Gender Management Systems in the Health Sector
Professor Stephen A. Matlin
Human Resource Development Division, Commonwealth Secretariat, London
Gender Management Systems (GMSs) are a powerful tool for mainstreaming gender within policies and programmes at all levels of government. The Commonwealth Secretariat has been pioneering the introduction of GMSs within the health sector as an innovative strategy for gender mainstreaming in this sector.
This paper examines the principles of GMSs and describes the processes that are being piloted in regions of the Commonwealth for the development of GMSs and for their implementation in the health sector.
In each region, the process has been initiated by conducting a workshop that brings together key stakeholders from a number of countries. The participants from each country comprise a cross section of senior policy-makers from the Health Ministry; leading representatives of the health professions; senior officials of the Ministry for Womens Affairs and Ministries of Finance or Planning; Parliamentary representatives with a health brief or able to influence health outcomes; and representatives of national and international non-governmental organisations. Following a series of seminars and discussions about the definitions of gender-related concepts and the nature and purpose of gender management systems, each country group develops a framework for a national action plan for the introduction of gender management systems in the health sector. Each national group undertakes that, following the end of the workshop, it will extend its membership to include all of the key stakeholders in the country, it will complete the detailed action plans and work to implement the GMS.
1. Women and Health - or Gender and Health?
During the last few decades, there has been a stepwise evolution in approaches to Women in Development (WID), followed recently by a more extensive shift to equality frameworks encompassed by Gender and Development (WID). Caroline Mosers book Gender and Development: Theory, Practice and Training" highlights six shifts in policy approaches towards women, as summarised in Table 1.
The final shift, from WID to GAD, acknowledges the different life courses and impacts of development policies on men and women. It recognises that gender is not merely biologically defined, but is a social construct that various according to time, place and local circumstances. Responding to this broader understanding, it seeks to incorporate gender perspectives into the mainstream policies and programmes, recognising that both women and men will ultimately gain from an approach that addresses their concerns in a comprehensive manner.
Table 1 Evolution of Approaches to Women in Development
1950s - 1970s
Linked to the model of social welfare. Focused on womens practical needs: maternal & child health schemes, nutrition, hygiene, education, food distribution programmes.
(UN Decade for Women)
Concentrated on womens strategic needs and advocated changing the economic, legal, social and ideological realities of womens situation. Equity projects encompassed consciousness-raising initiatives as well as practical action in areas such as legal rights and access to credit.
Perceived issue as underdevelopment rather than gender subordination. Aimed to improve material conditions of womens lives, enabling them to catch up with men through income generation, skills training, access to marketing and credit.
Harnessed womens labour to make development more efficient: assumed that womens increased economic participation would lead to increased equity.
Focuses on strategic needs identified by women at the grass roots. Concentrates more on changing practices and enabling people to define their own agendas, rather than on changing laws, rules, or frameworks.
Recognises different gender roles and stresses need for both men and women to have access to and control over resources and decision-making processes. Integrates gender awareness and competence into mainstream development.
This evolution of approaches to gender issues in general has been matched by a developing appreciation of gender factors within specific sectors, including health. There are many countries where the population - both men and women - suffer ill health due to poverty, disease, and ignorance. Throughout much of the world, and despite substantial progress in some areas, it is generally true that women continue to have poorer health than men. A primary prevention framework suggests that since women's health problems are mainly caused by societal arrangements, women's health is most effectively promoted through changes in societal structures and societal attitudes towards women.
At the same time, there is evidence from many countries that men suffer ill-health in a number of specific areas - such as those related to reproduction, work- and environment-related diseases and nutritional and lifestyle-related diseases, - which also need to be specifically addressed by alterations in systems and institutions.
Thus, there has been growing recognition of the need for a comprehensive gender perspective that acknowledges the different health experiences and health care needs of women and men. This has been a prominent feature of a series of world conferences - notably Cairo (1994) and Beijing (1995) - and is reflected in the strategies advanced in the Commonwealth Plan of Action on Gender and Development (1995), the recommendations of the Women and Health programme advocated by the Eleventh Commonwealth Health Ministers Meeting (1995), and the 5th Womens Affairs Ministers Meeting of the Commonwealth (1996).
In the aftermath of these major international conferences and the endorsement of the general principles and broad policy statements on gender and health by the overwhelming majority of governments, the remaining challenge is to translate these principles into practical activities. These must be aimed at significantly improving the health status of women and men, by fully recognising their different health perspectives and needs and by instituting in health systems the mechanisms that will comprehensively and equitably address these differences.
2. Gender Management Systems (GMSs): the Commonwealth initiative
The Commonwealth is pioneering a new approach to gender mainstreaming, both at the national level of government as a whole and within individual sectors, through the innovative mechanism of Gender Management Systems (GMSs).
