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![Sample gender & HIV indicators
Prevalence
Percentage (%) of young women who are HIV infected
Numerator: Number of antenatal clinic attendees (aged 15–24)
who test positive for HIV
Denominator: Number of antenatal clinic attendees (aged 15–
24) tested for HIV
Treatment
Percentage (%) of adults & children with HIV known to be on treatment 12
months after initiation of ART. [disaggregated by sex & age]
Numerator: Number 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](https://image.slidesharecdn.com/genderme-150526180229-lva1-app6891/85/Gender-m-e-46-320.jpg)
![Sample gender & HIV indicators (cont.)
Behavior: risk
Percentage (%) of young people who have had sexual intercourse before age 15.
[disaggregated by sex & age]
Numerator: Number of 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
Percentage (%) of people who correctly respond to prompted questions about
preventing maternal to child transmission of HIV through ART & avoiding
breastfeeding
Numerator: Number 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 number of respondents in survey](https://image.slidesharecdn.com/genderme-150526180229-lva1-app6891/85/Gender-m-e-47-320.jpg)
![• Programmatic Reach
Percentage (%) of sex workers reached by HIV
prevention programs [disaggregated by sex & age]
Numerator: Number 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 SWs surveyed
Sample gender & HIV indicators (cont.)](https://image.slidesharecdn.com/genderme-150526180229-lva1-app6891/85/Gender-m-e-49-320.jpg)
![Sample gender & HIV indicators (cont.)
• Most at Risk Populations (MARPs)
Percentage (%) of female sex workers reporting the use of a
condom with every client in the last month
Numerator: Number 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)
Percentage (%) of children under 18 who are orphans
[disaggregated by sex, age, type of orphan]
Numerator: Number of 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](https://image.slidesharecdn.com/genderme-150526180229-lva1-app6891/85/Gender-m-e-53-320.jpg)
![Sample gender & HIV indicators (cont.)
• HIV Stigma/Human Rights:
Percentage (%) of people 15-49 expressing accepting attitudes towards HIV+
people [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:
Percentage (%) of women & girls reporting incidents of sexual violence per 10,000
population in the emergency area
Numerator: Number 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.](https://image.slidesharecdn.com/genderme-150526180229-lva1-app6891/85/Gender-m-e-54-320.jpg)
Uploaded byJacqueline Kobusingye
Gender m&e
This document provides guidance on integrating gender into monitoring and evaluation (M&E) of health programs. It defines key terms like sex, gender, gender equality, and gender equity. Gender is a social construct that influences health outcomes, so gender must be addressed in M&E. The document outlines how to measure gender through collecting sex-disaggregated data, using gender-sensitive indicators, and evaluating programs' impact on gender norms and women's empowerment. Integrating gender into M&E ensures programs effectively address gender issues and health inequities.
More Related Content
Gender m&e
- 1. Monitoring & Evaluation ofGender and Health
- 2. Learning Objectives 1. Definegender and related terms 2. Identify why gender is important to health outcomes and programming 3. Identify donor gender M&E requirements 4. Identify criteria for addressing gender in programs 5. Determine how to measure gender progress 6. Understand how to apply gender indicators to programs to integrate gender into M&E
- 3. Definitions Sex: Biological classificationof males and females •Determined at birth based on biological characteristics •Universal for all human beings •Hard to change
- 4. Definitions Gender: •Culturally defined setof roles, duties, rights, responsibilities, and accepted behaviors associated with being male and female •Power relations between and among women & men, boys & girls. •Vary across cultures and over time. What does it meanto be a woman orman in your society?What are theexpectationsassociated withbeing a girl or boy,man or woman? What does it meanto be a woman orman in your society?What are theexpectationsassociated withbeing a girl or boy,man or woman?
- 5. Definitions: Gender Equality •The state that affords women and men equal enjoyment of human rights, socially valued goods, opportunities, and resources. • Genuine equality means more than parity in numbers or laws on the books; it means expanded freedoms and improved quality of life for all people. • Comes from written and unwritten norms, rules, laws and shared understandings.
