the methodology.

The Population Council and the Chr. Michelsen Institute

Rao, Aruna, Hilary Feldstein, Kathleen Cloud and Kathleen Staudt (1991). Gender Training and Development Planning: Learning from Experience. Report of the conference Gender Training and Development Planning: Learning from Experience sponsored by the Population Council and the Chr. Michelsen Institute held in Bergen, Norway, May 13-15, 1991. New York: The Population Council.

The Gender Training and Development Planning conference gathered people from a wide variety of institutional settings for the purpose of sharing experiences and exchange training strategies and techniques; identifying common problems encountered in gender work; extracting lessons regarding institutional and audience responses to and adaptation of gender training, and building a framework for analyzing the impact and effectiveness of gender training. The report includes steps to "growing your own methods and materials" for gender training, and provides a number of examples from various organizations that have done so.

Moore, Kirsten and Debbie Rogow (eds.) (1994). Family Planning and Reproductive Health: Briefing Sheets for Gender Analysis. New York: The Population Council.

In a concise volume containing five color-coded sections, The Population Council outlines major gender issues that arise at the nexus of family planning and sexuality, adolescence, gender-based abuse, childrearing, and the social and economic restrictions on women.

Aruna Rao et al.

Rao, Aruna, Mary B. Anderson and Catherine A. Overholt (eds.) (1991). Gender Analysis in Development Planning. West Hartford, Connecticut: Kumarian Press.

This book provides case studies that can be used for teaching the case method approach, but does not include any analysis. The case studies come from Bangladesh, India, Indonesia, the Philippines and Thailand.

Save the Children

Save the Children (1996). Best Practices in Gender Relations Analysis: From Analysis to Action: Integrating Gender into Programs. Report from the Advanced Gender Relations Analysis Workshop held in Washington, D.C., September 10-12, 1996. Washington: Woman/Child Impact, Save the Children.

Using examples from Save the Children projects worldwide, this workshop report discusses tools for analyses of program/project impact, participation, resource/livelihood and stakeholders. It also discusses institutional linkages, with examples from USAID and the World Bank.

UNFPA

United Nations Population Fund (1991) Incorporating Women into Population and Development: Knowing Why and Knowing How. New York: UNFPA.

Reproductive health concerns play an important role in this short piece outlining UNFPA's approach to incorporating women into development. The document also references other resources available from UNFPA; however, some of these are out of publication because UNFPA currently is updating its approach to gender issues as well as its gender analysis manual.

Women, Ink.

Women, Ink is the exclusive distributor of UNIFEM publications, but also acts as distributor for a wide range of publications related to gender issues within the PHN sector.

Section II: Food for Thought

Food for Thought

The following questions for reviewing a project for its attention to gender issues were adapted from a variety of sources.57 ,58 ,59 ,60 ,61 ,62 ,63 ,64 They follow the major steps in a PHN project life cycle - Project Design, Implementation and Monitoring, as well as Evaluation. However, many of these same questions can usefully be applied to the donor and implementing agencies' internal structure and functioning as well. The questions are meant to illustrate topics that should be considered when assessing the extent to which gender issues are incorporated into a project. However, they are not meant to constitute an evaluation tool or set of indicators; more precise indicators will need to be developed. Neither is the list comprehensive. Some will be more relevant to a given project than will others. Project managers might find some questions that at first might not appear to be very relevant but could have an important indirect effect on a project's outcomes. For example, division of household labor might not seem to affect a family planning service delivery project, yet an understanding of this issue could be essential when planning clinic hours.

The report on a 1996 national workshop organized by the Government of Bangladesh65 provides an example of a more thorough examination of gender issues in reproductive health care, including discussion of nutrition and other health matters. This workshop sought to define reproductive health within the context of Bangladesh, highlight gender considerations as they affect the country's reproductive health programs and develop gender-sensitive guidelines for a National Plan of Action on Reproductive Health with a Gender Perspective. While the workshop addressed the specific needs of Bangladesh, there is much in it that is generalizable to other country contexts.

