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Tant qu’on a la santé

Yvonne Preiswerk
Mary-Josée Burnier

Applying theory in practice, some experience in incorporating gender analysis in health programming

Sharon Fonn

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  • 1 United Nations Division for the advancement of women, World Health Organisation, United Nations Pop (...)
  • 2 Jahan R., Ahmad N., Hunt J., Klugman B., Schalkwyk J. and Silberschmidt M. Gender equality in sexua (...)
  • 3 The agencies reviewed were AusAID, BADC, CIDA, DANIDA, GTZ, Irish Aid, NZODA, Sida, DFID and USAID.

1Following on the consensus documents from the UN decade conferences on population in Cairo in 1994 and women in Beijing in 1995 attention has been focused on addressing gender inequality and these documents have included recommendations on health services. These consensus documents form a common understanding which underpins much of current debate and can, and has, be taken as a starting point in reevaluating health service provision. Gender audits of health programmes have indicated that positive steps towards add ressing gender inequality have been taken. A report coming out of a 1998 UN expert group meeting1 found that the “shift towards a gender perspective was an important step forward. However it has not yet delivered the expected results and two main reasons for this can be identified.” The report sites a lack of understanding about the concept of gender to be one reason and the second being “a lag in the development and dissemination of appropriate techniques for incorporating gender issues into the policy process”. A review2 commissioned by the Swedish International Development Co-operation Agency (Sida) on behalf of the Working Party on Gender Equality of the Development Assistance Committee (DAC) of the Organisation for Economic Cooperation and Development made similar findings. This study reviewed work undertaken or supported by 10 bilateral development agencies3. The study found that “though all agencies accept the goal of gender equality and the need for mainstreaming a gender equality perspective in operations, there is often a gap between agency policy and practise” they go on to say that “The language of policy and strategy documents has changed but the content of programmes and projects have remained mostly unchanged”. It seems there fore that the challenge is to consolidate an understanding of the relationship between gender inequality and health and to translate this theoretical understanding into everyday practice.

2Health programming is about provision of services from policy development to providing the physical infrastructure and resources, both human and material, as well as providing a package of care and the systems which need to be in place to ensure optimal functioning. How as a programmer do you know if, within this mammoth task, you are taking gender inequality into account?

3A useful first step is the framework developed by the DAC team in order to evaluate the agencies they reviewed. The framework postulated three areas which are influenced by gender inequalities in society: the health of men and women; access to health services; and the response structure of the health system. Within this framework, for each of these three areas they elaborated how these inequalities can be manifest and thereafter indicate actions that could be taken to promote gender equality in sexual and reproductive rights and health. This framework, presented below, provides a checklist both to review and plan interventions.




  • 4 This has been described in various publications: S. Fonn, M. Xaba, K. S. Tint, D. Conco, S. Varkey, (...)

4Both these documents describe challenges in operationalising a gender perspective in health service delivery. Interventions undertaken by Women’s Health Project, a South African NGO, have attempted to address some of these challenges. WHP undertook a project in conjunction with three of the provinces in South Africa – the Transformation of Reproductive Health Services Project (TRHSP) which explicitly and implicitly included a gender component. The TRHSP aimed to: strengthen reproductive health services in the provinces; to collect a body of information to inform health system development through a process which facilitates an openness to change among health service personnel; to identify barriers to quality care and methods to overcome these; to build the confidence and capacity of health providers at all levels of the health system; and to increase understanding on the impact of social inequality, especially gender inequality, on health and health services. The TRHSP has been described in detail elsewhere4, a table describing the data collection tools that comprised the TRHSP is appended.

5In this paper some of the tools and processes of the TRHSP are described to illustrate how a gender sensitive approach can be incorporated into health system development. The point of the paper is to indicate that incorporating a gender perspective in health service planning is possible. Further, that if gender interventions are consistent with health service priorities and complement other developments in the health sector, they will be embraced and their value as a method of health system development will be appreciated.

6The UN expert group meeting report sites poor understanding of the meaning of gender as the first reason for non delivery of improvements expected to come from adopting a gender perspective. The need for a greater understanding of the concept of gender was recognised and incorporated in the TRHSP. Thus the TRHSP included various interventions that helped people understand gender relations and their impact on health and health care.