- 6. Source: WHO 2009:Integrating gender into HIV/AIDS programmes in the health sector Gender inequality is the most pervasive form of social inequality Gender inequality cuts across all other forms such as class, caste, race and ethnicity
- 7. Definitions: Gender Equity •The process of being fair to women & men, boys & girls. ‒ Stress is on fairness as the end goal ‒ Different/unequal needs & barriers affecting women and men in accessing/benefiting from health-care programs must be considered in program resource allocation & design ‒ Should be inherent to program M&E Source: IGWG training resources
- 8. Gender inequality affectshealth status and leads to health inequities between men and women. A teenage boy dies in accident because he tried to meet peers’ expectations that young men should take risks A woman cannot access needed maternal health care because she does not have control of the household money. Source: World Health Organization, http://www.who.int/gender/genderandhealth/en/index.html A women contracts HIV because societal norms prevent wives from insisting on condom use with husbands, and yet tolerate husbands’ extra-marital sex
- 9. Why does gendermatter to health? • Gender inequality is associated with poor outcomes such as ‒ Higher child mortality, stunting & wasting ‒ Lower maternal health care utilization, higher maternal mortality ‒ Higher fertility, lower family planning use ‒ GBV • Gender inequality is a major driver of the AIDS epidemic and leads to lower awareness, knowledge ‒ Higher risky sex & PMTCT, lower VCT & ARV ‒ Higher prevalence & incidence
- 10. How can healthsystems address gender inequality? • Sex-disaggregated data ‒ Often collected or possible to collect, but is not reported or left out by design • Quality & ongoing training for M&E system staff • Gender-focused M&E to measure progress and impact • Involvement of stakeholders at all levels Source: Payne, Sarah (2009). How can gender equity be addressed through health systems? WHO, policy brief #12
- 11. Gender and Health:The New World-wide gender policy push • Global Health Initiative (GHI) 1st principle: Sharpen focus on women & girls across US global health efforts to improve outcomes for women, girls, families & communities • Country strategies ‒ Conduct gender assessments & analyses ‒ Provide narrative of gender implementation ‒ Disaggregate data by sex & age Source: Kaiser Family Foundation (2011). The United States Government Global Health Initiative, strategy document. http://www.kff.org/globalhealth/upload/8128.pdf U.S. GLOBAL HEALTH Initiative
- 12. GOAL: To improvethe 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. Recent USAID Policies: Gender Equality and Female Empowerment Source: Gender Equality and Female Empowerment, USAID Policy (March 2012) “We know that long-term, sustainable development will only be possible when women and men enjoy equal opportunity to rise to their potential...” - USAID Administrator Rajiv Shah
- 13. Recent USAID Policies:Gender-Based Violence PURPOSE: To establish a government- wide approach that identifies, coordinates, integrates, and leverages current GBV prevention and response efforts and resources. •Strategy includes discussion of research and M&E next steps and indicators for measuring progress Source: http://www.usaid.gov/gbv
- 14. Gender and Health:The New World-wide gender policy push • PEPFAR Gender Strategy ‒ Gender integration in all program areas (prevention, care & treatment) ‒ Programming along 5 strategic, cross cutting areas • Increase gender equity in activities/services • Reduce violence and coercion • Address male norms & behaviors • Increase women’s legal protection • Increase women’s access to income/productive resources
- 15. Bilateral & MultilateralAgency 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 ‒ Programs must analyze the role of gender and sex in areas of work and for developing appropriate gender- specific responses in all strategic objectives ‒ Equal participation of women and men in decision- making at all levels ‒ Performance management should include monitoring and evaluation of gender mainstreaming
- 16. Bilateral & MultilateralAgency Gender Strategies • World Bank Group Gender Action Plan (GAP) ‒ 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
- 17. Bilateral & MultilateralAgency Gender Strategies • UNAIDS Action Framework for addressing women, girls, gender equality and HIV ‒ Knowing, understanding & responding to the effects of the HIV epidemic on women and 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. Source: UNAIDS Action Framework: Addressing Women, Girls, Gender Equality and HIV1. The Action Framework (2009)
- 18. Gender and HIV/AIDS •Numerous studies document the relationship between gender inequality and HIV/AIDS outcomes. Gender inequality is associated with: ‒ Higher risk of transmission/higher prevalence ‒ Higher risk of intimate partner violence, which in turn increases the risk of HIV ‒ More risk-associated behaviors due to vulnerability ‒ Less knowledge about HIV/AIDS ‒ Less utilization of programs & services
- 19. Gender Inequalities &HIV/AIDS Programs • 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 Source: WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
- 20. WHAT DOES ITMEAN TO INTEGRATE GENDER INTO PROGRAMS? Photocredit:OneManCan Campaign
- 21. Source: USAID &IGWG. A manual for integrating gender into reproductive health and HIV programs: From commitment to action (2nd edition).2009
- 22.