At the national level, governments are being assisted to develop systematic approaches to the integration of gender issues and concerns into their whole machinery. This processes is initiated by a visit to each country by a Secretariat team, which works closely with the political leaders, cabinet and senior government policy makers to provide sensitisation and strategic support.
3. Gender mainstreaming in health - Challenges and opportunities
During the last few decades, there has been a stepwise development in approaches to Women and Health. Whilst, in many countries, initiatives are now under way that address particular issues that have been highlighted (such as: the functions and status of women as health workers; the reproductive health needs of women; gender differences in the effects of aging), these are, at best, partial solutions that are being attempted within an overall framework that has not been designed for the purpose.
During the present period, many countries are introducing deep-seated reforms of the health sector that are designed to improve the relevance, sustainability, efficiency and cost-effectiveness of health systems. This provides an ideal opportunity to ensure that the new frameworks and mechanisms being put in place are fundamentally structured in such a way that they deal with gender as an explicit and integral component of the health system: i.e. to ensure that a Gender Management System is carefully designed to meet the needs of the country and is fully integrated into its health sector.
Mainstreaming gender in the health sector presents both major challenges and exciting opportunities. The health systems in many countries are in serious difficulties - structurally and financially - and it may seem a daunting task to add further demands to an already overburdened system. However, it is precisely because the health systems are in need of change and reform, which many countries are now struggling to accomplish, that there is a golden opportunity to ensure that the reform process addresses the problems of long-standing lack of equality between women and men, both as providers and as recipients of health care.
Another challenge is that the determinants of health go far beyond the confines of the health sector, and any attempt to tackle the problems of gender must therefore grapple with a variety of cross-sectoral issues at a number of different levels. Obtaining political commitment at the highest levels of Government is just as important as securing cooperation between different ministries and between the ministries, health professionals and other stakeholders. It is for this reason that coalitions of stakeholders must be mobilised in each country that include not only officials from the ministries of health, but also ministries such as finance and planning, and representatives from Parliament with an interest in the health sector; and that as well as representatives from the major health care professions such as the medical associations and nursing associations, there are also participants from the NGOs and community-based groups. The challenge is to generate first a dialogue, then a comprehensive plan, and finally a commitment to collective action. The opportunity is to create a new, vigorous and effective working relationship among the stakeholders, which can have a major impact on the health system in their country and, by serving as a model for future working relationships of a holistic kind, may even have an impact that reaches far beyond the issue of gender and health.
4. GMS principles and goals
A Gender Management System is an integrated web of structures, mechanisms and procedures put in place within a given institutional framework for the purpose of guiding, managing and monitoring the process of gender integration into mainstream culture, policies and programmes in order to bring about gender equality and equity within the context of sustainable development.
Within the health sector, a GMS should lead to health policies, systems and programmes that are based on principles of gender equity and which take full account of the contributions that women and men can make to health care provision and of their different needs and experiences in health. The GMS will contribute to improvement in the health status of both women and men in the country, and will ensure that both women and men have equitable opportunities to work in the health sector and to influence its policies and practices.
This requires institutional infrastructures that:
support womens participation at all levels of the health system;
take deliberate action to include women in decision-making for health;
encourage partnerships between men and women;
explicitly consider the health problems and health needs of men and women and address the ways - whether separate, combined, or complementary - that these can be met.
Health systems are, by their nature, dynamic rather than static, and need to be flexible and responsive to changes in the societal factors that impact on health - e.g. economic, social, environmental, lifestyle, nutritional. For evolving policies and systems to remain continuously responsive to gender differences, it is necessary to institute a framework in which each component of the system - ministry, medical services, health ancillary services - automatically includes mechanisms by which the gender perspectives and gender differences are made explicit. This requires gender balance in areas such as participation in policy making, consultations, teaching, research, and arranging the collection of gender-disaggregated data. The gender-responsive mechanisms must operate at all levels and in all sub-sectors - primary, secondary and tertiary health care, publicly- and privately-funded provision.
5. Inter-sectoral nature of GMS for Health
Gender issues go far beyond the health sector and discrimination in the health sector reflects a complex set of societal attitudes, customs and laws. This leads to the conclusion that a situation of real gender equality in health will only be reached when all the other factors outside the health sector have been fully addressed - a seemingly gargantuan task! However, the crucial point to recognise is that the intention is not to solve the whole problem at one point in time, but rather to design Gender Management Systems that are able to evolve. These management systems are not so much end-products as processes - and while these processes are taking place, improvements will be occurring simultaneously in many other sectors of society and government. What is most important therefore is that the GMS should be seen as a way of managing a fluid and changing picture, so it must be flexible and able to adapt to the changing status of gender, always able to move forward and take the next step towards the final goal.
