Persistent and entrenched gender inequalities mean that women often experience lower human development outcomes than men. There are strong pressures on both men and women to behave in certain ways, and clear structural inequalities based on sex. A gender perspective on human development helps address the underlying social factors perpetuating gender inequality. These factors result in women’s disproportionate ill health, lower education levels and poor access to services. A gender perspective is rooted in a rights-based approach, and this chapter of the report is closely linked to the human rights chapter. As there is so much focus on women’s sexual and reproductive roles, here the health and SRH sections are merged.
Women’s vulnerability to poor human development is affected by the intersection of their class, gender, and other social statuses (Iyer et al., 2008). Interventions are therefore most effective if they address the multiple dimensions of inequality that women face. This can be achieved with, for example, improved access to post-primary education, economic and political opportunity and the guarantee of women’s safety.
Health, education and WASH services sometimes provide better services to men than to women. Women face individual-level barriers to access, such as girls being required to stay at home to care for relatives, and structural barriers, such as being less able than men to finance under-the-counter payments or bribes (Govender & Penn-Kekana, 2008). Women’s rights to participate in public life and to make decisions for themselves are not always supported by laws or informal institutions. Violence against women and girls remains a systemic problem globally, with multiple human development effects such as mental and physical health problems and school dropout. Women’s care roles and domestic duties also remain important mediating factors affecting their human development, limiting their access to paid work and schooling, and taking up a disproportionate amount of women’s ‘free’ time.
Health and Sexual and Reproductive Health
The health of both men and women can be placed at risk due to prevailing notions of manhood and masculinity. These notions stem from patriarchal structures and social norms (Barker et al., 2007). Programme evaluations suggest that men and boys who adhere to more rigid views of masculinity are more likely to have used violence against a partner, to have had a sexually transmitted infection, to have been arrested and to have used substances (Barker et al., 2007). In general, men are poorer users of healthcare systems than women, and may find it harder to express vulnerability (Govender & Penn-Kekana, 2008). Men and women sometimes receive differential care for similar illnesses, owing to differences in health-seeking and provider behaviour (Govender & Penn-Kekana, 2008; Berlan & Shiffman, 2012). Women also carry the main burden of caring for sick relatives and household members (Esplen, 2009). This may undermine their rights and limit their opportunities, for example when girls drop out of school to care for family members (Esplen, 2009).
Many countries do not support women’s rights in their legal and policy frameworks. This affects SRHR in particular. Restrictive laws and policies on access to contraception and abortion have significant human development costs, particularly when women seek unsafe abortion. Globally, forty per cent of women live in countries with restrictive abortion laws (Rasch, 2011). Unsafe abortion results in a large number of health consequences, including death. Poorer women are more likely to seek an unsafe method than richer women (Rasch, 2011).
Female Genital Mutilation/Cutting (FGM/C) is a serious violation of women’s human rights. It is a form of violence against women and girls held in place by powerful social norms (the customary or informal rules that govern behaviour in groups and societies). Up to nine out of ten women in parts of North and West Africa have undergone FGM/C (Berg & Denison, 2013). FGM/C causes a wide range of health complaints such as chronic pain, infections, fistula and difficulty in passing urine and faeces, severe psychological and emotional trauma, and mortality, (Berg & Denison, 2013). A recent systematic review confirms that, as there is no medical or religious requirement for FGM/C, its continuation and prevention are upheld by cultural practices and beliefs. Successful interventions have included legislation; awareness raising campaigns; and working through religious leaders and community health practitioners (Berg & Denison, 2013). More generally, violence against women is rooted in entrenched gender inequalities and must be tackled through community-based interventions that raise public awareness and challenge social norms, rather than by focusing on individuals (Garcia-Moreno et al., 2006).
Women’s empowerment is well-evidenced to increase use of maternal health services. A systematic review (Prost et al., 2013) suggests that women’s groups that focus on participatory learning and action are effective in reducing maternal mortality, neonatal mortality and stillbirths.
Iyer, A., Sen, G., & Östlin, P. (2008). The intersections of gender and class in health status and health care. Global Public Health, 3(S1), 13-24.
Different axes of social power relations, such as gender and class, intersect. This paper provides a comprehensive literature review, suggesting that the impacts of single dimensions of inequality change significantly when they intersect with other inequalities. Studies confirm that measures of socio-economic status cannot fully account for gender inequalities in health. This strongly suggests that economic class should not be analysed by itself, and that apparent class differences can be misinterpreted without gender analysis.