- 23. Gender M&E Why integrategender into M&E? • To ensure gender is addressed in programs in a measurable way • Provides evidence to: ‒ Raise awareness about gender inequity ‒ Advocate for change ‒ Address gender dimensions of health • Demonstrate program progress and impact
- 24. Gender M&E Defined •Gender integrated throughout program cycle, beginning with program objectives and measurable component of inputs, processes, outputs, outcomes • Data collected by sex and using gender- sensitive methods and sampling • Analyzed with eye towards potential gender differences • Used to improve programs and policy
- 25. Monitoring: Are programs(adequately) addressing gender? • Data collection ‒ Sex-disaggregated indicators ‒ Gender sensitive indicators • Gender & health indicators • Complex measures (attitudes, norms, power) • Data analysis, reporting, and use
- 26. Evaluation: Are gender-integrated programsand policies making a difference? • Turning to gender in evaluation, here we are hoping to measure the impact that gender-focused or gender- integrated programming has on health outcomes. Are gender-integrated programs or policies making a difference? What did or did not work and why? • At a basic level, when we evaluate gender-integrated or gender focused programs, we also use sex disaggregated data, as applicable, and use gender-sensitive indicators. • And we seek to measure the program elements that address gender equality.
- 27. • We usedata to demonstrate progress towards gender equality and the impact of the program on health status. • In turn, the findings from evaluation of gender- integrated programs create demand for richer data. There are many different ways to evaluate gender- integrated programs, depending on the topic, available resources, time, and other factors.
- 28. Gender-Based Analysis (GBA) •Explores 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 gender influences, omissions & implications of work in health policy, programming & planning.
- 29. Data required forGBA • Quantitative ‒ Collecting, reporting & analyzing health indicators and surveillance data (disaggregated by sex) ‒ Data on socioeconomic determinants of health, outcomes , treatments used, incidence of morbidity & mortality, decision- makers, formal & informal health providers (disaggregated by sex) ‒ When possible, further disaggregation by geographic location, age, income, ethnicity & education
- 30. Why do wewant to analyze and report data by sex?
- 31. Data required forGBA • Qualitative ‒ Information about personal experiences and perspectives ‒ In depth information about motivations, attitudes, behaviors, choices etc. ‒ Gets to the why or how ‒ In this case, meaning and contextualization of gender roles & norms and why people act the way they do within the health system Source: PAHO (2009). Guidelines got gender-based analysis of health data for decision making.
- 32. Activities Inputs Outputs Outcomes Outcomes and Impacts monitoring Publichealth questions approach to gender M&E Source: Adapted from Rugg et al. (2004). Global advances in HIV/AIDS monitoring and evaluation. New Directions for Evaluation. Hoboken, NJ, Wiley Periodicals, Inc. What is the nature and magnitude of the problem and why does it exist? What interventions can work? (Efficacy & Effectiveness) What interventions and resources are needed? What are we doing? Are we implementing the program as planned? Are interventions working/making a difference? Are efforts being implemented at large enough scale?
- 33. Now let’s thinkabout what kinds of questions you might ask in gender and health M&E. You may recognize this M&E staircase. This is helpful for thinking through the types of questions M&E can answer. The bottom two steps in purple are part of program planning. Then the next three steps in green are part of Monitoring. Finally, the last two steps in blue are questions we would look at in evaluation. On the next few slides we will have examples of questions at the outputs and outcomes levels near the top of the staircase.
- 34. Sample M&E questions •Are there gender differences in use of/access to services/treatment? For example: ‒ Use of ART? Adherence? ‒ Detection of TB? Referral for treatment? ‒ Malaria testing and treatment? • Data needed: sex and age disaggregated data from health information systems (HIS)
- 35. Sample M&E questions •Are we implementing gender-integrated programs/policies as planned? For example: ‒ Uganda National Guidelines on Medical Management of Rape and Sexual Violence • For rape cases presented within 72hrs, is appropriate medical care provided, including PEP? o Data needed: #s of survivors presenting for care within 72hrs and proportion receiving certain package of services including PEP; likely from medical record review
- 36. Sample M&E questions(cont.) • National Reproductive Health Strategy ‒ Strategy: Empowerment of Men and Women, Boys and Girls to Increase Utilization of RH Services • Has there been an increase in male involvement in reproductive health programs? o Data needed: Percentage (%) of male clients receiving RH services (data collected at multiple time points); HIS Photo credit: Jessica Fehringer
- 37.