7The official start of the TRHSP was a one day orientation workshop that was held for senior staff in the provinces. This intervention was included in the project design in order to build or consolidate political will, identified in the UN expert meeting document as an essential element in mainstreaming gender. This workshop was attended by 26 senior health staff, 18 of whom were male, and also including the Directors General of Health from two of the provinces and the Minister of Health from one of the provinces. It is worth describing in detail at least one aspect of this workshop as it gives a concrete example of how to build an understanding of the impact of gender relations on health and health care. Further this tool is described because it demonstrates how a gender training exercise can be adapted to health system development and people interested in applying it will hopefully be able to do so from the description.

8A common tool used by gender trainers is the “bubble – but why” exercise. A statement about a common health problem is written in a circle on the lower left hand side of a large sheet of paper. Participants then ask “but why?” and write the answer in a circle adjacent to the problem. There are usually more than one reason and as the answers relate the preceding statement, so the circles are laid. This exercise was done with these very senior health service personnel. The problem of infertility is common in Africa and represents a challenge to health planners trying to give expression to the sentiments expressed in the Cairo and Beijing documents – to address issues that are important to women; to extend existing services; and in particular move away from the population control orientation that had dominated family planning programmes. Infertility is a difficult issue given the low resource settings in which many health planners work. Thus this problem was chosen. Part of the answer as constructed through the exercise is illustrated below as a demonstration.

9In developing the answers to the question “but why” at each stage in the construction of the diagram, gender relations are explored. For example, participants had to discuss why a woman may not know she had an RTI (Reproductive Tract Infection), consequently: women’s education; inability for couples to talk openly about sex; the consequences of multiple sex partners; and dual standards for sexual freedom for men and women; all get discussed. Thus the exercise develops people understanding of the impact of gender relations on a health problem.

10After the diagram is completed, for each of the points identified, the health planners are asked what, if anything, can the health service do to address this. In this way the complexity of the issue is explored more fully and the health service sees its role as more than just providing health services. For example the need for education about the relationship between reproductive tract infections and infertility is made clear, this may be a role for the health services. The need for sexuality education in relation to conception and the role of schools in this kind of education or the role of NGOs in providing support for home based discussion of such issues become clear as well as the need for the health service to liaise with and support the development of such initiatives in other sectors. Although infertility is often viewed (incorrectly) as a women’s problem the educational intervention required, as the problem is fully explored, will clearly need to target both men and women. Men’s role in preventing infertility also becomes an obvious component of what is required to prevent infertility.

11Taking another aspect of the diagram, health workers’ attitudes as a barrier to health care access, often excluded from basic training and as an issue in health care management, can be identified and addressed. This tool itself can be used by trainers in in-service education to sensitise health workers, for example, to the issue of provider client relations. Similarly, patient privacy and confidentiality, highlighting patient’s rights, can be identified and addressed.

12The health systems issues that this exercise uncovers, such as unavailability of drugs and inadequate supervision, are issues of concern not only in relation to the treatment of RTI’s but also for other health problems.

13Thus this exercise, in a provoking but playful manner, pushes health care planners to explore a health issue within its broader social context. The response to this is, in our experience, positive. In one instance a regional manager said that given this huge range of things, he would focus only on the health systems aspects, specifically drug availability. If that were the case it would still be a method of meeting women’s needs better. However he also added that he now saw things differently and once drug ordering was improved he could imagine going onto another issue. “If this is what gender means I am prepared to take it up.”

14Gender analysis was recognised as a way of improving quality and assisting managers in their jobs instead of being an extra issue to deal with. In this process the planners could see the relevance of gender to their daily work.

15Further health planners can now decide on a rational basis that in their particular circumstance the way in which they could deal with the problem of infertility is to create awareness of the cause of infertility, promote sexual education, including the notion of joint responsibility for sexual health, and to promote prompt and adequate treatment of sexually transmitted diseases. As part of the exercise they had prioritised interventions, like adequate drug management systems or addressing provider client relations, which are a general concern within the health sector anyway and would benefit more than just an STD intervention. In addition this intervention dovetails with interventions aimed at addressing HIV infection. Through this exercise planners also came to understand and see the relevance of components of the Cairo and Beijing documents, like rights or intersectional action and thus no longer feel threatened by the expectation on them to fulfil commitments to these international agreements. They can now indicate in which ways they are in fact taking up some of these issues.