Following the policies of the ICPD, the discussion and recommendations made were broken down by four stages of the life cycle: before maturation, sexually matured and unmarried, sexually matured and married and after the fertile period. The overarching goal for the National Plan of Action was "[t]o adopt reproductive health policies, which prioritize the reproductive health rights of women and men to achieve a better quality of life." Targets included increasing life expectancy and reducing maternal, child and infant mortality rates. The broad strategies envisioned to accomplish these were the following:66

• Build capacity and design interventions sensitive to individual needs and rights.
• Decentralize the planning process, emphasizing participation of the beneficiaries: adolescents/youth, women and the hard-core (sic) poor.
• Integrate reproductive health programs within the broader context of health and population through a life-cycle approach.
• Enhance linkages between population and development, focusing on empowerment of women.

Specific strategies for each stage of the life cycle included:

Before sexual maturation: Design initiatives focusing on the parents of newborns and young children, including service interventions in the area of iodine deficiency, hepatitis B, breast milk supplementation and vitamin A supplementation; IE&C interventions including nutrition education for parents, compulsory secondary education, integration of reproductive health education into school curricula, involvement of parents and teachers in RH education and provider training in RH; and a gender equity intervention to mobilize community support for and awareness of gender equity and RH.

Sexually matured and unmarried: Integrate the RH needs of youth and adolescents into a broader health context through IE&C interventions including education of youth on RH, hygiene, nutrition, STDs/AIDS and reproductive tract infections; a mass media campaign on RH and violence against women and children and educating women about their rights; service interventions including strengthened outreach counseling and RH services and greater integration of STD and reproductive tract infection treatment into current services; and legal interventions including the enforcement of existing laws to protect women's rights and reform of laws on marriage, violence and abuse to ensure women and children are protected.

Sexually matured and married: Promote women's development through IE&C interventions regarding safe pregnancy, condom use for STD/AIDS and reproductive tract infection prevention and medically safe abortion; community fundraising interventions for safe delivery services; and service interventions to upgrade reproductive and emergency care services, expand and improve menstrual regulation services and meet unmet family planning needs and record all violence-related maternal mortality in official reports.

After fertile (both men and women): Integrate RH services into broader health care services for the after-fertile and old-age population through service interventions including reproductive cancer screening and calcium supplements, and IE&C interventions including awareness-raising campaigns regarding after-fertile RH care, factors contributing to infertility and the role and the responsibility of both men and women in infertility.

Project Policy Orientation and Project Staffing

Country Context

• Does the rationale for the country's PHN policies and programs explicitly include notions of self-determination and benefits for the overall quality of life of women and children, as well as for their health?
• How well are women represented in key policy making roles affecting the national PHN policies and programs?
• Have organized women's groups supported the family planning program? Have these constituencies participated in policy development activities? Have the wives of policy makers been reached?
• Are there legal and regulatory barriers that differentially affect women's/men's access to reproductive health services?
• Are PHN policies supported by other policies to improve the status of women and their opportunities for education and employment?
• What level of funding is being spent on gender-sensitive and gender-focused projects?

Management Issues*

• What is the ratio of women to men employed as health service providers? in other staff positions?
• To what extent are staff trained and informed on gender-sensitive standard operating procedures, research methodologies, service delivery practices? If this is absent, is access possible/available?
• Has the project identified the gender issues facing staff and made institutional arrangements to support change (for example, transport, flexible working hours for parents, adequate and fair wage, child care provision, sexual harassment complaint procedures)?
• Are the occupations and roles of female and male staff without gender stereotyping? If there is a gender bias, is this recognized openly (for example, if most of the managers are men and the women are in less influential positions)?
• Are women represented sufficiently in leadership structures, and if not, is there an organizational objective to achieve gender-equitable representation?

* While designed for staff at the field level, it could prove fruitful to explore these questions at the donor and implementing agency offices as well at the project level.