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Govender, V., & Penn-Kekana, L. (2008). Gender biases and discrimination: a review of health care interpersonal interactions. Global public health, 3(S1), 90-103.
This comprehensive literature review shows that gender inequality, either alone or in combination with other inequalities, influences interactions between health care providers and patients. This negatively affects both women and men. Much of the gender bias reflects societal norms, and so needs to be tackled at the societal level. The health system is a site where gender norms can be challenged.
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Barker, G., Ricardo, C., & Nascimento, M. (2007). Engaging Men and Boys in Changing Gender based Inequity in Health: Evidence from Programme Interventions. Geneva: WHO / Promudo.
How do social constructions of masculinity affect health equity? What kinds of interventions can produce behavioural change in men and boys? This review of 58 evaluations assesses the effectiveness of programmes seeking to engage men and boys in achieving gender equality and equity in health. The most effective programmes are those that include gender-transformative elements, which seek to change the social construction of masculinity and promote more gender-equitable relationships, and those that are integrated with wider community outreach or mobilisation initiatives.
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Esplen, E., (2009). Gender and care: overview report. Brighton: Institute of Development Studies.
How can we move towards a world in which individuals and society recognise and value the importance of different forms of care, but without reinforcing care work as something that only women can or should do? Three approaches are explored: challenging gender norms to encourage more equal sharing of unpaid care responsibilities between women and men and a less gender- segmented labour market in the care professions; greater recognition of the huge amount of unpaid care work performed and the value of this work; and the social policy measures needed to ensure that care-givers are not disadvantaged because of their unpaid care responsibilities. The final section of the report considers measures to better protect the rights of paid carers – to decent working conditions, minimum wages, basic benefits and protections, and the freedom to form associations and trade unions.
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Rasch, V. (2011). Unsafe abortion and postabortion care–an overview. Acta Obstetricia et Gynecologica Scandinavica, 90(7), 692-700.
This article describes how restrictive laws are associated with the occurrence of unsafe abortion. It is based on a near systematic review of articles from 2005 to 2010, and includes 67 publications. It describes providers and methods used to obtain unsafe abortion and the associated health consequences. Finally, it discusses post-abortion care as a means to address unsafe abortion. The most effective means of reducing unsafe abortion is legal change in restrictive laws, although this does not tackle anti-abortion attitudes in healthcare providers, or social norms.
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Berg, R. C., & Denison, E. (2013). A tradition in transition: factors perpetuating and hindering the continuance of female genital mutilation/cutting (FGM/C) summarized in a systematic review. Health Care for Women International, 34(10), 837-859.
This systematic review examines 21 studies. Six key factors underpin the continuance of FGM/C: cultural tradition, beliefs on sexual morals, marriageability, religion, health benefits, and perceptions of male sexual enjoyment. Four key factors are perceived to hinder FGM/C: health consequences, it not being a religious requirement, it being illegal, and the rejection of FGM/C in host society discourse. The results show that FGM/C is used as a tool of social control and control of women’s sexuality.
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Garcia-Moreno, C., Jansen, H. A., Ellsberg, M., Heise, L., & Watts, C. H. (2006). Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. The Lancet, 368(9543), 1260-1269.
This study estimates the prevalence of IPV by conducting standardised population-based household surveys in ten countries between 2000 and 2003 on women aged 15 to 49. The findings confirm that physical and sexual partner violence against women is widespread. The reported lifetime prevalence of physical and sexual IPV, or both, varied from 15 to 71 per cent and from 4 to 54 per cent in the past year. In all but one setting, women were at far greater risk of physical or sexual violence by a partner than of violence from other people.
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Prost, A., Colbourn, T., Seward, N., Azad, K., Coomarasamy, A., Copas, A., … & Costello, A. (2013). Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. The Lancet, 381(9879), 1736-1746.
What are the effects of women’s groups practising participatory learning and action, compared with usual care, on birth outcomes? This paper conducts a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal to assess the effects in low-resource settings. The results show that exposure to women’s groups was associated with a 23 per cent non-significant reduction in maternal mortality, a 20 per cent reduction in neonatal mortality, and a 7 per cent non-significant reduction in stillbirths. The authors conclude that women’s groups practising participatory learning and action are a cost-effective strategy to improve survival, when at least a third of pregnant women are participating.