  • 5 Fonn S and Xaba M. Health Workers for Change. WHO/WHP Geneva 1996.
  • 6 The findings of these research projects will be published shortly in Health Policy and Planning.
  • 7 Lund F. Mid term review of the Reproductive Health Transformation Project. Durban May 1997.

16The TRHSP also targeted primary care workers through Health Workers for Change5 workshops. This is a series of six workshops (tested in two multi-centre studies, one looking at acceptability and one at impact6) which explore the interpersonal component of quality of care. The workshops take participants through a process of reflection, to identify the various factors that deter delivering quality treatment and to formulate solutions to bring about change. In addition the Health Workers for Change brings to the fore gender issues. Each workshop has a defined objective and related activity during which health workers reflect on themselves, the situation in which they work and the clients that they serve. Each workshop has a theme: Why I am a health worker; How do our clients see us?; Women’s status in society; Unmet needs; Overcoming obstacles at work; and Solutions. This process builds health workers’ understanding of the impact of gender relations on health and health seeking behaviour. In exploring these issues both personal and institutional barriers to quality of care come up. The workshops involve analysis and critique of current practise and the development of action plans which primary care workers and managers can use to improve the health service. Health Workers for Change addressees key issues for health systems development while it builds gender consciousness. The external independent evaluation of the TRHSP7 commented “It is rare to find a training and management tool which has such impact. The facilitators (members of the provincial health departments trained by WHP to run the workshops) gave glowing reports of what the training had done for them. Health Service managers who were acquainted with the Health Workers for Change felt positively about it, and importantly, saw it is a useful management tool.” Health Workers for Change has also been described as “the most innovative management tool around” and as “the first manual to put gender into health workers training” by health service people involved in the TRHSP. What this intervention does is address key issues in the health sector such as management and change management, health systems development (a major issue internationally in the health sector reform process) and it does this through a gender eye. It is the combination of these factors that has made people respond positively to this tool.

  • 8 See note 5 above.

17Thus the TRHSP had as part of its brief to develop the conceptual understanding of gender relations of health personnel from senior management to primary care workers. This was not done in a theoretical manner, rather gender analysis was applied to current health care problems and health planners saw how it could be used as a tool for health system development. As a male top level manager in one province said “The TRHSP is about empowerment of users and providers. It is not just about sexuality and rape. It is about a whole package of the wider impact of gender on society.”8

18These aspects of the TRHSP are examples of overt attention to gender inequality. What is different about it is that it deals with issues that are already of concern for health planners and compliment, rather than place an additional burden on, their current work.

19There are ways of dealing with gender within health programming that are less overt and these too were incorporated in TRHSP. The project addresses many of the issues referred to in the DAC framework presented above. A few of these – adequate investment in the health system at PHC level (management, supervision, training drug supply, facilities, infrastructure and transport for emergency case; providing integrated services; organisation of services (privacy, queuing and booking systems, all services from one health worker)– and how they were incorporated into ongoing health system development will be described.

20Existing activity within the health sector at the time of the TRHSP was to develop and consolidate primary care within a district model. This was a priority in South Africa after the change to a democratic government. The TRHSP engaged in a participatory data collection process to provide information to inform this process. In various ways this data collection process took on gender issues.

  • 9 Tint, K. S., Varkey, J.-S., Fonn, S., Xaba, M., Conco, D. and Klugman B. Health systems assessment (...)
  • 10 Kay B., Germain A. and Bangser M. The Bangladesh Women’s Health Coalition. Quality 3: The Populatio (...)

21Firstly the data was collected from all stakeholders: users; primary care providers; managers; and planners within each province. Data was collected using qualitative, quantitative and change management tools. This data was then presented back for participants to interpret and analyse in a collective workshop process. At the end of the workshop a prioritised plan of action was determined. The dissemination workshop process is described in detail elsewhere9. This process in itself was a variation from usual practise. It was the beginning of the reorientation of staff to a new way of working that valued input from all role-players. This is in itself an important contribution in two ways. One, it demonstrates, and values, participatory methods of management and this has been shown to be an important element towards treating patients with respect and providing high quality care10. Secondly, service user’s opinions were also solicited which gives a practical example of how community participation may be incorporated into planning, values service users and gives real expression to the notion of patients’ rights. Thus the process itself was an important part of giving expression to the notion of equality.