Commitment to Gender Equity

• Are staff self-aware about the social context within which they work, specifically with regard to:
  1. girls' and women's social status, level of choice in partner selection, access to social structures outside the family (such as education and credit)?
  2. sexual norms and behaviors, control of resources, partnership patterns, inheritance patterns, level of gender-based violence?
• Do most project personnel believe in gender equity? Is this belief in gender equity expressed as a project objective or guideline? Is there a clear policy goal to ensure that this objective is met?
• Have gender relations and gender inequity been understood and accepted as factors influencing women's health and status, as well as development in general? Is this expressed as a project objective or guideline?
• Is there a recognition that men need to take more responsibility in child care, domestic work, family planning and sexual and reproductive health? Is this belief expressed as a project objective and implementation guideline?
• Are there project objectives and project activities aimed at increasing women's control over their fertility and sexual health, and men's inclusion in reproductive health issues?
• Do all of the project's promotional and educational resources depict images of women and men in non-stereotyped gender roles?
• Is the project positioned within wider local, national or regional activities aimed at reducing gender inequities and improving women's status?

Project Design

Gender Roles and Power

Division of Labor

• How is men's/women's (and boys'/girls') labor distributed by time over the day, week, season, and by type of role (reproductive, productive, community)? How much role conflict exists for each sex? How does this conflict manifest itself?
• How will the project affect this labor schedule and how can it best use it to advantage? Will the project increase women's workload, especially caregiving responsibilities?
• Is alleviation of women's workload a prerequisite for their full participation in the project's activities?

Decision-making

• In which spheres do women/men have direct/indirect decision-making power, both in the household and in the wider community? Who has ultimate decision-making authority? Who controls household economic resources? Which ones?
• To what extent are women included in local organizations (number of members, numbers in decision-making roles, level of participation)?
• Will the project increase women's/girls' decision-making power within their households, including resource expenditure, sexual relations, marital partner choice and age at first marriage, when and how they will bear and raise children, when and how household health needs are met? Will it increase their decision-making power in the wider community? Will it challenge their decision-making authority or that of others?

Access

• Which PHN resources do women/men have access to? Which are they barred from? What different constraints do men and women face in accessing resources (for example, social stigma, provider assumptions, community norms, cost, time)?
• Will the project improve women's and men's access to services and resources? Will women's access to services be restricted by lack of access to material resources (for example, fees for services or transportation)?

Control

• Which benefits do women/men get from the use of resources, including their own bodies, health, energy, money?
• Which benefits do women/men control?
• Will the project improve women's control over benefits and resources, including their own bodies, health, energy, money? Or is it likely to threaten their control over it?

Definition of Key Population

• Is the project clear that women are not a homogenous group, but are divided along age, class, caste, religious, ethnic lines? Is it clear that the project will benefit poorer, more marginalized women and families? Are different sorts of women/men/children included?
• How and to what degree are women and men involved in the PHN sector? If only men or only women play a role, should the other sex be involved? Why or why not?
• What is the proportion, position and specific constraints of women-headed households in the community?

Current Levels of Knowledge about PHN Issues and Services

• What knowledge do women/men have about PHN issues, including nutrition, sexuality, reproduction, family planning methods, breastfeeding, safe motherhood and/or maternal mortality, the value of girls, sexually transmitted diseases and infertility?
• What knowledge do women/men have about PHN services available in their community?
• What knowledge do women/men have about their reproductive and other health rights?
• Has the project understood the local methods used by women (and men) to safeguard physical and mental well-being? What form of traditional healing system exists? What different roles do women and men play in the system? How will the project tap into and affect these?

Deciding on Project Priorities

• What are women's/men's gender-specific health needs in the project area, as defined by the women and men themselves? What attempts have been made to gain a detailed knowledge of those needs? Are the areas that the project aims to address priorities for women/men?
• To what extent are women/men involved in setting research priorities in population, health and nutrition planning? To what extent are women and men from the key population involved in the research planning, implementation and dissemination of results?
• What are the reasons why women/men would be interested in getting involved in the project activities?
• Are any women or men likely to oppose the project? For what reasons?