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Gender gaps persist in education in a number of ways: sex disparities in enrolment or completion; girls experiencing violence at school; informal institutions reinforcing gender stereotypes; self-esteem; and aspirations. Schools are spaces that replicate wider societal power dynamics and gender roles; along with formal learning, they also transmit social expectations and attitudes (Reilly, 2014).
In general, girls’ access to school is responsive to external variables – the higher the distance or cost, the fewer the girls that go to school (Glick, 2008). Removing school fees has had a significant impact, increasing the numbers of girls in school. Boys tend to be sent to school even when there are high costs. Other factors also have more impact on whether girls, as opposed to boys, can access schooling. These factors include safety when walking to school, separate school toilets for boys and girls, and demand for domestic work (Glick, 2008). The policy implications are that schools closer to home, and reduced costs, will have disproportionately greater positive effects on girls’ education.
Violence keeps girls (and boys) out of school (Reilly, 2014). Gender-based violence at school or on the way to school can include corporal punishment, sexual harassment, transactional sex, and child-to-child violence. Sexual violence is, in the main, perpetrated by male teachers on female students, often in exchange for good grades (Reilly, 2014). Poorer girls are more vulnerable than others to sexual abuse if they cannot pay for school-related expenses, or are at risk of failing exams. When girls do not want to take up this kind of relationship, they often drop out of school to avoid it.
The Young Lives study shows that gender biases work against both boys and girls, and are often context-specific, varying with location and age of the child (Dercon & Singh, 2013). Gender inequalities manifest in different ways in education, and it is important for policymakers to target the specific biases in each community (Dercon & Singh, 2013).
Glick, P. (2008). What policies will reduce gender schooling gaps in developing countries: Evidence and interpretation. World Development, 36(9), 1623-1646.
This paper uses an economic model of why parents might invest in children’s human capital, and how policy can change this. The evidence is mostly drawn from econometric analyses and some randomised experiments. Girls appear to benefit more than boys from gender-neutral policies such as increasing the general quality of schooling. A common finding is that girls’ education is constrained more than boys’ by the distance to school, and is more sensitive to the direct and indirect costs of schooling. Gender-targeted interventions have also been very effective for girls, and may be more expedient where there are large gender gaps. In particular, household subsidies and financial incentives to teachers for enrolling girls are successful. Gender-targeted interventions are broadly more effective for girls than gender-neutral ones.
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Reilly, A. (2014). Adolescent girls’ experiences of violence in school in Sierra Leone and the challenges to sustainable change. Gender & Development, 22(1), 13-29.
How is gender-based violence in schools reduced? Plan UK have addressed violence in Sierra Leone through an integrated programme for adolescent girls focusing on four core areas: the attainment of a quality basic education, freedom from violence, economic empowerment and the enjoyment of sexual and reproductive health and rights. Physical and sexual violence is common for girls in schools, and parents and school boards often turn a blind eye. Plan has found that a holistic approach has helped reduce violence, through girls’ and boys’ rights clubs, teacher training, community discussion of the issue, engaging men and boys, and new school regulations.
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Dercon, S., & Singh, A. (2013). From nutrition to aspirations and self-efficacy: gender bias over time among children in four countries. World Development, 45, 31-50.
The Young Lives longitudinal study collects data from 12,000 children across Ethiopia, India (Andhra Pradesh), Peru, and Vietnam. This paper uses the data to assess gender gaps in nutrition, education, aspirations, subjective well-being, and psychosocial competencies. The paper finds that while gender gaps in child wellbeing persist, there is no overall trend in favour of boys, and trends vary considerably with location and age. It is suggested that gender inequalities in one dimension can perpetuate inequalities across different dimensions.
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Poor and rural women and girls bear the brunt of the consequences of unsafe water and inadequate sanitation (Kevany & Huisingh, 2013). Poor WASH services have disproportionately negative effects on women and girls as they use these services the most (UNICEF, 2012). Girls and women are often responsible for fetching water for the household, with many having to walk long distances every day (UNICEF, 2012). Any risks associated with travelling, or travelling after dark, therefore apply disproportionately to women. Women often have to wait until after dark to defecate if there are no suitable facilities, which leaves them open to health problems and increased risk of sexual assault (Fisher, 2006). Shortages of water or inability to collect enough sometimes results in repercussions, such as domestic violence against women (Kevany & Huisingh, 2013).