22Various data collection tools were used and a few of these will be described to elucidate the gender component in them. Facility check lists were sent out to all PHC clinics. This tool generated information on adequacy of physical resources like the quality of the building and presence of electricity and water, etc. Data was also gathered on community participation and patient privacy. Including these questions promoted the notion that issues such as privacy, for example, are as important as data on physical infrastructure. This also illustrates how gender issues can be incorporated into normal activities and did not require extra investment.

23Included in the questionnaire were questions about the availability of certain drugs. Oxytocin, essential for treating post-partum haemorrhage, was specifically audited because haemorrhage is an important cause of maternal mortality. A significant number of clinics did not have this drug. Highlighting this led to a discussion about the possibility of health service quality being judged on the availability of drugs required to prevent maternal mortality. It could be a useful indicator of health service quality and development, in as much as immunisation rates are currently. Pethidine, the drug of choice for pain relief in labour in South Africa, was also audited. Asking this specifically promotes the notion that women should have a choice about pain relief in labour. The combination of the process (discussing the implications of the findings in a workshop format) and the data itself make these links overt. This required facilitation by people who had previously thought through these issues and could make these links. Clearly the questions included in any circumstance have to be situation specific. However what is clear is that much can be done to promote the notion of meeting women’s needs – including those needs which result from the social roles ascribed to women – that threaten their lives and health.

24Integrating services is another challenge. To inform this all stakeholders were asked their opinion on how services should be organised. Users wanted a one-stop-shop under one roof and the vast majority of managers were also keen on this option. Providers were less sure that this was feasible. It is important to ascertain if it is in fact feasible to provide a one-stop-shop service and thus clinic based time flow and workload studies were incorporated into the TRHSP. One clinic per province, as a pilot intervention, was chosen for this component of the TRHSP. The studies looked at how staff and patients spent their time in a clinic on a typical day. The data formed the basis for discussion about the efficiency of the clinic and opportunities for improvements. The studies were again conducted in a participatory manner which allowed the people who would have to make changes to decide how to move forward. Data were collected on: the number of staff; number of patients seen per day; number and type of services provided; patient waiting time; time receiving care; time allocation of staff to different activities – productive and unproductive time, direct and indirect patient care etc. How does this technical intervention address gender? The data gathered indicated that the majority of people attending the health service are women. Reasons for this can be discussed when the data is analysed in each clinic. The role of women as care givers, or their reproductive role and thus their use of health services are made overt. The consequences of these roles in terms of women’s time can be discussed. In services where women wait a long time for services and the ratio of waiting time to time with a provider (waiting time often being disproportionately long) can be discussed and methods of addressing this can be put forward. For example, in user focus groups, users mentioned that an appointment system may be desirable. Providers, when analysing data and noting that all patients arrive at the same time in the morning and that this increases the average waiting time, may be open to the idea of an appointment system. These kinds of interventions are possible, are free of additional costs, value women’s time and take into account the extra burden of the reproductive and caring role that women play in society. These kinds of intervention acknowledges gender inequality. Of course gender equality will have been achieved when community wide change occurs which results in as many fathers as mothers bringing their children for immunisation. However this is beyond the scope of the health sector alone and until that time the health sector needs to recognise and compensate for gender inequality.

25The external evaluation of the TRHSP found that it “could deliver on gender”. The evaluator also found that “There was good understanding of one major goal of the project, which was to introduce comprehensive integrated services.” This particular understanding of the project was particularly gratifying as it indicated the degree to which an intervention which has a strong gender component was also seen as a health system development tool. Another finding in the evaluation was that the “The project was most appreciated by managers for its being an effective tool of the management of change, and as a vehicle for capacity building in the civil service.” These change management tools and the process of the TRHSP were overtly addressing gender inequality. Yet they were seen as methods of developing the health sector. We had succeeded in mainstreaming gender.

  • 11 See note 6 above.
  • 12 Health Workers for Change is available from TDR/WHO Geneva, and both manuals are available from Wom (...)

26As a consequence of the evaluation a manual describing the process and the content of the TRHSP has been produced. The health systems assessment and planning manual: transforming reproductive health services11 (with the companion manual Health Workers for Change) describes: the methodologies used; what information this method gives; who the target group for each method is; how the information helps in understanding the impact of inequalities between men and women on the health system; how the methodology involves people in the process of change; how managers can use this information; how to implement the methodology; how to analyse the data; and a section on inadequacies so that people can adapt and improve the methods in subsequent applications. These two manuals12 are available and provide a base for people wishing to incorporate gender into health systems development.

