1963-2013 - 50 years of Research for Social Change

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Back | Programme Area: Gender and Development (2000 - 2009), Special Events (2000 - 2009)

Gender and Health Sector Reform: Analytical Perspectives on African Experience (Draft)



Background paper prepared for the UNRISD report "Gender Equality: Striving for Justice in an Unequal World"

Differences between women and men in roles, access to resources and decision-making powers are reflected in economic and social inequalities between the two sexes. In recognition of this, that different international fora have agreed on a number of actions necessary to advance gender equity. One such forum was the Fourth World Conference on Women held in Beijing in 1995. The Conference adopted the Beijing Declaration and Platform for Action which made specific recommendations on, among other topics, women and health. These included increasing women’s access throughout the life cycle to appropriate, affordable, and quality health care; reducing maternal mortality by at least 75 percent of the 1990 levels by the year 2015; increasing resources for women’s health; undertaking gender sensitive initiatives that address sexually transmitted diseases, HIV/AIDS and sexual and reproductive health issues; and encouraging both women and men to take responsibility for their sexual and reproductive behaviour. A specific recommendation was also made regarding the girl child—that of eliminating discrimination against girls in health and nutrition.

These recommendations clearly show how the issue of women’s health is not only defined by their biological reproductive role, but also includes their general health as affected by social, cultural and economic factors in a broader societal context. Some interconnection between gender equality and women’s health is picked up in the Millennium Development Goals that include gender equality and women’s empowerment (specifically equal education for women) and better maternal health (specifically a sharp decline in maternal deaths). To move towards gender equity in health implies both the elimination of discrimination against women where male and female needs coincide, and attention to the differentiated needs of women including, but not limited to, reproductive health.

This paper draws upon these established themes in the literature on gender and health to explore perspectives on the gendered impacts of Health Sector Reforms (HSRs), with particular reference to African experience. We include implications for women’s health that go beyond those related to reproductive health, and assess the impact of HSRs on women’s health as affected by cultural, social, economic, and institutional constraints. In the health literature there has been extensive questioning of the extent to which the health sector reforms introduced in many low-income countries since the 1980s, with the stated objectives of improving, among other things, efficiency, equity and performance of health services have actually attained those objectives. This paper addresses one important aspect of equity, the impact of HSRs on women’s access to and utilisation of health services, and some of its effects on outcomes in terms of women’s health.

Our objectives however are primarily conceptual, rather than focusing on a compilation of existing evidence. We argue in Section 2 that the current literature on health sector reform in the African context (and indeed, internationally) is strikingly silent on the topic of gender. Gender is the ‘silent term’ in the model of HSR. Drawing on feminist writing internationally on gender and health, and on the (limited) literature on gender and HSR in low income contexts written from a feminist perspective, we aim to break this silence. Thus Section 2 argues that the health sector reform model is implicitly gendered: the basic model of reform has gender built inaudibly into its assumptions.

The following sections draw together arguments and evidence concerning the gendered nature and impacts of health sector reform in Africa, drawing on the gender equity, women’s health needs and gendered health systems approaches (all defined below). These approaches are not in contradiction, though we believe that an analysis based on the concept of gendered health systems will be particularly productive of additional future insights. Some aspects introduced by the gendered health systems approach are very little studied at present, and the paper identifies some areas for needed empirical research.

Our objectives in this paper are:
  • To examine the conceptual issues arising in the study of health sector reform through a gender ‘lens’, considering the extent to which both process and outcomes of the reforms are gendered, and the extent to which that engendering process operates to the detriment of women, especially poor women;
  • To set our arguments in the context of the existing literature on gender and health sector reform, and to illustrate them with a range of empirical evidence drawn largely but not exclusively from Africa; and
  • To consider policy implications.