6. GMS stakeholders and ownership
An important factor in developing a sustainable GMS is the issue of involvement and ownership. A health sector GMS requires close cooperation between many players both inside and outside the health sector, so that cooperation, both horizontally and vertically, is an essential characteristic for any GMS that is going to achieve results in practice.
In this regard, an interesting issue, which often attracts insufficient attention in debates about reform of the health sector, is the role of the private sector. In many countries, the private sector is the major provider of health care - at least for those who are insured or who can afford to pay. The question must be addressed of how to ensure that this sector can be included in a GMS that is intended to set comprehensive norms and practices for the whole health sector.
A related question concerns the roles of the NGOs within the Health Sector GMS. How can it be ensured that the NGOs, some of which may have a general concern for the health of people, whilst others may have a particular issue in focus and see their objective as being to maximise the effort to deliver one specialised type of service - are able to participate in both the setting and the implementation of GMS policies?
A Gender Management System must involve all key stakeholders and partners proactively, including national women's machineries; politicians and core government Ministries of strategic importance for the achievement of gender equality; local government; community-based organisations; and non-governmental organisations, including women's NGOs; research and educational institutions; trade unions; the media, inter-governmental organisations; the private sector; and civil society.
7. Development of a GMS
The construction of a national Gender Management System for the Health Sector and its incorporation into the health system in a country will necessarily be a complex operation involving a number of key stages:
Sensitisation of the key actors in the health field (government, health professionals, NGOs, supporting agencies) to the needs and opportunities;
detailed planning of a system which meets national requirements and which is set in the context of local economic and cultural factors;
generation of political commitment , leading to effective political action;
sustained effort at all levels to maintain momentum and ensure continued responsiveness and relevance of GMS.
The Commonwealth Secretariat, in collaboration with the Commonwealth Medical Association and with the support from sources including the Commonwealth Fund for Technical Cooperation and UNFPA, has undertaken a series of regional workshops to initiate the processes that will lead to the design and implementation of GMSs in each member country.
Each Workshop brings together senior representatives of the health sector: senior policy-makers from the Health Ministry; leading representatives of the health professions; senior officials of the Ministry for Womens Affairs and Ministries of Finance or Planning; Parliamentary representatives with a health brief or able to influence health outcomes; and representatives of national and international non-governmental organisations. The pattern of membership of a typical country team and its relationship to the national GMS strategy are illustrated in Figure 1. Participants are drawn from several countries in the region and the workshop runs for a period of 5 days of discussion, training and planning, with inter-country discussion groups providing an important mechanism for uncovering problems and sharing experiences.
The objectives are:
To increase the skills of senior officials and policy makers in gender analysis and gender planning;
To identify and explore key factors which contribute to major gender disparities in health within the participating countries;
To determine strategies to be used to influence the development of policies and programmes which will improve the health of both women and men;
To examine the concept of Gender Management Systems and initiate frameworks for developing national action plans to facilitate their implementation;
To secure the commitment of each national grouping of key representatives to take forward the planning, design and implementation of Gender Management Systems for the Health Sector after the end of the workshop;
To examine the opportunities for mechanisms that can help to support and sustain the efforts to implement GMS initiatives through national, regional and international cooperation.
The structure and composition of each workshop is adjusted to local/regional circumstances and is illustrated by the generic workshop programme in Table 2. Following a series of seminars and discussions about the definitions of gender-related concepts and the nature and purpose of a GMS, each country group develops a framework for a national action plan for the introduction of GMSs in the health sector. Each national group undertakes that, following the end of the workshop, it will extend its membership to include all of the the key stakeholders in the country, and will complete the detailed action plans and work to implement the GMS.
The concept of Gender Management Systems has been warmly received. GMSs, adapted to the specific conditions and requirements of each country, are seen as a highly attractive and potentially very effective mechanism for gender mainstreaming in the health sector.
The Commonwealth Secretariat is working with its partners to identify mechanisms that can help to support and sustain the efforts to implement GMS initiatives through national, regional and international cooperation.
A number of important issues can be highlighted that have emerged during the process of conducting the regional GMS workshops:
1. Although there is a widespread awareness of the need for progress on issues affecting womens equality, including health, gender concepts are generally poorly understood even by many senior officials and leaders of organisations in the health sector.
2. It is necessary to distinguish clearly between programmes that have evolved specifically to address womens issues and the new initiatives to address gender equality. Without this, there is a tendency to confuse the two, to fail to appreciate their differences, and to convert the former into the latter merely by substitution of terms referring to women by those referring to gender, without any effort to change the underlying perspectives or objectives. Some countries have made substantial strides with advancing the position of women and have begun to make the transition in terminology to the broader issues of gender equality. However, there often remains a gulf between rhetoric and the reality of practice on the ground.