Project Implementation/Monitoring

Project Decision-Making

• Are project participants (women and men) fully involved in deciding the project/program priorities and how they will be implemented?
• Is there a community advisory committee and is it holding regular meetings?
• Is participation in advisory committees equal by socio-economic group and sex?
• Were rules developed in a participatory manner, involving all community members?
• What are the number of women and men in decision-making positions, by socio-economic group?
• Do people in leadership positions rotate regularly?

Participation/Service Utilization Rates

• Are data disaggregated by sex, socio-economic status and age?
• Can women/men, in practice, make productive use of health facilities and services, taking into account their workload, daily and seasonal peaks in activities, financial resources, and lack of mobility and decision-making power? How does the project address these constraints?
• What percentage of births in the region are attended by trained personnel?
• What are the service utilization rates by socio-economic groups, sex, age and ethnic background? Are these as expected, given local demographics? Are the desired populations being reached?
• How often are clients accompanied by their partners/others and how often do they come alone?
• Are there differences in the payments made (cash or in-kind) by socio-economic grouping of household (for example, is a sliding scale fee system in place)?
• What mechanisms are in place for users of services to provide ongoing feedback? What means of redress exist?

Service Quality

• Are the benefits from the project/program attractive for women? for men?
• What are the success rates of clients achieving their reproductive intentions, by socio-economic group and sex?
• How are the issues/concerns/needs of clients' partners addressed in counseling?
• Is health education planned to include discussion of the following gender issues:
  1. the equal value of men and women and the need for joint decision-making and shared responsibilities
  2. women's and men's roles in family planning and reproductive health
  3. women's right to good health, quality health services, freedom from violence, joint decisions about household expenditures and so on
  4. women's human rights and local legal rights, especially those related to health issues
  5. the dynamics of men's and women's decision making in the areas of sexuality, contraception, childbearing, nutrition and other health matters
• What is done to maintain client confidentiality?

Project Evaluation

Process Evaluation

• Are data disaggregated by sex, age, social class?
• To what extent were participants' own assessments of the project used to measure its success?
• Were appropriate indicators used (or developed) to describe the situation for women and men, so as to inform project development, implementation and monitoring?
• Were women employed and trained by the project, so that women and men were able to participate on an equal basis in project activities?
• Does the project use the extent to which women's relations with men have improved (for example, cessation of violence, more independent and assertive decision making, greater knowledge of legal rights, and so forth) as an indicator of effectiveness or success?
• Are women and men treated with equivalent respect, both as participants and staff personnel?
• Are staff rewarded for providing better counseling, linkages with other services, addressing sexual and other health needs beyond family planning? Are the issues of violence and non-voluntary sex addressed?
• Have indicators or incentives for steering clients toward certain family planning methods been removed? Are staff well trained on all methods? Is a full range of methods available? Are clients provided with sufficient information for informed decision-making and consent?
• Are women and men treated as different audiences for information, education and communication efforts, and are they being reached with gender-appropriate messages that challenge oppressive gender stereotypes? What gender-related messages are included?
• Is there sufficient effort devoted to male needs, participation, methods, services and responsibility?
• What mechanisms have been used to educate male and older female family members on the need for prenatal and postnatal care? the importance of birth spacing? the value of daughters? the benefits of breastfeeding?

Impact on Gender Equity

• Has the project improved women's access to and control over PHN services and infrastructural facilities? How? What new services exist?
• What impact has the project had on relationships between men and women?
• Has the project increased women's ability to carry out their decisions in a sustained way within their households and the wider community?
• Are men more involved in family planning? family life? Are they more supportive and safeguarding of women's and children's health, as well as their own?

Impact on Health

• Has the project or activity improved women's and men's health? their level of knowledge?
• How has the project enhanced women's and men's roles as health care providers? What impact has this had on male and female clients' access to health care advice and services and their perception of the quality of these? Have objective measures of quality improved?
• What are the continuation rates, by age, socio-economic group and sex? To what extent do male and female clients feel they are meeting their health care needs?

