M&E of Gender and Health

1. M&E of Gender and Health

2. Learning Objectives • Define gender & related terms • Identify why gender is important to Health outcomes & programming • Identify criteria for how gender is addressed in programs • Identify donor gender M&E requirements • Identify measures of different gender factors • Apply gender indicators to programs to integrate gender into M&E

3. Activity: Vote with your feet!1 This will help us explore gender concepts Our own beliefs on gender make a difference We need to keep this in mind when we ask people to address gender 1 USAID Training of Trainers: Gender and Reproductive Health 101

4. Definitions1 Sex:Biological difference between males & females • Universal for all human beings • Unchanging • Determined at birth • Gender:Beliefs about the appropriate roles, duties, rights, responsibilities, accepted behaviors, opportunities and status of women and men, in relation to one another • Constructed by society • Differs between cultures • Dynamic, changes over time • Acquired 1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector

5. Definitions1: Gender Equality • Equal treatment of women and men in laws and policies, and equal access to resources and services within families, communities and society at large. • Comes from written and unwritten norms, rules, laws and shared understandings. • Pervasive across societies • Most prevalent form of social inequality • Cuts across other forms of inequality such as class, caste, race and ethnicity. 1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector

6. Definitions1: Gender Equity • Stress is on fairness • Refers to the absence of unfair/avoidable or preventable differences in health between women and men • Different/unequal needs of & barriers affecting women and men in accessing/benefiting from health-care programs must be considered in program resource allocation & design • Includes and should be inherent to program monitoring and evaluation 1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector

7. Gender inequality is the most pervasive form of social inequality Gender inequality cuts across all other forms such as class, caste, race and ethnicity1 1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector

8. Why do we think about gender & health? • High gender equality is associated with: • Low child mortality, low rates of stunting and wasting • Higher rates of health care utilization for maternal, child, and reproductive health services (including STI/HIV) • Lower rates of maternal mortality • Lower rates of gender-based violence • High gender inequality is associated with lower health outcomes

9. Gender and HIV/AIDS Programming “Gender equality must be at the core of all our actions. Together we must energize the global response to AIDS, while vigorously advancing global equality” -Michel Sidibé, UNAIDS Executive Director “Gender-related inequalities compromise the health of women and girls and, in turn, affect families and communities. Gender-based violence is a serious and widespread human rights violation, as well as a key driver of the HIV epidemic.” -Deborah von Zinkernagel, Principal Deputy Global AIDS Coordinator (OGAC)

10. Gender and HIV/AIDS • Numerous studies document the relationship between gender inequality and HIV/AIDS outcomes: • Increased risk of transmission/higher prevalence • Less knowledge about HIV/AIDS • Higher levels of risk-associated behaviors due to vulnerability • Association with the incidence of intimate partner violence, which in turn influences the risk of HIV • Less utilization of programs & services

11. Gender inequalities & HIV/AIDS Programs1 • Women may not have the power to negotiate condom use with partners • So: risk reduction counseling that does not empower women may be less effective than programs providing skills to negotiate safer sex • Women often fear that abandonment or violence would occur if they disclosed their HIV status to their partners, and this is a barrier to HIV testing. • In many societies, women need permission from partners and families to seek health care, which reduces their access to health services, including those for HIV. 1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector

12. Gender and health programming:Gender integration continuum1 1 USAID Training of Trainers: Gender and Reproductive Health 101

13. Gender norms: accommodating or transformative?

14. At a New Delhi bus stop

15. Gender norms: accommodating or transformative?

16. Gender-based analysis1 • Understanding how experiences of women and men differ and are similar • Considers roles and responsibilities of men & women have in society re: power & decision-making • Health—differences in • Health status & determinants • Care utilization in view of needs • Ability to pay for services • Participation of women & men in health management • Bottom line: GBA reveals influences, omissions & implications of work in health policy, programming & planning. 1PAHO (2009). Guidelines got gender-based analysis of health data for decision making. PAHO.

17. Data required for GBA1 • Quantitative • Collecting, reporting & analyzing health indicator and surveillance data that are disaggregated by sex • Data on socioeconomic determinants of health, health status, outcomes , treatments used, incidence of morbidity & mortality, decision-makers, formal & informal health providers all collected and reported by sex • When possible, further disaggregation by geographic location, age, income, ethnicity & education 1PAHO (2009). Guidelines got gender-based analysis of health data for decision making. PAHO.