3. Beyond the above confusion, there is sometimes initial reluctance to adopting the concepts of gender equality and gender mainstreaming from workshop participants. This reluctance can come from a number of quarters, including individuals who are resistant to changes that they feel threaten their own status, and those who have been fighting vigorously for womens rights and fear that the new approaches may lead to a slowing of the pace of progress or even a loss of ground.
4. The presentations, discussions and group activities during the first two days of each workshop are therefore vital in providing mechanisms for resolving these tensions and apprehensions and in establishing a common platform of definitions, vocabulary and agreed objectives. Only when this has been achieved and the participants have accepted the new gender perspectives can the second phase proceed of discussing the detailed processes and structures required for a GMS. By this means they agree to define themselves as stakeholders and accept the commitments implicit in developing the frameworks for the National Action Plans that they will promote and carry forward.
5. The presence of participating groups from several countries within a region is not merely an efficient device for simultaneously carrying out the process of preliminary sensitisation and initiating of national GMS activities. It also provides a very powerful tool for identifying and dismantling barriers to change. Thus, within each national group, there is a normal tendency for the established hierarchy to dominate, with group meetings chaired by the most senior official or politician present. More junior members often feel inhibited from fully expressing their views, challenging the prevailing orthodoxy or disagreeing with those in authority in their own country. Cross-country discussion groups, involving either randomising of the different nationalities present or combining of officials from similar positions, can help to remove inhibitions and, through sharing of perspectives and problems across boundaries, lead to uncovering of hidden problems and taboo areas.
6. Nearly all those who have participated in these GMS workshops have enthusiastically embraced the process and have departed with strong commitments to carry forward the processes in their countries.
7. Initial follow-up work with individual countries has, as anticipated, revealed that the pace of progress is extremely variable. The factor that emerges as the single most important determinant of progress is the degree of political commitment at the highest levels: the process is unlikely to proceed beyond a few token steps unless the Health Minister and senior cabinet colleagues accept to become stakeholders and product champions.
8. In terms of the requirements for further external support for the initiation, development and implementation of Gender Management Systems for the health sector, the most critical factors that have been identified in this work are:
the need to develop and provide training materials on gender concepts in general and on gender and health issues in particular;
the need for advocacy directed to national governments and other stakeholders, to build commitment and to encourage the widest possible participation in the GMS process;
the need for continuing contact with the groups working to build and implement the national frameworks, in order to encourage them and sustain the momentum once the process has begun.
Figure 1 Development of Gender Management Sysems for the Health Sector: National stakeholders (pdf file)
Table 2 Programme for A Regional Workshop to Initiate National GMS Frameworks
·Opening and Introductory Remarks
·Review of workshop programme, objectives, expected outcomes
·Discussion: background; need for gender mainstreaming in health sector
·Group work: establishing definitions of principle gender concepts:
- gender; gender analysis; gender sensitivity; gender equality; gender planning; gender integration; gender mainstreaming
·Presentation of results
·Group activity: Preparation of country profiles on status of gender and health
·Presentation and discussion on the status of gender integration in the health sectors of participating countries.
·Feedback : Summary and review of previous day's discussions
·Gender in the Context of Ethics and Human Rights
·Introduction to Gender Management Systems (Interactive session):
-Definition of GMS
-Vision , mission, goals, objectives of GMS in the health sector
-Stakeholders in a GMS : roles and responsibilities
·Priority setting: Setting health sector priorities and including the gender dimension (Group work by country and discussion)
·Implementing a GMS in the Health Sector
- priority setting
- monitoring and evaluation
·Discussion and clarification of issues involved in implementation of GMS in the health sector
·Continuation of discussion of priority issues
·(Interactive session) Identification of:
- stakeholders in health sectors of participating countries
- levels/methods of interaction between stakeholders within health sector
- stakeholders in other public sectors and the private organisations
·Group activity: Impact of GMS on priority issues in health sector, including policies, programmes, service delivery, recruitment and training, terms and conditions of service, health information systems, health service financing
·Presentation and discussion of group work
·Group activity: discussion of GMS relating to: the identification of available resources; monitoring and evaluation
·Group work: each country group commences preparing an outline for implementation of a GMS, via development of a National Action Plan in the health sector, addressing process, content, structures and mechanisms
·Reports of progress and problems
·Group work continued
·Finalisation of group work
·The Way Forward: Implementing the plan; Evaluating the process; Role of national governments; Role of regional and international agencies
·Closure and final remarks
The views presented in this paper are those of the author's and do not necessarily reflect the views and position of the United Nations.