- 38. • No single“gold standard” for measuring gender norms, attitudes, women’s empowerment • Use multiple measures ‒ Cannot use a single measure because gender is a complex construct, and operates in multiple spheres ‒ A scale combining several items is more valid than single scale item used alone Measuring gender
- 39. • Quantitative measuresfor gender equality ‒ Norms for women and men ‒ Experience of gender-based violence ‒ Women’s autonomy and empowerment • Household decision-making power • Economic empowerment ‒ Couples counseling and male involvement ‒ Legal and policy framework Measuring gender (cont.)
- 40. • Gender equitablemen (GEM) scale: measure attitudes towards gender norms in intimate relationships. • Respondents: men and women, boys and girls • Applied in multiple countries; culturally sensitive • Example items: ‒ “If someone insults a man, he should defend his reputation with force if he has to” ‒ “A man needs other women even if things with his wife are fine.” Measuring gender: norms/beliefs Source: Compendium of Gender Scales http://www.c-changeprogram.org/content/gender-scales-compendium/index.html
- 41. • Measure women'shousehold decision- making perceived by couples • Respondents: men and women, separately • Applicability in multiple settings? • Example items: ‒Who usually makes decisions about making purchases for daily household needs? ‒Who usually makes decisions about visits to family or relatives? Measuring gender: Decision-making
- 42. Measuring gender: Women’s economicempowerment • There is no universal set of indicators. • DHS has standard questions on economic empowerment. • Respondents: men and women, separately Example items: ‒Knowledge of /use of micro-credit programs ‒Having a bank account, asset ownership ‒Control over money for different purposes
- 43. Push for harmonizedgender & health indicators • HIV field is ahead of the rest • All part of the new demand for gender-aware programming streams, based on old knowledge • Recent guides: ‒ Compendium of Gender Equality and HIV indicators ‒ Harmonized indicators for violence against women and girls (guide on the resource list)
- 44. Areas of measurement: Genderin 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
- 45. Areas of measurement: Genderin 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 & girls • Most at Risk Populations (MARPS): people in sex work • Orphans and Vulnerable Children (OVC) Photo credit: Jessica Fehringer
- 46. Sample gender &HIV indicators Prevalence Percentage (%) of young women who are HIV infected Numerator: Number of antenatal clinic attendees (aged 15–24) who test positive for HIV Denominator: Number of antenatal clinic attendees (aged 15– 24) tested for HIV Treatment Percentage (%) of adults & children with HIV known to be on treatment 12 months after initiation of ART. [disaggregated by sex & age] Numerator: Number 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
- 47. Sample gender &HIV indicators (cont.) Behavior: risk Percentage (%) of young people who have had sexual intercourse before age 15. [disaggregated by sex & age] Numerator: Number of 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 Percentage (%) of people who correctly respond to prompted questions about preventing maternal to child transmission of HIV through ART & avoiding breastfeeding Numerator: Number 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 number of respondents in survey
- 48. • Gender EqualityMeasures Percentage (%) 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 Sample gender & HIV indicators (cont.)
- 49. • Programmatic Reach Percentage(%) of sex workers reached by HIV prevention programs [disaggregated by sex & age] Numerator: Number 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 SWs surveyed Sample gender & HIV indicators (cont.)
- 50. • Gender-based violence Percentage(%) of health units that have documented & adopted a protocol for the clinical management of VAW/G survivors Numerator: Number of 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 Sample gender & HIV indicators (cont.)
- 51. • Gender-based violence Percentage(%) of people who agree that rape can take place between a man and woman who are married Numerator: Number 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 Sample gender & HIV indicators (cont.)
- 52. Sample gender &HIV indicators (cont.) • Gender-based violence Percentage (%) of youth-serving organizations that include trainings for beneficiaries on sexual and physical VAW/G Numerator: Number 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 number of youth serving organizations surveyed.