18. Data required for GBA1 • Qualitative • Information about personal experiences and perspectives • In depth information about motivations, attitudes, behaviors, choices etc. • Gets to the why of what quantitative data shows but often cannot explain • In this case, meaning and contextualization of gender roles & norms and why people act the way they do within the health system 1PAHO (2009). Guidelines got gender-based analysis of health data for decision making. PAHO.

19. Gender and M&E1: What? 11 USAID IGWG 2009, A manual for integrating gender into reproductive health and HIV programs

20. Gender and M&E: How? • Track and evaluate how well gender is addressed in the program • Demand for gender integration or mainstreaming as prerequisite for activity/program planning • Adhere to donor requirements • MDG, UNGASS, PEPFAR, UNICEF, UNWOMEN, GFATM, World Bank • Ensure that Gender is a part of M&E Plans, reflecting how gender is addressed in the program • Conceptual Framework, Logic model, indicators, data use

21. How can health systems address gender inequality? 1 • Sex-disaggregated data available • Collected or possible to collect, but not reported or left out by design • Quality & ongoing training involved for M&E system staff • Gender-focused monitoring & evaluations to measure progress and impact • Involvement of stakeholders at all levels 1Payne, Sarah (2009). How can gender equity be addressed through health systems? WHO, policy brief #12

22. Gender M&E & Health Policies • New international push led by USG, UN and others to address gender in programmatic streams • Demand for gender integration or mainstreaming as prerequisite for activity/program planning • Adhere to donor requirements • Now: gender should be part of M&E Plan, reflecting how gender is addressed in the program • Conceptual Framework, Logic model, indicators, data use • Who is demanding this? • USG Global Health Initiative, gender strategies of USAID, WHO, World Bank • HIV/AIDS: PEPFAR, UNAIDS, GFATM,

23. Gender and Health: The NewWorld-wide gender policy push1 • GHI 1st principle: Women, girls and gender equality • Sharpen focus on women & girls across USG global health efforts • Better outcomes for women, girls, families & communities • Country strategies • Conduct gender assessments & analyses • Provide narrative of gender implementation • Data disaggregated by sex & age for M&E of principle 1The United States Government Global Health Initiative, strategy document http://www.kff.org/globalhealth/upload/8128.pdf

24. New USAID Policy: Gender Equality and Female Empowerment GOAL: To improve the lives of citizens around the world by advancing equality between females and males, and empowering women and girls to participate fully in and benefit from the development of their societies. “We know that long-term, sustainable development will only be possible when women and men enjoy equal opportunity to rise to their potential. But today, women and girls continue to face disadvantages in every sector in which we work, and in other cases, boys are falling behind. With this policy, we can ensure our values and commitments are reflected in durable, meaningful results for all.” - USAID Administrator Rajiv Shah 1Gender Equality and Female Empowerment, USAID Policy (March 2012)

25. Gender and Health: The NewWorld-wide gender policy push • PEPFAR Gender Strategy1 • Gender integration in all program areas (prevention, care & treatment) • Programming along 5 strategic, cross cutting areas • USAID • New gender policy published March 2012 • New office: Gender equality & women’s empowerment 1http://www.pepfar.gov/strategy/ghi/134852.htm

26. Bilateral & Multilateral Agency Gender Strategies • WHO guiding principles • Addressing gender-based discrimination is a prerequisite for health equity • Leadership and ultimate responsibility for gender mainstreaming lie at the highest policy /technical levels of the WHO • Programs must analyze the role of gender and sex in areas of work and for developing appropriate gender-specific responses in all strategic objectives on a continuing basis • Equal participation of women and men in decision-making at all levels of WHO is essential in order to take account of their diverse needs • Performance management should include monitoring and evaluation of gender mainstreaming.