Impact on Policy

• Has the project strengthened linkages between research/OR/service evaluation findings on gender issues and the formulation of PHN policies? Have policies been revised based on those findings?
• What gender-related process and outcome lessons have been disseminated to key decision makers at the implementing organization? local, national and regional organizations and governing bodies? international donor agencies? What, if anything, has changed as a result of these efforts?
• Has the project had an impact on the extent to which the implementing agency integrates a gender perspective into their policies and procedures?
• What information has the project given policy makers to show that taking gender issues into account contributed to its success?

Section III: Next Steps

Next Steps

While the tools for addressing gender issues that were discussed earlier, and those referenced in the accompanying Gender Lens Bibliography, might be adapted for use in the application of gender issues into Population, Health and Nutrition projects, it would be preferable to have tools based directly on PHN issues and examples, and formulated specifically for use by USAID-funded projects. Four key deliverables are recommended:

1) Manual for integration of gender issues into USAID's PHN work

• discusses and provides examples and guidance for all three topic areas
• based on USAID's past experience, priorities and mandate
• includes USAID senior management as an audience, since management support strongly influences the success of an initiative

2) Revised strategic framework to specifically address gender issues within the PHN sector

3) Gender-sensitive and PHN-specific baseline, process and outcome indicators that are:

• flexible enough to allow forward movement regardless of baseline
• ranked and/or weighted to provide direction for improvement
• topic-specific (i.e., different indicators for population, health and nutrition, although some overlap will occur)

4) Working paper of lessons learned in incorporating gender in different circumstances

• based on a systematic review of PHN projects (emphasizing USAID projects, but also including other organizations' experiences)
• conducted by gender expert with strong track record in baseline and process as well as outcome evaluation

A gender consultatory group of select USAID and a small number of Cooperating Agency (CA) staff was convened on April 29, 1997, at the Washington, D.C., offices of the Partnership for Appropriate Technologies in Heath. The group suggested that USAID create a USAID/CA Gender Working Group, based on the Maximizing Access to Quality (MAQ) Working Group model. Suggested purposes of such a group included sharing information, helping USAID implement gender policies and the operationalization of the next steps outlined above, as well as a review of the PHN Center's Strategic Objectives. In addition, the Gender Working Group discussed the possibility of identifying a point person in the PHN Center to liaise with senior-level staff, and a person to handle the technical and administrative tasks associated with the CA Gender Working Group.

The first meeting of the USAID/CA Gender Working Group was held on September 3, 1997, at the offices of the Centre for Development and Population Activities in Washington, D.C. At this meeting, the Gender Working Group ListServ was launched to facilitate communication, and four subcommittees were formed:

• Program Objectives, Strategies, and Implementation
• Indicators and Research
• Policy and Resource Allocation
• Male Involvement

For more information on the USAID PHN Center/CA Gender Working Group or its subcommittees, please contact one of its three co-chairs: Jennifer Adams (jeadams@usaid.gov), Estelle Quain (equain@usaid.gov), and Laurie Krieger (lkrieger@usaid.gov).

-- Susan Pfannenschmidt, Arlene McKay and Erin McNeill
Family Health International for
The Gender Working Group
Population, Health and Nutrition Center
U.S. Agency for International Development

Acknowledgments

The authors would like to express their gratitude to the members of the Gender Working Group at the U.S. Agency for International Development as well as to our contacts at other organizations striving to incorporate gender issues into their work. The pooled wisdom, knowledge and resources of these individuals have contributed substantially to the quality of this paper.