There is a culture of embarrassment and taboos surrounding menstruation (Mahon & Fernandes, 2010). In parts of South Asia, it is common for women to be considered ‘polluted’ while menstruating, and for them to restrict their public and private interactions (Mahon & Fernandes, 2010). Around the world, girls often miss several days of school while they are menstruating. This is usually due to the lack of privacy and water in latrines for washing themselves and menstrual cloths, and because of anxiety and social stigma (Mahon & Fernandes, 2010). Access to facilities is not enough to improve menstrual hygiene; cultural norms must also be taken into account (Mahon & Fernandes, 2010).
It is well-established that a gender perspective significantly improves WASH programmes’ effectiveness and sustainability, improves women’s lives, and improves health in the wider community (Fisher, 2006).
Kevany, K., & Huisingh, D. (2013). A review of progress in empowerment of women in rural water management decision-making processes. Journal of Cleaner Production, 60, 53-64.
What are the links between water infrastructure, water policies, processes and protections, and women’s leadership and decision-making? This comprehensive literature review takes the approach that privatisation, climate change, and cost negatively affect women’s access to water. It identifies seven key issues that affect women: 1) water insecurity contributes to poor mental well-being; 2) spiritual and physical well-being are undermined by eco-disequilibrium and disrespect; 3) gender violence is associated with unsafe and inaccessible water; 4) climate change, inconsistencies in rainfall, harvests, community income, and global pressures in commodity trading have impacts on rural well-being and gender equality; 5) legislation that prohibits women’s entitlement to resources and land creates problems; 6) gender inequality is maintained by political philosophies, policies and practices and 7) strategies to privatise and commercialise water are rapidly expanding. The paper then outlines the international policy principles responding to these issues.
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UNICEF. (2012). Water, Sanitation and Hygiene. 2012 Annual Report. UNICEF.
This annual report outlines UNICEF’s work and progress on WASH globally. It contains chapters on emergency coordination, the environment and climate change, gender and monitoring.
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Fisher, J. (2006). For her it’s the big issue: putting women at the centre of water supply, sanitation and hygiene (Water, Sanitation and Hygiene: Evidence Report).
How does women’s involvement in WASH create benefits? This paper uses global case studies to build a case for women’s involvement. It provides evidence that shows that women’s involvement in WASH improves efficiency and effectiveness of the interventions; promotes changes in hygiene practices; changes traditional gender roles; increases opportunities for women’s employment; increased girls’ school attendance; reduced child mortality; and increased women’s safety.
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Mahon, T., & Fernandes, M. (2010). Menstrual hygiene in South Asia: a neglected issue for WASH (water, sanitation and hygiene) programmes. WaterAid.
Why is menstrual hygiene management not generally included in WASH initiatives? What are the social and health impacts of this neglect on women and girls? Women are often excluded from decision-making and management of WASH programmes, which compounds the reluctance to speak openly about menstruation. This paper provides examples of successful approaches to tackling menstrual hygiene in WASH in the South Asia region. It is supported with a case study of WaterAid in India.
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- Kangas, A. (2011). Female Genital Mutilation/Cutting and gender indicators (GSDRC Helpdesk report).
- Kangas, A., Haider, H., Fraser, E. & Browne, E. (2014). ‘Sexual and reproductive health and rights’, in GSDRC Gender Topic Guide.
- HEART. (2011). Safe transport for girls. (HEART Helpdesk report).
- HEART. (2013). Community-led total sanitation in Africa (HEART Helpdesk report).
- HEART. (2013). Women’s literacy and the links between maternal health, reproductive health and daughter education (HEART Helpdesk report).
- HEART. (2014). Family planning topic guide.
- MacAslan Fraser, E. (2012). Risks, effects and prevalence of VAWG (GSDRC Helpdesk report).
- Mcloughlin, C. (2011). Impact evaluations of programmes to prevent and respond to violence against women and girls (GSDRC Helpdesk report).
- Miller, J. (2013). Female Genital Mutilation (HEART multimedia resources).
- Tomlinson, M. (2014). Maternal mental health in the context of community based home visiting: ‘Acting urgently, building slowly’ (HEART multimedia resources).
- UNFPA-UNICEF (2013). UNFPA-UNICEF Joint Programme on Female Genital Mutilation/Cutting: Accelerating change 2008-2012. Final report (Volume I). New York.