- 53. Sample gender &HIV indicators (cont.) • Most at Risk Populations (MARPs) Percentage (%) of female sex workers reporting the use of a condom with every client in the last month Numerator: Number 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) Percentage (%) of children under 18 who are orphans [disaggregated by sex, age, type of orphan] Numerator: Number of 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
- 54. Sample gender &HIV indicators (cont.) • HIV Stigma/Human Rights: Percentage (%) of people 15-49 expressing accepting attitudes towards HIV+ people [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: Percentage (%) of women & girls reporting incidents of sexual violence per 10,000 population in the emergency area Numerator: Number 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.
- 55. Activity: Integrating genderinto M&E • Look at your program objective(s) & think about how gender can be addressed • Modify the activities that stem from that objective(s) ‒ 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
Editor's Notes
- #4 Let’s start with some definitions. What do we mean by “sex” versus “gender”? Sex is the classification of people as male or female. At birth, infants are assigned a sex based on a combination of bodily characteristics including: chromosomes, hormones, internal reproductive organs, and genitalia. (USAID March 2012 Gender Equality and Female Empowerment Policy) An individual’s sex does not change over place or time, except in rare and surgical circumstances. In this photo, the sex of the baby is not evident.
- #9 First, the reason we must think about gender in M&E is because it has a powerful impact on health outcomes. Gender inequality affects health status and leads to health inequities between men and women. In each of these cases I have here as examples, gender norms and values, and resulting behaviors, are negatively affecting health. [read examples] The gender picture in a given time and place can be one of the main obstacles - sometimes the most important obstacle - standing between men and women and the achievement of well-being.
- #11 [read slide]. Collecting and reporting sex-disaggregated data is the first step. Often, data is collected sex-disaggregated or it is easily possible to collect data in this way, but the sex-disaggregated results are not analyzed and reported, or the design of the data collection or system leaves out sex disaggregation. You must also endeavor to put in place training and refresher training for M&E system staff on what it means to address gender through M&E. Your M&E must have gender-focused components so as to measure the progress and impact of gender integration in programs. Lastly, stakeholders must be involved at all levels, from start to finish.
- #12 Over the last decade, as a result of the evidence in support of gender integration in health programs, multi- and bilateral donors have increased their focus on gender integration. [note to presenter: depending on audience and time availability, you may consider skipping one or more of these slides on donor policies. You could just show one or two as an example instead of going through them all] On these next few slides, I will briefly describe the gender-related policies of several major donors. [read slide]
- #13 As you can see, USAID is very much invested in gender equality and female empowerment. They are also evaluating how you are going to integrate gender considerations into your programs and M&E when they consider who to fund.
- #14 USAID also recently published its Strategy to Prevent and Respond to Gender-Based Violence. You can see here the purpose of this strategy is to [read purpose]. The strategy specifically sets out how to measure progress towards achievement of GBV prevention and response goals and discusses USAID’s next steps in this area.
- #15 Similarly, PEPFAR requires gender integration in all program areas. It has the following strategies: Increase gender equity in activities/services Reduce violence and coercion Address male norms & behaviors Increase women’s legal protection Increase women’s access to income/productive resources
- #16 The same with the World Health Organization. You can see in the last two bullets that they want equal participating of men and women in decision making and that performance management should include monitoring and evaluation of gender mainstreaming. [briefly go through slide]
- #17 There is also a World Bank rationale for expanding women’s and girl’s economic opportunities. While women’s and girls’ education and health levels have improved in most poor countries, progress is lagging on improving their economic opportunities. This is inefficient, since increased women’s labor force participation and earnings are associated with reduced poverty and faster growth. This is also why the GAP concentrates on facilitating girls’ transition from school to work. Women will benefit from their economic empowerment, and so will men, children and society as a whole.
- #18 UNAIDS also has an Action Framework for addressing gender as described here. [go through slide] As you can see, gender is inextricably linked to health and development and most major funding agencies are actively looking for programs that monitor gender integration and collect gender indicators.