• AIDSCAP, Family Health International, E. Maxine Ankrah
• American College of Nurse Midwives, Frances Ganges
• AVSC International, Mary Nell Wegner
• Canadian International Development Agency, Diana Rivington, Barbara Brown
• Centre for Development and Population Activities, Hannah Searing, Sumali Ray-Ross, Phyllis Craun-Selka
• Family Health International, Staff of the Women's Studies Division, JoAnn Lewis, Roberto Rivera, Susan Palmore
• Ford Foundation, Jan Jaffe, Margaret Hempel
• Institute for Development Studies, Susan Joekes
• InterAction, AnneMarie Reerink
• International Center for Research on Women, Ellen Weiss, Joanne Spicehandler, Patricia Martin
• International Planned Parenthood Federation, Pramilla Senanayake
• International Planned Parenthood Federation/ Western Hemisphere, Judith Helzner
• MacArthur Foundation, Caren Grown
• MotherCare/John Snow Inc., Colleen Conroy
• Options UK, Cathy Green
• Pan American Health Organization, Pamela Hartigan, Matilde Maddaleno, Victoria Imas-Duchovny, Carol Collado, Martine de Schutter
• PATH/D.C., Elaine Murphy, Anne Wilson
• The Population Council, Nicole Haberland, Joanne Gleason
• Research Triangle Institute, Susan Settergren
• Save the Children, A. Rani Parker
• World Bank, Tom Merrick
• World Health Organization, Jane Cottingham
• UNFPA, Diane Langston
• UNICEF, Mizrak Elias, Hilda Maisch
• USAID, Erin McNeill (now at FHI), Estelle Quain, Jennifer Adams, Laurie Krieger, Elizabeth Maguire, Margaret Neuse, Barbara Crane, Claudia Morrissey, Cate Johnson, John Rose, Karen Ringheim, Ann Ferray

This publication was made possible through support provided by the Office of Population, Research and Development (R&D) Bureau, U.S. Agency for International Development, under Cooperative Agreement No. CCP-A-00-93-00021-05. The views expressed in this document do not necessarily reflect those of FHI or USAID.

Bibliography

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Endnotes

0. This is in spite of a new widespread recognition that development investments in women benefit them and other family members more than do similar investments in men.

1. United States Agency for International Development (1982). A.I.D. Policy Paper: Women in Development. Washington, D.C.: USAID Bureau for Program and Policy Coordination. p. 1.
2. Atwood, J. Brian (1996). "Gender Plan of Action." Statement by J. Brian Atwood, Administrator, U.S. Agency for International Development, March 12, 1996. Washington, D.C.: USAID.
3. Ibid.
4. United Nations General Assembly (1948). Universal Declaration of Human Rights. Resolution 217 A (III). New York: UN.
5. Alcala, Maria Jose (1995). Commitments to Sexual and Reproductive Health and Rights for All: Framework for Action. New York: Family Care International.
6. Packer, Corine A. (1996). The Right to Reproductive Choice: A Study in International Law.
7. International Planned Parenthood Federation (1996). IPPF Charter on Sexual and Reproductive Rights. London: IPPF.
8. United Nations (1995). Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995. New York: United Nations.
9. United Nations (1994). Population and Development: Programme of Action Adopted at the International Conference on Population and Development, Cairo, 5-13 September 1994:Volume 1. New York: United Nations Department for Economic and Social Information and Policy Analysis.
10. Alcala, Maria Jose (1995). Commitments to Sexual and Reproductive Health and Rights for All: Framework for Action. New York: Family Care International. p. 11.
11. United Nations (1995). Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995. New York: United Nations.
12. United Nations (1994). Population and Development: Programme of Action Adopted at the International Conference on Population and Development, Cairo, 5-13 September 1994:Volume 1. New York: United Nations Department for Economic and Social Information and Policy Analysis.
13. Casssard, Sandra D., Carol S. Weisman, Stacey B. Plichta and Tracy L. Johnson (1997). Physician gender and women's preventive services. Journal of Women's Health, 6 (2), 199-207.
14. Pittman, Patricia and Pamela Hartigan (1995). Quality of care and the gender perspective. Women's Health Journal, 3-4, pp. 94-99.
15. Gagnon, John H. (1990). Scripting in Sex Research. Annual Review of Sex Research, Vol.1, pp. 1-43.
16. United Nations (1995). Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995). New York: United Nations.
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36. Ibid.
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56. Ibid. p. 7.
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