27As has been emphasised during the paper it is the combination of the data collection and the process of that collection which makes this an intervention which builds understanding and develops individuals and institutions. The role of individuals to facilitate this is important. Incorporating a gender perspective into planning requires a significant level of interest in the issue on the part of planners and health service managers. South Africa was fertile ground for this kind of intervention in that the entire country at every level was focused on inequality as a consequence of the removal of the apartheid government. The impetus of the ICPD (International Conference on Population and Development) document provides a similar, if less forceful, focus internationally. However the relevance of gender to health planning and how it can assist planners do their usual job is required in this case study. WHP was able to facilitate this by capitalising on the political process in South Africa. Building this elsewhere requires an a priory investment. In order to foster this knowledge WHP has undertaken another initiative in conjunction with WHO and the FXB Centre (Fondation François-Xavier Bagnoud) at the Harvard School of Public Health. We have initiated a three week training course in gender and reproductive health with a very strong focus on health systems. In this course senior health managers, aid agency and NGO staff are taken through modules on: gender and health; human rights; policy; using research data; and on health systems development. These all interrelate and through this a cadre of health workers who are able to apply gender analysis to health systems development is graduating. It is hoped that this cadre of people will be able to act on and carry forward the ideas and momentum that can be generated by an intervention such as the one described. This has been a limitation on the impact of the TRHSP in South Africa.

28In this paper I have tried to illustrate that incorporating gender into health programming and health system development is possible. Further, that gender analysis can be used as a tool for improving service quality. In addition tools have been described which can be used by institutions or individuals who wish to do so.




1 United Nations Division for the advancement of women, World Health Organisation, United Nations Population Fund, Commonwealth Secretariate, Tunisian Ministry of Women and Family. Women and Health Mainstreaming the Gender Perspective into the Health Sector expert group meeting report 1998.

2 Jahan R., Ahmad N., Hunt J., Klugman B., Schalkwyk J. and Silberschmidt M. Gender equality in sexual and reproductive rights and health. OECD/DAC Working Party on Gender Equality. 1998.

3 The agencies reviewed were AusAID, BADC, CIDA, DANIDA, GTZ, Irish Aid, NZODA, Sida, DFID and USAID.

4 This has been described in various publications: S. Fonn, M. Xaba, K. S. Tint, D. Conco, S. Varkey, T. Maluleke, B. Klugman. Reproductive Health Services Transformation Project – an example of mainstreaming gender in health systems development. Innovations 1997; 5: 15-30.
S Fonn. M. Xaba. K Tint. D Conco. S Varkey. Maternal Health Services in South Africa South African Medical Journal 1998; 88: 697-702.
Sharon Fonn, Makhosazana Xaba, Kin San Tint, Daphney Conco, Sanjani Varkey. Reproductive health services from rhetoric to implementation: South African experience. Reproductive Health Matters 1998; 6h22-32.
Fonn S., Xaba M., Tint K S., Conco D., Varkey S. Transforming reproductive health services: results from a multi-faceted research and implementation process in three South African provinces. Forthcoming Women’s Health Project.

5 Fonn S and Xaba M. Health Workers for Change. WHO/WHP Geneva 1996.

6 The findings of these research projects will be published shortly in Health Policy and Planning.

7 Lund F. Mid term review of the Reproductive Health Transformation Project. Durban May 1997.

8 See note 5 above.

9 Tint, K. S., Varkey, J.-S., Fonn, S., Xaba, M., Conco, D. and Klugman B. Health systems assessment and planning manual: Transforming Reproductive Health Services. Women’s Health Project, Department of Community Health, University of the Witwatersrand March 1998.

10 Kay B., Germain A. and Bangser M. The Bangladesh Women’s Health Coalition. Quality 3: The Population Council. 1991.

11 See note 6 above.

12 Health Workers for Change is available from TDR/WHO Geneva, and both manuals are available from Women’s Health Project P. O. Box 1038 Johannesburg 2000.

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Medical Doctor, Deputy Director, Women’s Health Project, Department of Community Health, University of Witwatersrand, South Africa.


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