- #19 Gender has strong impacts on all HIV/AIDS related outcomes. The AIDS epidemic in Sub-Saharan Africa is increasingly female. Worldwide, anywhere from 15% to 71% of women have experienced intimate partner violence sometime in their lives. Research has shown that violence against women is a clear intersection of gender and health and it is a driver of HIV. Image: http://developmentdiaries.com/malawi-drilled-on-gender-transformative-hiv-programming-approach/
- #20 Here are some examples of how gender inequalities impact HIV/AIDS programming. [go through slide] Can you think of any others? [wait for responses and discuss]
- #22 This is a diagram of the types of gender programming and how programmatic outcomes will be affected: all programs that take gender into account fall somewhere on this continuum. The Gender Equality Continuum is a Tool for planners and implementers to use in planning how to integrate gender into their programs/policies. It categorizes approaches by how to treat gender norms and inequities in the design, implementation, and evaluation of program/policy . A gender aware intervention, which you see on this slide in purple, is one that uses strategies to take gender considerations into account and to compensate for gender-based inequalities. Also here we can see that gender aware interventions can be divided into exploitative, accommodating, and transformative interventions. Exploitative approaches to gender integration reinforce or take advantage of gender inequalities; this is not a desirable approach. Gender accommodating approaches recognize gender norms and inequalities and work the intervention around this. They do not address/challenge/change gender norms and inequalities. In contrast, a gender transformative intervention focuses on creating critical awareness about gender norms, roles, and inequalities and actively challenges and addresses those. [ask group] Where does your program fall on the continuum? What can you change to move towards the transformative goal?
- #23 Gender is an essential cross cutting issue in the field of monitoring and evaluation (M&E).
- #24 Given the evidence documenting the correlation between gender equality and better health outcomes, it is necessary to incorporate gender into health program planning, implementation, and assessment at all levels. Retaining a specific focus on gender in the M&E of health programs will ensure that gender is integrated into programs in a tangible way and will be a measureable component of program inputs, outputs and outcomes. When gender is not well integrated into program development and M&E systems, gender norms and inequalities that influence health and health seeking behaviors may become invisible or marginalized in favor of issues currently supported by stronger information. Gender-related information provides evidence to raise awareness of gender imbalances, advocate for change, address gender dimensions of health, and demonstrate program progress and impact.
- #25 Most conventional M/E systems do not fully assess the responsiveness of projects to the different needs of men and women, boys and girls, and gender differences in project impacts. Gender M&E ensures that gender is integrated throughout the program cycle in a tangible way, beginning with the program objectives, and will be a measureable component of Inputs, processes, outputs and outcomes. It also ensures that this data is collected by sex and by using gender-sensitive methods and sampling, analyzed with an eye towards potential gender differentials and reported and used to improve programs and policy.
- #26 When looking at monitoring from a gender perspective, we want to ask “are programs adequately addressing gender?” Gender monitoring looks similar to typical monitoring but with added questions to help measure differences in how men and women, boys and girls, benefit from a program. At the most basic level, gender Monitoring requires sex-stratified analyses of routine data to examine gender differences in program implementation and outcomes differentials between women and men (or girls and boys) that occur in programmatic outputs and related health outcomes. Gender monitoring should ideally also use gender sensitive indicators. These are indicators that go beyond sex disaggregation (but are still to be collected by male/female, as applicable) try to directly measure aspects of gender, and try to more thoroughly examine how gender relations affect development outcomes. These measures can be more complex like attitudes and norms (for example, the belief that intimate partner violence is justified), power differences (for example, who makes the decisions in the household, who controls money), and others. These are often collected in special surveys, such as the DHS or other surveys and studies. In any efforts to monitor programs or policies, it is important to analyze by sex, and when possible, use gender sensitive indicators that specifically look at gender and health. Then it is crucial to report those differences, or lack of differences, in order to draw attention to gender. And data and results should always be used for informed decision making.
- #29 Now let’s look at gender-based analysis. Gender-Based Analysis is used to understand and explore how the experiences of women and men differ because of the social constructs of gender in that community. This can be used in many different settings and for difference health issues. For example, when considering barriers to health care utilization you might find that gender constructs for women and men prevent one or both genders from seeking and receiving the care they need. I want to emphasize that gender is not just a consideration for women. GBA has revealed important barriers for men in health-seeking behavior. Can you think of any? [example: men may not seek health care because it is not considered to be masculine in some settings;] Bottom line: GBA reveals gender influences, omissions and implications of work in health policy, programming & planning.
- #30 What is required for GBA? Quantitative data is one component. This brings us back to the importance of collecting sex-disaggregated data. It is important to brainstorm what data you might need to fully understand the work you are doing. Quantitative data gives us hard evidence of gender imbalances. But it frequently does not help us understand why those gender imbalances occur.