27. Bilateral & Multilateral Agency Gender Strategies • World Bank Group Gender Action Plan (GAP)1 • Rationale: Progress is lagging on women’s economic opportunities • Gender equality as smart economics, a 4 year plan that invests in the improvement of women's access to : • Jobs • Land rights • Financial services • Agricultural inputs • Infrastructure 1 World Bank. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTGENDER/0,,contentMDK:22386117~pagePK:210058~piPK:210062~theSitePK:336868,00.html

28. Bilateral & Multilateral Agency Gender Strategies • UNAIDS Action Framework for addressing women, girls, gender equality and HIV1 • Knowing, understanding &responding to the effects of the HIV epidemic on women/girls. • Translating political commitments into scaled-up action addressing rights & needs of women /girls in the context of HIV. • An enabling environment for the fulfillment of women’s and girls’ human rights and their empowerment, in the context of HIV. 1UNAIDS Action Framework: Addressing Women, Girls, Gender Equality and HIV1. The Action Framework (2009)

29. Measuring Gender • Gender differentials in HIV incidence, prevalence, and service utilization/delivery • Complex construct unlike many risk factors • Gender equality measures that have been used for quantitative analyses in HIV/AIDS studies • Norms for women and men, including attitudes about gender-based violence (GBV) • Beliefs about roles • Relationship factors • Women’s autonomy—decision making power in various areas • Independent access to economic resources • Experience of GBV

30. Example of complex gender equality measure: GEM Scale • Objective is to measure attitudes towards gender norms in intimate relationships among men • Used to predict multiple partners, family planning use, IPV & more in varied contexts (Brazil, India, China, Uganda etc.) • 24 items, 2 sub scales: Inequitable gender norms, Equitable gender norms • Requires asking 24 (can be more or less, depending on context) items, then performing a statistical analysis

31. Push for harmonized gender & health indicators • HIV field is ahead of the rest • New guides are coming in the next year • All part of the new demand for gender-aware programming streams, based on old knowledge • Harmonized indicators for violence against women and girls (guide on the resource list)

32. Areas of measurement:Gender in the context of HIV • Prevalence: gender differentials • Treatment: who gets treatment • Behavior: risk and care seeking • Knowledge: differentials in levels and patterns (what people know) • Gender Equality Measures (as on previous slides) • Programmatic Reach: target populations & coverage

33. Areas of measurement:Gender in the context of HIV • Gender Based Violence (GBV): prevalence and health service related • Stigma/Human Rights: Attitudes, laws and policies • Humanitarian Emergencies: situation for women and girls • Most at Risk Populations (MARPS): people in sex work • Orphans and Vulnerable Children (OVC)

34. Sample gender & HIV indicators • Prevalence % of young women who are HIV infected  Numerator: # of antenatal clinic attendees (aged 15–24) who test positive for HIV  Denominator: # of antenatal clinic attendees (aged 15–24) tested for HIV • Treatment % of adults &children with HIV known to be on treatment 12 months after initiation of ART. [disaggregated by sex & age] Numerator: # of adults and children still alive & on ART 12 months after initiating treatment Denominator: Total number of adults and children who initiated antiretroviral therapy who were expected to achieve 12-month outcomes

35. Sample gender indicators for health programs • Behavior: risk %of young people who have had sexual intercourse before age 15. [disaggregated by sex & age] Numerator: # respondents (15–24) reporting age at which they first had sexual intercourse as under 15 Denominator: Number of all respondents aged 15–24 years • Knowledge: % of people who correctly respond to prompted questions about preventing maternal to child transmission of HIV through ART & avoiding breastfeeding Numerator: # of respondents who say that HIV transmission from women who have tested HIV positive can be prevented by the mother taking drugs during pregnancy &avoiding breastfeeding Denominator: Total respondents in survey

36. Sample gender indicators for health programs • Gender Equality Measures Proportion of people who say that wife beating is an acceptable way for husbands to discipline their wives Numerator: Number of respondents in an area (region, community, country) who respond "yes" to any of the following questions: Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife if • she is unfaithful to him • disobeys her husband • argues with him • refuses to have sex with him • does not do the housework adequately Denominator: Total number of people surveyed

37. Sample Indicators • Programmatic Reach: % sex workers reached by HIV prevention programs [disaggregated by sex & age] Numerator: #of SWs who replied “yes” to both: • Do you know where you can go if you wish to receive an HIV test? • In the last twelve months, have you been given condoms (e.g. through an outreach service, drop-in center or sexual health clinic)? Denominator: Total number of respondents surveyed