- #31 Let’s look at an example from routine HIV data to see what we can learn from gender based analysis. Here we have graphs showing data on clients who tested HIV positive by month between August 2010 and August 2012 in a country in sub-Saharan Africa. When we look at the first graph on the left, we can see the total number of clients that tested positive by month, over 2 years. Taken alone, you can see some fluctuations, but not much overall change. However, when we look at this second graph on the right that is sex disaggregated, the picture looks much different. The overall trend is similar, but the difference between men and women is obvious. While this is total number of people (without a denominator) it is clear that women are testing positive more, but this also means women are getting tested more, which also points to the conclusion that not as many men are being tested, and that is an area for improvement. These are the types of gender differences we want to highlight by analyzing and reporting by sex. After you see this graph, decision makers might ask, why are there differences? What can we do to address these differences? What could be done to produce more sex-disaggregated data? What type of reports would best highlight the gaps?
- #32 Qualitative data can also be very informative when trying to understand the context of an issue. Qualitative provides important insight that you can only guess at with quantitative data. Qualitative data might help you understand the why or how of your research question or program challenge. For example, in the last slide the quantitative data showed that there was a difference in prevalence of HIV between women and men. Qualitative interviewing might help you understand why (cultural experience of violence, women can’t negotiate safe sex, etc.) this difference was observed.
- #35 Here is an example of a question at the outcomes level. On this slide we have questions related to gender differences in health service provision. These require basic age and sex disaggregated data from routine health information systems.
- #36 Now let’s look at some sample M&E questions for a gender-integrated program/policy. You may want to understand whether a gender-integrated program is being implemented according to plans or guidelines and/or whether the program is making a difference in health outcomes. The example on this slide is a question at the outputs level and looks at the Kenya National Guidelines on Medical Management of Rape and Sexual Violence. If we wanted to understand whether health facilities are following the guidelines, we could look at medical data from treatment of rape and sexual violence survivors. For example, one recommendation in the guidelines is for survivors presenting at clinics within 72 hours of the abuse to receive a certain set of services, including PEP for HIV prevention. We could look at data taken from a review of medical records to see if providers are following the recommendation. This would require a special study, unless the HIS already collects this information.
- #37 Here we have an another example of a M&E question looking at measuring gender-integrated programming/policy and whether it is being implemented according to plans or guidelines and/or achieving desired outcomes. This question is at the outcomes level. Under one country’s National Reproductive Health Strategy, one of the major strategies is Empowerment of Men and Women, Boys and Girls to Increase Utilization of RH Services. The National Strategy outlines two key activities to help achieve this. This first is: Increasing male involvement in reproductive health programs. One way we could try to answer a question on whether there has been increased male involvement in reproductive health programs is by looking at routine data on % of male clients receiving RH services and see if this has increased over time. This data should already be available in the HIS. (Note that looking at this data alone could not tell you whether an increase can be attributed to your program; answering that would require more complex methods)
- #39 It’s difficult to measure abstract social concepts such as gender, and measures for this concept are still under development. Yet, many surveys have explored these issues, and some have already been rigorously tested for their reliability and validity (i.e., confidence that the questions related to gender norms are actually measuring these norms). Because there is no single "gold standard" for measuring gender norms, gender attitudes, women's empowerment, and other aspects of gender, we often use multiple measures. Using a single measure is not possible because gender operates in multiple spheres and has many facets. When a single measure is preferred, a scale combining several items creates a more valid measure than any single scale item used alone.
- #40 The types of measures most frequently used in evaluation are those that track changes in the power dynamics in sexual relations between men and women, individual norms or attitudes towards gender equality (including attitudes about gender-based violence (GBV)), experience of GBV, women’s autonomy and empowerment (for example: questions on women’s and men’s employment, household decision-making among women and men and access to and control of economic resources). We can also look at couples Counseling and Male Involvement ( for example: Individuals who received couples/partner VCT and learned the results of their HIV test together with their partner(s) in the past 12 months) And indicators on gender equality at the national level will assess if policies and programs reflect structural inequalities (such as policy commitment, legal frameworks and national legislation). For example, “Is there a multi-sectoral strategy to respond to HIV which has a specific HIV women’s budget?” I will go into a few examples of on how some of these can be measured.
- #41 Here is an example of a more complex scale to measure attitudes related to gender. The GEM or (Gender Equitable Men) Scale created by Promundo, a NGO in Brazil. It has been used to measure attitudes toward gender norms in intimate relationships or differing social expectations for men and women. Use with men, women, boys and girls to predict outcomes of condom use, contraceptive use, multiple sexual partners and partner violence. The GEM Scale has been tested in Brazil, China, India and several countries in Africa. Adaptations in multiple contexts have worked well. Findings suggest the GEM Scale is a sensitive and cross-culturally relevant tool. Examples of items on the scale are: “If someone insults a man, he should defend his reputation with force if he has to” or “A man needs other women even if things with his wife are fine.” Responses to sets of questions are quantified and those who score the highest would be the “most” gender equitable on the GEM scale.
- #42 Measures of household decision-making are commonly used in the Demographics and Health Survey (DHS). They have been used to predict family planning use, IPV, women’s nutritional status, child health and nutrition & more. They were developed in South Asia and have since been applied to other contexts. There is some question of their applicability to Africa and other contexts. Questions such as “Who usually makes decisions about making purchases for daily household needs?” and “Who usually makes decisions about whether to use FP?” are used in analysis to predict family planning use, prevalence of IPV and other health outcomes. Another way of examining women’s autonomy and empowerment is through women’s ability to succeed and advance economically and the power to make and act on economic decisions.
- #43 Indicators of women’s economic empowerment are abundant. Women’s economic empowerment is multidimensional and is specific to the context under consideration. Programs address economic empowerment through different pathways hence indicators suitable for one program may not be relevant for another. There is no universal set of indictors appropriate for every project, in every sector and in every context. The Demographic and Health Surveys (DHS) include indicators of women's economic empowerment:Employment and occupation (all), Control over own earnings (most surveys). In a select number of countries, the DHS has a module of additional questions on women's status and empowerment in a Women's Status Module. Indicators available from the module include: Knowledge and use of micro-credit programs, Membership in any association, Having a bank account, Asset ownership, Control over money for different purposes. There are many other indicators that are useful for measuring WEE at different levels (individual, community, institutional) of a program. A useful resources for using and measuring women’s economic empowerment is the guide by ICRW on “Understanding and Measuring Women's Economic Empowerment - Definition, Framework and Indicators, International Center for Research on Women.” As you see from the examples I have given there are a variety of available scales and indicators to measure gender-related outcomes. [At the end of this presentation, we’ll provide more resources to help you find the right measures for your evaluation.] At this point you may be thinking, “How far out do we need to measure these gender-specific outcomes to know they are being maintained?” [NEXT slide]
- #45 Since the HIV field has moved a little faster in developing harmonized indicators, we’ll go through these areas and sample indicators as an example. The GEM scale mentioned earlier is one such harmonized indicator.
- #46 [read slide] These are all potential gender issues that interact with HIV and measurement would tell us more about the how and why.
- #47 These are examples of how prevalence and treatment data can be transformed into gender and HIV indicators, with clear descriptions of how you would calculate the proportions. [read slide] We have a list of resources at the end of this presentation that include those with indicators.
- #48 Similarly, these are examples of how behavior and knowledge data can be transformed into gender and HIV indicators, with clear descriptions of how you would calculate the proportions. [read slide]
- #49 Here is a gender and equality measure that tells you about the population you are working with. This is similar to the Gender Equitable Men scale, except you don’t need to only ask men. Women often have a gender-inequitable worldview as well!
- #50 Programmatic reach tells you more about how many people your program is reaching than about the gender-equitable nature of your program. But it is an important measure as well.
- #51 This GBV indicator tells you how gender-aware or sensitive the health system is to the significant problem posed by GBV.
- #52 This GBV indicator again tells you about the gender-equitable nature of the population surveyed.
- #53 I have explained several gender indicators to you. What do you think that this indicator would help you understand?
- #54 The MARPs indicator might be a good measure of how empowered the sex-workers are or how effective an intervention is. There are many ways to interpret the data. It is important to collect comprehensive data.
- #55 Here are a couple more indicators that might be useful to you so we have included them in the presentation.
- #56 This activity can be omitted if there is not time, or put as part of evening group work. It is based on what the groups are working on. It is OK if there is no specific gender piece of the program. Now we have spoken about gender and gender indicators for quite a while. Let’s see how some of this can be applied to your programs! The point of the activity is to find an area that is relevant to gender—you will find one!! Or, to develop one, and then find a few indicators that might be used for reporting on that aspect. Look at the areas in the indicators to see what may best apply to the program, and the identify how it will be measured within the context of the program.