38. Sample Indicators: Violence against women • Gender-based violence: %of health units that have documented & adopted a protocol for the clinical management of VAW/G survivors Numerator: # health facilities in the geographic region of study (country, region, community) reporting that they have both documented and adopted a protocol for the clinical management of VAW/G survivors Denominator: Total number of health units surveyed in the geographic region of study

39. Sample Indicators • Gender-based violence: Proportion of people who agree that rape can take place between a man and woman who are married Numerator: # of people who agree with the statement: When a husband forces his wife to have sex when she does not want to, he is raping her1 Denominator: Total number of people surveyed • 1 wording of this question needs to be carefully developed in order to use language that conveys the meaning within the cultural context

40. Sample Indicators • Gender-based violence: Proportion of youth-serving organizations that include trainings for beneficiaries on sexual and physical VAW/G Numerator: # of youth serving organizations that train beneficiaries on VAW/G issues. Training curriculums aimed at youth should include components covering: • Acts of VAW/G that affect youth along with the health and social consequences • How power, coercion and gender issues place youth at risk for VAW/G • Where are how youth can get help if they have experienced an act of VAW/G Denominator: Total # of youth serving organizations surveyed.

41. Sample Indicators • Most at Risk Populations (MARPS): %of female sex workers reporting the use of a condom with every client in the last month Numerator: %of FSW respondents who report always using a condom with every client in the last month Denominator: Total number of FSW respondents interviewed • Orphans and Vulnerable Children (OVC) % children under 18 who are orphans [disaggregated by sex, age, type of orphan Numerator: # children under 18 whose mother or father or both parents have died, as listed by survey respondents Denominator: All children under 18, as listed by survey respondents

42. Sample Indicators • HIV Stigma/Human Rights: %of people 15-49 expressing accepting attitudes towards people living with HIV [disaggregated by sex, age, & education Numerator: Number of women and men aged 15-49 who report accepting attitudes towards people living with HIV Denominator: All respondents 15-49 who have heard of HIV • Humanitarian Emergencies: # of women & girls reporting incidents of sexual violence per 10,000 population in the emergency area Numerator: # of incidents of sexual violence reported by women and girls in the specified period Denominator: The total camp/area/country population during the same time period.

43. Gender M&E Resources and Tools • MEASURE Evaluation gender website: www.measureevaluation.org/gender • VAW/G compendium • https://www.cpc.unc.edu/measure/publications/ms-08-30 • HIV indicator Registry (UNAIDS) • http://www.indicatorregistry.org/ • Go to: browse indicators—need to identify the gender indicators here • Gender scales • http://www.c-changeprogram.org/content/gender-scales-compendium/index.html • K4 Health IGWG Gender and Health Toolkit • http://www.k4health.org/toolkits/igwg-gender • New: Resource guide for gender data and statistics (WHO, IGWG/USAID & MEASURE Evaluation)https://www.cpc.unc.edu/measure/publications/ms-12-52 • Questions about Gender M&E? Ask the expert! • https://www.cpc.unc.edu/measure/our-work/gender/ask-the-gender-expert

44. Coming Resources • Gender and HIV menu of indicator options • Set of harmonized, agreed-on indicators • Technical advisory group of global donors & independent experts, including • UN: UNIFEM, UNAIDS, WHO, UNFPA • USG’s GHI: USAID, PEPFAR • World Bank, GFATM • Organized by areas of measurement-intersection of HIV & AIDS and gender

45. Activity: Integrating gender into M&E • Look at your program objective(s) & think about how gender can be addressed • Modify the activities that stem from that objective(s) • Using any of the indicator resources listed above in your group work projects: • Look at one or two of the resources & match an area of measurement that is relevant to your modified activities • Select 1-2 indicators that you can use to reflect how gender is addressed that can be tracked in both the outputs and outcomes (or modify ones already there) • Fill in a matrix for these indicators • If time allows, look for another area

46. MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) through Cooperative Agreement GHA-A-00-08-00003-00 and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership With Futures Group International, John Snow, Inc., Macro International Inc., Management Sciences for Health, and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States government.