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Integrating Poverty and Genderinto Health ProgrammesA Sourcebook for Health ProfessionalsModule on Sexualand Reproductive Health

Integrating Poverty and Genderinto Health ProgrammesA Sourcebook for Health ProfessionalsModule on Sexualand Reproductive

Photograph credits: cover, © 2005 Stéphane Janin, Courtesy of Photoshare; pp. 1 © 2007 Julius Peter Obligacion, Courtesyof Photoshare; pp. 3 © 2004 D. H. Friendly, Courtesy of Photoshare; pp. 16 © 2004 Philippe Blanc, Courtesy of Photoshare;pp. 46 © 2001 Marcel Reyners, Courtesy of Photoshare; pp. 89 © 1989 CCP, Courtesy of Photoshare; pp. 41, 82 WHO/WPRO.WHO Library Cataloguing in Publication DataIntegrating poverty and gender into health programmes:and reproductive health.a sourcebook for health professionals: module on sexual1. Sexual health. 2. Reproductive health. 3. Poverty. 4. Gender. 5. Education, Professional. 6. Health programmes.ISBN 13 978 92 9061 389 3 (NLM Classification: WA 30 )© World Health Organization 2008All rights reserved.The designations employed and the presentation of the material in this publication do not imply the expression of any opinionwhatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area orof its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximateborder lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommendedby the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissionsexcepted, the names of proprietary products are distinguished by initial capital letters.The World Health Organization does not warrant that the information contained in this publication is complete and correctand shall not be liable for any damages incurred as a result of its use.Publications of the World Health Organization can be obtained from Marketing and Dissemination, World HealthOrganization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; Requests for permission to reproduce WHO publications, in part or in whole, or to translatethem whether for sale or for noncommercial distribution should be addressed to Publications, at the above address(fax: +41 22 791 4806; email: For WHO Western Pacific Regional Publications, request for permissionto reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific,P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email:

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsiACKNOWLEDGEMENTSABBREVIATIONSPREFACECONTENTSINTRODUCTION 11. What is Sexual and Reproductive Health? 3Reproductive rights 4Sexual health, sexuality and sexual rights 5Measuring sexual and reproductive health 6The global burden of mortality and morbidity related to sexual and reproductive health 7Maternal mortality 7Men’s reproductive health 10Family planning 11Sexually transmitted infections 12Gender-based violence 142. What are the links between poverty, gender, and sexual and reproductive health? 16The influence of poverty on reproductive health 17Poverty is a determinant of sexual and reproductive health 17Poverty-related inequalities in access to reproductive health care 20Quality of care 25Inequalities in reproductive health outcomes 26The influence of reproductive health on poverty 28The influence of gender on reproductive health 30Biological differences in sexual and reproductive health 30Gender-based differences in sexual and reproductive health 31Gender is a determinant of sexual and reproductive health 31Gender-based inequalities in access to health services 35Gender bias in health service provision 37Gender-based differentials in sexual and reproductive health outcomes 39Gendered consequences of poor sexual and reproductive health 403. Why is it important for health professionals to address poverty and gender concerns insexual and reproductive health? 41Efficiency 42Equity 43Human rights 44viviiviiiContents

iiIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals4. How can health professionals address poverty and gender in sexual and reproductivehealth programmes? 46Policy level 47International policies 47National policies 50Cross-sectoral action 52Health sector response 54Health financing 54Human resources 56Health information 57Service delivery 61Addressing geographical barriers 61Addressing economic barriers 63Addressing sociocultural barriers 65Improving the quality of health services 68Improving health communication and awareness 72Monitoring and evaluation and research 745. Facilitator’s notes 82Expected learning outcomes 83Lesson plans 83Session 1: Exploring beliefs, values and prejudices in reproductive and sexual health 83Session 2: Educating the public 84Session 3: Role-play: overcoming barriers hindering access to sexual and reproductivehealth services 86Session 4: Submission to the Commission on Health Care Reform 876. Tools, resources and references 89Tools 90Resources 93Working with men 93Sexual and reproductive rights 94References 95Endnotes 110Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsiiiBOXESBox 1: Links between maternal and child health 10Box 2: Defining poverty 17Box 3: Economic growth, poverty reduction and reproductive health 29Box 4: Defining gender 30Box 5: Female genital mutilation 35Box 6: Defining equity in health 42Box 7:Box 8:Government obligations to respect, protect and fulfil human rights: examples ofreproductive rights 43Yogyakarta Principles on the Application of International Law in Relation to Issues ofSexual Orientation and Gender Identity 44Box 9: A rights-based approach to sexual and reproductive health 45Box 10: International goals and targets for sexual and reproductive health 48Box 11: Core components of the WHO Global Reproductive Health Strategy 50Box 12: Maternal health services: a cost-effective investment 51Box 13: Why has sexual and reproductive health not received higher priority? 51Box 14: Political support for health reform enhances reproductive health in Brazil 52Box 15:Including men in laws and policies to prevent and control HIV/AIDS among womenand girls in Cambodia 53Box 16: Health sector reform and sexual and reproductive health 55Box 17:Example of a prepayment scheme that includes reproductive health services in thebenefits package 57Box 18: Reproductive health indicators 58Box 19: Developing gender-sensitive indicators for reproductive health services 59Box 20: Strengthening reproductive health programmes 60Box 21: Visual inspection with acetic acid wash for cervical cancer 62Box 22: Reaching the poor and ethnic minority families in Viet Nam 63Box 23: Mobile reproductive health clinics serving the very poor in India 64Box 24: Improving the economic accessibility of delivery care for women in Nepal 65Box 25:Box 26:Box 27:Meeting the sexual and reproductive health needs of female adolescents in low-incomeurban areas through a voucher scheme in Managua, Nicaragua 66Partnering with Buddhist monks and nuns to curb the HIV/AIDS epidemic inCambodia 68Using peer education to challenge gender norms among young male and femalefactory workers in Chiang Mai, Thailand 69Box 28: Enhancing the quality of care of reproductive health services in Bangladesh 70Box 29:Challenging service providers to explore their attitudes and values regardingpost-abortion care in the Philippines 71Contents

ivIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 30: Strategies to create youth-friendly services 72Box 31: Strategies to create male-friendly services 72Box 32:Satisfied men as advocates and community-based promoters for vasectomies inKiribati 73Box 33: Gender sensitivity checklist for programme implementation 91FIGURESFigure 1: Maternal mortality ratios by country, 2000 8Figure 2: Maternal mortality ratios by medical cause and region, 2002 9Figure 3: Maternal mortality ratios for selected countries in the Region, 2002 9Figure 4: Total fertility rate for selected countries in the Region, 2002 11Figure 5: Number of STI cases in Solomon Islands, 1992–2000 13Figure 6: HIV prevalence among the general population in Cambodia, 1995-2006 14Figure 7:Figure 8:Proportion of women aged 15–49 years who know at least one way to avoid sexualtransmission of HIV/AIDS, by income quintile, in Cambodia (2000), the Philippines(2003) and Viet Nam (2002) 18Percentage of women receiving delivery assistance from a doctor, nurse or midwife inCambodia, the Philippines and Viet Nam 21Figure 9: Maternal deaths per 100 000 live births in China, 2003 28Figure 10: Infant mortality rate (per 1000 live births) by sex for selected countries in the Region,2002 38Figure 11: Percentage of adults (15+) living with HIV who are women, 1990–2007 39TABLESTable 1: Share of DALYs lost due to reproductive health-related causes, by region, 2001(percent) 7Table 2: Leading risk factors of the burden of disease in poorest and developed countries 12Table 3: Global summary of the AIDS epidemic 14Table 4: Adult literacy rates for selected countries in the Region, 2000–2004* 19Table 5: Total fertility rates (actual and wanted) by income quintile in the Philippines, 2003 21Table 6:Table 7:Share of public health spending received by households in the poorest and richestincome quintiles 22Infant mortality rates in provinces with a high concentration of ethnic minoritiescompared to the national average in the Lao People’s Democratic Republic and VietNam 26Table 8: Locus and manifestations of gender-based violence 34Table 9: Revised total costs for achieving the ICPD Programme of Action 50Table 10.Public financing mechanisms for the health sector in selected countries in the Region in2001 56Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsvTable 11:Right to health indicators: applying a human rights-based approach to WHO’sreproductive health strategy, 2004 76Table 12: Integrating gender and poverty into quality assurance programmes 90Contents

viIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsACKNOWLEDGEMENTSThis module is one of a complete set entitled Integrating Poverty and Gender into Health Programmes: ASourcebook for Health Professionals. It was prepared by a team comprising Sarah Coll-Black and ElizabethLindsey, consultants and principal writers, Anjana Bhushan, Technical Officer, Health in Development,and Kathleen Fritsch, Regional Adviser in Nursing at the World Health Organization’s Regional Officefor the Western Pacific. Mario Festin and Khine Sabai Latt provided valuable comments. BreedaHickey provided supplementary technical inputs and did preliminary editing of the module. RhondaVandeworp did the final editing. Design and layout were done by Zando Escultura.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsviiABBREVIATIONSADBAIDSANCCMHCPRCRCDALYDHSFWCWGBVHIVHPVICPDIMFIMRITNLBWLGBTMDGMMRNGONMROECDPHCPNDPoAPRSPPTSDRHIRTISEWASTITFRUNAIDSUNICEFUNDPUNFPAVIAWHAWHOYLDAsian Development BankAcquired immunodeficiency syndromeAntenatal careCommission on Macroeconomics and HealthContraceptive prevalence rateConvention on the Rights of the ChildDisability-adjusted life yearDemographic and Health SurveyFourth World Conference on WomenGender-based violenceHuman immunodeficiency virusHuman papilloma virusInternational Conference on Population and DevelopmentInternational Monetary FundInfant mortality rateInsecticide-treated netLow birth weightLesbian, gay, bisexual and transgenderedMillennium Development GoalMaternal mortality rateNongovernmental organizationNeonatal mortality rateOrganisation for Economic Co-operation and DevelopmentPrimary health carePost-natal depressionProgramme of ActionPoverty Reduction Strategy PaperPost-traumatic stress disorderReproductive health initiativeReproductive tract infectionSelf-Employed Women’s AssociationSexually transmitted infectionTotal fertility rateJoint United Nations Programme on HIV/AIDSUnited Nations Children’s FundUnited Nations Development ProgrammeUnited Nations Population FundVisual inspection with acetic acidWorld Health AssemblyWorld Health OrganizationYears lived with disabilityNote: In this publication, $ means US dollar.Abbreviations

viiiIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsPREFACEOver the past two or three decades, our understanding of poverty has broadened from a narrow focuson income and consumption to a multidimensional notion of education, health, social and politicalparticipation, personal security and freedom, and environmental quality. 1 Thus, it encompasses not justlow income, but lack of access to services, resources and skills; vulnerability; insecurity; and voicelessnessand powerlessness. Multidimensional poverty is a determinant of health risks, health seeking behaviour,health care access and health outcomes.As analysis of health outcomes becomes more refined, it is increasingly apparent that the impressivegains in health experienced over recent decades are unevenly distributed. Aggregate indicators, whetherat the global, regional or national level, often tend to mask striking variations in health outcomesbetween men and women, rich and poor, both across and within countries.An estimated 70% of the world’s poor are women. 2 Similarly, in the Western Pacific Region, povertyoften wears a woman’s face. Indicators of human poverty, including health indicators, often reflectsevere gender-based disparities. In this way, gender inequality is a significant determinant of healthoutcomes in the Region, with women and girls often at a severe societal disadvantage.Although poverty and gender significantly influence health and socioeconomic development, healthprofessionals are not always adequately prepared to address such issues in their work. This publicationaims to improve the awareness, knowledge and skills of health professionals in the Region on povertyand gender concerns.The set of modules that comprise this Sourcebook are intended for use in pre-service and in-servicetraining of health professionals. This publication is also expected to be of use to health policy-makersand programme managers as a reference document, or in conjunction with in-service training.All modules in the series are linked, but each one can be used on a stand-alone basis if required. Thereare two foundational modules that respectively set out the conceptual framework for the analysis ofpoverty and gender issues in health. Each of the other modules is intended for use in conjunction withthese two foundational modules. The Sourcebook also contains a module on curricular integration tosupport health professional educational institutions in integrating poverty and gender concerns intoexisting curricula.All modules in the Sourcebook are designed for use through participatory learning methods that involvethe learner, taking advantage of his or her experience and knowledge. Each module contains facilitators’notes and suggested exercises to assist in this process.It is hoped that the Sourcebook will prove useful in bringing greater attention to poverty and genderconcerns in the design, implementation and monitoring and evaluation of health policies, programmesand interventions.Module on Sexual and Reproductive Health

IntroductionIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

2Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsIntroductionSexual and reproductive health is now widelyunderstood to be a holistic concept thatencompasses physical, mental and social wellbeingin all matters relating to sexuality andreproduction. This approach aims to enable menand women to make healthy, voluntary and safesexual and reproductive choices. As such, it isframed by a commitment to human rights andgender equality.Nevertheless, the burden of sexual and reproductivehealth remains considerable. Estimates suggestthat sexual and reproductive conditions accountfor 18.4% of the global burden of disease and32.0% of the burden of disease among womenaged 15–44 years of age, although there issignificant variation among regions. 3 In manyareas, young adults may be particularly vulnerableto sexual and reproductive ill-health, while inother areas, ageing populations draw attentionto how sexual and reproductive health concernscontinue throughout the life cycle.As evidence on the burden of sexual andreproductive ill-health mounts, it is becomingincreasingly clear that poverty and genderinequality are important determinants of sexualand reproductive health. In the Western PacificRegion, the burden of sexual and reproductiveill-health, such as maternal mortality, HIV/AIDS and unplanned pregnancies, is higher indeveloping countries than in developed ones.Similarly, within countries, poor householdsand communities appear to experience greatermortality and morbidity related to sexual andreproductive conditions than those who arebetter off. Conversely, research shows that sexualand reproductive ill-health can lead to increasedpoverty and vulnerability.Gender inequality has also been shown todetermine the opportunity for good sexual andreproductive health among men and women of allages. Most simply, men and women have differentreproductive health systems. These biologicaldifferences interact with social norms that ascribedifferent roles, behaviours and expectations to menand women. These norms stratify the opportunitiesfor good sexual and reproductive health that menand women enjoy, such as their exposure to therisk factors of sexual and reproductive ill-healthand their access to appropriate quality healthcare.The growing commitment to addressing sexualand reproductive health requires that healthprofessionals at the community, provincial, nationaland international level have the knowledge, skillsand tools to more effectively respond to the healthneeds of poor and marginalized people. Similarcommitment to addressing gender inequality andthe empowerment of women demands that healthprofessionals respond to the different health needsof men and women. The need for such knowledgeand skills among health professionals is even morenecessary given the pledge to ensure universalaccess to reproductive health services in theRegion. However, many health professionals inthe Region are not adequately prepared to addressthese issues.This module is designed to improve the awareness,knowledge and skills of health professionals onsexual and reproductive health. The module isdivided into six sections: Section 1 provides an overview of keyconcepts in sexual and reproductive healthand reviews the global and regional burdenof mortality and morbidity related to sexualand reproductive health. Section 2 examines WHAT the links arebetween poverty, gender and sexual andreproductive health. Section 3 discusses WHY it is important forhealth professionals to address poverty andgender concerns in sexual and reproductivehealth, from efficiency, equity and humanrights perspectives. Section 4 discusses HOW healthprofessionals can address poverty and genderconcerns in sexual and reproductive healthpolicies, plans and programmes. Section 5 provides notes for facilitators. Section 6 is a collection of tools,resources and references to support healthprofessionals in their work in this field.Module on Sexual and Reproductive Health

1. What is Sexualand Reproductive Health?Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

4Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals1. What is sexual and reproductive health?The concept of reproductive health has evolvedfrom a historic concern with populationand development. For decades internationalorganizations and national governmentsmobilized financial and political support forlarge-scale population control programmesthat aimed to control fertility by encouragingwidespread contraceptive use. This concern forpopulation control led the United Nations toconvene international conferences on populationand development every 10 years since 1947. 4The last such conference, the 1994 InternationalConference on Population and Development(ICPD) in Cairo, marked a watershed in theinternational discourse on population anddevelopment. 5The ICPD fundamentally redefined the dominantapproach to population and development. TheProgramme of Action (PoA), which outlineda consensus reached by 179 countries, shiftedfocus from the delivery of contraceptive servicesto broader notions of reproductive health framedin terms of human rights, gender equality andwomen’s empowerment. 6 The PoA definedreproductive health as: 7… a state of complete physical, mentaland social well-being and not merely theabsence of disease or infirmity, in all mattersrelating to the reproductive system and to itsfunctions and processes. Reproductive healththerefore implies that people are able to havea satisfying and safe sex life and that theyhave the capability to reproduce and thefreedom to decide if, when and how often todo so.In contrast to the traditional approach ofproviding contraceptives to married women, thisdefinition of reproductive health aims to enablemen and women to make healthy, voluntary andsafe sexual and reproductive choices. Importantly,this applies to married and unmarried men andwomen, including adolescents and older people,thereby recognizing that issues of reproductivehealth are not restricted to people in theirreproductive years. Indeed, this definition ofreproductive health places the needs of men andwomen at the centre of debates. 8 The PoA goes onto recognize reproductive health as the cornerstoneof population and development programmes. 9Reproductive rightsImplicitly, this definition of reproductive healthrefers to the rights of men and women to makeinformed decisions for themselves and to haveaccess to safe and appropriate reproductive healthservices that respond to their needs. The ICPDPoA defines reproductive rights thus:[Reproductive rights] rest on the recognitionof the basic right of all couples andindividuals to decide freely and responsiblythe number, spacing and time of theirchildren and to have the information andmeans to do so, and the right to attain thehighest standard of sexual and reproductivehealth. It also includes their right to makedecisions concerning reproduction free ofdiscrimination, coercion and violence, asexpressed in human rights documents. 10Reproductive rights advance our understanding ofreproductive health beyond a concern for the adverseoutcomes of sexual behaviour and reproduction toa focus on the minimum entitlement to well-beingfor all men and women. 11 These principles and thebroad definition of reproductive health adoptedin the PoA were reinforced and expanded at theFourth World Conference on Women (FWCW)in Beijing in 1995. The conference’s Platform forAction clearly articulates the right of women andmen to freely decide matters concerning theirreproduction.[R]eproductive rights embrace certainhuman rights that are already recognized innational laws, international human rightsdocuments and other consensus documents.These rights rest on the recognition of thebasic right of all couples and individuals todecide freely and responsibly the number,spacing and timing of their children andto have the information and means toModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 5do so, and the right to attain the higheststandard of sexual and reproductivehealth. It also includes their right to makedecisions concerning reproduction free ofdiscrimination, coercion and violence, asexpressed in human rights documents. 12Sexual health, sexuality and sexual rightsThe definition of reproductive health outlined inthe ICPD PoA includes the ability of people tohave safe and satisfying sexual relationships. Thisconcern for sexual health arose in response to theHIV epidemic, among other health issues, andchallenged the traditional linking of sexual activitywith reproduction. 13 Attention was also drawn tohow the long-established approach neglected theemotional, mental and physical health aspects ofsexual activity and reproduction. 14 As a result,sexual health is being proposed as a necessaryprerequisite for reproductive health, instead of anaspect of reproductive health. According to thefollowing working definition, sexual health is:…a state of physical, emotional, mentaland social well-being in relation to sexuality;it is not merely the absence of disease,dysfunction or infirmity. Sexual healthrequires a positive and respectful approachto sexuality and sexual relationships, aswell as the possibility of having pleasurableand safe sexual experiences, free of coercion,discrimination and violence. 15This definition of sexual health remains relevantthroughout life and is not restricted to thereproductive years. It also gives explicit attentionto sexuality and safer sex, while recognizing theneed to address sexual behaviour, social stigmaand discrimination. 16 Sexual health encompassespeople’s beliefs, values and attitudes includingtheir roles, identity and personality and theirindividual thoughts, feelings and behaviourswithin relationships.A central concept in this understanding ofsexual health is that of sexuality. Sexuality is afundamental aspect of being human. 17 And yetit remains taboo in many societies. While debateconcerning how to define sexuality continues,WHO recently proposed the following workingdefinition:Sexuality is a central aspect of beinghuman throughout life and encompassessex, gender identities and roles, sexualorientation, eroticism, pleasure, intimacyand reproduction. Sexuality is experiencedand expressed in thoughts, fantasies, desires,beliefs, attitudes, values, behaviours,practices, roles and relationships. Whilesexuality can include all of these dimensions,not all of them are always experienced orexpressed. Sexuality is influenced by theinteraction of biological, psychological,social, economic, political, cultural, ethical,legal, historical, religious and spiritualfactors. 18This definition of sexuality encompasses biologicalsex, gender identities and roles and sexualorientation. As such, sexuality includes attention topeople’s cultural norms, practices and behaviours,while also dealing with anatomy, physiology andthe biochemistry of the sexual response system. Itdraws attention to the multiple ways sexuality isexperienced and expressed and the ways in whichmen and women of all ages and sexual orientationsseek out, desire and/or refuse sexual activity. 19Importantly, this conceptualization of sexualityexpands the traditional concern with the negativeimplications of sexual activity, such as disease anddiscrimination, to include positive aspects suchas pleasure, fulfilment and affirmation. 20 It alsorecognizes the possibility of multiple sexualities,thereby moving away from the belief that thereonly two genders (male and female) and thatheterosexuality is the norm. 21The process of translating the concepts of sexualhealth and sexuality into the language of humanrights continues. To date, sexual rights havenot been defined in international documentsor treaties. The ICPD PoA noted the right ofindividuals to have a “satisfying and safe sex life”,yet it does not use the term “sexual rights”. TheWhat is sexual and reproductive health?

6Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBeijing Declaration and Platform for Actiontook one step further than the ICPD PoA. 22 ThePlatform for Action stated that the human rightsof women include the ability to:… have control over and decide freelyand responsibly on matters related to theirsexuality, including sexual and reproductivehealth, free of coercion, discriminationand violence. Equal relationships betweenwomen and men in matters of sexualrelations and reproduction, includingfull respect for the integrity of the person,require mutual respect, consent and sharedresponsibility for sexual behaviour and itsconsequences. 23This passage defines “sexual rights” without usingthe specific term. 24The concept of sexual rights remains contested.However, some common ground has recentlybeen reached; sexual rights are understood tosupport the ability of people to decide whether toengage in reproductive or non-reproductive sexualactivity and to enjoy sexual health regardless oftheir reproductive capacity. Indeed, the right ofwomen and men to control their bodies and makedecisions concerning their fertility is a centralaspect of both sexual and reproductive health. 25According to the proposed working definition ofsexual rights, all persons are entitled to: 26the highest attainable standard of sexualhealth, including access to sexual andreproductive health care services;seek, receive and impart informationrelated to sexuality;sexuality education;respect for bodily integrity;choose their partner;decide to be sexually active or not;consensual sexual relations;consensual marriage;decide whether or not, and when, tohave children; andpursue a satisfying, safe and pleasurablesexual life. 27This definition of sexual rights applies to allindividuals regardless of their age, gender orsexual orientation. Sexual rights recognize and,thereby, challenge discrimination rooted ingender inequality and sexual orientation and theadvantages heterosexual men and women enjoyover those who are homosexual or transgendered.Sexual rights thus protect against the possiblenegative impacts of sexuality and sexual activity,such as morbidity, mortality, discrimination andviolence, and promote the positive aspects ofsexuality and sexual activity. 28Measuring sexual and reproductive healthThe broad definition of sexual and reproductivehealth adopted at the ICPD advances a holisticapproach to sexual and reproductive health,underpinned by respect for human rights, genderequality and empowerment of sexual minorities,such as those who are lesbian, gay, bisexual ortransgendered (LGBT).While this approach enhances our understandingof sexual and reproductive health, it alsocomplicates the process of estimating the burdenof morbidity and mortality related to sexual andreproductive health at the international, nationaland community levels. As a result of broadeneddefinitions, sexual and reproductive healthhave come to encompass not only physiologicalprocesses, such as pregnancy, but alsocommunicable diseases, i.e. sexually transmittedinfections (STIs), and noncommunicable diseases,such as breast or cervical cancers. 29Moreover, the factors that can increase or decreasethe risk of poor sexual and reproductive healthin individuals and communities are intimatelyconnected with cultural beliefs, traditions anda range of social and economic factors. It canthus be difficult to elucidate and objectivelymeasure these and other determinants ofsexual and reproductive health. 30 In particular,sexual and reproductive health issues are oftenunderreported in countries where discussions ofsexual activity and sexuality are taboo. Keepingthese constraints in mind, the sections belowModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 7Table 1: Share of DALYs lost due to reproductive health-related causes, by region, 2001 (percent)World Africa Americas EuropeEasternMediterraneanSoutheastAsiaWesternPacificSTIs (excludingHIV/AIDS) 0.8 1.4 0.4 0.2 1.0 1.0 0.2HIV/AIDS 6.0 18.8 1.9 0.6 1.3 3.2 0.8Maternalconditions 2.1 3.2 1.3 0.5 3.0 2.4 1.1Perinatalconditions 6.7 6.1 4.9 1.9 9.1 9.4 5.7Other SRHconditions 2.7 1.7 3.5 3.7 2.5 2.8 3.0Total (percent) 18.4 31.3 12.0 6.9 16.9 18.9 10.8Total DALYs(thousands) 270 112 17 10 23 79 28Source: Vlassoff et al. 2004. In: United Nations Millennium Project 2006.consider some aspects of sexual and reproductivehealth.The global burden of mortality andmorbidity related to sexual andreproductive healthDepending on the definition used, reproductiveill-health was estimated to constitute between 5%and 20% of the global burden of disease in 1998. 31More recent calculations suggest that death anddisability related to sexual and reproductive healthaccount for 18.4% of the global burden of diseaseand 32.0% of the burden of disease among womenaged 15–44 years of age. 32 Calculations suggestthat the distribution of morbidity and mortalityrelated to sexual and reproductive health variesamong conditions and regions. Table 1 presentsthe share of disability-adjusted life years (DALYs)lost due to reproductive health-related causes byregion in 2001.An estimated 50% of the global population isunder the age of 25 years. 33 Adolescents (10–19years of age) and young people (ages 10–24 years)are particularly vulnerable to death and disabilityrelated to sexual and reproductive health. Recentanalysis concludes that the adverse effects of STIs,including HIV, and early pregnancy threaten theseage groups more than any other. 34 Adolescents donot always plan sexual activity and may not havethe knowledge and skills to protect themselvesfrom STIs. This vulnerability is amplified byprofound changing social norms in manydeveloping countries that include a trend towardsdelays in marriage and childbearing, urbanization,weaker influence of families and culture andgreater autonomy for women. In this changingenvironment, many adolescents continue toexperience difficulties accessing information andappropriate health care services.At the other end of the lifecycle, older peopleconstitute an increasing proportion of thepopulation in many developing countries. Aspopulations age, the reproductive health needsof older people will come to the fore. In general,women are disproportionately represented amongolder people. In developing countries, thesewomen tend to be widows and are often poorand illiterate. As a result, older women may beparticularly vulnerable to sexual and reproductiveill-health.Maternal mortalityComplications during pregnancy and childbirthare the leading cause of mortality and morbidityamong women of reproductive age in developingcountries. 35 Each year, an estimated 210 millionWhat is sexual and reproductive health?

8Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsFigure 1: Maternal mortality ratios by country, 2000< 50 50–299 300–549≥550No dataSource: World Health Organization 2005b.women experience life-threatening complicationsduring pregnancy, which often result in seriousdisability and perhaps death. 36 Based on 2000 data,at least 529 000 maternal deaths occur worldwideevery year. 37 About 90% of these deaths take placein developing countries.Globally, the maternal mortality ratio (MMR) is400 per 100 000 live births. However, maternalmortality in developing countries is more than 100times higher than that in industrialized countries,making it the health indicator with the greatestdisparity between rich and poor nations. Thelifetime risk of maternal deaths in Sub-SaharanAfrica is 1 in 16, as compared with 1 in 43 in SouthAsia, and 1 in 2800 in industrialized countries. 38Figure 1 presents the worldwide distribution ofMMR among countries.Maternal mortality is also a sensitive indicatorof women’s status within societies. In manycountries, gender inequality and the low statusof women cause high numbers of women todie in pregnancy and childbirth. Globally, fewimprovements in maternal mortality have beenachieved over the last 15 years. 39 The reasons arecomplex and tend to vary across countries. Indeveloping countries, much of the stagnationhas been attributed to low coverage of healthservices during pregnancy and the tendency forwomen to deliver outside health facilities withoutskilled birth attendants. 40 More broadly, genderinequality, including women’s lack of decisionmakingpower and unequal access to economicand political resources, impinges upon theirhealth during pregnancy and childbirth. 41Most maternal deaths occur between the thirdtrimester and the first week after pregnancy. Therisk of mortality can be particularly high during thefirst and second days after birth. 42 Recent evidenceshows that maternal deaths can be especially highfollowing an abortion or stillbirth. In Bangladesh,for example, up to 50% of maternal deathsModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 9Figure 2: Maternal mortality ratios bymedical cause and region, 2002Figure 3: Maternal mortality ratios forselected countries in the Region, 20021006009080500Maternal mortality ratio7060504030Maternal mortality ratio40030020020100Sub-Saharan AfricaHaemorrhageSepsis/infectionOther directIndirect causesSouth AsiaSource: Ronsmans et al. 2006.East Asia and PacificLatin America and theCarribeanDeveloped regionsHypertensive diseasesObstructed labourAbortionUnclassifiedduring the first week after pregnancy occurred inwomen whose pregnancy had ended in abortionor stillbirth. 43 Unsafe abortions 44 cause up to 17%of maternal deaths in Latin America and 19% inSouth-East Asia. About 26 million legal abortionsare performed each year. Roughly 97% of theestimated 20 million unsafe abortions that occurannually take place in developing countries. Anestimated 68 000 women die from complicationsrelated to unsafe abortions each year. 45 Giventhe sensitive nature of induced abortions, thesefigures likely underestimate the true extent of theproblem.The causes of maternal death can be classified as“direct” and “indirect”. Direct causes account forthe majority of maternal mortality in developingcountries. Direct causes include: haemorrhage,anaemia, infection or sepsis, obstructed labourand hypertensive disorders of pregnancy. Up to1000Lao PDRCambodiaPapua New GuineaMicronesia, Federated StatesNauruJapanNew ZealandAustraliaSingaporeHong Kong, ChinaSource: World Health Organization Regional Office for the WesternPacific 2005a.166 000 maternal deaths are caused each yearby severe bleeding. 46 Figure 2 breaks down thedirect causes of maternal mortality by region. Theindirect causes of maternal deaths, such as HIV/AIDS and malaria, differ between regions andcountries. 47An estimated 25 to 30 million deliveries areperformed in the Western Pacific Regionannually. Of these, more than 30 000 result inmaternal death. 48 Although improvements havebeen made in maternal health, the Region’s MMRwas estimated in 2001 to be 120 per 100 000live births. 49 This average masks stark differencesbetween countries in the Region (Figure 3). Therisk of death among pregnant women in the LaoPeople’s Democratic Republic was 530 per 100000 live births in 2002, compared to 7 per 100000 live births in Japan. 50 Data indicate thatadolescents bear a significant burden of maternalmortality in the Region. In the Philippines, forWhat is sexual and reproductive health?

10Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 1: Links between maternal and child healthThe health and well-being of newborns, infants and children are closely linked to that of their mothers.While this relationship continues throughout the lifecycle, maternal health affects the well-being of childrenmost drastically during the first four weeks of life (the neonatal period). Simply, mothers who are healthy andwell nourished tend to have healthy babies. Effective health care during pregnancy and delivery also benefitsnewborns. Globally, maternal health complications contribute to the deaths of at least 1.5 million infants inthe first week of life and 1.4 million stillborn babies.In contrast to maternal deaths, child deaths have declined from a global average of 146 per 1000 livebirths in 1970 to 79 in 2003. The under-five mortality rate in the Western Pacific Region fell from 154per 1000 live births in 1955-1959 to 48 in 1995-1999. Recent analysis suggests, however, that this declinein child mortality is slowing and approximately 3000 children under five years of age die every day in theRegion.Moreover, these substantial reductions in chid mortality have not translated into similar improvements inneonatal survival. From 1998 to 2000, child mortality after one month of life (from two months to fiveyears) decreased by one third, while mortality during the neonatal period declined by only one fourth. As aresult, an increasing proportion of child deaths occur during the first four weeks of life. Neonatal deaths nowaccount for about 40% of all deaths among children under five years of age. In the Western Pacific Region,this proportion rises to 50%.These deaths account for only a fraction of the problems associated with neonatal health. The conditions thatcause neonatal deaths and stillbirths often lead to severe disability that can last throughout a lifetime. Forexample, birth asphyxia can lead to cerebral palsy, learning difficulties and other disabilities. The extent ofsuch morbidity is suggested by the fact that for every newborn baby who dies, another 20 suffer birth injury,infection, complications of preterm birth and other neonatal conditions. 51Sources: World Health Organization 2005b; Filippi et al. 2006; Lawn et al. 2005; Ahmad, Lopez and Inoue 2000; World HealthOrganization Regional Office for the Western Pacific 2005b.example, 20% of maternal deaths occur amongteenage mothers. 52Apart from pregnancy-related deaths, illness anddisease related to pregnancy and childbirth affectup to one quarter of adult women in developingcountries. 53 Maternal morbidity is estimatedto be 30 times the number of maternal deaths,accounting for 2.1% of the global burden of diseaseand 13.0% of DALYs lost among women aged 15to 44 years of age in 2001. 54 Short-term morbidityfrom pregnancy and childbirth can includeanaemia, reproductive tract infections (RTIs) anddepression, while uterine prolapse, vesicovaginalfistulae, incontinence, dyspareunia, and infertilitycan affect women in the longer term. 55 High ratesof depression arising from childbirth have beenreported throughout the world, with childbirthbeing one of the factors potentially responsiblefor the high rates of unipolar depression amongyoung women. 56Worldwide, teenagers give birth to one in 10 babies.In developing countries, this proportion rises toone in six. 57 Adolescent girls are at particular riskof pregnancy- and childbirth-related morbidityand mortality. Girls under 15 years of age are morelikely to have premature labour and four timesmore likely to die from pregnancy-related causesthan are women older than 20 years of age. 58 Box1 discusses the links between maternal and childhealth.Men’s reproductive healthTraditionally, family planning and reproductivehealth services concentrated largely on women.While an awareness of the need to involve menModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 11Figure 4: Total fertility rate for selected countries in the Region, 200265Total fertility rate43210Source: World Health Organization Regional Office for the Western Pacific reproductive health initiatives is growing, therecontinues to be a general lack of informationon the reproductive health needs of men indeveloping countries. Men can suffer from a rangeof reproductive health problems. Several cancers,such as prostate, colon and testicular, can affectthe male reproductive system. An estimated 30%of infertility cases are due to problems in the malereproductive system, while an additional 20% ofcases are caused by problems in the reproductivesystem of both the man and women. Sexual healthissues include erectile dysfunction and prematureejaculation. 59 In one study, men in Pune, Indiamentioned masturbation, the consequences ofloss of semen, menstruation, pregnancy andAIDS as sexual issues that affected them. 60 A studyconducted in a men’s clinic in Bangladesh foundthat patients complained most about: pain passingurine; psychosexual problems such as impotence,premature ejaculation and sexual dissatisfaction;and urethral discharge. 61Family planningAustraliaCambodiaChinaFijiKiribatiA spectacular decline has occurred globally in thetotal fertility rate (TFR). TFR is defined as theLao PDRMalaysiaMongoliaNew ZealandNiuePalauPapua New GuineaPhilippinesRepublic of KoreaSamoaSolomon IslandsTongaTuvaluVanuatuViet Namtotal number of children a woman would haveby the end of her reproductive life if she met theprevailing age-specific fertility rates from 15–49years. 62 While fertility rates have declined in mostcountries, women dwelling in developing countriestend to have more children than those living indeveloped countries. This trend is apparent inthe Western Pacific Region, where TFR rangesfrom 1.0 and 1.2 in Hong Kong (China) andSingapore, respectively, to 4.8 in Cambodia andthe Lao People’s Democratic Republic. 63 Figure 4presents TFR in 2002 for selected countries in theRegion.Contraception is an integral component ofreproductive health because of its positive effecton the health of women. Contraception enableswomen to postpone or cease childbearing, whichcan protect them from the harmful health effectsof frequently giving birth. In 2000, the use ofeffective contraception by women who did notwant to become pregnant may have averted upto 90% of abortion-related and 20% of obstetricrelatedmorbidity and mortality. 64 Moreover, theability to regulate the timing and frequency ofpregnancies is held to be a fundamental rightWhat is sexual and reproductive health?

12Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsof all individuals. Contraceptive prevalencerates (CPRs) in married women aged 15–49years vary considerably throughout the world.Globally, the proportion of married womenusing contraceptives has increased from 10% in1960 to 60% in 2000. During this period, theaverage number of children per woman declinedfrom six to three. 65 Concomitantly, the numberof children men and women desire has similarlydecreased.Contraceptive prevalence has similarly increasedthroughout the Region. Contraceptive use amongCambodian women doubled from 6.9% in 1995to 18.5% in 2000. 66 Although contraceptive usein the Lao People’s Democratic Republic hasrisen rapidly since 1995, it remains at 32%. In1998, 33% of all women and 46% of marriedwomen in Mongolia used contraceptives.Among Filipino women, 33.1% were usingmodern contraceptives in 2001, while in PapuaNew Guinea 20% of couples use moderncontraceptives. 67 In contrast, the contraceptiveprevalence rate in China and Viet Nam was 83%and 75%, respectively.Although contraceptive prevalence is increasing,the unmet need for contraceptives remains highin some parts of the world. More than 120million couples worldwide have an unmet needfor family planning services. 68 This situationcontributes to the continued high maternalmortality and morbidity in many countries. Anestimated 80 million women have unintendedpregnancies, of which 45 million are terminated.Roughly 40% of these women are under 25 yearsof age. 69 Many more women are unable to planthe timing of their first pregnancy and the spacebetween subsequent births. Up to 201 millionwomen who wish to limit or space their birthsare not using modern contraceptive methods. Ofthese, 137 million are using no method, whilethe remaining 64 million rely on traditionalmethods, which are less effective. 70 Vasectomies,which are simple, safe and effective, are rare inmany developing countries in the Region, exceptChina. For example, this method of contraceptionwas almost nonexistent in Cambodia prior to2000. 71The unmet need for contraceptives is very highamong adolescents. Early marriage contributesto high fertility rates in adolescents (please seesection on early marriage below). Estimates from2006 suggest that between 17% and 47% ofmarried women aged 15–19 years of age do notuse contraceptives. Among married women aged20–24 years, this proportion decreases to between16% and 40%. 72Sexually transmitted infectionsUnsafe sexual activity has been identified asthe second most important risk factor leadingTable 2: Leading risk factors of the burden of disease in poorest and developed countriesPoorest countriesDeveloped countries1. Underweight 1. Tobacco2. Unsafe sex 2. High blood pressure3. Unsafe water, sanitation and hygiene 3. Alcohol4. Indoor smoke from solid fuels 4. High cholesterol5. Zinc deficiency 5. High body mass index6. Iron deficiency 6. Low fruit and vegetable intake7. Vitamin A deficiency 7. Physical inactivity8. High blood pressure 8. Illicit drugs9. Tobacco 9. Unsafe sex10. High cholesterol 10. Iron deficiencySource: Ezzati et al. 2002.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 13to mortality and morbidity in the poorestcountries. In developed countries, unsafe sexis ranked ninth (Table 2). 73 In 2001, sexuallytransmitted infections (STIs) (excluding HIV/AIDS) accounted for 0.9% of the global burdenof disease, having declined from 1.3% in 1990. 74Estimates from 1990 suggest that STIs (excludingHIV/AIDS) account for 8.9% of the diseaseburden among women aged 15–45 years of ageand 1.5% in men of the same age. 75 When theburden of HIV/AIDS is added to these figures,STIs are a leading cause of death and disability indeveloping nations.In 1999, WHO estimated that 340 million newcases of four curable STIs—gonorrhoea, syphilis,chlamydia, trichomonas—were acquired annually.There are at least 30 other bacterial, viral andparasitic STIs. 76 Some cause low morbidity butare stressing, such as scabies and pubic lice, whileothers can be physically damaging, such as thehuman papillomavirus (HPV) and herpes simplexvirus. Worldwide, roughly 20% of women underthe age of 24 years are positive for HPV. OtherRTIs and various gynaecological problems plaguewomen throughout the world. STIs often affectyoung people who are vulnerable to forced sex andoften do not have the skills to protect themselves.At least 25% of gonorrhoea, syphilis, chlamydia,trichomonas cases occur in people under the ageof 25 years. The proportion of some STIs amongyoung people rises to 50%. 77Estimates of the burden of STIs in countries in theRegion are scarce. 78 A recent study concluded thatthe incidence of primary and secondary syphilis inChina was 5.67 per 100 000 people in 2005. 79 InSolomon Islands, clinical data show an increasingnumber of STI cases since 1992 (Figure 5). Highlevels of STIs were observed among womenattending antenatal clinics and among seafarersin Tarawa, Kiribati in 2003. The prevalence ofchlamydia and syphilis were estimated to be 9.3%and 2.7%, respectively. 80STIs can lead to a myriad of reproductive healthproblems, including infertility and negativepregnancy outcomes. 81 For example, data reportedin 2006 suggest that, if left untreated, syphiliscan result in stillbirth rates of 25% and perinatalmortality of up to 20%. Globally, maternalgonorrhoea causes up to 4000 new babies to goblind annually.Around 33.2 million people worldwide are infectedwith HIV and roughly 2.1 million people died30 00025 00020 00015 00010 0005 00003000250020001500100050001992Figure 5: Number of STI cases in Solomon Islands, 1992–2000Diarrhoea199219931994199519961997STIs19981999200019931994199519961997199819992000200 000150 000100 00050 000Source: Government of Solomon Islands and United Nations Development Programme 2002.0500400300200100019921992ARI19931994199519961997199819992000Annual Malaria incidence rate19931994199519961997199819992000What is sexual and reproductive health?

14Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsTable 3: Global summary of the AIDS epidemic2001 2007Number of adults (15+) and childrenliving with HIV29.0 million(26.9 million–32.4 million)33.2 million(30.6 million–36.1 million)Number of adults (15+) and childrennewly infected with HIV3.2 million(2.1 million–4.4 million)2.5 million(1.8 million–4.1 million)HIV prevalence in adults (15–49) 0.8%(0.7%–0.9%)0.8%(0.7%–0.9%)Number of adult (15+) and childdeaths due to AIDS1.7 million(1.6 million–2.3 million)2.1 million(1.9 million–2.4 million)Source: Joint United Nations Programme on HIV/AIDS 2007.of AIDS in 2007. 82 Another 2.4 million peoplebecome infected with HIV annually. AIDS is nowthe leading cause of death and productive lifeyears lost for adults aged 15–59 years worldwide. 83Table 3 presents a global summary of the AIDSepidemic in 2001 and 2007.In many parts of the developing world, most newinfections occur in young adults, with youngwomen being especially vulnerable. In 2006,roughly 40% of all adults aged 15 years and overliving with HIV/AIDS were young people (15–24 years of age). 84 In Sub-Saharan Africa, threewomen are infected for every two men. Amongthose aged 15–44 years of age, the ratio of femaleto male infection increases to 3:1. 85In the Western Pacific Region, generalizedepidemics 86 were previously reported in Cambodiaand Papua New Guinea. However, in Cambodiathe prevalence of HIV has decreased among somevulnerable groups, such as female sex workers. InChina, Malaysia and Viet Nam, HIV transmissionoccurs primarily among vulnerable groups,especially sex workers and their clients, men whohave sex with men and injecting drug users. Figure6 presents HIV prevalence rates among the generalpopulation in Cambodia from 1995 to 2006.Gender-based violenceGender-based violence affects people in countriesworldwide and is an underlying determinant ofmany other reproductive health problems. Genderbasedviolence encompasses physical, sexual andpsychological violence. Measuring the prevalenceof gender-based violence is often challenging, as itcontinues to be viewed as a private matter in manycountries. Globally, violence against women ismost common in the private sphere and is usuallyFigure 6: HIV prevalence among the general population in Cambodia, 1995-20063Adult HIV prevalence (%)2101995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Urban Rural TotalSource: Joint United Nations Programme on HIV/AIDS and World Health Organization 2007.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 15carried out by an intimate male partner, familymember or acquaintance. The lifetime prevalenceof physical or sexual violence, or both, amongwomen varies by country and ranges from 15%to 71% worldwide. Among women who wereor who had ever been married, the prevalenceof physical abuse by an intimate partner ranged13% to 61% in 2002, and the prevalence ofsexual violence was calculated to be between 6%and 59%. 87 A high incidence of non-consensualsex, particularly among young women, has beenreported globally. 88 Some men, particularly thosewho are young, also suffer coerced sex or intimatepartner violence. Homosexual men, or othermen who do not conform to dominant notionsof masculinity, can also experience gender-basedviolence. Violence, or the threat of violence, canaffect all aspects of men and women’s sexual andreproductive health. The World Bank estimatedthat domestic violence and rape accountedfor 5%–16% of DALYs lost among women ofreproductive age. 89What is sexual and reproductive health?

2. What are the links betweenpoverty, gender, and sexual andreproductive health?Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 172. What are the links between poverty, gender, and sexual and reproductivehealth?Sexual and reproductive health is a holisticconcept that encompasses a collectionof diseases as well as healthy physiologicalfunctioning. Social factors, such as genderrelations, sexual identities and social inequalities,play a primary role in determining an individual’sability to achieve good sexual and reproductivehealth. Gender-based violence is also recognizedas a determinant of poor outcomes with respectto other reproductive health indicators, such asmaternal mortality and RTIs.Poverty and gender inequality exercise considerableinfluence and constitute important determinantsof men’s and women’s sexual and productive healthat all ages. They also shape the access of men andwomen to appropriate reproductive health care.That is, poor people are less likely than those whoare better-off to purchase or access promotive,preventive or curative reproductive health services.The cumulative adverse effects of living in povertyand experiencing unequal gender relations arereflected in inequalities in the burden of poorsexual and reproductive health and differencesin how men and women experience sexual andreproductive health.In the following sections, the relationship betweenpoverty and sexual and reproductive healthis considered, followed by a discussion of theinfluence of gender inequality on the sexual andreproductive health of men and women. In eachcase, the effects of poverty and gender inequalityon the reproductive health of adolescents andolder people are highlighted.The influence of poverty on reproductivehealthPoverty is a determinant of sexual andreproductive healthHousehold incomeHousehold income is a powerful determinant ofsexual and reproductive health outcomes bothbetween and within countries. Women residingin poor households are more likely to experienceearly childbearing, short birth spacing and highparity births. 90 As much as 70% of the variancein infant mortality witnessed across and withincountries can be attributed to differences inincome. 91Within countries, low household income is alsoassociated with malnutrition and low educationalattainment, factors that also increase the risk ofadverse sexual and reproductive health outcomes.Evidence shows that women residing in poorhouseholds are more likely than those from betterBox 2: Defining povertyIn this module, poverty is defined to encompassnot only low income but also other formsof deprivation, including limited economicopportunities; diminished education and healthoutcomes; reduced access to services, resourcesand skills; and voicelessness and powerlessnessto influence decisions that affect one’s life. 92This definition of poverty moves beyond thenarrow association of poverty with low incomeand consumption, which tends to inadequatelycapture the experience of poverty in the Region.For example, among communities in the Pacific,poverty, as measured by income or consumption,may be deemed to be low or nonexistent. However,households in the Pacific may be vulnerable tonatural disasters; located in isolated or remoteplaces; lack economic choices or opportunitiesto earn income; have limited access to education,health and financial services; and suffer from socialexclusion. 93Poverty often overlaps with and reinforces othertypes of social exclusion that are based on age,ethnicity, geographical location and gender.Because of this, communities, households, andeven members within the same household tend tohave different experiences of poverty. The povertyexperienced in rural communities often differsfrom that of urban poor communities, such asslum dwellers. Women within poor householdstend to be particularly disadvantaged, as womenlag behind men in almost every social andeconomic indicator of well-being.Sources: Lightfoot and Ryan 2001; Lampietti and Stalker2000.What are the links between poverty, gender, and sexual and reproductive health?

18Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsFigure 7: Proportion of women aged 15–49 years who know at least one way to avoid sexual transmissionof HIV/AIDS, by income quintile, in Cambodia (2000), the Philippines (2003) and Viet Nam (2002)100908070Percent (%)6050403020100Lowest Second Middle Fourth HighestCambodia Philippines Viet NamSource: Gwatkin et al. 2007a, 2007b and households to experience early child bearing,short birth spacing and high parity births. Adultnutrition and health-seeking have also been foundto improve with income level. 94A clear correlation between household income andthe likelihood of HIV infection has been observedin a number of countries. Analysis of data fromCambodia and Viet Nam found that householdincome was associated with reduced risk factorsfor HIV, such as increased awareness aboutmodern contraceptives and about the benefits ofusing condoms. 95 A study carried out in Thailandfound that people from the poorest householdswere the most likely to be infected with HIV. 96Similarly, in Cambodia, the Philippines and VietNam, women’s awareness of HIV preventionappears to improve as household income rises(Figure 7).Across countries in the Region, household incomestend to be lower in rural areas than in urban areas.As a result, rural residence may be considered asa dimension of poverty or social exclusion. In theLao People’s Democratic Republic, knowledgeof contraceptives was found to be higher amongurban youth aged 15 to 24 years than youth inrural areas (79% vs. 45%). Similarly, youth inurban areas were more likely than their ruralcounterparts (69% vs. 40%) to have heard ofSTIs.Restricted economic opportunitiesPoverty may increase the likelihood of women andmen engaging in income-generating activities thatcan be harmful to their sexual and reproductivehealth. Although women enter sex work for avariety of reasons, female sex workers often comefrom households that are poor or otherwisedeprived. For example, a study carried out in SiemReap, Cambodia found that 51.4% of female sexworkers had never attended school. 97 Similarly,transgendered individuals who face socialmarginalization and extreme exclusion from thelabour market may be left with few options otherthan sex work to survive. Sex workers who livein poverty are vulnerable to inadequate workingconditions that can increase the risk of physicaland reproductive health problems, unwanted andcomplicated pregnancies, STIs and a range ofother negative health outcomes.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 19In many parts of the world, men and womenleave their homes to find work. Migration mightoccur from rural to urban areas within a country(internal), or to destinations outside the countryof origin (external). Studies from countries acrossthe Region show that the risk of poor reproductivehealth is often greater for mobile populationsthan for non-mobile populations. Most notably,migrant populations are more vulnerable to HIVinfection than the general population in manycountries. This vulnerability is attributed, in part,to the absence of family and social norms and toconstrained access to reproductive health services. 98Work-related migration can create an imbalance inthe ratio of men and women in sending or receivingareas. In some cases, these disproportions can leadto the sharing of sex partners. 99 For example, astudy in Sichuan province, China reported thatmigrant workers constituted the majority of maleclients of female sex workers. On average, migrantworkers were found to have bought sex 11 timesduring the previous six months and the majority(64%) had not used a condom the last time theypaid for sex. 100Limited access to educationWorldwide, a larger share of men (80%) thanwomen (64%) is literate. While boys and girlsin more developed countries are both enrolledin primary and secondary school, women inless developed countries complete fewer yearsof education than men and are more likely tobe illiterate. 101 Table 4 presents the literacy ratesfor men and women in selected countries in theRegion.Although the literacy rates of women are generallylower than men, evidence shows that women whocan read and write are better equipped to protecttheir health and their family’s health. Girls whohave at least seven years of schooling are less likelythan those with little or no education to becomepregnant during adolescence and are more likelyto postpone marriage. 102 In Mongolia, a higherpregnancy rate was observed among girls withonly primary schooling compared to those whohad completed grade 10. 103 In the Lao People’sDemocratic Republic, youth aged 15–24 yearswith some education were nearly three times asknowledgeable as those with no education (60%vs. 21%) about contraceptive methods. Similarly,as many as 52% of youth with some education andonly 21% of those with no education had heardof STIs. 104 In the Philippines, youth who wereattending school knew more about reproductivehealth than out-of-school youth. 105 Moreover,Filipino youth with lower education reporteda higher incidence of sex work than those withhigher levels of education. 106 Studies report thatpoor, uneducated men and women have higherrates of STI including HIV. 107 Similarly, a studyconducted in Long An, Viet Nam in 2002 revealeda lower prevalence of HIV among injectingdrug users with high school or undergraduateeducation. 108Educating women is a long-term strategy foradvancing their reproductive health. Educatedwomen generally have a better understanding ofhealth care practices and nutrition. Women withhigher levels of education are more likely thanthose with lower education to seek care duringpregnancy and childbirth, to pay attention tonutrition and to increase spacing between births. 109Table 4: Adult literacy rates for selectedcountries in the Region, 2000–2004*Adult literacy rate (%)Country Male FemaleCambodia 85 64China 95 87Fiji 94 91Lao People’s Democratic 77 61RepublicMalaysia 92 85Mongolia 98 98Papua New Guinea 63 51Philippines 93 93Singapore 97 89Tonga 99 99Viet Nam 94 87*Data refer to the most recent year available during the periodindicated in column headingSource: United Nations Children’s Fund 2006.What are the links between poverty, gender, and sexual and reproductive health?

20Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsData collected in Peninsular Malaysia from 1950to1998 revealed that educational attainmentpositively influenced a woman’s decision toobtain prenatal care and to deliver in a clinic orhospital. 110 Research from the past 20 years showsthat educated women tend to have smaller andhealthier families. In contrast, women with noschooling have about twice as many children as dowomen with 10 or more years of education. 111 Forall of these reasons, educated women are less likelythan uneducated women to die in childbirth.Indeed, the World Bank estimates that, for every1000 women, an extra year of education couldprevent two maternal deaths. 112UndernutritionHunger and undernutrition are closely associatedwith poverty. Undernutrition includes proteinenergyundernutrition and deficiencies inmicronutrients such as iron, vitamin A, iodine andzinc. 113 In Cambodia, the rate of undernutrition(BMI

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 21and 40% of deliveries are not attended by a trainedhealth staff. 125In countries in the Region with the highest riskof maternal death, the coverage of appropriatematernal health services may be even lower.Analysis of data from Cambodia and the LaoPeople’s Democratic Republic suggests that asmany as 90% of deliveries occur at home withouta skilled birth attendant. 126 Roughly 58% ofwomen in Papua New Guinea attended antenatalclinics during pregnancy. 127 In the Philippines,70% of women have the recommended fourantenatal check-ups. 128The continued unmet need for family planningin many countries in the Region points tothe incomplete coverage of family planningprogrammes. Unmet need for family planningamong women who are married or in union wasestimated to range from 40.0% in the Lao People’sDemocratic Republic to 18.8% in the Philippinesin 2005. 129 The unmet need for contraceptivescorrelates strongly with household income indeveloping countries. 130 Estimates suggest thatunmet need in the poorest fifth of the populationin Asia and Latin America might be twice as highas that of the wealthiest fifth. 131 A similar trend isobserved among countries in the Region (Table5).While these data illustrate the general incompletecoverage of many reproductive health servicesin the Region, they say little about thedistribution of these services within countriesTable 5: Total fertility rates (actual and wanted)by income quintile in the Philippines, 2003Wealth index quintile Wanted ActualLowest 3.8 5.9Second 3.1 4.6Middle 2.6 3.5Fourth 2.2 2.8Highest 1.7 2.0Total 2.5 3.5Source: National Demographic Health Survey 2003. In: HealthAction Information Network 2005.and between communities. Further analysis ofdata from more than 50 developing countriesreveals that reproductive health services tend todisproportionately benefit better-off communitieswithin countries, even though poor individualsand households are more vulnerable than the nonpoorto reproductive ill-health.Among women in the poorest income quintile,for example, births are five times less likely to beattended by trained health personnel than birthsto women from the highest income quintile. 132The proportion of women from households in thepoorest income quintile in the Philippines andViet Nam who received at least one antenatal careconsultation with an adequately trained personwas 71.5% and 78.5%, respectively, in comparisonwith over 97% of women from households inthe richest income quintile in both countries.The inequalities in deliveries attended by trainedpersonnel are even starker: only 21.2% of birthsto women from the poorest income quintile inthe Philippines were assisted by a doctor, nurseor trained midwife, while over 91.0% of womenfrom the richest income quintile received suchassistance. Figure 8 compares the proportion ofdeliveries assisted by a trained health worker forwomen in the poorest and richest income quintilesPercent (%)Figure 8: Percentage of women receiving deliveryassistance from a doctor, nurse or midwife inCambodia, the Philippines and Viet Nam1009080706050403020100Cambodia,2000Poorest quintilePhilippines,1998Richest quintileSource: Gwatkin. 2000. In: Carr 2004.Viet Nam,2000What are the links between poverty, gender, and sexual and reproductive health?

22Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsin Cambodia, the Philippines and Viet Nam.Over 90% of women from the poorest quintilein the Philippines gave birth at home, while amere 20% of those from the richest quintile chosehome births. 133 Women from households in therichest quintile in Viet Nam are more than 150%more likely than women from the poorest quintileto have deliveries in health facilities. 134Barriers to access to servicesAccess to reproductive health services canbe constrained by geographical, economic,knowledge- and awareness-related, or socioculturalbarriers. This section describes the barriers thatdelay or prevent poor men and women fromaccessing appropriate services. It then discussesinequalities in the quality of reproductive healthservices received by the poor—the quality of careis often worse in health facilities serving poorcommunities.Geographical barriersThe availability of appropriate reproductive healthservices can depend on the allocation of financialresources for health. In developing countries, thepoorest 20% of the population typically receivesless than 20% of the benefits from public healthspending (Table 6). 135 Government resources forhealth often disproportionately benefit wealthierhouseholds and communities; public resourcestend to be allocated to hospital-based curativeservices in urban areas, leaving primary healthservices and other health initiatives targeting poorcommunities or households under-funded.This skewed distribution of health resourcestends to disadvantage poor populations and oftenTable 6: Share of public health spendingreceived by households in the poorestand richest income quintilesCountry Poorest quintile Richest quintileMalaysia, 1989 29% 11%Viet Nam, 1992 12% 29%Source: Hsiao and Liu. In: Evans et al. 2001.results in substandard health services in the areaswere they live. In Vanuatu, for example, almost75% of the health budget in 1996 was allocatedto urban rather than rural services. As a result,only 20% of the population benefited from publicspending on health services. 136 In Cambodia, 13%of government staff are located in rural areas,where 85% of the Cambodian population lives. 137In Mongolia, the geographical distribution ofhealth staff may be partly why people from ruralhouseholds visit health facilities only half as oftenas those from urban households. 138 In 2002, theratio of physicians to population ranged from1:206 in Ulaanbaatar to 1:794 in Zavhan. 139Similarly, health staff in the Philippines are largelyconcentrated in urban areas. 140Inequalities in the distribution of health resourcesare also evidenced by the distances that somepeople must travel to access health services. Forexample, the proportion of households withaccess to primary health services in the LaoPeople’s Democratic Republic ranges from 82%in the southern parts of the country to 67% inthe northern areas. In the Northern Region,13% of households live more than eight hoursaway from a hospital, which is more than twicethe distance for those living in the other tworegions. 141 Remote islands in the Pacific, such asTorba and Tafea in Vanuatu, can suffer particulartransportation constraints. 142 Travel time to thenearest aid post (nursing station clinic) in PapuaNew Guinea ranges from 67 minutes in Papua/South Coast to 28 minutes in the New GuineaIslands. 143 The incomplete coverage of services inrural, remote and marginalized areas can delaya poor household’s access to health services andincrease the overall costs of seeking health care.The distribution of reproductive health servicescorrespondingly reflects the low and incompletecoverage of health services in many poor andmarginalized areas of the Region. In Mongolia,reproductive health information, education andcommunication (IEC) materials and infrastructureare concentrated in Ulaanbaatar. 144 A study inCambodia found that HIV/AIDS preventionefforts were largely focused on urban populations,Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 23thereby missing the 85% of the populationliving in rural areas. 145 Research carried out inthe Lao People’s Democratic Republic in 1999found that contraceptives were not reaching ruralcommunities. Indeed, transportation was citedas a key challenge in obtaining contraceptives. 146Maternal deaths from infection, hypertensionand uterine rupture are rarely reported in urbanareas of Viet Nam. In contrast, these are themost common causes of maternal death in ruralareas. 147Urban–rural inequalities in the coverage ofantenatal care and skilled attendance at deliveryappear to be prevalent in countries in the Region.A survey carried out in 2000 in Cambodia foundthat only 33.8% of rural women with a recentbirth had one or more antenatal care (ANC)visits to medically trained personnel as comparedwith 62.3% of urban women. The proportion ofurban births assisted by a trained health workerwas almost double (57.2%) that in rural areas(28.0%). 148 Similarly, in 2003, women in urbanareas of the Philippines were more likely thanthose in rural areas (91.2% vs. 83.9%) to have hadat least one ANC visit to a trained health worker.The discrepancy in births assisted by a trainedhealth worker were even more striking, however,ranging from 79.0% among urban women to40.8% among rural women. 149 In the same way,many women in rural parts of China have beenfound to deliver at home with no skilled healthworker in attendance. 150 Antenatal care coveragein Solomon Islands ranges from 78% in Honiarato 47% in the remote province of RennellBellona. 151Economic barriersThe total cost of seeking care can be disaggregatedinto direct costs (such as fees charged for healthservices), indirect costs (such as the cost oftransportation and food) and opportunity costs(such as time away from work). Many people inthe Region, particularly those who are poor, haveto pay for their own health care at the time ofillness and greatest need. 152 For example, in theLao People’s Democratic Republic, out-of-pocketpayments financed more than 50% of householdhealth care costs, which consisted mainly ofdrugs. 153Yet the costs of seeking health care are oftenmore than poor households can bear. In Tianjian,China, for example, 64.8% of women and55.6% of men reported that financial difficultiesprevented them from accessing hospital serviceswhen referred by a doctor. 154 A case study in threepoor rural counties in China found that financialdifficulties prevented 41% of sick peasants fromseeking treatment. 155 With regards to sexual andreproductive health specifically, studies fromBangladesh and India found that the cost ofdelivery in government facilities could be two toeight times the monthly income of the poorest25% of the population. In Rajasthan, India,treatment for one RTI episode in a governmenthealth centre costs more than the average monthlyhousehold income, while the cost of an abortionis two to three times the monthly income. Inone rural area of China, the cost of health caredeterred 74% of women with complicationsrelated to pregnancy or delivery from seekingcare in 1994-1995. 156Payments for health care services, such as userfees, have been found to adversely affect theability of poor men and women to access services,including those for reproductive health. 157 A studyin Kenya observed that the introduction of userfees, which were equivalent to half a day’s incomefor poor individuals, resulted in fewer men andwomen seeking care for STIs, and the reductionin access was significantly greater for womenthan men. 158 A study in Nigeria showed thatgovernment attempts to improve health servicesby charging user fees led to a precipitate declinein the uptake of maternity services, accompaniedby increasing numbers of deaths. 159 In a study inthe rural areas of Yunnan province in China, localwomen were unwilling to pay the 15 yuan chargedby village birth attendants for home delivery andmedication in 1999. At the time of the study, thecost of a normal delivery at a hospital was 200yuan. In 2002, the cost of a normal delivery hadincreased to 30 yuan at village level, 250 yuan atWhat are the links between poverty, gender, and sexual and reproductive health?

24Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalstownship level and 600-800 yuan at county levelinstitutions. 160Even when services are provided free of charge, theindirect costs of transportation, drugs, and foodand lodging for accompanying family memberscan increase the financial burden of seekingreproductive health care. A number of studieshave observed that, when admitted to a healthfacility for delivery, women must purchase bleachto sterilize materials, bed sheets, gauze, gloves,sanitary pads and other supplies. 161 A case study ina northern district of Viet Nam reported that thecost of transportation alone was equivalent to onethird of monthly expenditure in the locality. 162A 1999 study from the Lao People’s DemocraticRepublic estimated the cost of transportation incase of emergencies to be 2000–3000 kip 163 forless than 8 km and 60 000 for a trip longer than70 km in 1999. 164 The high cost of transportationfor long trips can limit the access of men andwomen living in rural areas to adequate healthservices, depriving them of basic care. 165 It can alsostop women from seeking emergency obstetriccare, which tends to be more available in districtor provincial health facilities located in largercommunities.In addition, the economic costs associated withseeking health care can be amplified for womenwho typically have lower access to and control overhousehold and community resources, includingmeans of transportation. In such cases, manywomen must rely on their husbands, other familymembers or community leaders to decide whetheror not their health emergency warrants the use ofhousehold or community resources.In some countries, reproductive health servicesare included in benefit packages under healthinsurance schemes. However, vulnerable groupswho need these services the most are often unableto participate in such schemes. For example, allMongolian children under the age of 16 or up tothe age of 18 while in school are covered by thehealth insurance scheme. The notable exceptionis street children and young migrants, who mightnot have the documentation required to accessservices. 166 In the Philippines and Viet Nam, asin other countries, the poor are underrepresentedin insurance schemes because few are employedin the formal sector. 167 They are also less likely tohave sufficient income to pay the fees associatedwith membership.Lack of knowledge and awarenessAccess to reliable information can enable womenand men to recognize the signs and symptoms ofreproductive health problems, such as STIs. Onthe other hand, limited health-related informationand awareness have been found to reduce demandfor preventive and curative health services. Astudy conducted in the Lao People’s DemocraticRepublic found a generally low understandingof danger signs during pregnancy, particularlyamong ethnic minorities. In addition, limitedunderstanding of the risk of malaria for pregnantwomen resulted in few pregnant women beinggiven anti-malarial medications. 168 Knowledgeof sexual and reproductive health was found tobe low among female sex workers in Cambodiaregardless of their age. 169 A study carried out in2002 in an urban slum in New Delhi reportedthat only 12.5% of respondents knew that aPap test could diagnose cervical cancer. Furtheranalysis showed that education was significantlyand positively associated with correct knowledgeand health-seeking. 170Health information may not reach poor andmarginalized households and communities for avariety of reasons. Most simply, IEC materialsmay not be available in health facilities servingpoor communities. A study in Viet Nam reportedthat abortion clinics did not have patientfriendlymaterials to help women to make aninformed choice about the method used. 171A similar lack of IEC materials for patientswas observed among health clinics in the LaoPeople’s Democratic Republic. In particular, noIEC materials were available in ethnic minoritylanguages. 172Poor men and women, who may have littleeducation, are less likely to be able to readModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 25printed information materials and labels on drugpackaging. Marginalized populations, such asethnic minorities, may not be able to benefit fromIEC materials and outreach activities if they donot speak the main language in the area.Other forms of media may be similarlyinaccessible to individuals residing in poorhouseholds that may not have radios ortelevisions. For example, a study in Indonesiaobserved that poor women were less likely thantheir better-off counterparts to be exposed tofamily planning messages through broadcastmedia. Among the poorest women, 20% recalledhaving seen or heard a family planning messagein the previous six months, as compared to 56%of the wealthiest. Fewer radios and televisionsamong the poor households partially explainedthe disparity. 173Communities in remote or rural areas may notbenefit from outreach activities. In contrastto the generally high level of awareness aboutcontraceptives in the Lao People’s DemocraticRepublic, for example, one study fund thatrural and remote communities not reachedby the national programme knew little aboutcontraceptives. 174Sociocultural barriersAccess to health services can be a particularproblem for women and men from indigenous orethnic minority groups. Throughout the world,health care for ethnic minorities has proved to bechallenging. Reasons for this challenge include: poverty and isolation of many ethnicminority populations differences between the dominant and ethnicminority populations with respect to: cultural norms and values that differfrom the dominant culture health care practices that differ from thedominant culture health-seeking behaviours beliefs and values about life, death anddestiny religious beliefs and practicesQuality of careMany health facilities that serve poor communitiesare poorly resourced and thus tend to lack adequatemedicines, equipment and supplies. These samecommunities often suffer from substandardinfrastructure such as roads, transportation,electricity, water, sanitation, communicationand links with other levels of care. 175 In SolomonIslands, for example, roughly 70% of thepopulation lives within one-hour walking distanceof a health facility. However, a study found thatmany of these facilities lacked staff and essentialdrugs and equipment. 176 A review of healthfacilities in the Lao People’s Democratic Republicin 1999 reported that few had the supplies andequipment needed to provide adequate pregnancyrelatedcare. In many facilities, privacy for patientswas questionable and referral systems weregenerally inadequate: many health facilities lackedtelephones or transmitters to contact district orprovincial hospitals in the case of emergency. 177 Inother cases, preventive efforts to reduce the riskfactors for reproductive health problems have notbeen integrated into general health care services.For example, preventive efforts for cervical cancerappear to be lacking and effective methods ofscreening and treating cervical cancer have notyet become routinely available in primary healthcare. 178It is often difficult to recruit, educate and retainhealth workers in rural and remote areas. As a result,reproductive health services in poor areas are oftenprovided by partially trained or untrained birthattendants and community or family membersusing traditional therapies and delivery methods.These methods often put the woman and baby atconsiderable risk.Health staff in rural and remote areas may alsolack the skills to assess and manage complexconditions or to know when a woman’s conditionrequires referral to a higher-level health facility.Some women in peri-urban and rural areasprefer to give birth at home for this reason, evenwhen institutional care is available. A study inthe Lao People’s Democratic Republic observedWhat are the links between poverty, gender, and sexual and reproductive health?

26Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsthat women cited low quality of care in healthfacilities and the absence of drugs and equipmentas reasons for preferring home deliveries. 179 Astudy in four poor counties in Yunnan found that29%–55% of township-level reproductive healthservice providers and 71%–91% of village-levelproviders lacked the competencies to diagnoseand treat common RTIs. 180 Clinics providingtreatment for STIs in Papua New Guinea aregenerally concentrated in the larger cities, suchas the provincial capitals. Rural health staff weregenerally found to lack the training necessaryto provide appropriate treatment and care forSTIs, and the required drugs were not alwaysavailable. 181Drug sellers in the Region often provide treatmentfor STIs. However, the quality of their servicesmay be uneven. For example, evidence from VietNam suggests that drug sellers rarely dispensetreatment for STIs in accordance with nationalguidelines or provide an adequate daily dose ofdrugs. 182In seeking health care, the poor are interested notonly in the technical competence of health staff,but also in their interpersonal skills. This may beespecially the case for women. The importanceof interpersonal relations between clients andhealth service providers is evidenced by a studyfrom Bangladesh. The study was carried out fromJanuary 1998 to July 2000 in two urban and tworural areas of Bangladesh to assess the impactof fees for services offered by nongovernmentalorganizations. The study concluded that poorrespondents were willing to travel farther andpay more for better quality services, where theinterpersonal dimension—treating clients withrespect and kindness—was a critical dimension ofquality. 183 Yet health staff may not receive trainingon interpersonal communication, as was foundto be the case in the Lao People’s DemocraticRepublic, for example. 184 Similarly, counsellingby health staff for reproductive health conditionsappears to be rare in Viet Nam. 185Poor women are particularly unlikely to seekcare from providers they view as disrespectfuland insensitive to their needs. 186 Studies fromMongolia and Viet Nam report that, even thoughinduced abortions are offered by the public healthsystem, women, especially those who are young,prefer to seek care at private hospitals because ofthe confidentiality and privacy afforded. In somecases, however, private providers may have fewskills and little training. 187Inequalities in reproductive health outcomesThe relatively high burden of reproductive illhealthamong poor individuals, combined withtheir generally lower access to preventive andcurative reproductive health services, results insignificantly worse reproductive health outcomes,including morbidity and mortality, as comparedwith the non-poor.The risk of death in childhood was estimated tobe 10 times higher for the poorest 20% of theglobal population than for the richest 20%. 188Within countries in the Region, infants andchildren from poor households and communitiessuffer disproportionately from disease and death.An inverse association between infant mortalityand maternal education has been observed inCambodia, the Philippines and Viet Nam. 189In 2003, the IMR in rural areas of Papua NewGuinea was 2.5 times higher than in urban areas. 190Table 7: Infant mortality rates in provinces with a high concentration of ethnic minoritiescompared to the national average in the Lao People’s Democratic Republic and Viet NamCountry National IMR IMR in provincesLao People’s Democratic Republic 100 per 1000 (1995) 132 per 1000 (Luang Prabang, 1999)Viet Nam 36 per 1000 (1996) 52 per 1000 (Northern Highlands)55 per 1000 (Central Highlands, 1996)Source: Asian Development Bank 2001.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 27Rates of infant and child survival tend to be loweramong marginalized communities in the Region,such as ethnic minorities (Table 7).As noted above, data on the prevalence of STIsin the Region are scarce, particularly data on thedistribution of STIs within countries. 191 Rates ofRTIs among rural women in Yunnan province,China, might be as high as 50%. 192 Evidencesuggests that genital discharge was higheramong poor rather than non-poor women in thePhilippines in 2003. 193Inequalities in the total fertility rate withincountries correlate with various indicators ofsocial exclusion. In the Lao People’s DemocraticRepublic, the TFR ranges from 5.4 in rural areasto 2.8 in urban areas. 194 Similarly, the TFR hasbeen found to be significantly higher amonguneducated women as compared with those whoare educated. 195 The TFR of Mongolian womenliving in remote western aimags is 3.85, whichis higher than the national average of 3.00 andsignificantly higher than the TFR for womenliving in Ulaanbaatar (2.17). 196In more than 50 developing countries, the rates ofundernutrition among women from the poorestincome quintile are almost twice the rates amongwomen from the richest income quintile. 197 Forexample, the incidence of anaemia is 71% amongwomen living in rural Mongolia, compared to45% among women residing in urban areas. 198Anaemia is similarly more prevalent among ruralthan urban women in Cambodia (59.1% vs.51.2%). Furthermore, women with no educationin Cambodia were found to be more likely tobe anaemic (62.1%) than their better-educatedcounterparts (57.8%). 199 Directly or indirectly,anaemia contributes to a significant proportion ofmaternal deaths in the developing world. Severeanaemia can lead to cardiac failure in pregnancyand childbirth with lesser grades of severityaccounting for haemorrhage, infection anddecreased maternal well-being. Anaemia may alsocontribute to perinatal morbidity and mortalityby increasing the likelihood of intrauterine growthretardation and pre-term delivery.Across developing countries in the Region,the likelihood of a woman dying in childbirthis higher in rural than in urban communities.In Mongolia, the maternal mortality rate inrural areas is 145 per 100 000 live births ascompared with 79 in urban areas. Women fromherding communities appear to be particularlydisadvantaged. Although these womenconstitute 29.0% of all pregnant women inMongolia, they account for 49.3% of maternaldeaths. 200 The risk of maternal death in the LaoPeople’s Democratic Republic is the highest inthe Region, estimated to be 530 per 100 000live births. Some estimates suggest that theMMR in rural areas might be as high as 900 per100 000. 201Areas and communities in the Region that arepoor and marginalized appear to experiencehigher rates of maternal mortality than those thatare better-off. For example, the MMR in westernareas of China is as high as 200 per 100 000live births, which is four times higher than theaverage in urban areas and twice as high as thatin rural areas (Figure 9). 202 The floating (migrant)population in China appears to be particularlyvulnerable to maternal deaths. 203 The risk ofmaternal death in Viet Nam has been found tobe 3.25 times higher for illiterate women than forliterate women. 204Women from ethnic minorities appear to beparticularly vulnerable to death in childbirth.In Viet Nam, the risk of maternal death wascalculated to be 3.92 times higher for womenfrom ethnic minorities than for Kinh women.A second calculation found that the MMR inthe highland areas of Viet Nam, where ethnicminorities are concentrated, was nearly 10 timesthat in the lowland areas. 205 Maternal deathsoccur more frequently in the AutonomousRegion of Muslim Mindanao (ARRM) of thePhilippines (320 per 100 000) than among thegeneral population (96 per 100 000). Similarly,estimates from China suggest that the MMR inTibet province (466 per 100 000 live births) ismuch higher than the national average (43 per100 000). 206What are the links between poverty, gender, and sexual and reproductive health?

28Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsFigure 9: Maternal deaths per 100 000 live births in China, 2003HeilongjiangJilinMaternal Mortality Ratio(ratio per 100 000 births)XinjiangTibetHigh Development < 50Medium Development 41–80Low Development > 80LiaoningGansuInner Mongolia BeijingTianjinNingxia HebeiTheBohaiSeaQinghaiShanxi ShandongThe Yellow SeaShaanxi HenanJiangsuAnhuiSichuanHubeiShanghaiChongqingZhejiangJiangxiThe East China SeaHunanGuizhouYunnanGuangxi GuangdongTaiwanHong KongThe South China SeaHainanSource: United Nations Country Team China, 2004. In: World Health Organization Regional Office for the Western Pacific 2005e.The influence of reproductive health on povertyEvidence suggests that the social and developmentalconsequences of poor reproductive healthoutcomes can be far-reaching and can weakenpoverty reduction efforts at the household andnational level.Household impoverishment as a result of poorreproductive health can arise from the economiccosts of seeking health care, as discussed above.Reproductive health-related morbidity can leadto decreased productivity and time away fromwork, thereby reducing household income. Thedeath of an income-earning adult can have severeconsequences for household survival. In addition,the opportunity costs of caring for an ill householdmember may also impose a substantial burden forpoor households. Household members (usuallygirls and women) may have to forgo incomegeneratingactivities or leave school to providethe necessary care. In Sri Lanka, for example,the annual lifetime earnings lost because of anAIDS death were estimated to be 11 times theannual cost of treatment. In Nepal, these costswere equivalent to more than four times the percapita annual income. 207 The negative impact ofpoor reproductive health can be especially severeor prolonged if households are forced to sellproductive assets, such as land or livestock.Limited access to contraceptives can undermine ahousehold’s efforts to escape from poverty. Earlypregnancy has been found to reduce women’seducational attainment. 208 A study in northeasternBrazil found that young women who continuedtheir pregnancy were more likely to drop out ofschool than were those who sought an abortion. 209Evidence also suggests that early pregnancy cannegatively affect women’s economic opportunities.For example, a study in Mexico observed thatearly childbearing led to lower monthly earningsfor mothers and lower child nutritional status forwomen who were poor, but not for women whowere not poor. 210 However, the negative effects ofearly pregnancy on women may be transitory andcan be overcome with time. 211Early marriage is of great concern for the wellbeingof women and their children. A recentModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 29report uncovered the negative consequences ofearly marriage for women. The study argued thatwomen who married young had less education andfewer schooling opportunities, had less householdand economic power than older married women,and had limited access to modern media and socialnetworks. In addition, young married womenwere found to be at greater risk of gender-basedviolence and of poor health, including exposureto HIV and the negative health effects associatedwith early childbearing. 212Available evidence shows that children whoare unwanted at conception and birth can bedisadvantaged with regards to the allocationof household resources, such as nutrition andeducation. For example, an analysis of data from11 countries and one Indian state concluded thatunwanted children were 10%–50% more likelyto be ill than wanted children. 213 Large familiesmust allocate household resources among morechildren, which can result in fewer investmentsin the health and education of each child. Forexample, a child’s school enrolment is negativelyassociated with the number of siblings with whomthe child lives. 214The death of a mother can have staggeringrepercussions for her surviving children. InNepal, for example, infants of mothers who diedduring childbirth were six times more likely todie in the first week of life, 12 times more likelybetween eight and 28 days, and 52 times morelikely between four and 24 weeks. 215 A mother’sdeath can negatively affect the health of her otherchildren as well. A study from the Kagera regionof Tanzania reported that children in householdswhere an adult woman had died in the previoussix months spent half as much time in schoolthan did those from households with no femaleadult deaths. The same pattern was not observedin households where an adult male had died. 216Analysis of data from Indonesia shows that theloss of a mother decreases the likelihood of schoolBox 3: Economic growth, poverty reduction and reproductive healthArguments for investing in family planning and reproductive health have historically concentrated on therelationship between population dynamics (population growth, the age structure, and rural–urban migration)and economic growth. While these theories remain controversial, attention is increasingly being devotedto elucidate the mechanisms through which reproductive health can spur economic growth and povertyreduction.Recent analysis suggests that demographic changes contribute an estimated 25%–40% to macroeconomicgrowth, which is roughly split between decreased mortality and decreased fertility. Decreased mortality isassociated with improved productivity while lower fertility leads to improved investments in human capital(health and education).More nuanced arguments show that, as fertility declines, a window of opportunity opens when youthdependency in a society declines before the dependency associated with ageing increases. Research has shownthat, when combined with good economic policies, the resulting swell in the working age population cancreate a ‘demographic bonus’ or ‘dividend’ that leads to economic growth. The most solid evidence for thistheory comes from East Asia, where the demographic bonus is estimated to have contributed up to one-thirdof economic growth between 1965 and 1990. Further analysis suggests that this bonus could reduce povertyin developing countries by about 14% between 2000 and 2015.Conversely, societies with a high dependency ratio need to devote a greater proportion of output toconsumption than investments in education, nutrition or health. Such lower rates of investment canundermine the potential for economic growth and poverty reduction.Sources: Birdsall 2001. In: United Nations Millennium Project 2006; Bloom and Canning 2004. In: United Nations PopulationFund 2005; Mason and Lee 2004. In: United Nations Population Fund 2005.What are the links between poverty, gender, and sexual and reproductive health?

30Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsenrolment, and increases the probably of chiddeath and undernutrition. 217Aggregating these costs to the national level,the negative effect of poor reproductive healthon economic growth and development may besubstantial. For example, ill-health among womenhas been estimated to reduce the productivity ofthe female labour force by as much as 20%. 218Moreover, healthier and better-educated womenhave smaller families, invest more in each child’shealth and education and enjoy greater earningopportunities than women who are less educated.This suggests that improved reproductive healthhas strong intergenerational effects.The influence of gender on reproductivehealthAnalysis reveals that men and women’s experienceof sexual and reproductive health tends to differ.These differences are now understood to arise notonly from biological characteristics (male andfemale sex), but also from the socially constructedcategory of gender.Biological differences in sexual andreproductive healthBiological differences between men and womeninclude anatomical and physiological differencesand variations in genetic susceptibilitiesand immune systems. 219 Women experiencereproductive health issues related to pregnancy,childbearing and menopause. The biologicalcharacteristics of young women, namely immaturereproductive and immune systems and incompletebody growth, contribute to an increased riskof negative outcomes from pregnancy anddelivery. 220 While women must deal with healthissues such as RTIs and cervical and breast cancer,men must contend with cancer of the prostate andhaemophilia, for example.During the neonatal period, newborn girls havea biological survival advantage over newbornboys. 221 Evidence also shows, however, that olderwomen are more vulnerable than men to anaemia,osteoporosis and STIs, among other health issues,due to physiological factors. The transmission ofHIV from men to women appears to be 24 timesmore efficient than transmission from womento men. 222 Women have a larger surface area ofmucosa exposed to their partner’s sexual secretionsduring intercourse. Semen also contains a higherconcentration of HIV than vaginal secretions.Moreover, semen can stay in the vagina for hoursafter intercourse. In addition, STIs are morefrequently asymptomatic in women than in men.Pregnancy also influences the biologicalvulnerability of women to poor sexual andreproductive health outcomes. Pregnant womentend to be more vulnerable than non-pregnantwomen or men to malarial infection, in areas ofstable and unstable malaria transmission. 223 InPapua New Guinea, for example, the prevalenceand incidence of malaria are highest in youngchildren and pregnant women. 224 A study fromUganda observed that the risk of infection withBox 4: Defining genderGender refers to the differences and inequalities in the situations and needs of men and women that arebased on societal understanding of being male or female, not on biological differences. Gender dynamicsare understood as the different roles, expectations, identities, needs, opportunities and obstacles that societyassigns to women and men based on sex. While sex is biologically determined, gender is socially ascribed.Girls and boys, women and men, may have the same rights, potential and capacities, but discriminationagainst girls and women based on sociocultural norms often relegates them to lower status and value. Thisbias often places them at a considerable disadvantage in terms of access to resources and goods, decisionmakingpower, choices and opportunities across all spheres of life. It determines how individuals and societiesperceive what it means to be male or female and influences how roles, attitudes, behaviours and relationshipsare enacted.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 31HIV was much higher for pregnant and lactatingwomen than for non-pregnant or non-lactatingwomen. The incidence of HIV was reported tohave increased from 1.1 per 100 person years to2.3 in pregnant women. The study concludedthat biological changes in pregnant and lactatingwomen accounted for a large proportion of thisincreased risk. 225Gender-based differences in sexual andreproductive healthGender inequality within societies can influencethe sexual and reproductive health of men andwomen, starting with the differential exposure ofmen and women to various determinants of sexualand reproductive health, and continuing on todifferences in health-seeking and utilization ofgood quality health services. The discussion thatfollows analyses how gender inequality influencesthe sexual and reproductive health of men andwomen.Gender is a determinant of sexual andreproductive healthGender normsSocial norms give primacy to heterosexualrelationships, which are primarily defined interms of male dominance and desire. 226 Thesegender norms and others often translate intodifferent ideas about appropriate behaviour formen and women with regards to sexuality andreproduction. According to dominant gendernorms in many societies, men are expected to bemacho, while women are to be sexually passive.In the Philippines, as in many countries in theRegion, there is greater tolerance, and evenexpectation, of premarital sex for men, whilewomen are expected to remain virgins untilmarriage. 227 Moreover, while men are encouragedto engage in sexual activity and to have multiplepartners, women are expected to control and putlimits on male sexual behaviour. 228 Societal normsin Cambodia dictate that women should be shy,submissive and unassertive. In contrast, men areunderstood to have irrepressible sexual needs and,therefore, are accepted to have multiple partnersor to visit sex workers. 229In many settings, women have no legal orcustomary right to refuse sex with theirhusbands. 230 In Cambodia, for example, a studydocumented the widely held belief that husbandshave a right to the bodies of their wives. 231 Inother countries, the laws regarding marriage anddivorce have different implications for men andwomen. For example, Philippine law definesextramarital affairs differently for men than forwomen. 232 Under such circumstances, womenfind it difficult to assert their preference for safersex, for their partner’s fidelity or for no sex at all.Double standards on sexuality deny women theability to refuse sex or negotiate condom use andat the same time encourage men to have multiplesex partners, thereby putting both at increasedrisk of STIs. Such sexual norms and practices putmen and women at great risk for infection andpoor reproductive health outcomes.Gender norms spill over into other aspects ofwomen’s lives. In the Lao People’s DemocraticRepublic, for example, pregnancy is not expectedto interfere with a woman’s workload and womenmust often resume work shortly after delivery. 233Many women feel pressured to have many, closelyspaced children to fulfil their reproductive rolesin society.Gender norms also tend to marginalizetransgendered individuals and people whose sexualidentities do not conform to social ideals. In manysocieties, heterosexuality is considered the normand gender roles demand that individuals onlyexpress desire for the opposite sex. 234 In manyareas, individuals who are lesbian, gay, bisexualand trangendered face discriminatory attitudesand, at times, violence. For example, a study fromCambodia found that transgendered individualsexperience discrimination and abuse. 235 InIndia, established communities of transgenderedpeople, known as Hijras, are often stigmatizedand harassed. 236 In some areas, discrimination isrooted in the law, while in others, progressive lawsprotecting against discrimination on the basis ofWhat are the links between poverty, gender, and sexual and reproductive health?

32Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalssexual orientation may not be implemented. Forexample, although Fiji was one of the first countriesto enshrine protection against discriminationon the basis of sexual orientation in its 1997Constitution, implementation of this law hasbeen weak in practice. 237Social movements for LGBT rights from aroundthe world are increasingly drawing attention togender and sexual orientation as an importantsource of bias and discrimination. Thesemovements challenge common understandingsof gender to move beyond the male/femaledichotomy and to explore the possibility of“gender plurality.” 238Masculinity and male dominanceGender norms in many societies prescribe maledominant behaviour, with the expectation thatmen be risk-takers and the initiators of sex. Forexample, wearing a condom can be considered“unmanly”, so men may be unwilling to do so aswell as being ill-informed about the health risks ofsuch actions. Admitting to gaps in their knowledgecan also be difficult, due to social expectations thatmen “know everything”.In many countries in the Region, men are morelikely than women to have several sexual partners.In other cases, some men find it difficult toconform to the male stereotype of masculinity andmay feel compromised by their inability to matchup to expectations. For example, homosexual menmay be the subject of harassment, discriminationor physical abuse because their sexual orientationdiffers from the norm. In addition, men may havesex with men without recognizing the need topractice safe sex.Gender stereotypes can also lead men to takeup certain occupations or behaviours that affecttheir health. For example, men often hold jobsthat require seasonal migration or frequent travel,removing them from their home environment.Such circumstances result in the increasedlikelihood of causal sex with multiple partners,including with commercial sex workers. 239Importantly, men’s behaviour and attitudes notonly affect their own health but also the health oftheir partners.Women’s lack of power and autonomyThe low status of women relative to that of menin many societies limits their ability to controltheir own lives, including their fertility and accessto health services. In many communities, genderroles assign men primary authority over sexual andreproductive health decisions. Thus, women maylack the ability to make independent decisionsabout using contraceptives or seeking reproductivehealth services. 240 For example, a study from theLao People’s Democratic Republic found that whencouples use contraceptives, men often make thedecision regarding the method to be used. Similarly,husbands and other family members, particularlyin-laws, appear to make decisions concerningwhether or not a woman can seek health care. 241 Astudy in Indonesia found that one in seven womensurveyed did not use contraceptives because theirhusband did not approve. 242 Similarly, a studyfrom Diandong county in rural China found that45%–55% of women respondents required theirhusbands’ permission to go to the market, clinicor natal village. 243Gendered communication patternsIn many instances, communication betweenpartners is limited. It is often taboo for couplesto discuss issues related to sexual and reproductivehealth. Also, many men have erroneousinformation about sexual and reproductive healthbecause their sources of information are generallytheir peers, who may be as uninformed as theyare. 244 However, men often share many of thesame concerns as women about family planning,childbirth, child spacing and number of children,whether contraception is safe, and how to selectand use an effective contraceptive. 245 In addition,gender role expectations may also make menfeel constrained in expressing their feelings andintimate experiences associated with sexuality.Cultural norms also often make it difficultfor men to express devotion to their partnersModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 33or to participate in child raising or householdmanagement, lest they risk ridicule from friendsand neighbours.Such gendered communication patterns canparticularly affect young men and women’saccess to information on sexual and reproductivehealth. Often, parents, teachers and health serviceproviders are unwilling or embarrassed to discusssuch issues with young people. For example, arecent study from Mongolia reported parentsand the health system devote little attentionto the reproductive health of young people.Consequently, only 25% of adolescents had basicknowledge of reproductive health and 50% hadsome knowledge of STIs. 246 According to a 2002study, most sexually active Filipino youth werenot aware of safe sex practices. 247Adult discomfort with young people’s sexualityis common and often rooted in notions ofappropriate behaviour for young men and women.Some adults mistakenly believe that providingyoung people with information on sexual andreproductive health will lead to promiscuity. Inaddition, many traditional families believe that ayoung girl should enter marriage innocent aboutissues related to reproductive and sexual health. Asa result, young people in countries in the Region,particularly women, may be unable to accessaccurate information on sexual and reproductivehealth. As young people tend to be denied explicitinformation about sexuality and reproduction,they are often ill prepared for sexual relations orunable to protect themselves from unintendedpregnancy and STIs.Son preferenceIn some communities, the higher social valueascribed to men has resulted in practices thatprefer sons over daughters. As noted earlier,evidence suggests that the distribution of foodamong children within households might benefitmale children at the expense of female children insome places in the Region. In some cases, the birthof girls may not be registered or girls may not becounted in censuses. In other cases, sex-selectiveabortions may be performed. In more extremeforms, practices that prefer sons over daughters canresult in the death of daughters over time, resultingin a skewed sex ratio or a disproportionate shareof men within populations. In countries wheresons are favoured over daughters, the natural ratioof 105 boys born to every 100 girls tends to beexceeded. Son preference is evident in China, theRepublic of Korea and Viet Nam, where the sexratios at birth in 2005 were 112:100, 108:100 and108:100, respectively. 248Early marriage, sexual activity andchildbearingWorldwide, most men and women becomesexually active in their late teen years, althoughthere is substantial variation between regions.For most women, sexual activity has been closelyassociated with marriage. Early marriage can leadto childbearing before physical development iscomplete and to frequent pregnancies thereafter.As discussed above, adolescent pregnancies canbe particularly damaging to women’s health. Theassociation between marriage and first sexualintercourse among men is more variable. 249The practice of women marrying and bearingchildren at a young age is slowly changing in theRegion with economic development and rural–urban migration. Variations within countries,however, are increasingly noticeable. For example,rural women in the Philippines marry at a youngerage than do those from urban areas. In Viet Nam,adolescent marriage and childbearing are generallymore common among rural and ethnic minoritycommunities than among urban communities. 250A 2002 review in Mongolia found that 11.5%of adolescents in provincial centres gave birth ascompared with 4.4% in Ulaanbaatar. The highestrate of adolescent births was found in rural areas ofthe south (26.3%). 251 Adolescents in rural areas ofthe Lao People’s Democratic Republic were foundto be twice as likely as their urban counterparts(21% vs. 9%) to have started childbearing.Education is generally inversely associated with theinitiation of childbearing, as was found to be theWhat are the links between poverty, gender, and sexual and reproductive health?

34Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalscase among Laotian adolescents, for example. 252 InCambodia, women with high school education orhigher marry a year later than their less educatedcounterparts on average. 253 Adolescent birthswere also found to be more common amongwomen with low educational attainment in thePhilippines. Among women with low educationaloutcomes, 40% had given birth before the age of20 as compared with 20% among women whowere better educated. 254As young people in the Region are waiting longerto marry and have children, they are becomingincreasingly sexually active outside of marriage.That is, the average time between the first sexualencounter and marriage is widening for both menand women. For example, dating has becomecommon among young people in urban areas ofMalaysia. 255 Premarital sex was found to be morecommon among women in urban than in ruralareas of the Philippines (23.1% vs. 10.7%). 256 Astudy in the Lao People’s Democratic Republicfound that early sexual activity was more commonamong women who were less educated, less literate,and from the northern region or rural areas. 257Whatever their reasons, such changing sexualnorms—and the increasing delay between sexualinitiation and marriage—can have importantimplications for the sexual and reproductivehealth of young people in the Region.Gender-based violenceGender-based violence encompasses physical,sexual and psychological violence. 258 Althoughboth men and women experience violence, womenTable 8: Locus and manifestations of gender-based violenceLocus and agentFamily Community StatePhysical aggression murder (dowry or other) battery genital mutilation foeticide deprivation of food deprivation of medical care reproductive coercion and/orcontrolSexual abuse rape incestEmotional abuse confinement forced marriage threats of reprisalSocial reference group violence directed towards womenwithin or outside the group (e.g.cultural, religious)Physical abuse battery physical chastisement reproductive coercion and/or control witch burning sati (widow burning)Sexual assault rapeWorkplace sexual aggression harassment intimidationCommercialized violence trafficking forced prostitutionPolitical violence(policies, laws, etc.) illegitimate detention forced sterilization tolerating gender violenceby non-state agentsCustodial violence(military, police, etc.) rape tortureSource: Schuler 1992.Media pornography commercialization of women’s bodiesModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 35constitute a higher share of victims of gender-basedviolence throughout the lifespan, from pre-birthto old age. Acts of violence against women (andgirls) are manifestations of the power dynamicsin the family, society and state, which seek tocontrol women and ensure their subjugation topatriarchy. 259 Table 8 provides an overview of thepower dynamics of family, society and state thatunderpin gender-based violence.The roots of gender-based violence are complexand multiple, ranging from culture to patriarchalsystems. Just as victims of gender-based violenceare usually women, the perpetrators of suchviolence tend to be men. Male violence stems fromthe patriarchal model of masculinity that enablesand justifies such behaviour. Men who tend to beviolent believe that violence, like sexuality, is abiological and uncontrollable “instinct”, and thusan integral part of their masculinity. These men,who are often raised in a violent atmosphere, tendto learn how to be violent from their fathers.Women who experience violence or the threatof violence are often unable to meet theirreproductive health needs. 260 Coerced sex can leadto unwanted pregnancies, STIs (including HIV/AIDS) and gynaecological problems. In addition,physical abuse during pregnancy is associatedwith miscarriage, stillbirth and low birth weightbabies. Abuse at an early age is also associated withrisky behaviours later in life, including substanceabuse, sexual risk-taking and smoking. Violencecan also lead to mental health problems, such asdepression, anxiety, post-traumatic stress disorderand suicide. 261Gender-based inequalities in access to healthservicesA number of studies from the Region haveobserved that access to services may not beequitably distributed between men and women orboys and girls. For example, a study from 2000in Cambodia found that an estimated 36.1% ofboys suffering from fever were seen by a healthservice provider, while only 32.0% of girls wereseen. Evidence from the Philippines shows that in2002 girls were slightly more likely than boys to betaken to a health service provider when they weresick with fever, while boys were more likely thangirls to receive medical attention when sufferingfrom acute respiratory tract infection (ARI). 262 In2002, the proportion of Vietnamese children withARI seen by a health service provider was 76.0%among boys and 64.8% among girls. 263 A studyfrom Papua New Guinea found that motherstook their sons to health centres more oftenand travelled further with them than with theirdaughters. 264A study from three rural counties in Yunnanprovince, China in 1994–1996 found that mostwomen suffering from RTIs did not seek healthcare. 265 A second study from Yunnan provinceBox 5: Female genital mutilationFemale genital mutilation (FGM) refers to theremoval of part or all of the genitalia. FGM isprevalent in Africa, in some parts of the MiddleEast and Asia, and also among immigrantpopulations in many other parts of the world.Many parents view FGM as an essential rite fortheir daughters to find a husband. Some in-lawsinsist on FGM for their sons’ spouses as a sign ofchastity and purity. In many cases, older familymembers, such as grandmothers and mothersin-law,and circumcision providers, influence thedecision to have a girl mutilated.Type I FGM involves the removal of the clitoralhood, with or without the rest of the clitoris. TypeII involves the removal of the clitoris and partor all of the labia minora. Type III is also calledinfibulation, where part or all of the externalgenitalia is removed and the vaginal openingstitched together until only a small opening isleft.While Type III is the most serious, all forms ofFGM can lead to internal bleeding, painful sexualintercourse, urinary tract infections, blockedmenses and difficult deliveries that can end in thedeath of the mother and child and depression.Source: World Health Organization 2007.What are the links between poverty, gender, and sexual and reproductive health?

36Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsreported that while as many as 71.7% of womensurveyed suffered from RTI symptoms, as few as25.38% had sought care. 266 Similarly, unmarriedwomen in the Lao People’s Democratic Republicappear not to seek care for RTIs. Among themen and women in the Lao People’s DemocraticRepublic who did seek care for STIs, men tendedto visit drug sellers, while women sought care at alater stage of infection and therefore suffered moreserious complications. 267 In India, a study foundthat only 8% of rural women had ever soughtcare for gynaecological illnesses, although 92%had one or more reproductive health problems,including some relatively serious conditionssuch as reproductive tract infections, pelvicinflammatory disease, genital prolapse and urinarytract infections. 268Barriers to access to servicesSuch differences in the access of men and womento sexual and reproductive health services mayarise for a number of reasons. Some of the barriersto access that were discussed above—geographical,economic and sociocultural—often constrainwomen from seeking health care to an even greaterextent than men.Geographical barriersIn some areas, women may enjoy less mobilitythan men. Women may have difficulty accessingtransportation either because they do not havetheir own source of transportation or becausetheir generally lower access to and control overhousehold resources or cash income preventsthem from using public transportation. Theseconstraints can be further reinforced throughnormative expectations that women remain inthe private sphere or near the household or villagewhile men move freely over long distances inpublic space. In some areas, women must obtainpermission from their husbands or fathers toseek health care, while in others they must beaccompanied, often by a male family member,when travelling beyond their community. Thisincreases the cost of seeking care, both in terms oflost household labour and transportation costs.A study of demand for prenatal care among pregnantwomen in Cebu, Philippines observed that womenliving in rural areas faced significantly longer traveltimes to facilities than did those living in urbanareas. Travel costs in rural areas were reported tobe almost double those in urban areas. 269 Whenfaced with such constrained mobility, women mayseek diagnosis and treatment from nearby but lessqualified providers, traditional healers or villagepharmacies, or may self-medicate rather thantravelling farther to access better quality primaryhealth care. 270Economic barriersCompared to men, women’s generally lower accessto and control over economic resources, includingincome, productive assets and health insurance,might constrain their access to preventive andcurative health services. A case study in Tianjian,China found that women were less likely thanmen (41.9% vs. 46.3%) to be covered by theGovernment Insurance Scheme or the LabourInsurance Scheme in 1998. 271 Additional estimatessuggest that up to 70% of women in China arenot covered by any health insurance. 272 In the caseof sexual and reproductive health, stereotypicalnotions about men and women’s roles might restrictmen’s financial access to services. For example, inMongolia, reproductive health services are coveredby health insurance only for women. 273The association between household income andhealth has been found to be further influencedby the degree to which women can influence howtheir household income is spent. Studies suggestthat use of health care services, as measured byantenatal visits, is less common among womenwho have relatively lower control over householdresources. 274 A study in the Philippines observedthat as the value of women’s time (as measuredby an estimated wage rate) increases, so does theintrahousehold allocation of calories to womenand children, resulting in improved nutritionalstatus for women and their children. 275Many women work in the informal sector or athome during their reproductive years. BecauseModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 37of inequalities in income and wealth in earlierlife, older women are more likely to have fewermaterial resources, and are less likely than men toreceive assistance from their relatives and friendsduring their old age. 276 In general, women outlivemen. However, widow’s pensions, old age securitypayments and medical insurance coverage areoften meagre or non-existent for older women.In addition, in circumstances where older womenhave the benefit of a husband’s pension, this maybe severely reduced or discontinued upon thedeath of the husband.Sociocultural barriersThe lower priority typically given to women’shealth in households and communities, relativeto that of men, can delay health care seeking bywomen and girls. In some areas, women continueto rely on traditional birthing practices. This ispartly due to prevailing norms and values withinsociety and partly due to women’s low status inthe family.In many parts of the developing world, access toappropriate perinatal care is limited. Women oftenprefer traditional birth attendants to hospital care,since they may feel isolated and alienated from theircultural norms and values in hospital settings. Forexample, in the Lao People’s Democratic Republic,women from the Lao Theung community (anethnic minority group) normally deliver alonein a forest or field behind her house because theblood of childbirth is understood to be “dirty”.More recently, women have begun to give birthin small huts or underneath the house. In someareas of the Lao People’s Democratic Republic,intrauterine devices are not a popular form ofcontraceptive because of traditional notions ofthe uterus as a moving organ. 277 In rural areas ofYunnan province, China, RTIs among women areseen to be normal and therefore are not consideredto require medical attention. 278The social norms of communities may influencepeople’s decisions on their health. Low condomuse in Malaysia and the Lao People’s DemocraticRepublic, for example, has been ascribed to thecommonly held belief that condoms are usedduring extramarital affairs and with sex workersand not in the context of marriage. 279 In manycommunities in the Region, adults deny thepossibility of young people, particularly youngwomen, engaging in sexual relations. As a result,young people may be discouraged from discussingor asking questions about sexual matters. 280 Stigmacan also deter men and women from being testedfor HIV and other STIs. Evidence suggests thatstigma and discrimination restrict the access ofmen who have sex with men to information andhealth services. 281Gender bias in health service provisionHealth systems and services also suffer fromgender bias. For example, health service providersmay demonstrate disrespectful or dismissiveattitudes towards women patients, as comparedto men. In addition, some physicians may viewwomen’s bodies and their reproductive processesas potential medical problems. This medicalizationof normal reproductive health and childbirth hasbeen noted as a problem in many industrializedcountries with a loss of control by women overdecisions concerning their bodies, health andreproduction, as well as lack of psychosocialsupport for women. 282In many of the parts of the world, women preferto seek care for reproductive health issues fromwomen health care professionals. Where womenhealth workers are not available, treatment bya man may be deemed to dishonour a womanand her family, deterring women from seekingcare. Evidence from China demonstrates theimportance of having women staff available forreproductive health services. One study in ruralYunnan province found that male rural doctorsappeared to be reluctant to provide care forwomen’s reproductive health. In turn, rural womenwere embarrassed to seek care for RTIs from maledoctors. 283 A second study observed that womenin China were unwilling to speak with male healthservice providers about physical and contraceptiveproblems and that follow-up by male providersafter women’s sterilization was rare because of theWhat are the links between poverty, gender, and sexual and reproductive health?

38Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsperceived impropriety of a man visiting anotherman’s wife. 284For sexually active young people, particularlyunmarried women, obtaining reproductive healthservices is even more difficult than gaining accurate,culturally relevant and age-specific information.Few clinics are designed, prepared or even willingto provide services to young people. Many youngpeople are left with an unmet need for contraceptionand other reproductive health services. For example,many health service providers in the Lao People’sDemocratic Republic and Viet Nam disapprove ofpremarital sex and, therefore, may provide poorerquality services to young men and women. A studyof formal and informal health service providers inVientiane in 2000-2001 found that 18% of providerssurveyed would inform parents if their unmarriedchildren sought reproductive health services. 285A second study in the Lao People’s DemocraticRepublic reported that youth aged 15 to 24 yearsprefer to seek treatment for STIs at pharmaciesbecause of the perceived greater confidentiality andgreater ease of obtaining the required drugs. 286 Astudy in Viet Nam found that health providers arenot adequately trained to counsel young people onsexual and reproductive health issues. 287 Similarly,a recent survey in Cambodia found that female sexworkers—many of whom were between the agesof 16 and 26 years—preferred to seek care fromprivate health providers. They described publicfacilities as lacking in confidentiality, privacy andanonymity. In addition to providing more privacy,the staff at private facilities were perceived to treatthem with more dignity and respect. 288In many countries, the reproductive healthneeds of men have been neglected. Historically,most family planning and reproductive healthprogrammes have focused exclusively on (married)women. For example, a study found that familyplanning programmes in Solomon Islands targetedonly women. 289 Male gender stereotypes may alsodiscourage men from accessing health care services.Barriers to men’s inclusion in reproductive healthservices include: lack of information about men’s perspectivesthat could be used to help design appropriateprogrammes; men’s discomfort at reproductive healthclinics (many feel out of place or unwelcomebecause they have been excluded fromservices for so long); men’s hesitation in seeking medical care; limited availability of contraceptive methodsfor men; negative attitudes of policy-makers andservice providers towards men (e.g. men canbe viewed as irresponsible, not interested inplaying a positive role or not appropriateclientele for reproductive health services); unfavourable policies, such as prohibitionson condom advertising; and logistical constraints such as lack of trainedmale staff, male-friendly clinics, convenienthours, or separate waiting and service areasfor men. 290Access to termination of pregnancyRoughly 61% of the world’s population reside incountries where induced abortion is permitted forInfant mortality rate80706050403020100Figure 10: Infant mortality rate (per1000 live births) by sex for selectedcountries in the Region, 2002Cook IslandsMaleKiribatiMarshall IslandsPapua New GuineaFemaleSamoaVanuatuSource: World Health Organization Regional Office for the WesternPacific 2005a.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 39a range of reasons, while 26% live in countrieswhere abortion is prohibited or allowed only tosave a woman’s life. 291 In countries in the Regionwhere abortion is legal, evidence suggests thatsome clinics provide poor quality services, withvery little pre- and post-abortion counselling. 292The lack of privacy in public facilities can leadwomen, particularly those who are young, toseek care from private providers. In areas wheregovernment regulation of the private sectorremains weak, the skills of private providers andstandards of care do not necessary comply withmandated guidelines and protocols. 293 As a result,women seeking care in private facilities maysuffer abortion-related complications, includinglong-term disability and death. To be accessible,abortion services need to be affordable, respectfuland offered in the communities where womenlive.Gender-based differentials in sexual andreproductive health outcomesWhile sex-disaggregated data on health outcomesin countries in the Region are limited, there issome evidence of how sex and gender interact toproduce differential sexual and reproductive healthoutcomes among men and women and boys andgirls. For example, data collected in 2002 suggestthat infant mortality is higher among boys thangirls in the Region (see Figure 10). In contrast, therisk of dying is estimated to be 33% higher amonggirls than boys in China. 294Women’s biological characteristics, combined withgender inequality, increase their vulnerability toinfection with STIs. Globally, the burden of STIsamong women is five times higher than amongmen. 295 Globally, 15.4 million women were livingwith HIV/AIDS in 2007. 296 The prevalence ofHIV in men and women differs across countries inthe Region. This is because the nature of the HIVepidemic, as well as gender norms, varies acrosscountries. According to projections, the numberof newly infected men and women in Cambodiawas more or less equal in 2007. Thereafter, it isprojected to be higher in the male population. 297In the Philippines, where the status of HIV waspreviously described as “low and slow”, butwhere local experts now consider the possibilityof a “hidden and growing” trend in HIV, almosttwice as many men as women were reported to beliving with HIV by the end of 2007. 298 Similarly,in Viet Nam men accounted for 85.2% of totalreported HIV cases, as of 2007. 299 Since its earlydays, the HIV epidemic in Malaysia has beenpredominantly male, with intravenous drug useas the main mode of transmission. However, by2006, women and girls comprised almost 20%of newly-infected persons, compared to onlyFigure 11: Percentage of adults (15+) living with HIV who are women, 1990–2007706050Percent (%)4030201001990199119921993Sub-Saharan AfricaAsia199419961996Source: Joint United Nations Programme on HIV/AIDS 2007.GlobalLatin America19971998199920002001200220032004200520062007CaribbeanEastern Europe and Central AsiaWhat are the links between poverty, gender, and sexual and reproductive health?

40Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsabout five percent 10 years ago, with heterosexualintercourse being the main mode of transmissionfor women. 300 In Papua New Guinea, where theepidemic is now generalized, of the total numberof people diagnosed with HIV by the end of 2006,46% were men and 48% women (six percent ofinfections occurred among those whose sex wasnot reported). Besides, the number of infectedyoung women is rising the fastest. 301 Worldwide,women constitute an increasing proportion ofadults (aged 15 and above) living with HIV(Figure 11).Assessing the prevalence of gender-basedviolence in the Western Pacific Region ishampered by the varying definitions of genderbasedviolence, the silence that continues toshroud issues of domestic violence, and thenormalization of violence in some areas. Theprevalence rates for domestic physical violenceagainst women ranges between 5.8% and 65%and for sexual abuse between 4% and 50% incountries and areas in the Region. It is likelythat these figures underestimate the true extentof the problem. 302 In the Philippines, 10% ofwomen who have had premarital sex did soagainst their will. 303 One study found that gangrape is a major concern in Cambodia, PapuaNew Guinea and the Solomon Islands. 304 Asurvey of male school students in Phnom Penh,Cambodia, concluded that 34% of respondentsknew someone who had participated in bauk(gang rape). 305 Analysis of a national surveyconcluded that 4% of women in the Philippineshave had non-consensual sex. 306Men, particularly young men and boys, mayalso be vulnerable to sexual abuse. A study inCambodia concluded that sexual abuse is quitecommon among male street children. Of thestudy population, 41% homeless boys aged 15-19 years reported being raped and 18% reportedexperiencing incest. 307 An estimated 1% of men inthe Philippines have experienced non-consensualsex. 308Studies in developing countries have found thatwomen carry a heavy burden of gynaecologicalproblems throughout their reproductive yearsand into later life. This burden is partly due tothe limited medical care they received duringpregnancy, labour and delivery. 309 Women’sreproductive health problems in later life includecervical cancer, uterine prolapse, fistulas, bladderproblems and breast cancer. In addition, duringmenopause, women experience a decline in theirreproductive hormone levels. As men age, erectiledysfunction can become common as a result inchanges in penile blood flow. At the same time,the incidence of prostate cancer tends to increasewith age. These conditions can lead to urinary,erectile or libido problems. 310Gendered consequences of poor sexual andreproductive healthThe social and economic consequences of poorsexual and reproductive health tend to be differentfor men and women. For example, the socialrepercussions of infertility, including that arisingfrom abortion-related complications or maternalmorbidity, tend to be more severe for women thanfor men. Infertile women may be discriminatedagainst within their households, and divorced orseparated from their families. In some societies,survivors of severe forms of gender-based violencesuch as rape tend to be blamed and scorned as “fallenwomen” who have lost their honour and, at times,their virginity. A study from Cambodia foundthat survivors of rape were perceived as bringingshame to their family and are often forced intoprostitution or to marry the perpetrator. 311 Similartrends have been reported in the Philippines. 312Women are often stigmatized as being reservoirsof STIs and other diseases.The social and developmental consequences ofreproductive health decisions can also be farreaching.For example, an unintended pregnancycan severely compromise a young girl’s health,education and job preparation.Module on Sexual and Reproductive Health

3. Why is it important for healthprofessionals to address povertyand gender concerns in sexual andreproductive health?Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

42Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals3. Why is it important for health professionals to address poverty and genderconcerns in sexual and reproductive health?EfficiencyImportant gains in sexual and reproductivehealth have been made in the Region. In someareas, however, gains in maternal health havebeen slow and the contraceptive needs of manycouples have not been met. Many countries in theRegion are also contending with progressing HIV/AIDS epidemics and a growing burden of STIs,particularly among young people. Innovativestrategies are required to address poverty andgender-related concerns in sexual and reproductivehealth care. Tailoring efforts in this way can betterensure that the sexual and reproductive needs ofpoor and marginalized men and women are metthroughout their lifecycle.As discussed above, poor and marginalizedpopulations often bear a higher burden ofreproductive and sexual ill-health than affluentgroups. Unfortunately, investments in sexualand reproductive health care have not equallybenefited the poor. Similarly, prevailinggender norms in the Region can constrictthe ability of men and women, especiallyyoung men and women, to make decisionsthat protect and promote their sexual andreproductive health. Young people tend tobe excluded from accessing services for andinformation on sexual and reproductive health;men have often been neglected by preventiveand curative sexual and reproductive healthprogrammes.Nevertheless, healthy, voluntary and safe sexualand reproductive health has been recognized asbeing critical to human well-being. 313 Sexualand reproductive health has been identified asintegral to efforts to reduce maternal mortality,improve child health and reduce the burden ofHIV and STIs, among other health conditions.Universal access to reproductive health isunderstood to be a prerequisite for meetingmany of the Millennium Development Goals(MDGs). As such, innovative strategies arerequired to address poverty and gender-relatedconcerns in sexual and reproductive healthcare.Prevailing gender norms likewise influence effortsto improve sexual and reproductive health amongmany communities in the Region. In particular,gender-related barriers can limit women’s accessto effective health care and professional adviceduring pregnancy, delivery and in the postnatalperiod. By tailoring programmes to addressthese barriers, many of the health-related risksof pregnancy and childbirth can be avoided.That is, targeting poor men and women withappropriate sexual and reproductive healthcare can reduce maternal and other sexual andreproductive health-related morbidity andmortality, thereby reducing the overall financialburden of reproductive health care. Incorporatinga gender-sensitive response can likewise ensurethat men and women benefit equitably from suchefforts. Together these approaches can enhancethe overall efficiency of sexual and reproductivehealth programmes.The efficiency gains from better targeting poormen and women of all ages with preventive andcurative sexual and reproductive health careare even more significant when considering thecentral role improved sexual and reproductivehealth can play in poverty reduction strategies.Improving the sexual and reproductive health ofpoor men and women can advance their overallhealth and well-being. Strategies that better meetthe needs of poor men and women, includingfinancial constraints, can protect poor householdsfrom the impoverishing effects of ill-health.Enhanced sexual and reproductive health amongmen and women can also lead to better health fortheir children. Such gains, when aggregated at thenational level, can contribute towards improvedBox 6: Defining equity in healthEquity in health may be defined as the “absenceof systematic disparities in health (or majorsocial determinants) between groups withdifferent levels of underlying social advantage ordisadvantage, such as different positions in thesocial hierarchy.”Source: Braveman and Gruskin 2003.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 43economic growth and poverty reduction in thelonger-term.EquityInequities refer to inequalities that are seen asunfair, unjust and avoidable (Box 6). 314 In termsof access to sexual and reproductive health,inequities exist between men and women, betweenthe rich and poor, and between industrialized anddeveloping countries. Because of gender-basedequities, women may face additional disadvantagescompared to men from the same social class, race,caste or ethnicity.Pursuing equity in sexual and reproductive healthis a commitment to increasing the opportunitiesfor positive sexual and reproductive healthoutcomes among groups within societies that havesuffered discrimination and marginalization. 315Box 7: Government obligations to respect, protect and fulfil human rights:examples of reproductive rights The right to life: Includes the obligation of the state in relation to maternal mortality. Rights to bodily integrity and security of the person: Includes security from sexual violenceand assault at the hands of partners and/or others. Also includes protection against populationprogrammes that compel sterilization and abortion or those that physically prohibit women fromreceiving family planning services. The right to privacy: Includes some protections in relation to sexuality. The treaty body thatmonitors governmental compliance with the International Covenant on Civil and Political Rights hasstated that “it is undisputed that sexuality is covered by the concept of privacy” and that “moral issuesare not exclusively a matter of national concern in that they are subject to review for consistency withinternational human rights instruments.” The right to the benefits of scientific progress: This right now includes a woman’s right to controlher own reproduction through access to microbicides, female controlled methods of contraception,research into a greater range of male contraceptives and access to safe abortion. The right to seek, receive and impart information: Includes a woman’s ability to make fullyinformed choices in reproductive decision-making, including her ability to protect herself againstsexual exploitation, abuse or infection. The right to education: Literacy is critical to reproductive health and education about sexuality as anelement of human personality is equally important. The right to health: Increasingly understood to mean that governments must create conditionsthat assure, for all, the enjoyment of the highest attainable standard of health. This interpretationwould also draw attention to the almost complete lack of attention and resources devoted to theearly detection of cervical cancer by a number of governments or state-controlled reproductive healthprogrammes that exist for some populations groups but exclude certain marginalized communitiesfrom their consideration and outreach. The right to equality in marriage and divorce: Understood to refer to the equal ability of womenand men to voluntarily enter into marriage and divorce. This right is being recognized by peopleinvolved in reproductive health because of its relevance to women’s ability to control and makedecisions about their lives. Non-discrimination: Traditionally understood to mean that all people should be treated equally andgiven equal opportunity, including assurance of equal protection under the law. All treatment mustbe based on objective and reasonable criteria, therefore, applying different approaches to girls andboys in reproductive and sexual health policy and programme development must be based on a validrecognition of gender related differentials. The influence of prescribed gender roles and cultural normswhen determining these differentials should be minimized.Adapted from World Health Organization 2001d.Why is it important for health professionals to address poverty and gender concerns in sexual and reproductive health?

44Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsAlthough experience shows that some variationin health status is unavoidable—due to biologicaldifferences between men and women, forexample—inequalities in sexual and reproductivehealth between the poor and non-poor and betweenmen and women are increasingly understood to atleast partially mirror social disadvantage, such asthat based on income, ethnicity or geographicallocation.Access to reproductive health services for all peoplein need, regardless of their socioeconomic status,is a matter of social justice, fairness and equity.Equity involves the distribution of well-beingamong social groups so that vulnerable, poorand marginalized people can access sexual andreproductive health care services and programmes.Therefore, achieving the goal of social justicerequires addressing the inequities between menand women, the rich and poor, and disparitiesin reproductive health outcomes between thedeveloping and industrialized nations of theworld.Human rightsHuman rights refer to an agreed-upon set ofprinciples and norms that are contained intreaties, conventions, declarations, resolutionsand guidelines at the international and regionallevel. The right to the highest attainable standardof physical and mental health, or the right tohealth, is rooted in the Universal Declarationof Human Rights. International laws makegovernments accountable for their actions inplanning and implementing public health policiesand programmes. 316Active, free and meaningful participation ofindividuals, affected communities and other keystakeholders is a key component of a rights-basedapproach.While the right to health encompasses sexualand reproductive health, the right to the highestattainable standard of sexual and reproductivehealth was advanced at the ICPD and FWCW.These gatherings acknowledged the right of menand women to have information on sexual andreproductive health, to have access to appropriatehealth services and to decide when to engage insexual relations and have children, among otherrights. Box 7 contains examples of rights that canbe used to protect and promote gender equalityin reproductive and sexual health. The right tosexual and reproductive health articulated by theICPD and the FWCW have been widely endorsedby national governments, nongovernmentalorganizations and multinational agencies.The Convention of the Rights of the Child(CRC) is another important framework forBox 8: Yogyakarta Principles on theApplication of International Law in Relationto Issues of Sexual Orientation and GenderIdentityIndividuals experience human rights violationsbecause of their actual or perceived sexualorientation or gender identity. Such documentedhuman rights violations have included: extrajudicialkillings; torture; sexual assault andrape; detentions; repression of free speech andassembly; denial of employment and educationopportunities; and discrimination in work,health, education, housing, access to justice andimmigration.A group of international law experts recentlyadvanced the struggle to apply international humanrights law to sexual orientation and gender identity.The group launched the “Yogyakarta Principles onthe Application of International Law in Relation toIssues of Sexual Orientation and Gender Identity”in Yogyakarta, Indonesia in November 2006. ThePrinciples affirm 29 key human rights and outlinethe basic legal standards for governments andother actors to protect and promote the rights ofpeople who are discriminated on the basis of sexualand gender orientation. The Principles providerecommendations for ending discriminationand abuse for governments, the United Nationshuman rights system, human rights institutions,nongovernmental organizations and others.Source: The Yogyakarta Principles: Principles on theApplication of International Human Rights Law in Relationto Sexual Orientation and Gender Identity 2007.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 45addressing reproductive health, especially amongadolescents and young people. The Conventionstates that children are entitled to the enjoymentof the highest attainable standard of health and tofacilities for prevention, treatment of illness andrehabilitation of health. Nearly every country inthe world has ratified the Convention.The 2004 report of the United Nations SpecialRapporteur on the Right to Health to the UnitedNations Human Rights Committee paid particularattention to sexual and reproductive rights. 317 Thereport underscored the fact that discriminationon the basis of sexual orientation is impermissibleunder international human rights law. TheUnited Nations Human Rights Committee hasruled that discrimination on the basis of sexualorientation violates the rights to privacy andnon-discrimination. 318 International initiativeshave recently applied international human rightslaw to sexual orientation and gender identity(Box 8). 319Non-discrimination is a key concept within theright to health. It forbids “any discriminationin access to health care and the underlyingdeterminants, as well as to means and entitlementsfor their procurement, on the grounds of race,colour, sex, language, religion, political or otheropinion, national or social origin, property,birth, physical or mental disability, health status(including HIV/AIDS), sexual orientation, civil,political, social or other status, which has theintention or effect of nullifying or impairingthe equal enjoyment or exercise of the right tohealth”. 320 Yet, as discussed above, many poor andmarginalized men and women, boys and girls, donot have adequate access to appropriate sexualand reproductive health care.The concept of non-discrimination in conjunctionwith other human rights, such as the rightsto information and privacy, should guide theinteraction of individuals with the health system.Further, the notion of inclusiveness encompassesthe right to health services and the right to theunderlying determinants of health, such aseducation and food. Moreover, since the ICPD,the international community has consistentlyreaffirmed the right of young people to ageappropriatereproductive health information andservices that safeguard their rights to privacy,confidentiality, respect and informed consent.The international community has also reaffirmedthat the rights and responsibilities of parents toprovide guidance in such matters should notprevent young people from having access to theinformation and services they require for effectivereproductive health. 321Member States are responsible for the progressiverealization of human rights, including sexualand reproductive rights. Therefore, governmentsmust put in place policies and plans that willmake sexual and reproductive health careavailable and accessible, and will lead to theefficient realization of other human rights (Box9). Governments must also regulate the actionsof non-state actors to ensure the right to healthis realized.Box 9: A rights-based approach to sexual andreproductive healthActive, free and meaningful participation ofindividuals is a key component of a rights-basedapproach. Four criteria may be used to evaluatethe right to health, in general, and the right tosexual and reproductive health, specifically:1. Availability: Sexual and reproductive healthcare is well-functioning and adequatelyavailable.2. Accessibility: Sexual and reproductivehealth care is accessible to all, encompassingfour dimensions: non-discrimination,physical accessibility, economic accessibility(affordability) and information accessibility.3. Acceptability: Sexual and reproductive healthcare is respectful, culturally appropriate,gender-sensitive and honour the confidentialityof all patients.4. Quality: Sexual and reproductive health care isscientifically and medically appropriate and ofgood quality.Source: World Health Organization 2002b.Why is it important for health professionals to address poverty and gender concerns in sexual and reproductive health?

4. How can health professionalsaddress poverty and genderin sexual and reproductive healthprogrammes?Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 474. How can health professionals address poverty and gender in sexual andreproductive health programmes?The burden of sexual and reproductiveill-health appears to be concentrated indeveloping countries in the Region. Withinthese countries, poor communities seem tosuffer a disproportionate burden. For example,women from poor households are more likelythan their better-off counterparts to die duringpregnancy and childbirth. In addition, men andwomen experience sexual and reproductive healthdifferently, with women of all ages appearing tobe particularly affected by sexual and reproductiveill-health.Despite this, the technical solutions necessary toimprove the sexual and reproductive health of thepoor exist: effective methods of contraception havebeen known for decades and simple technologiesto make pregnancy safer are available; the ability toenhance safe-sex practices has been documented;and many STIs are treatable. 322 Overall, wehave the information and means to expand thecoverage of quality sexual and reproductive healthservices. 323 What is needed are ways to ensure thatthese solutions reach those who are most in need.The sections below discuss strategies to tackle theburden of sexual and reproductive health amongthe poor in the Region and suggest approaches torespond to the different sexual and reproductivehealth needs of men and women.Policy levelInternational policiesAt the international level, human rights havebecome a central framework for conceptualizingsexual and reproductive health. As recognizedat the ICPD, men and women have the right tomake voluntary, informed decisions concerningtheir sexual and reproductive health. The abilityto make such decisions, however, depends onthe realization of a range of entitlements, suchas the right to appropriate reproductive healthservices and to adequate information. This rightsbasedapproach to sexual and reproductive healthreferences a range of human rights treaties, asdiscussed in section 3, and has been reiteratedin the outcome documents of a number ofinternational conferences.United Nations Member States committedthemselves to realizing a series of time-bound andmeasurable targets—the Millennium DevelopmentGoals—by signing the Millennium Declarationin 2000. The MDGs reflect a multidimensionalunderstanding of poverty. As such, progress towardsany goal contributes to the achievement of all ofthem. Health issues feature prominently in theMDGs (three goals, eight targets, 18 indicators).Sexual and reproductive health is not articulatedin a single goal, but rather spread unevenly overfour goals and numerous targets and indicators(see Box 10). Some fear that compartmentalizingsexual and reproductive health across these threegoals might divert attention from the morecomprehensive notion of sexual and reproductivehealth adopted at the ICPD. A growing body ofevidence demonstrates the importance of sexualand reproductive health for all of the MDGs,with particular reference to Goals 3, 4, 5 and 6. 324In response, the international community hasacknowledged the close links between the ICPDPoA and realization of the MDGs.In many ways, the MDGs echo the goals andtargets put forward in the ICPD PoA: reducingmaternal mortality, reducing child mortality,ensuring universal access to primary educationand ensuring access to secondary education. 325 Thetwenty-first special session of the United NationsGeneral Assembly, held to review and appraisethe implementation of the ICPD PoA in 1999(ICPD +5), outlined additional benchmarks,including a goal for preventing HIV/AIDS,which is also included among the MDGs. At theWorld Summit held in September 2005, worldleaders affirmed the importance of sexual andreproductive health for the achievement of all theMDGs by committing themselves to:…achieving universal access to reproductivehealth by 2015, as set out at theInternational Conference on Populationand Development, integrating this goal instrategies to attain the internationally agreedHow can health professionals address poverty and gender in sexual and reproductive health programmes?

48Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 10: International goals and targets for sexual and reproductive healthMillennium Development GoalsGoal 3. Promote gender equality and empower womenTarget 4. Eliminate gender disparity in primary and secondary education, preferably by 2005, and in alllevels of education no later than 2015Indicators:9. Ratio of girls to boys in primary, secondary and tertiary education10. Ratio of literate women to men, 15–24 years old11. Share of women in wage employment in the non-agricultural sector12. Proportion of seats held by women in national parliamentGoal 4. Reduce child mortalityTarget 5: Reduce by two thirds, between 1990 and 2015, the under-five mortality rateIndicators:13. Under-five mortality rate14. Infant mortality rate15. Proportion of one-year-old children immunized against measlesGoal 5. Improve maternal healthTarget 6. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratioIndicators:16. Maternal mortality ratio17. Proportion of births attended by skilled health personnelGoal 6. Combat HIV/AIDS, malaria and other diseasesTarget 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDSIndicators:18. HIV prevalence among pregnant women aged 15–24 years19. Condom use rate of the contraceptive prevalence rate19a. Condom use at last high-risk sex19b.Percentage of population aged 15–24 years with comprehensive correct knowledge of HIV/AIDS19c. Contraceptive prevalence rate20. Ratio of school attendance of orphans to school attendance of non-orphans aged 10–14 yearsContinued on next pagedevelopment goals, including those containedin the Millennium Declaration, aimed atreducing maternal mortality, improvingmaternal health, reducing child mortality,promoting gender equality, combating HIV/AIDS and eradicating poverty. 326These commitments, along with human rightstreaties more generally, have become a key platformfor advocating the advancement of sexual andreproductive health internationally.The Partnership for Safe Motherhood andNewborn Health, which was established inJanuary 2004, promotes the health of womenand newborns, especially the most vulnerable.The Partnership builds on the scope of the globalSafe Motherhood Initiative and the work of theSafe Motherhood Inter-Agency Group. It aims tostrengthen maternal and newborn health effortsat the global, regional and national levels, in thecontext of equity, poverty reduction and humanrights. 327 It focuses on the areas of advocacy andinformation-sharing, technical advancement andcountry-level support and partnership.Acknowledging the significance of sexual andreproductive health for social and economicModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 49Box 10 (continued)ICPD goals and targetsICPD GoalsUniversal access to primaryeducationAccess to secondary and highereducationReduction of infant and childmortalityTargets“…countries should….strive to ensure complete access to primaryschool or equivalent level of education by girls and boys as quickly aspossible, and in any case before 2015“ (paragraph 11.6)“Beyond the achievement of the goal of universal primary educationin all countries before the year 2015, all countries are urged to ensurethe widest and earliest possible access by girls and women to secondaryand higher levels of education, as well as to vocational education andtechnical training“ (paragraph 4.18)“By 2015, all countries should aim to achieve an infant mortality ratebelow 35 per 1,000 live births and an under-five mortality rate below45 per 1,000. Countries that achieve these levels earlier should strive tolower them further” (paragraph 8.16)Reduction of maternal mortality “Countries should strive to effect significant reductions in maternalmortality and morbidity by the year 2015 (...) to levels where theyno longer constitute a public health problem. Disparities in maternalmortality within countries and between geographical regions, socioeconomicand ethnic groups should be narrowed” (paragraph 8.21)Universal access to reproductiveand sexual health servicesincluding family planning“All countries should strive to make accessible through the primaryhealth-care system, reproductive health to all individuals of appropriateages as soon as possible and no later than the year 2015” (paragraph7.6)A number of these goals and targets have been tailored to meet the specific context of the Western PacificRegion. For example, the maternal mortality goal has been recast as: “To reduce, by 2015, the maternalmortality ratio by 75% of the 1990 level, and to contribute to the reduction of infant mortality by reducingthe number of neonatal deaths.”Sources: United Nations Millennium Project. 2006; WHO Regional Office for the Western Pacific 2005b.development worldwide, the World HealthAssembly adopted WHO’s first GlobalReproductive Health Strategy at its fifty-seventhsession in May 2004 (Box 11). The global strategystrongly urges governments to fulfil commitmentsmade at the ICPD, the Fourth World Conferenceon Women and their respective five-year reviewconferences. The resolution recognizes thataccelerated action is critical for meeting theMDGs.To this end, the strategy is designed to mobilizeaction in the following areas: strengthening health systems capacity improving information for prioritysetting mobilizing political will creating supportive legislative and regulatoryframeworks strengthening monitoring, evaluation andaccountabilityMember States are urged to use the strategyto develop and strengthen their reproductivehealth programmes and to meet their specificreproductive health needs. Almost all MemberStates of the World Health Assembly fullyendorsed the strategy. 328How can health professionals address poverty and gender in sexual and reproductive health programmes?

50Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 11: Core components of the WHO GlobalReproductive Health Strategy1. Improvement of antenatal, perinatal,postpartum and newborn care2. Provision of high-quality services for familyplanning, including infertility3. Elimination of unsafe abortion4. Prevention and treatment of sexuallytransmitted infections including HIV,reproductive tract infections, cervical cancersand other gynaecological morbidities5. Promotion of sexual healthSource: World Health Organization. 2006e.The political commitment for sexual andreproductive health, as illustrated by the rangeof international treaties and commitments, hasnot always been backed by adequate financialresources. One 2005 estimate puts the annualcost of achieving the ICPD goals by 2015 at $23billion (or $18.5 billion in 1994 dollars), withone third of this amount coming from donors. 329However, the ICPD estimates were based on amore modest set of actions. More recent estimatesuse revised figures to estimate the resourcesrequired to meet the ICPD goals by 2015(Table 9).Levels of donor funding for reproductive healthinitially declined during the post-ICPD period.For example, the World Bank’s contribution topopulation assistance decreased from 25% oftotal global resources in 1994 to 10% in 2002. 330Since 2002, international assistance has begunto increase. 331 However, funding for ICPD goalsremains consistently below the financial estimatesoutlined in the ICPD PoA. 332The recent trend towards increased funding forsexual and reproductive health can largely beexplained by the increase in resources for HIV/AIDS programmes. Funding for the preventionand treatment of HIV/AIDS (and STIs) oftencomes at the expense of family planning andother reproductive health programming. A recentreport on financial flows to meet the ICPD goalsconcludes that while funding for HIV/AIDSprogrammes is rising, it remains below the levelsrequired to meet current HIV/AIDS needs,which have outpaced those anticipated in 1994.In contrast to the improved financial flows toHIV/AIDS, funding for family planning has beensteadily decreasing since 1994 and now stands atbelow the suggested target of $11.5 million in2005. It is estimated that despite recent increasesfor sexual and reproductive health, internationaldonors would have to triple the amount of fundingdedicated to sexual and reproductive health tomeet the ICPD goals. 333 Nevertheless, manysexual and reproductive health interventions, suchas maternal health services (Box 12), are still costeffectiveinvestments.National policiesAchieving the MDGs and ICPD goals, amongother international commitments, requires broadand sustained political commitment for sexualand reproductive health at the national level. 334As such, broad-based political support must begenerated for the rights-based approaches to sexualand reproductive health, which are expressed ininternational declarations and commitments.Ministries of health can lead efforts to mobilizepolitical support and buy-in for sexual andTable 9: Revised total costs for achieving the ICPD Programme of ActionUS$ (2005) billions2005 2010 2015Basic reproductive health services (including family planning) 13.9 19.4 24.4Sexually transmitted diseases and HIV/AIDS activities 4.1 9.7 11.1Basic research data and population and development policy analysis 0.3 0.8 0.4Total 18.2 29.8 35.8Source: Vlassof and Bernstein 2006. In: United Nations Millennium Project 2006.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 51reproductive health from a range of stakeholders,including politicians, civil society organizations,academics, the private sector and diversegovernment ministries. Support from politicalleaders is vital to ensure that appropriate policiesand plans are formulated and implemented.Support from poor and marginalized communitiesand groups, such as urban poor organizationsand women’s groups, can be leveraged to sustainupward pressure on political leaders over time.Box 13 discusses some reasons why sexual andreproductive health has remained a low priorityamong some decision-makers.To be effective, however, political commitmentneeds to be translated into clear policy goalswith dedicated financial and human resources. Aclearly articulated national policy on sexual andreproductive health can create a framework toguide actions at all levels of the health sector. Manycountries have had national population policiesfor decades. Following the ICPD, many of thesenational policies were revised and strengthenedto reflect the priorities outlined in the ICPDPoA. 335 According to WHO, the adoption of newreproductive health policies and programmesBox 12: Maternal health services: a costeffectiveinvestmentThe World Bank estimates that, in developingcountries, the financial cost of basic maternal andnewborn health services is approximately $3 perperson, per year, while maternal services alonecost as little as $2 per person. Safe motherhoodinitiatives are a sound investment, offering highsocial and economic returns at low cost. A recentstudy found that investments in maternal health,particularly antenatal care, can reduce maternalmorality in low-income countries by an averageof 26%. Providing essential obstetric services canreduce that figure by a further 48%. Estimatingthat women with complications from unsafeabortions occupy 20% to 50% of gynaecologicalwards in some countries and consume up to 50%of hospital budgets, investments in maternal carecan significantly reduce hospital bed use.Sources: World Bank 1993; Jowett 2000.has led to significant changes in the delivery ofmaternal and child health or family planningservices in some countries. 336 Box 14 illustrateshow enhanced political commitment has led toimprovements in sexual and reproductive healthin Brazil.Of particular concern is how the goals of nationalsexual and reproductive health policies are worded.Evidence suggests that policies aiming to maximizehealth gains across the population may not havean impact on the health of marginalized or hardto-reachpopulations, 337 and may not address thedifferent sexual and reproductive needs of men andBox 13: Why has sexual and reproductivehealth not received higher priority?Although the benefits of improved sexual andreproductive health for women’s empowerment,gender equality and poverty reduction have beenclearly documented, decision-makers and leadersat the national and international levels have notprioritized sexual and reproductive health for anumber of reasons.1. Sexual and reproductive health, ascomprehensively defined in the ICPDPoA, recognizes the complex influences ofeconomic factors, social dynamics and powerrelationships. This multifaceted understandingof sexual and reproductive health doesnot lend itself to a “quick fix” approach.Instead, it implies the need for a long-termmultidimensional and multisectoral response.The responsibility for various aspects ofsexual and reproductive health is distributedacross different government departments andmanagers within departments, just as theconcept is fragmented across assorted MDGsand other international goals.2. Many core sexual and reproductive healthapproaches are preventive in nature. As withother preventive measures, it is difficult tomeasure progress and attribute success.3. Many aspects of sexual and reproductivehealth are politically sensitive. Politicians andother community leaders are often hesitant tosupport such issues publicly.Source: United Nations Millennium Project 2006.How can health professionals address poverty and gender in sexual and reproductive health programmes?

52Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 14: Political support for health reform enhances reproductive health in BrazilIn 1984, Brazil developed a comprehensive approach to women’s health that included nearly all of theelements called for 10 years later at the ICPD in Cairo. However, for more than a decade, the programmeremained isolated and under-funded and was never integrated into the national health system. Politicalturmoil and economic crises also hampered progress in reproductive health.Since 1995, Brazil has had greater institutional capacity and a political climate favourable to the Cairoagenda. Reproductive health and rights also gained greater visibility as a result of Brazil’s active participationin the 1995 Fourth World Conference on Women in Beijing. This renewed political interest, combined withreform of the health system, paved the way for substantial progress in the provision of reproductive healthservices.The Government has advanced primary health care through community-based strategies that emphasizefamily health and has pushed for the decentralization of health services. Decentralization of the healthsystem has put municipalities in control of budgets and the provision of services, which they can accomplisheither through public health providers or contracts with private providers. Under the health system, allindividuals are guaranteed access to a minimum package of basic health services, which includes familyplanning, prenatal care, maternity assistance and preventive services.Is Brazil a model for other countries? Health systems cannot be replicated easily in another country becauseof unique social, political and economic circumstances. Nevertheless, reproductive health experts in Brazilhave observed that the major principles underlying health reform—universal access, comprehensive care,equity (among different population subgroups), decentralization and public accountability—are necessaryelements of a comprehensive approach to reproductive health. These reforms have been critical for addressingthe wide inequalities in health status and access to care among the country’s citizens.Source: Ashford 2001.women. Therefore, sexual and reproductive healthpolicies need to be articulated in terms of bothimproving the health of all women and men andthe health of those who are poor and marginalized.Expressing policy goals in these terms can help toexplicitly integrate poverty and gender concernsinto sexual and reproductive health policies.Cross-sectoral actionMany of the determinants of sexual andreproductive health lie beyond the health sector.Therefore, action needs to extend beyond thehealth sector, particularly to national policiesand plans related to poverty reduction andgender equality. Incorporating analysis of sexualand reproductive health into national povertyreduction plans and policies on gender equalityand women’s empowerment can address themultiple determinants of sexual and reproductivehealth. Such an approach also acknowledgesthe role that improved sexual and reproductivehealth can play in poverty reduction and women’sempowerment.The conceptualization of sexual and reproductivehealth adopted at the ICPD in 1994 involves avariety of interventions with a number of actorsfrom diverse sectors, including education, finance,agriculture, youth, women’s affairs and povertyreduction, among others. 338 Strong links betweenthe development of sexual and reproductivehealth policies and programmes and those ofother relevant sectors can produce synergies. 339 Forexample, improving women’s education, accessto economic opportunities and decision-makingwithin households will enhance their access tosexual and reproductive health services.At the global level, WHO has set up aCommission on the Social Determinants ofHealth to draw attention to how inequalitiesModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 53in health are produced and sustained by socialfactors and processes. The Commission’s mandateincludes making recommendations on how toreduce such inequities and improve the health ofthe poor through actions related to these socialdeterminants of health. 340At the national level, Poverty ReductionStrategy Papers (PRSPs) or other multisectoralsocioeconomic planning instruments can offeran opportunity to increase policy coherenceand undertake joint planning to address thedeterminants of sexual and reproductive health. 341PRSPs also aim to promote more effectiveresource mobilization and allocation. However,evidence suggests that, although PRSPs recognizesexual and reproductive health as a determinant ofpoverty, the PRSP process has not systematicallyincorporated attention to sexual and reproductivehealth. A recent review concluded that therecord of incorporating population dynamicsand reproductive health into PRSPs wasdisappointing. 342 Ministries of health, therefore,need to secure a more central role in the PRSPprocess and to advocate for the inclusion of sexualand reproductive health within such multisectoralplanning instruments. These arguments can bepremised on the economic benefits of investing insexual and reproductive health and internationalcommitments to promote and protect sexual andreproductive health and sexual rights, especiallythose of youth and women. 343Similarly, creating an enabling environment forsexual and reproductive health extends beyondthe health sector to include a range of nationallaws, regulations and policies that may determinethe ability of men and women of all ages to enjoygood sexual and reproductive health. Laws andregulations in the areas of education, social welfare,infrastructure, justice, finance, employmentand family affairs all impact upon sexual andreproductive health. 344A review and, where appropriate, amendment oflaws, regulations and policies that affect variousaspects of sexual and reproductive health can ensurethat they are harmonized and that human rights ofBox 15: Including men in laws and policies toprevent and control HIV/AIDS among womenand girls in CambodiaWhen analysing the effect of laws, regulations andpolicies on particular aspects of the sexual andreproductive health of men and women, it canbe useful not only to assess how a law, regulationor policy approaches a given issue or impactsdifferent groups from a human rights and genderperspective, but also to consider what it addressesand omits. A powerful example of this approachcomes from Cambodia in the area of HIV/AIDSprevention and control.Traditionally, men of all ages have been excludedfrom education and services for sexual andreproductive health. The HIV/AIDS pandemichas increasingly highlighted the cost of such anomission in terms of men’s health and the healthand well-being of their wives, partners and children.In response, Cambodia’s Ministry of Women’sand Veterans’ Affairs developed a gender-sensitivepolicy on “Women, the Girl Child and STI/HIV/AIDS”. The policy acknowledges that the:“recognition of gender and gender inequalityshould not lead to a sole focus on women.Globally, we have learned that HIV/AIDSprojects that have focused solely on women inrecognition of their need for empowermenthave failed or been unsustainable because theyhave failed to involve men.”The policy is premised on the recognition thatHIV/AIDS is a gender-based pandemic and thatcurbing the spread of HIV/AIDS among womenand girls also requires concrete changes in the sexualbehaviour of men. The policy aims to put men’sbehaviour change on the agenda of policy-makersand service providers, along with prevention, care,support and protection for women and girls. Thisapproach guides Ministry-supported activities ineducation, prevention and services provision.Source: Ministry of Women’s and Veterans’ Affairs,Government of Cambodia 2003. In: Greene et al. and women are respected and promoted. 345Such analysis could assess whether laws adequatelyprotect women and girls from gender-basedviolence, for example. This assessment shouldHow can health professionals address poverty and gender in sexual and reproductive health programmes?

54Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsalso consider how the implementation theselaws, regulations and policies affect the sexualand reproductive health of individuals who arepoor as compared to those who are non-poor. Arecent review of the legislation in Mongolia, asit relates to HIV/AIDS prevention and control,concluded that the current legislation outlawingsex work should be revised to outlaw the act ofhiring someone for purposes of prostitution. Thisshift in the law would effectively make the actof buying sex illegal (instead of selling sex, as itcurrently stands). Such a change, it is hoped, candecrease the vulnerability of many sex workers byencouraging them to dialogue with the police andto seek out government services, such as those forSTIs. 346 In addition, the process of developinglaws, regulations and policies should respect,protect and fulfil the human rights of everyone. 347Box 15 discusses how legislation in Cambodiaaddresses gender inequality as it relates to HIV/AIDS prevention and control.Involving civil society organizations in processesto develop, assess and revise laws, regulationsand policies can improve the transparency andaccountability of such processes and therebycontribute towards building broad-based supportfor sexual and reproductive health. 348 In addition,the participation of these organizations in theassessment and revision of sexual and reproductivehealth laws, regulations and policies can generateconsensus and support for further action andimplementation.Health sector responseAchieving universal access to sexual andreproductive health services requires theintegration of sexual and reproductive healthinto the institutions and structures of the healthsystem. 349 During the integration process,particular attention must be paid to ensuringthat a full range of sexual and reproductive healthservices are available to all those in need. Thisapproach to sexual and reproductive health wasfirst outlined in the ICPD PoA and has sincebeen elaborated in the WHO Global Strategy forReproductive Health.In many countries in the Region, responsibility forthe development, implementation and evaluationof policies and programmes rests with differentactors or departments. As various aspects ofsexual and reproductive health tend to fall underdifferent programmatic areas, such as HIV/AIDS,maternal and child health and adolescent health,collaboration between these and other priorityprogrammes, such as malaria and tuberculosis,is required. 350 In this context, the integration ofsexual and reproductive health can be achievedthrough continuous, effective communication andcollaboration between actors and departments toestablish links at various levels of service delivery.While communication and collaboration arecritical to the successful integration of sexualand reproductive health services, these processesneed to be supported by policies that strengthenhealth systems in three vital areas, namely, (1)appropriate arrangements for the financing ofand payment for health services, (2) procurementand distribution of essential medicines, and (3)management of human resources. These policiesare needed to ensure the integration of a full rangeof sexual and reproductive health services. 351 Box16 considers some of these issues with regard tothe case of health sector reform. The sectionsthat follow discuss health financing, humanresources and health information for sexual andreproductive health as they relate to poverty andgender inequality.Health financingThe manner in which revenue is raised and fundsare allocated can influence access to sexual andreproductive health services for men and women,and poor and non-poor. Countries in the Regionuse various methods to determine how to mobilizeand allocate resources in the health sector. Oneapproach, which is becoming increasingly popular,is the sector-wide approach (SWAp). SWAps andsimilar methods for allocating resources tend torely upon priority-setting measures such as DALYs.However, such measures have been demonstratedto undervalue sexual and reproductive healthneeds, including maternal health care. 352 WhenModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 55Box 16: Health sector reform and sexual and reproductive healthHealth sector reform profoundly alters how health services are financed and delivered, in turn influencinghow sexual and reproductive health care is provided. Many reproductive health priorities, such as improvingservice quality and client satisfaction, educating patients and providing more choices are consistent with healthsector reform. However, reforms inevitably involve trade-offs and can have negative effects. Reproductivehealth managers and advocates interested in influencing how services are funded and provided need tobecome familiar with the objectives, principles and strategies of health sector reform and take part in policydiscussions at the national and local level. The following are some ideas on what can be done:Engage in continuous dialogue with health planners. Mechanisms may vary from country to country,but groups working on health sector reform and sexual and reproductive health need to share informationregularly. Sexual and reproductive health specialists need to be involved when critical decisions about thefinancing, organization and regulation of services are made. Having allies inside the government can beessential for gaining access to the process.Show that reproductive health is a good investment. To influence the reform agenda, advocates mustprove to policy-makers that sexual and reproductive health accounts for a significant proportion of thecountry’s overall disease burden and has social implications beyond the burden of disease; that interventionsfor sexual and reproductive health are cost effective; and that gross inequalities in reproductive health statusand the allocation of resources can and should be addressed.Use participatory approaches to influence decisions and monitor progress. Participatory processes thatestablish clear programme goals and measurable indicators of progress can be essential in bringing togetherhealth reformers and reproductive health advocates. Donors might consider investing in increasing thetechnical and analytical capacity of local administrators and civil society organizations to help those groupstake part in shaping health reform.Health sector reform has the potential to improve both the quality and the sustainability of sexual andreproductive health services, but its success depends in part on participation from a range of stakeholders.Local health administrators must be able to solicit and use the input of diverse stakeholders, and to addressreproductive health issues in a transformed health system.Source: Dmytraczenko et al. 2003.plans for resource allocation are formulated, sexualand reproductive health must be prioritized. In asimilar manner, the formulation of an essentialpackage of services must include sexual andreproductive health services that meet the needsof the target population.Most countries in the Region finance the healthsector through a combination of revenue-raisingmechanisms: taxes, social health insurance, donorfunding, prepayment schemes, private healthinsurance, and/or out-of-pocket payments oruser fees. Table 10 presents some of the publicfinancing mechanisms employed by countries inthe Region, as a percentage of the total revenue. 353In practice, private financing in most countriestakes the form of out-of-pocket payments at thepoint of service.Analysis suggests that taxes and social insuranceschemes offer the most equitable form ofhealth financing. 354 Social insurance and otherprepayment schemes tend to cover services thatmeet the needs of the target population in acost-effective manner; however, as with resourceallocation more generally, they have also beenshown to undervalue sexual and reproductivehealth needs. These types of schemes, for example,tend to exclude routine contraceptive and deliverycare for women, thereby resulting in unnecessaryHow can health professionals address poverty and gender in sexual and reproductive health programmes?

56Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsTable 10. Public financing mechanismsfor the health sector in selectedcountries in the Region in 2001CountryTax Social Externalrevenue insurance assistanceCambodia 51.0%China 87.0%Japan 89.0%Lao People’s 86.3%Democratic RepublicMalaysia 98.8%Mongolia 76.5%Papua New Guinea 83.5%Republic of Korea 71.9%Viet Nam 93.3%Source: Musgrove et al. 2001. In: Ravindran 2005.Caesarean sections and other surgical procedures,which are more often covered. 355 Insuranceschemes also tend to exclude pharmaceuticals thatare not prescribed by a health provider, such asoral or emergency contraception. In addition, keyaspects of sexual and reproductive health care arepreventive rather than curative. As such, prioritysetting for social insurance and other prepaymentschemes need to include other criteria to promote,rather than discourage, the availability of sexualand reproductive health services.In addition to the range of services covered byinsurance, the criteria used to identify who iseligible for coverage have important implicationsfor sexual and reproductive health. 356 For example,detailed analysis suggests that women may enjoylower access than men to social insurance schemesfinanced through payroll deductions, because oftheir lower participation in formal wage labour.Social insurance and other prepayment schemesmight also exclude same-sex couples. Financingsexual and reproductive health services throughtax revenue may be a more effective means ofensuring that these services are accessible to poorand marginalized groups.Greater reliance on private for-profit healthinsurance and direct user fees in many countriesappears to have adversely affected the access ofthe poor to health services. 357 Reliance on forprofitservice providers tends to leave poor andmarginalized communities underserved. Analysisof experience in 39 countries suggests that theintroduction of user fees increased revenue tothe health sector only slightly, while significantlyreducing access to basic health services for lowincomepeople. 358 Evidence suggests that womenhave been disproportionately affected as comparedto men by the increasing reliance on user fees andmay enjoy lower coverage of health insuranceschemes. While social marketing campaignsmay reach some motivated individuals, they areunlikely to meet the needs of poor householdswho may depend on subsidized contraceptives tomeet their family planning needs.Human resourcesHuman resource policies can have majorimplications for the effective delivery of sexual andreproductive health services. Human resourcesneed be distributed in a manner that meets thehealth needs of the population generally, such asby ensuring adequate numbers of trained staffin rural and remote health centres and in urbanpoor communities. The allocation of healthstaff between primary, secondary and tertiarylevels also influences the capability of the healthsystem to adequately respond to the sexual andreproductive health needs of men and women.Appropriate human resource policies can create aworkforce that is motivated and competent. Forexample, sexual and reproductive health issuesremain taboo in many areas and can be a sourceof embarrassment where men or women are madeto seek care from a health service provider of theopposite sex. Women frequently cite the absenceof a woman health professional as an importantreason for not seeking treatment. Because of this,it is vital to ensure the availability of both maleand female health staff.Good coordination can promote the successfuldelivery of sexual and reproductive health services.Timely referrals to higher levels of services arecritical for obstetric emergencies, for example.Indeed, timely emergency care has been identifiedModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 57Box 17: Example of a prepayment scheme thatincludes reproductive health services in thebenefits packageBolivia formulated the Maternal and ChildNational Insurance Plan in 1996 to improvethe coverage of maternal and child health care.The programme finances the total costs ofantenatal care, labour and delivery, includingCaesarean sections and other obstetricemergencies, postpartum care and newborncare for women and children under five yearsof age. The insurance package does not covercontraceptives.Between 1994 and 1998, the proportion of birthswith a skilled birth attendant increased from 43%to 59%. Disaggregating these data further showsthat the use of skilled birth attendants increasedfrom 11% to 20% among the poorest incomequintile. An evaluation conducted in 1998 ofthe National Insurance Programme for Mothersand Children (SNMN) in Bolivia concludedthat the benefits of the programme weredisproportionately enjoyed by poor households.Among clients seeking care for maternal care, forexample, 68% were from households classifiedas having low socioeconomic status and 32%were belonged to middle-socioeconomic statushouseholds.Source: Dmytraczenko and Scribner a core aspect of strategies to reduce maternalmortality. 359 Coordination between voluntarytesting and counselling for HIV and STIs andfamily planning services can create positivesynergies for sexual and reproductive health.Links also tend to extend from the health systemto volunteer or community-based health workers.Evidence suggests that trained traditional birthattendants can successfully identify early signs ofcomplication during labour and delivery and referwomen for treatment. 360 Other actors may also beinvolved in the provision of services for sexual andreproductive health, such as private providers andnongovernmental organizations (NGOs). Often,mid-level professionals and paramedical workersprovide many core sexual and reproductive healthservices. 361 Respectful working relationships withhealth providers beyond the health sector canfurther enable the delivery of comprehensive,good-quality sexual and reproductive healthservices.Health workers require continuous training andcapacity-building to ensure that they have upto-dateknowledge and skills. Access to currentknowledge and research on various sexual andreproductive health issues can also enable healthstaff to better counsel and advise patients. Thisincludes ensuring that men and women clientsare fully informed of their options, such as likelybenefits and potential side-effects, and thatproperly trained personnel obtain voluntary andinformed consent from clients.Enhancing the awareness of health staff onhuman rights and gender-sensitive standardscan further improve the delivery of sexual andreproductive health services and ensure that theymeet international standards, such as those laidout in the ICPD. Such an approach can includeredesigning services and training for health workersso that they are gender-sensitive and reflect theuser’s perspectives with regard to interpersonaland communication skills as well as the client’sright to privacy and confidentiality. Given thesensitive nature of sexual and reproductive healthin many communities, health service providersneed to be particularly considerate of the needsand perspectives of their men and women clients.Privacy and confidentiality are critical to youngpeople seeking sexual and reproductive healthservices. Not only do health centres need privatespaces for counselling and consultation, but healthproviders must also strive to offer confidentialservices to all patients.Health informationTo be effective, sexual and reproductive healthpolicies need to be grounded in an analysis oftimely and accurate data and research on the sexualand reproductive health needs of the population,including those of various groups within society,such as women and men and those who arepoor or live in rural areas. In addition, policiesHow can health professionals address poverty and gender in sexual and reproductive health programmes?

58Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsneed to be based on a thorough understandingof the social, cultural, political and economicdynamics and trends that influence the sexual andreproductive health of men and women of all ages.This information must then be analysed and usedto guide the allocation of financial and humanresources for sexual and reproductive health in themost equitable and effective way. 362Equipped with sound evidence, advocates canadvance efforts to build broad-based politicalsupport for sexual and reproductive health. ThatBox 18: Reproductive health indicators1. Total fertility rate2. Contraceptive prevalence rate3. Maternal mortality ratio4. Percentage of women attended, at leastonce during pregnancy, by skilled healthpersonnel (excluding trained or untrainedtraditional birth attendants) for reasons ofpregnancy5. Percentage of births attended by skilledhealth personnel (excluding trained anduntrained traditional birth attendants)6. Number of facilities with functioningbasic essential obstetric care per 500 000population7. Number of facilities with functioningcomprehensive essential obstetric care per500 000 population8. Perinatal mortality rate, by sex9. Percentage of live births with low birthweight (

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 59Box 19: Developing gender-sensitive indicators for reproductive health servicesComparison to a norm: Indicators should involve comparison to a norm, for example, the situation of menin the same country or the situation of women in another country. In this way, the indicator can focus onquestions of gender equality and equity rather than only on the status of women.Disaggregation: Data should be disaggregated by sex. Whenever possible, national-level indicators shouldalso be disaggregated by age, socioeconomic grouping, urban and rural setting, ethnicity and national and/orregional origin. The time period, geographical coverage, and data sources should be noted.Ease of access: Data should be easy to use and understand. Indicators should be phrased simply and shouldbe developed at a level relevant to the institutional capabilities of the country concerned.Scope of availability: Indicators should be available for the whole country.Reliability: Data should be relatively reliable. No data is absolutely reliable but reliability checks should becarried out. For example, findings from consensus should be compared to findings from micro-level studiesfor accuracy.Measurability: Indicators must be measurable. Concepts such as ‘women’s empowerment’ and ‘women’sequity’ may be difficult to define and measure. In this case, indicators that measure women’s access to healthcare or education may be used instead of the less precise concepts.Time frame: Gender-sensitive indicators should be reliable enough to use as a time series. The time framethat the indicator covers should be clearly specified.International compatibility: Gender-sensitive indicators should use internationally accepted definitions.While definitions are sometimes imprecise, they are usually the best terms available and allow for internationalcomparisons.Measuring impact: Gender-sensitive indicators should, where possible, measure the outcome or impact ofa situation rather then the input. For example, female mortality rates are a better measure of women’s healthstatus than access to health facilities.Participation: Indicators should be used and developed in a participatory process. This process will involvesetting up interdepartmental government committees and holding focus group meetings with the public toelicit the opinions of women and men whenever possible.Source: Commonwealth Secretariat. In: Baume 2001.Once collected, data should be disaggregated andanalysed by socioeconomic status, sex, urban-rurallocation, ethnicity and other relevant indicatorsof social exclusion. Through this process, analystswould learn how sexual and reproductive healthrelatedmorbidity and mortality are distributedamong the population generally and withinspecific subgroups, such as the urban poor andethnic minorities. Disaggregated analysis canalso refine understanding of unmet needs, suchas family planning services. Employing genderanalysis can also reveal how gender roles, such asthe gender division of labour, gender norms andaccess to and control over resources, influencethe sexual and reproductive health of men andwomen across the life cycle. This analysis can thenguide the identification of effective, appropriateand equitable policies and interventions for sexualand reproductive health.Data collection and analysis should besupplemented by case studies and otherHow can health professionals address poverty and gender in sexual and reproductive health programmes?

60Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 20: Strengthening reproductive health programmesPlanning process questions What is the current reproductive health situation? What are the needs? They should be identifiedthrough situation analysis or a needs assessment. What has been done to address the current situation? Programmes should be developed through strategicplanning to bring about change or improve a specific situation through appropriate interventions. How should progress and achievements be monitored and evaluated? Programme evaluationshould be integrated into the strategic plan to assess the effectiveness/impact or the outcome of itsintervention(s).Programme managers should: determine available resources and tools for various aspects of reproductive health; produce evidence-based and culturally sensitive information, education and communication messages;and explicitly involve all key stakeholders in the planning and implementation process.The strategic planning process should: identify relevant background information based on a situation analysis; identify priority interventions; develop objectives and strategies with a work plan containing key activities, indicators, time frame,estimated cost, proposed evaluation and assignment of responsibilities.The strategic framework should take into account the following key elements: creation of an enabling environment through advocacy and social mobilization that targets therelevant communities, policy-makers and all key stakeholders; promotion of healthy reproductive health behaviour; promotion of equitable access to quality health services while improving provider-client relationshipsand best practices in the context of national policy; providing opportunities for training through workshops and other capacity-building activities; fostering collaboration, partnership and strong reproductive health networks; developing a research agenda and strengthening the dissemination and utilization of researchinformation, including a commitment to improve access to and quality of reproductive healthprogrammes.Adapted from World Health Organization 2002a.qualitative methods of research in order to assessunmet needs for sexual and reproductive healthservices, perceived quality of health services, andvarious financial and non-financial barriers thatpoor men and women may face when accessingservices for sexual and reproductive health. Casestudies and other qualitative analytical methodscan provide information that an analysis of datafrom health information systems would otherwisemiss.Once collected and analysed, quantitative andqualitative information can be harnessed todevelop sexual and reproductive health policiesor to advocate for increased political and financialsupport for sexual and reproductive health. Box20 provides guidance for programme managersin outlining a strategic plan for developing andstrengthening reproductive health plans at thenational and district level. Such strategic planningentails the adaptation of norms and/or tools to agiven or changing situation. It takes into accountthe underlying determinants or variables thataffect the delivery of reproductive health care suchas gender and sociocultural perspectives.Building coalitions with diverse organizations canalso ensure that the process for formulating sexualModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 61and reproductive health policies and plans areinformed by the needs of the poor and of men andwomen. Strong links with marginalized groups,for example through civil society organizations,can help to elucidate the views and needs ofpoor individuals and of men and women. Thiscan be achieved through participatory methods,community consultation or identification ofrepresentatives from these groups to sit on a policyadvisory board. Involving men and women andthose who are poor and marginalized can ensurethat policies and plans are better tailored to meettheir sexual and reproductive health needs.Service deliveryProviding sexual and reproductive health care inan integrated manner has important implicationsfor how services are delivered. The aim ofintegration is to improve the overall effectivenessand efficiency of service delivery and to meet theneeds of all people for “accessible, acceptable,convenient and client-centred comprehensivecare.” 366 At the point of service delivery, theintegration of sexual and reproductive health caremeans bringing together all aspects, such as thoseoutlined in Box 10, and building strong workingrelations with other health services and, whereappropriate, with related social services. Ideally,this approach should include preventive measures,the provision of information and counselling toclients in addition to screening, diagnosis andcurative care.All of these services do not need to be providedin the same health clinic or site. Instead, healthservice providers need to be equipped with theknowledge and skills to provide an appropriatepackage of basic services and to refer patients torequired services that are lodged in other areasor levels of the health care system. Decisionsconcerning which services to offer and whichto link through referral systems need to takeinto account the capacity of the health system,including the knowledge and skills of healthservice providers, and the perspectives of localcommunities. The manner in which these servicesare delivered also needs to respond to gender andpoverty concerns to address inequalities in sexualand reproductive ill-health.The following section presents information oninnovative strategies that health professionalsare employing to improve the accessibility ofhealth care for the poor and to ensure that menand women benefit equally from resourcesallocated to sexual and reproductive health. Theseinterventions are still in their early stages and havenot yet been rigorously evaluated or standardized.However, they suggest some ways forward. Eachstrategy must be refined based on further analysisand country-specific situations. This is not anexhaustive list of strategies, as the evidence base forequity-promoting and gender-sensitive strategiesneeds to be augmented through more systematicoperational research.Addressing geographical barriersThe coverage of health services in many developingcountries in the Region remains incomplete andthe distribution of available services often benefitsnon-poor communities to a greater extent thanthose that are poor. Among countries in the Pacific,for example, health services may not effectivelycover remote and small island communities.Limited coverage of health facilities constitutegeographical barriers that may prevent or delaycare-seeking by poor individuals. Travelling longdistances for health care may be more difficultfor women than for men, whose mobility may berestricted by social norms or by limited access tocash income and household resources.Primary health facilities are often more accessiblefor poor households than are services offered insecondary or tertiary level facilities, which tendto be concentrated in urban centres. This greateraccessibility of primary health facilities wasrecognized in the ICPD PoA, which committedcountries to provide a full range of sexual andreproductive health services in an integratedmanner within the primary health system.Prioritizing sexual and reproductive health servicesthat can be successfully integrated into primaryhealth facilities can be an effective method ofHow can health professionals address poverty and gender in sexual and reproductive health programmes?

62Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsincreasing the geographical accessibility of theseservices to poor men and women.An approach that prioritizes the delivery of sexualand reproductive health services through primarycare facilities may require improved coverage ofappropriate diagnosis and treatment methods.That is, primary health care facilities requiresimple, low-cost methods for the diagnosis andtreatment. Box 21 discusses advances in simple,low-cost technologies to diagnosis cervical cancer.While the primary health care system in manycountries is quite extensive, some areas remainbeyond its reach. Financial incentives canencourage local NGOs and private providers tooffer appropriate sexual and reproductive healthservices in such areas. Partnering with NGOsmight be especially fruitful for scaling up sensitivecomponents of sexual and reproductive healthservices. 367 NGOs working with youth in ruraland remote communities, for example, may bepersuaded to integrate adolescent reproductivehealth services into their programming. Financialincentives may also motivate alternative healthservice providers to enter into underserved areas.Cambodia, for example, has successfully employeda strategy of contracting NGOs to provide healthservices in several districts, thereby increasing theaccessibility of health services, often to the benefitof the poor. 368 Contracting with private providersis increasingly used to improve the accessibilityof sexual and reproductive health services. 369In areas where poor individuals consult privatepractitioners, coordinating between private andpublic providers can improve the coverage andquality of services.Regular outreach services in poor and remotecommunities can bring sexual and reproductiveBox 21: Visual inspection with acetic acid wash for cervical cancerCervical cancer is one of the most common forms of cancer among women in low-income settings. Anestimated 80% of deaths from cervical cancer occur in developing countries. Among women in low- andmiddle-income countries, the majority of cervical cancer cases are caused by infection with a subtypeof human papillomavirus (HPV). HPV is a sexually transmitted virus that infects cells and may led toprecancerous lesions and invasive cancer.Cervical cytology programmes, which screen sexually active women annually or once every two to five years,have resulted in a large decline in cervical cancer incidence and mortality in developed countries. To beeffective, cervical cytology programmes require established laboratories, highly trained cytotechnologists andup to three visits for screening, evaluation of cytologic abnormalities and treatment. This approach hasremained largely ineffective in developing countries, where organized programmes are limited and testing isoften of poor quality and performed inadequately. In recognition of these constraints, alternative methodsbased on visual examination of the cervix have been investigated.Among these approaches, visual inspection with acetic acid (VIA) has received the most attention. VIAinvolves swabbing the cervix with diluted (3%–5%) acetic acid and then examining it with the nakedeye, i.e. without any magnification; illumination is provided by a bright source of light. Nurses or otherparamedical health workers usually perform this test. To be considered positive, the test detects well-defined,dull acetowhite lesions on the cervix. This detection aims for the early diagnosis of high-grade cervicalintraepithelial neoplasia and early preclinical, asymptomatic invasive cancer.Evidence suggests that VIA has similar sensitivity to that of cervical cytology, but with lower specificity.Because the outcome of VIA is known immediately, it reduces the amount of time women must devoteto screening procedures. VIA has been found to be cost effective, as it decreases the direct medical cost ofscreening to the health system and the patient.Sources: Sankaranarayanan et al. 2001; Goldie et al. 2005; World Health Organization 2002c.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 63health services closer to those in need. Outreachservices include regular health staff visits, mobileclinics and village health posts. Outreach serviceshave been used to provide contraceptives in hardto-reachcommunities. Outreach services needto be tailored to meet the needs of specific subpopulations,such as ethnic minorities, islandcommunities and migrants. A case study from VietNam (Box 22) provides an example of how oneBox 22: Reaching the poor and ethnicminority families in Viet NamEthnic minorities account for more than half ofthe population in three of the provinces servedby the Population and Family Health Projectin Viet Nam. To ensure that women in remotemountainous areas have access to improved healthand family planning services, two model outreachprogrammes are being tested. Village health postsare being established together with a hamletbased“collaborator” network. Locally selectedcollaborators are being provided with bicycles toensure that health care is available to settlementswhen they need it.Staff trained within the ethnic communitiessupplement the hamlet-based collaborators.Improved clinical training is also being provided towomen health and family planning workers. Morewomen are being trained as health workers, nurses,midwives and doctor’s assistants. If successful,these outreach programmes will be replicated inthe other 12 provinces of Viet Nam, where theproject is upgrading and expanding health andfamily planning services.To reach women unfamiliar with the services beingoffered, the project includes the use of innovativesocial marketing methods, such as the use ofnon-traditional outlets to promote new services.Through the project, thousands of Vietnamesewomen are starting to experience improved carein pregnancy and during deliveries. Access to awider range of contraceptives is now available forwomen and men. As their health improves andthey are able to control the birth spacing of theirfamilies, women are becoming better equipped tomove out of poverty and into a productive life.Source: Asian Development Bank 2002.programme addressed the problem of providingeffective and accessible reproductive health care toan ethnic minority group. Box 23 discusses themobile reproductive health clinics run by the Self-Employed Women’s Association (SEWA).Communities play an important role in thedelivery of health services in countries throughoutthe Region. Their involvement ranges from therecruitment of community-based health workers toincreasing reliance on home-based care for chronicillnesses, such as HIV/AIDS. Other approachesaim to mobilize the participation of communitiesin decisions that affect their health. While suchstrategies can effectively extend the reach of thehealth system and improve its responsiveness tocommunities, the benefits of community-basedapproaches cannot be guaranteed. For example,power dynamics within communities may silencethe voices of marginalized members, such aswomen and individuals from poor households;youth may also experience difficulty expressingtheir opinions in arenas that include their parents,teachers and community leaders. Care also needsto be taken to ensure that women’s unpaid workburden is not increased in the process, as in manyareas, the work of caring for the ill at home is oftenviewed to be the responsibility of women and girls.Approaches that are sensitive to these and otherissues can better ensure that the interests of suchgroups feature in planning and implementationprocesses.Addressing economic barriersThe mix of financing mechanisms adopted to fundhealth services largely determines the economicaccessibility of sexual and reproductive healthservices. As discussed above, careful planningcan tailor the mix in such a way as to reduce thepossible adverse effects on women as comparedwith men and those who are poor as comparedwith those who are better-off. Once thesemechanisms have been decided upon, additionalstrategies can be employed to further improve theeconomic accessibility of sexual and reproductivehealth services. To be effective, such strategiesHow can health professionals address poverty and gender in sexual and reproductive health programmes?

64Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 23: Mobile reproductive health clinics serving the very poor in IndiaThe Self-Employed Women’s Association (SEWA), a trade union of informal women workers, was foundedin 1972 in Ahmedabad, Gujarat. The aims of SEWA are: (1) to organize women to achieve full employment(work security, income security, food security and social security), and (2) to make women independentlyand collectively self-reliant, economically independent and capable of making their own decisions.SEWA has been involved in public health initiatives and the delivery of health services to members and nonmemberssince the early 1970s. The primary objective of these initiatives has been to provide services to thevery poor, particularly those who live in areas that are not otherwise served by the government or NGOs.In response to the need for reproductive health services for women in remote and underserved areas, SEWAorganized mobile reproductive health clinics in 1999. The mobile clinics initially provided services in slumareas of Ahmedabad city and villages in three districts. The clinics are largely funded by UNFPA and theGovernment of India.The mobile clinics usually operate for three to four hours in the afternoon and provide health education andtraining, examination and diagnostic tests (including cervical examination and Pap smears), treatment, referraland yearly follow-up visits to each target area. Physicians and community health workers staff the mobileclinics, which see an average of 30 women per month. Women who attend the mobile clinics are requested tomake a contribution of 5 rupees ($0.11) and to pay one third of the total costs of the medicines provided.More recently, SEWA has been collaborating with the government of Gujarat to hold mobile camps inpublic health centres in rural areas of the province. In contrast to the standard mobile clinics, services areprovided by public doctors and nurses and medication is available free of charge. In addition, SEWA coversthe transportation costs of women living in neighbouring villages.A recent evaluation concluded that the urban mobile clinics were successful in reaching the very poorest,while the rural camps were less effective. The success of urban camps was attributed to design of the mobileclinics, which brings services and education to poor people and incorporates poor people into the deliveryof many, if not all, health services. In addition, the mobile clinics are often combined with initiatives tomobilize and educate the larger community and the costs of services are significantly lower than those byother local service providers. Finally, SEWA is a well known and trusted institution in Ahmedabad city.SEWA health providers also attributed their success to the warm and respectful way they treat their clientsand that fact that most health providers are women.While the reasons for the limited success of the rural clinics in reaching the poorest remain largely unexplored,some contend that the registration fee may prevent very poor women from seeking care and that the clinichours tend to conflict with the working hours of many rural women.Source: Ranson et al. 2005.should be informed by research and analysis thatconsiders how the various financial mechanismsadopted affect the accessibility of sexual andreproductive health services for various groups.For example, evidence from Cambodia suggeststhat, in some areas, condoms are available freeof charge to women sex workers, while in othersthey must be bought from health facilities, brothelowners or NGOs. 370 Such detailed analysis canidentify how to address economic barriers, such asthrough exemptions targeting vulnerable groupsof adolescents, unmarried mothers or ethnicminorities. Other strategies can include exemptingpriority health services from user fees. Ghana, forexample, adopted a policy of free delivery care forall women. Instead of financing deliveries throughuser fees, as is the case with other health services, theGovernment opted to finance this priority serviceModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 65Box 24: Improving the economic accessibilityof delivery care for women in NepalThe costs associated with delivery care in Nepal,most notably transportation, are considerable.Evidence shows that they prevent or deter womenfrom accessing delivery care, thereby hinderingprogress towards the Government’s goal ofincreased skilled attendance at birth.To address the economic barriers to deliverycare, the Government of Nepal, in July 2005,introduced a new policy that provides:1. transportation allowances for all women whodeliver with a skilled attendant (payment variesdepending upon the topology of the area);2. financial incentives for skilled birth attendantswho assist deliveries; and3. free institutionalized delivery care in thepoorest districts.During the first year of implementation, less thanhalf of the districts had initiated the new policymeasures. While an increase in deliveries withskilled birth attendants has been observed, it isstill too early to assess the impact of this policy onthe poorest districts and on the health of womenand children in Nepal.Source: Borghi et al. 2006.through the PRSP process. 371 Box 24 describesthe Government of Nepal’s policy to provide cashpayments to women for transportation costs andfree institutional delivery for women residing inthe poorest districts.Financial incentives constitute an innovativeapproach to improving access to sexual andreproductive health services by stimulatingdemand among specific groups. For example,conditional cash transfers have been shown tobe an effective method for improving access toselected sexual and reproductive health servicesfor poor households in Latin American countries.Conditional cash transfers aim to mobilizedemand for a given health service among thetargeted community. More specifically, theseschemes transfer a set amount of money to preidentifiedfamilies, or individuals within families,conditional on certain behaviours or actions,such as their use of specific services. Evaluationsreport that conditional cash transfer schemes haveincreased uptake of antenatal care by 8% duringthe first trimester of pregnancy in Mexico, and by15%–20% in Honduras, especially among poorerhouseholds. 372Many developing countries have used voucherschemes to generate demand for sexual andreproductive health services. This approachprovides vouchers to targeted individuals orhouseholds, which can be exchanged for a preidentifiedservice, such as maternal care ordiagnosis and treatment for STIs. These servicesare often delivered in health facilities that havebeen contracted in advance to provide theredeemable services. This approach is seen to beparticularly effective because it overcomes thechallenges associated with cost-sharing schemesthat require advanced payment for care. 373 Box25 describes the experience with vouchers inmeeting the sexual and reproductive health needsof adolescents in low-income areas of Managua,Nicaragua.Community-based health insurance schemes,which generally operate on a much smaller scalethan other types of insurance schemes, have beenestablished in many areas. Such schemes spreadthe financial burden of ill-health across householdsin the community and over predictable periodsof time. However, community-based insuranceschemes may not cover sexual and reproductivehealth services that are considered sensitive,such as family planning and post-abortion care.Similarly, these schemes may exclude people whoare deemed to not need particular services, suchas unmarried adolescents and ageing men andwomen. Experience also shows that these schemesare not always accessible to poor households,who may not be able to make the requiredprepayments.Addressing sociocultural barriersWhile prevention, diagnosis and treatment canimprove the well-being of men and women, theHow can health professionals address poverty and gender in sexual and reproductive health programmes?

66Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 25: Meeting the sexual and reproductive health needs of female adolescents in low-income urbanareas through a voucher scheme in Managua, NicaraguaNicaragua is one of the poorest countries in Latin America. Of the 5.2 million people living in the nation’scapital, Managua, 25% are between the ages of 10 and 20 years. The adolescent fertility rate is one of thehighest in Latin America, with 119 births per 1000 women (15–19 years of age). By the age of 19 years,45% of young women either are mothers or are pregnant. Contraceptive use among adolescents is low, asis the use of sexual and reproductive health services. Limited access to information and poor quality of carehave been held responsible.In response, the Central American Health Institute (ICAS), in partnership with the London School ofTropical Medicine and Hygiene, launched an innovative pilot project to improve the use of quality sexualand reproductive health care among adolescents in poor and underserved areas of Managua. The pilot project,which was funded by the Department for International Development of the United Kingdom, aimed toincrease demand for sexual and reproductive health services through a competitive voucher scheme.Through the project, 28 711 vouchers were distributed to male and female adolescents in poor and underservedareas of Managua from September 2000 to July 2001. The vouchers were issued by ICAS and distributedby ICAS and NGOs in markets, outside public schools, in clinics, on streets and in poor neighbourhoods(house-to-house).Valid for three months, the vouchers were redeemable for one consultation and one follow-up visit forcounselling, family planning, pregnancy testing, antenatal care, STI treatment or a combination of theseservices. The voucher did not have to be used by the person who originally received it and could instead bepassed on to another adolescent. Adolescents who redeemed their vouchers for services also received a bookleton adolescent health, two condoms as well as any necessary laboratory tests, drugs and contraceptives.Continued on next pagepromotion of sexual and reproductive healthmust often confront sensitive and contentiousissues. This is because sexual and reproductivehealth initiatives often need to challenge socialnorms, conventions and stereotypes. Socioculturalissues also influence the appropriateness andefficiency of policies and programmes for sexualand reproductive health in different settings. 374Experience suggests that local ownership and theempowerment of stakeholders is fundamentalto the success of development programmes,including sexual and reproductive healthinitiatives. As such, sociocultural barriers need tobe identified and acknowledged as both challengesand opportunities for the realization of sexual andreproductive health. 375Approaches to sexual and reproductive healththat seek to tackle sociocultural barriers can createtension and conflict with local communities,particularly where efforts aim to change socialnorms, social relations and power dynamicsin households, communities and societies. 376Individuals or groups who feel threatened bythe intervention may react negatively and hinderactivities. However, individuals, communities,their representatives and institutions are the maindrivers of change. Thus, to influence social normsto improve the sexual and reproductive health ofmen and women, strategic alliances need to beforged with these actors to mobilize support andstrengthen ownership.Efforts to tackle sociocultural barriers, such asgender norms and notions of appropriate sexualbehaviour for young men and women, must befounded on an understanding and appreciationof local cultures and the differences, conflictsor hierarchies between various actors. To thisend, health staff need to listen and learn fromcommunities. Partnerships based on trust andopen dialogue can be supportive of positiveModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 67Box 25 (continued)The vouchers were redeemable at 20 clinics: four public, five private and 11 run by NGOs. These clinicswere selected on the basis of suitability (such as prior experience with sexual and reproductive health) andproximity to the targeted areas. Staff at participating clinics attended a short introduction to the programmeand were encouraged to attend training sessions on counselling, adolescent sexuality and sexual abuse. Clinicsreceived reimbursement according to agreed-upon fees. The average price per consultation and follow-upvisit was $4.56.Of the vouchers distributed, 20% of those issued to girls and 6% of those issued to boys were redeemed.In total, 3067 female adolescents used 3301 vouchers, of which 34% were for family planning, 31% fortreatment of RTIs and STIs, 28% for antenatal care, 28% for counselling, 18% for pregnancy testing and15% for other reasons. The majority of vouchers were redeemed at NGO clinics.An evaluation of the impact of the pilot programme on female adolescents concluded that, after controllingfor different characteristics, the vouchers had significantly increased the use of sexual and reproductivehealth services, knowledge of contraceptives and knowledge of STIs and prevention with condoms amongthose who had redeemed vouchers as compared with those who had not. The increase in use of sexual andreproductive health care was most marked among younger female adolescents, those still in school and thosewith the lowest level of education. In particular, female adolescents who were neither pregnant nor motherswere found to benefit the most from increased access to sexual and reproductive health services.The results of focus group discussions revealed that the voucher programme had increased the use of sexualand reproductive health services by eliminating out-of-pocket payments for services, removing the needto make an appointment, and informing female adolescents of clinic hours of operation and locations. Inaddition, the guarantee of confidentiality by a health provider of choice was identified as key in convincingadolescents to seek sexual and reproductive health services.Sources: Meuwissen et al. 2006a, 2006b and 2006c.change and knowledge-sharing for improvedsexual and reproductive health. In particular,it is vital that sexual and reproductive healthinitiatives avoid language and practices thatare judgmental of cultures and social practices.For example, an effective way of engaging withcultural norms and institutions is to make novalue judgement on particular cultural practices,while advocating against traditional practices thatbreach human rights and have negative effectson maternal and child health. One strategythat has proven to be effective is to engage localpower structures and faith-based institutions(Box 26). Such organizations are often willingto cooperate on sexual and reproductive healthinitiatives when they are engaged in a culturallyinformed and sensitive manner based on relevantevidence and information. 377 As well, thesetypes of interventions often need to be carriedout over time, as short-term change may not beunsustainable. 378Participatory methods that engage with andrespond to the perceptions, views and needsof all community members are often moreeffective in creating social change than are top–down interventions initiated by organizationsor individuals outside the community. Suchparticipatory approaches can be used to determinethe sexual and reproductive health needs ofcommunities and to build support for sexualand reproductive health services across diversestakeholders.Care needs to be taken, however, to ensure thatthe voices of all community members are heard.This requires efforts to ensure the inclusion andequal participation of men and women and thosefrom poor or ethnic minority households. Wherewomen are especially disempowered, they maybe enabled to speak in focus group discussionsheld separately from those held with the men.Similarly, it may be better to seek the input ofHow can health professionals address poverty and gender in sexual and reproductive health programmes?

68Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 26: Partnering with Buddhist monks and nuns to curb the HIV/AIDS epidemic in CambodiaMost ethnic Cambodians are Theravada Buddhists. While the constitution of Cambodia protects religiousfreedom, Buddhism is the dominant religion. The Government promotes national Buddhist holidays andprovides education, training and other support to monks. Close associations exist between Buddhism,Khmer cultural tradition and daily life in Cambodia. Buddhist traditions are widespread and dynamic in allprovinces and have been enjoying a revival following the decades of civil war.Buddhist monks and the wat (spiritual centre) are core components of Buddhism. Each village traditionallyhas a wat, which houses anywhere from five to 70 monks depending upon the local population. About 80%of monks join the monkhood temporarily; boys and young men join for a variety of reasons, ranging fromthe need for shelter and protection to seeking an education.Monks occupy high moral status in Cambodian society and often wield great influence. Although monksare expected to remain politically neutral, many have become active in the fight against HIV/AIDS. TheSupreme Patriarchs of the two monastic orders spoke of the urgent need to prevent the spread of HIV/AIDSin their discourses during the 1990s. The Supreme Patriarchs have also encouraged monks and nuns toprovide services to their communities. Monks and nuns in many parts of the country have become advocatesof reducing discrimination against people affected by HIV/AIDS. While monks rarely talk explicitly aboutsexual issues, they tend to preach precepts, such as value of abstaining from sexual harassment and the virtueof fidelity and chastity.In response to the influence of Buddhist monks and nuns in Cambodia, UNFPA has sought to forge strategicpartnerships to further efforts to curb the HIV/AIDS epidemic and achieve improved reproductive health.According to UNFPA, monks and nuns have been largely involved in four main types of activities: (1)preventing the spread of HIV/AIDS through information and education campaigns inside and outsidemonasteries; (2) providing care and support to people living with HIV and AIDS; (3) training other monksto handle young people with HIV/AIDS; and (4) eliminating the stigma of HIV/AIDS through preachingthe teachings of the Buddha, emphasizing compassion and easing the burdens of those affected by theepidemic. Given the position of monks and nuns in Cambodian society, many other strategic entry pointshave been identified. For example, efforts to integrate information on HIV/AIDS, reproductive health andgender equality into the Buddhist educational system could reach a large number of boys and young men.Encouraging monks to speak with couples about reproductive health when blessing newly married couplescould improve the knowledge of young men and women on reproductive health issues and the threat ofHIV/AIDS.Source: United Nations Population Fund 2004b.marginalized groups in a forum where powerfulmembers of the community are not present. Box27 discusses an initiative that used participatorymethods to challenge gender norms among youngmale and female factory workers in Chiang Mai,Thailand.Improving the quality of health servicesIn order for the health system to integrate sexualand reproductive health care, health serviceproviders must have the capacity to offer a basicpackage of quality services and to refer clients toother service providers as necessary. For example,antenatal and maternal service providers need tobe able to care for, or refer, a woman who is HIVpositive; health workers providing HIV treatmentand care need to be able diagnose and treat otherSTIs. 379Health service providers require knowledge andskills to provide a range of services to individualswith different needs and who may enter the healthsystem through various points. For example,Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 69Box 27: Using peer education to challenge gender norms among young male and female factoryworkers in Chiang Mai, ThailandWith rapid social change in many countries across the Region, women are increasingly engaging in nontraditionalforms of employment. Many in Cambodia, China, the Philippines and Viet Nam, among othercountries, are leaving their rural homes to work in electronics and garment factories. The demand for femalelabour in factories is high, and wages and working conditions are perceived as being better than that in othersectors. Women who migrate to urban areas are often far from parents, families and traditional social norms.This detachment can alter perceptions of acceptable male-female behaviour.A study among young male and female factory workers in Chiang Mai City, Thailand, revealed that socialnorms in the city associate masculinity with sexual prowess and that men prefer women who are sexuallyinexperienced. Young men and women agree that it is the responsibility of the woman to prevent pregnancy.With regard to HIV and STI prevention, few men take precautions unless the woman is perceived to beinfected, while fear of being perceived as socially undesirable often prevents young women from adoptingpreventive behaviour. In combination, these social norms may place young men and women at high risk ofSTIs, including HIV.In response, a peer education programme was set up to explore how gender roles and social norms influencedsexual behaviour, attitudes, relationships and communication patterns. The initiative aimed to increaseawareness among young factory workers (aged 15–25 years) who had never been married. Eighteen peerleaders were trained to facilitate small groups through a variety of activities, including reading comic booksand romance novels.An evaluation of the programme found that peer education increased awareness and reduced risky behaviouramong participants. An increased proportion of respondents were able to identity challenges to adoptingrisk reducing behaviour, such as peer pressure and male promiscuity. Following peer education, 42.3% ofparticipants said that it was acceptable for women to raise the issue of HIV with men, compared to 29.9%before the programme. An increasing number of participants also felt it was appropriate for women to carrycondoms. This suggests that both men and women developed an awareness of gender norms and how theyinfluence the practice of safe sex.Source: Cash et al. 1997. In: Boender et al. 2004.voluntary counselling and/or testing for HIV,family planning and RTIs/STIs should be equallyaccessible to a man who seeks treatment from aSTI clinic and a woman who attends an antenatalclinic. Again, as noted above, these services canbe housed in a single clinic or linked throughan effective referral system. However, whendetermining which services should be offered underone roof and which should be integrated through areferral system, the social norms and expectationsof the target communities need to be consideredto ensure that the system responds adequately totheir needs. 380 For example, adolescents may notbe comfortable seeking care from a clinic that hastraditionally offered only antenatal and maternalcare. Similarly, women may not be willing to sit ina waiting room together with men. In these cases,it may be more effective to link these servicestogether through referral networks rather thanhousing them in a single clinic.Besides integrating sexual and reproductive healthservices, the health system needs to be sensitiveto how men and women’s sexual and reproductivehealth needs change throughout their lifecycleand to respond with an appropriate range ofservices. This comprehensive approach requires adifferent set of skills. It also demands that healthproviders have information on the health carepreviously received by a man or woman and thehealth outcomes. The integration of sexual andreproductive health services over time has crucialHow can health professionals address poverty and gender in sexual and reproductive health programmes?

70Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 28: Enhancing the quality of care of reproductive health services in BangladeshA reproductive health initiative in Bangladesh was developed to deliver a comprehensive package ofreproductive health services in urban and under-served areas, with a special emphasis on quality of care. Themain lessons from this project are as follows:Quality of care increases client satisfaction.In Bangladesh, health providers have a reputation for mistreating clients. Traditionally, poor communitymembers were hesitant to visit clean and well-decorated clinics, assuming that the services were not meantfor them or would be too expensive. The Government tried to change this perception by introducingreproductive health service protocols and teaching service providers how to treat and communicate withclients. At the same time, clients were educated on the type of care they should expect. Clients were asked torate the conduct of service providers during exit interviews; most expressed an increase in satisfaction. At thesame time, clients were educated in the type of care they should expect.If possible, adapt existing protocols and guidelines.The availability of standard protocols and guidelines for clinical services, which were developed by theGovernment in collaboration with nongovernmental organizations, saved time and resources. In addition,the adaptation of existing protocols contributed to an internally coherent and homogenous approach tofamily planning and reproductive health services in Bangladesh.The process of improving the quality of care is lengthy and should be uninterrupted.Improving the quality of care is a labour-intensive process that requires time, effort and motivation. Thisholds particularly true for behavioural change, which is necessary if a better understanding of the clientsituation is to be achieved. Service providers need encouragement to see the value in using service protocolsand giving time to communicate with clients. Close monitoring and supervision are required, as well asregular refresher training to sustain quality and to compensate for the dropout of service providers.Quality of care increases client attendance.Investing in the quality of care pays off in the end. Improvements in the management of clinics, servicedeliveryprocedures, staff attitudes and behaviour towards clients, as well as cleanliness, led to a substantialincrease in clients (between 19% and 48%, depending on the facility, within one year). For example, one ofthe project hospitals expanded their facilities from 10 beds to 35 beds, introduced blood bank services, andcontinued to offer reproductive health services, including family planning. As a result, the number of totalservices rendered increased from 23 861 in 2000 to 35 527 in 2001.Source: EC/UNFPA 2002.implications for health information systems,particularly continued maintenance of clientrecords. 381 Box 28 discusses a reproductive healthinitiative in Bangladesh, which aimed to delivera comprehensive package of reproductive healthservices to poor communities.The manner in which health providers interactwith men and women is a core aspect of theoverall quality of health services. In additionto the knowledge and skills required to providea range of services for sexual and reproductivehealth, training and awareness-building at alllevels of the health system are required to improvethe sensitivity and responsiveness of healthservice providers to the needs of their clients.This is particularly true in the area of sexual andreproductive health because of its sensitive naturein many communities. For example, it is vital thathealth professionals be aware of and responsive topatients’ feelings and concerns and do not belittlethem. Demeaning treatment from health workersis a common complaint among women, whichdeters them from seeking care. In particular,efforts should be made to increase awareness,sensitivity and skills of health service providersModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 71Box 29: Challenging service providers to explore their attitudes and values regarding post-abortioncare in the PhilippinesOne approach that can improve the sensitivity and responsiveness of service providers to the needs of theirmen and women clients is for providers to explore and challenge their own values and attitudes. An exampleof this approach comes from the Philippines, where a programme to improve post-abortion care encouragedservice providers to become self-reflective.An initial situation analysis identified a number of weaknesses in post-abortion care in the Philippines. Postabortioncare clients rarely received routine counselling, referrals to family planning or other reproductivehealth services. Clients were treated poorly and punitive treatment was common.In response, EngenderHealth, an international NGO, implemented a programme from 2001 to 2002 thataimed to improve the skills of health providers in post-abortion care. The Prevention and Managementof Abortion Complications programme adopted a two-pronged approach. The first aspect consisted of aforum wherein participatory methods were used to enable service providers to explore their attitudes andvalues concerning post-abortion clients. The second aspect consisted of a technical working group made upof representatives from the Department of Health, academia, doctors, nursing and midwifery associations,NGOs and tertiary hospitals. This working group was tasked to formulate a national work plan for postabortion care.The programme trained health providers in post-abortion care counselling, family planning counselling,infection prevention and clinical post-abortion skills. As a result, the attitudes of health staff towardspost-abortion clinics were found to change significantly; health service providers sought to improve boththeir behaviour and practice. Providers were more sensitive to and aware of the needs of their clinics. Thisencouraged them to treat their clients with dignity and respect. Preserving confidentiality and privacy duringprocedures and counselling became paramount.Source: EngenderHealth 2003. In: United Nations Population Fund dealing with marginalized communities, suchas ethnic minorities and migrant communities,to ensure that all clients, especially those who arepoor, are treated with dignity and respect. Forexample, in the city of Chengdu, China, the GayMen’s Community Care Organisation works withdoctors in local STI clinics to ensure that men whohave sex with men are treated with respect anddignity and that their needs are understood. 382Health service providers need to be trained to dealwith men and women patients as both clients andpartners of other clients. This approach, coupledwith an understanding of gender issues andcommunication and power dynamics in sexualrelations between partners, can inform effectivecounselling and interventions with couples. It canalso help ensure that women’s rights and safetyare maintained. 383 Box 29 discusses one approachthat has been used to improve the awareness andsensitivity of health service providers to the needsof their clients.Sensitivity to the needs of individuals andcommunities extends beyond the interactionbetween clients and providers into to the spacewhere health services are offered. For example,efforts to incorporate services for unmarriedwomen, adolescents and men into health centresthat have traditionally catered to married women,such as maternal and antenatal clinics, often requireinnovative strategies to ensure responsiveness to thespecific needs of each of these groups. Catering toa variety of groups may require separate entrancesand waiting rooms or different hours of serviceto create a sense of privacy and confidentiality. Insome cases, separate youth-friendly services maybe required (see Box 30). 384 Box 31 describes howto make sexual and reproductive health services“male friendly.”How can health professionals address poverty and gender in sexual and reproductive health programmes?

72Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsImproving health communication andawarenessAdvocacy or health communication strategiesare often used in sexual and reproductive healthBox 30: Strategies to create youth-friendlyservicesYoung people can face many barriers when seekingto access sexual and reproductive health services.Experience shows that, to make services moreaccessible to young people, the following strategiescan be adopted.Service providers: Have specially trained staff. Show respect for young people. Honour privacy and confidentiality. Devote adequate time for client–providerinteraction. Make peer counsellors available.Health facilities: Set aside separate space or special times. Ensure convenient hours and location. Provide adequate space and sufficient privacy. Have comfortable surroundings.Program design: Involve youth in design, service outreachand delivery, and continuing feedback. Welcome drop-in clients or arrange theirappointments rapidly. Reduce overcrowding and waiting times. Ensure affordable fees. Adopt publicity and recruitment thatinform and reassure youth. Welcome and serve boys and young men. Make a wide range of services available. Make necessary referrals available.Other possible characteristics: Ensure availability of educational material. Make group discussions available. Set timing of pelvic examination and bloodtests to meet needs. Provide alternative ways to accessinformation, counselling and services.Source: United Nations Population Fund 2003.programmes to communicate informationstrategically, with the aim of changing theperceptions and influencing the decisionmakingof individuals. Indeed, interventions thatencourage the adoption of risk-reducing practicesand actions remain a core aspect of sexual andreproductive health promotion. Education andraising awareness are key to improving the healthof populations, communities and individuals.Providing information on preventive practices,such as family planning and condom use, and thesigns and symptoms of STIs and maternal health,can enable people to make decisions that positivelyinfluence their sexual and reproductive health.Health communication strategies typically focuson creating change at the level of individual orhousehold. With regard to sexual and reproductivehealth, experience has shown that such strategiesBox 31: Strategies to create male-friendlyservicesExperience shows that a number of strategies cancontribute to creating sexual and reproductivehealth services that are responsive to men. Use a name for the programme and/orfacility that welcomes men and women. Decorate the facility in a way that appeals tomen and women. Designate a male restroom. In waiting areas, include reading materialsthat interest men. Make information, education andcommunication materials readily availableto men. Make condoms easily available. Create an individual medical chart foreach man, rather than keeping his medicalinformation in his woman partner’s file. Provide facility space and time for seeingcouples so that men and women can receivecounselling together, if desired. Create awareness of men’s reproductive healthin the community. Advertise the availabilityof men’s reproductive health services. Adapt clinic hours to meet men’s needs.Source: United Nations Population Fund n.d.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 73are unlikely to lead to sustained changes inbehaviour and perceptions. This is because theseapproaches may fail to recognize the influencethat broad sociocultural elements can have onindividuals. To be effective, these strategies needto target the individual and aim to create anenvironment that supports the advocated socialor behavioural change. For example, to promotesafe sexual practices, a health communicationcampaign can be combined with counselling andtraining on safe sex negotiation among young menand women. A wider advocacy campaign couldthen address the social norms that work againstthe adoption of safe sex practices. 385Health communication strategies also needto be tailored to the specific characteristicsand needs of the intended population group.For example, school-based sex education hasbeen found to improve the knowledge of riskreductionstrategies among youth. 386 Targetingcommunication strategies to in-school youth,the military, women and farmers, among othergroups, requires collaboration between variousministries, including health, education, defencewomen’s affairs and agriculture. The ministry ofhealth should play a leading role in formulatingand providing appropriate educational materials.It should also establish and maintain therelationships with other government ministriesthat are required to implement effective sexualeducation programmes for multiple groups. 387Such health communication materials need tobe developed to pique the users’ interest andmeet their needs. For example, UNFPA explainshow HIV- and STI-related materials need tobe developed from a men’s perspective and thatmaterials that address issues of pleasure, powerand security have been found to be particularlyeffective. 388 Often, community members are ameans of disseminating information, as they aretrusted and well-versed in the local situation.This approach was harnessed to advocate forvasectomies among men in Kiribati (Box 32).Health communication and advocacy initiativesthat target the general population may notreach poor households because of generallylower levels of education and lower access tomodes of communication, such as television andradio. Numerous factors, including distance,cultural and linguistic barriers, may preventhealth communication messages from reachingethnic minority communities. Communicationstrategies and messages, therefore, must betailored to these groups, such as throughillustrated messages for those with low literacylevels. When targeting minority groups, culturallyappropriate messages delivered in local languagesare required. Outreach strategies may likewisebe undertaken by health staff or communitybasedhealth workers to increase knowledge andBox 32: Satisfied men as advocates andcommunity-based promoters for vasectomiesin KiribatiUNFPA supported a vasectomy project inKiribati to improve the health of men andwomen and to enhance male involvement infamily planning. The project enlisted the supportof men from the target communities who weresatisfied with their vasectomies to disseminateinformation and to encourage men to considerthe procedure (instead of female modes of familyplanning). These men promoted family planningand worked as health personnel. Their advocacywas based on their personal experience, whichtestified to the simplicity, safety and effectivenessof the method. Mobile family planning teamsoffered a range of family planning services,including vasectomy, to all outer islands andrural areas.The efforts of the community advocates weresupplemented with health communicationmaterials (pamphlets, posters, videos andcalendars). Primary health staff further encouragedmen who had had vasectomies to share theirexperiences in peer meetings, seminars, radioand video programmes and through one-to-onecommunication. As a result, the number of menwho have had vasectomies is greater than thenumber of sterilized women.Source: UNFPA Country Support Team in Fiji. In: UnitedNations Population Fund n.d.How can health professionals address poverty and gender in sexual and reproductive health programmes?

74Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsawareness among hard-to-reach groups and lowincomesettings.Women may be similarly hard to reach throughconventional health promotion campaignsbecause of lower levels of literacy than men andgender norms that may restrict women’s accessto mainstream media. Because women tend togather health-related information from relativesand social networks, interpersonal modes ofcommunication may be more effective than printmedia, for example. Involving poor individualsand women in the design and implementationof health communication campaigns can ensurethat local knowledge, priorities and needs areunderstood and subsequently addressed. Thesestrategies may likewise ensure that the messageand medium of health promotion campaigns areaccessible for women.Young people who have access to accurateinformation and the opportunity to discusssexual and reproductive health issues have beenfound to change their behaviour to reduce theirrisk of disease. 389 Responsibility for providingadolescents with the information they need toprotect their sexual and reproductive health lieswith parents and teachers, with the support of thewider community. 390 Peer counselling and othermeans of involving informed youth in educatingother young people have also been found to besuccessful.Age-appropriate sexual and reproductive healthinformation can empower youth to makeresponsible decisions. 391 Some examples of theseapproaches are as follows: The Youth Zone Project in the Philippinesprovides a safe space for young people tolearn about HIV/AIDS through a varietyof innovative strategies. It provides services,including medical care, to around 20–25young people each day, particularlyvulnerable groups. Peer education was used to promotenegotiation skills and safe sex practicesamong women working in bars in theLao People’s Democratic Republic andCambodia. Women working in bars tendto engage in casual commercial sex but donot necessarily identify themselves as sexworkers. 392Monitoring and evaluation and researchDespite the growing recognition of ongoingand often increasing health inequities both indeveloping and developed countries, healthinformation systems have, to date, been weak inyielding information needed to assess and addresshealth inequities. The challenges are to determinethe information needs for addressing healthinequities; to shape health information systemsto meet those needs; to promote sensitization toequity issues; and to develop the skills required touse information for effective planning and policymaking.393The Health Metrics Network has begun workon the construction of equity indicators and oncreating mechanisms to link records betweendata sources. 394 Complementary measures to theglobal Health Metrics Network for sexual andreproductive health can be undertaken at thecountry level.At the national level, disaggregated data are requiredto assess and analyse the extent of inequalities inthe determinants of sexual and reproductive illhealthand related morbidity and mortality, aswell as to monitor changes in these patterns overtime. Likewise, disaggregated data are required toidentify priority areas and interventions that willbenefit poor individuals and how interventionsmay differently affect men as compared to women.Table 11 presents an example applying a humanrights-based approach to health indicators tothe reproductive health strategy endorsed by theWorld Health Assembly in May 2004.Data collected routinely within the healthsystem should be disaggregated and analysedby socioeconomic status, gender, urban-rurallocation, by region or province, by level ofeducational, occupation, or other indicators ofdisadvantages identified through a poverty analysis.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 75Monitoring and evaluation also should considerthese variables. These efforts can be supplementedwith appropriate research, including qualitativedata to assess unmet needs, perceived quality ofhealth care services, and various financial andnon-financial barriers that poor men and womenmay face when accessing sexual and reproductivehealth services.How can health professionals address poverty and gender in sexual and reproductive health programmes?

76Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsTable 11: Right to health indicators: applying a human rights-based approach to WHO’s reproductivehealth strategy, 2004Structural indicatorsBasic legal context S1. Has the State ratified the following international treaties recognizing the right tohealth:a. ICESCR? yes/no.b. CRC? yes/no.c. CEDAW? yes/no.d. ICERD? yes/no.S2. Does the State’s constitution include the right to health? yes/no.S3. Does State legislation expressly recognize the right to health, including sexual andreproductive health rights? yes/no.Basic financialcontextS4. Does the State have a law to ensure universal access to sexual and reproductive healthcare? yes/no.National strategy andplan of actionS5. Does the State have a national sexual and reproductive health strategy and plan ofaction? yes/no.S6. Does the strategy and plan of action provide for universal access to sexual andreproductive health care? yes/no.S7. Does the strategy and plan of action:a. expressly recognize sexual and reproductive health rights? yes/no.b. clearly identify:i. objectives? yes/no.ii. time frames? yes/no.iii. duty holders and their responsibilities? yes/no.iv. reporting procedures? yes/no.c. specifically include measures to benefit vulnerable groups? yes/no.Participation S8. Does the strategy and plan of action establish a procedure for the State to regularlyconsult with a wide range of representatives of the following groups when formulating,implementing and monitoring sexual and reproductive health policy:a. nongovernmental organizations? yes/no.b. health professional organizations? yes/no.c. local governments? yes/no.d. community leaders? yes/no.e. vulnerable groups? yes/no.f. private sector? yes/no.Information S9. Does State law protect the right to seek, receive and impart information on sexual andreproductive health? yes/no.S10. Does the State have a strategy and plan of action to disseminate information on sexualand reproductive health to the public? yes/no.S11. Does the strategy and plan of action establish a procedure for the State to regularlydisseminate information on its sexual and reproductive health policies to:a. nongovernmental organizations? yes/no.b. health professional organizations? yes/no.c. local governments? yes/no.d. media accessible in rural areas? yes/no.S12. Does State law protect the confidentiality of personal health information?S13. Does State law require informed consent of the individual to accept or refusetreatment?Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 77Process indicatorsP1. Number of reports the State has submitted to the treatybasedbodies monitoring the following treaties:a. ICESCRb. CRCc. CEDAWd. ICERDP2. Number of national judicial decisions that consideredsexual and reproductive health rights in the last five yearsOutcome indicatorsP3. Percentage of government budget allocated to healthP4. Percentage of government health budget allocated to sexualand reproductive healthP5. Percentage of government health expenditure directed tosexual and reproductive healthP6. Per capita expenditure on sexual and reproductive healthP7. Does the State collect data adequate to evaluateperformance under the strategy and plan of action,particularly in relation to vulnerable groups? yes/no.P8. Does the State regularly consult with a wide range ofrepresentatives of the following groups when formulating,implementing and monitoring sexual and reproductivehealth policy:a. nongovernmental organizations? yes/no.b. health professional organizations? yes/no.c. local governments? yes/no.d. community leaders? yes/no.e. vulnerable groups? yes/no.f. private sector? yes/no.P9. Percentage of people exposed to information on:a. maternal and newborn careb. family planning servicesc. abortion and post-abortion cared. prevention and treatment of sexually transmittedinfectionse. prevention and treatment of cervical cancer and othergynaecological morbiditiesP10. Does the State regularly disseminate information on itssexual and reproductive health policies to:a. nongovernmental organizations? yes/no.b. health professional organizations? yes/no.c. local governments? yes/no.O1. Percentage of women who know about contraceptivemethods traditional or modern. disaggregated atleast by age, race, ethnicity, socioeconomic status andrural/urban.O2. Percentage of people 15–24 years old who know howto prevent HIV infection disaggregated at least bysex, race, ethnicity, socioeconomic status and rural/urban.O3. Percentage of people who believe that personalinformation disclosed to health professionalsremains confidential disaggregated at least by age,sex, race, ethnicity, socioeconomic status and rural/urban.Continued on next pageHow can health professionals address poverty and gender in sexual and reproductive health programmes?

78Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsTable 11 (continued)Structural indicatorsNational humanrights institutionsS14. Does the State have a national human rights institution with a mandate that includessexual and reproductive health rights? yes/no.Internationalassistance andcooperation theseindicators are fordonors.S15. Is the State’s overseas development assistance policy rights-based? yes/no.S16. Does the State’s overseas development policy include specific provisions to promoteand protect sexual and reproductive health rights? yes/no.Priority Aspect 1:Improving antenatal,delivery, post-partumand newborn careS17. Does the State have a strategy and plan of action:a. to reduce maternal deaths and their causes? yes/no.b. to ensure a universal system of referral for obstetric emergencies? yes/no.c. for access to care, treatment and support for HIV-infected pregnant women? yes/no.Priority Aspect 2:Delivering highqualityservices forfamily planningS18. Does State law:a. require third-party authorization for women to receive family planning services? yes/no.b. specify that only married women may receive family planning services? yes/no.S19. Does the national essential medicines list include:a. condoms? yes/no.b. hormonal contraceptives, including emergency contraceptives? yes/no.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 79Process indicatorsd. media accessible in rural areas? yes/no.P11. Percentage of health facilities with protocols on theconfidentiality of personal health informationP12. Percentage of health professionals who have receivedtraining on:a. the confidentiality of personal health informationb. the requirement of informed consent to accept or refusetreatmentP13. Number of the following activities the institution has runon sexual and reproductive health rights in the last fiveyears:a. training programmesb. public campaignsP14. Number of complaints concerning sexual and reproductivehealth rights the institution has considered in the last fiveyearsP15. Percentage of overseas development assistance directed tosexual and reproductive healthP16. Do the State’s reports to the human rights treaty-basedbodies include a detailed account of the internationalassistance and cooperation it is providing, including inrelation to sexual and reproductive health? yes/no/notapplicable.P17. Does the State provide a country-specific annual report ofits international assistance and cooperation, including inrelation to sexual and reproductive health:a. to the government of the recipient country? yes/no.b. to the public of the recipient country? yes/no.P18. Number of facilities per 500 000 population providing:a. basic obstetric careb. comprehensive obstetric careP19. Percentage of births attended by skilled health personnel*disaggregated at least by age, race, ethnicity, socioeconomicstatus and rural/urban.P20. Percentage of pregnant women counselled and tested forHIV/AIDS disaggregated at least by age, race, ethnicity,socioeconomic status and rural/urban.P21. Percentage of pregnant women screened for syphilisdisaggregated at least by age, race, ethnicity, socioeconomicstatus and rural/urban.P22. Percentage of primary health care facilities providingcomprehensive family planning services full range ofcontraceptive information, counselling and supplies for atleast six methods, including male and female, temporary,permanent and emergency contraception.Outcome indicatorsO4. Percentage of women with access to antenatal,delivery, post-partum and newborn caredisaggregated at least by age, race, ethnicity,socioeconomic status and rural/urban.O5. Maternal mortality ratio number of maternaldeaths per 100 000 live births.* disaggregated atleast by age, race, ethnicity, socioeconomic status andrural/urban.O6. HIV prevalence among pregnant women whoare 15–24 years old* disaggregated at least by race,ethnicity, socioeconomic status and rural/urban.O7. Syphilis prevalence among pregnant women whoare 15–24 years old disaggregated at least by race,ethnicity, socioeconomic status and rural/urban.O8. Neonatal mortality rate number of infantdeaths within one month of birth per 1000 livebirths. disaggregated at least by age, race, ethnicity,socioeconomic status and rural/urban.O9. Percentage of people with access to comprehensivefamily planning services disaggregated at least by age,sex, race, ethnicity, socioeconomic status and rural/urban.O10. Percentage of women at risk of pregnancy who areusing or whose partner is using. a contraceptiveContinued on next pageHow can health professionals address poverty and gender in sexual and reproductive health programmes?

80Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsTable 11 (continued)Structural indicatorsPriority Aspect 3:Eliminating unsafeabortionPriority Aspect 4:Combating sexuallytransmittedinfections, cervicalcancer and othergynaecologicalmorbiditiesS20. Does State law allow abortion:a. on request? yes/no.b. for economic or social reasons? yes/no.c. for the physical and/or mental health of the woman? yes/no.d. to save the life of the woman? yes/no.e. for cases of rape or incest? yes/no.f. for foetal impairment? yes/no.g. in no circumstances? yes/no.S21. Does State law criminalize abortion? yes/no.S22. Does the State have a strategy and plan of action to:a. prevent unsafe abortion? yes/no.b. provide post-abortion care? yes/no.S23. Does the State have a strategy and/or plan of action:a. to prevent sexually transmitted infections, including HIV? yes/no.b. to treat sexually transmitted infections? yes/no.c. to make antiretroviral treatment available for people living with HIV? yes/no.d. to prevent cervical cancer? yes/no.Priority Aspect 5:Promoting sexualhealth including foradolescentsS24. Does State law require comprehensive sexual health education during the compulsoryschool years? yes/no.S25. Does the State have a strategy and/or plan of action to promote adolescent sexual andreproductive health? yes/no.S26. Does State law prohibit sexual violence, including marital rape? yes/no.S27. Does State law prohibit female genital mutilation and other harmful traditionalpractices? yes/no.S28. Does State law prohibit marriage for both men and women prior to age 18? yes/no.S29. Does State law require full and free consent of the parties to a marriage? yes/no.CEDAW = Convention on the Elimination of All Forms of Discrimination Against Women; CRC = United Nations Convention onthe Rights of the Child; ICERD = International Convention on the Elimination of All Forms of Racial Discrimination; ICESCR =International Covenant on Economic, Social and Cultural Rights* Indicates a Millennium Development Goal indicatorNote: This illustration was developed by Prof Paul Hunt, the Special Rapporteur on the right of everyone to the enjoyment of thehighest attainable standard of physical and mental health, in his report to the Sixty-second session of the Commission on Human Rightsin March 2006.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 81Process indicatorsP23. Percentage of service delivery points providing abortionand/or post-abortion careP24. Percentage of practitioners trained in abortion and/or postabortioncareOutcome indicatorsmethod all methods.* disaggregated at least by age,race, ethnicity, socioeconomic status and rural/urban.O11. Percentage of women at risk of pregnancy whodesire to avoid pregnancy, but who are not usingand whose partner is not using. a contraceptivemethod disaggregated at least by age race, ethnicity,socioeconomic status and rural/urban.O12. Percentage of women with access to abortion and/orpost-abortion care disaggregated at least by age, race,ethnicity, socioeconomic status and rural/urban.O13. Abortion rate number of abortions per 1000women of reproductive age. disaggregated at leastby age, race, ethnicity, socioeconomic status and rural/urban.O14. Percentage of maternal deaths attributed to unsafeabortion disaggregated at least by age, race, ethnicity,socioeconomic status and rural/urban.P25. Number of condoms available for distribution nationwideduring the preceding 12 months. per population aged15–49 yearsP26. Percentage of family planning service delivery pointsoffering counselling on dual protection from sexuallytransmitted infections including HIV and unwantedpregnanciesP27. Percentage of women screened for cervical cancer withinthe past five years disaggregated at least by age, race, ethnicity,socioeconomic status and rural/urban.P28. Percentage of people 15–19 years old who have receivedcomprehensive sexual health education in schooldisaggregated at least by sex, race, ethnicity, socioeconomicstatus and rural/urban.P29. Number of incidents of sexual violence, includingmarital rape, reported to law enforcement and/or healthprofessionals in the past five yearsO15. Percentage of people with access to:a. health care for sexually transmitted infectionsb. preventative care for cervical cancer and othergynaecological morbidities disaggregated at least byage, race, ethnicity, socioeconomic status and rural/urban.O16. Percentage of people with self-reported ordiagnosed symptoms of sexually transmittedinfections, classified by condition disaggregated atleast by age, sex, race, ethnicity, socioeconomic statusand rural/urban.O17. HIV prevalence in subpopulations with high-riskbehaviour disaggregated at least by age, sex, race,ethnicity, socioeconomic status and rural/urban.O18. Percentage of women with cervical cancerdisaggregated at least by age, race, ethnicity,socioeconomic status and rural/urban.O19. Percentage of 15–19 year olds who know how toprevent HIV infectionO20. Age-specific fertility rate 15–19 and 20–24year olds. disaggregated at least by race, ethnicity,socioeconomic status and rural/urban.O21. Age at marriage disaggregated at least by sex, race,ethnicity, socioeconomic status and rural/urban.O22. Percentage of women who have undergone femalegenital mutilation – disaggregated at least by sex,race, ethnicity, socioeconomic status and rural/urban.How can health professionals address poverty and gender in sexual and reproductive health programmes?

5. Facilitator’s notesIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 835. Facilitator’s notesThese notes are provided to support facilitatorsas they work with learners on integratingpoverty and gender issues into specific health topics.Facilitators are recommended to refer to Section 5of the foundational modules of this Sourcebook,dealing respectively with poverty and gender,which contain additional notes on the targetaudience, role of the facilitator and suggestedmethodologies for learning sessions and evaluation.The learning sessions and exercises that follow arepractical and oriented toward “active learning.”That is, they are designed to promote groupdiscussion and presentation in analysing sexualand reproductive health in terms of gender andpoverty. The time required for all learning sessionsis approximately eight hours.Expected learning outcomesUpon completion of this module, participantswill be able to: demonstrate an understanding of sexual andreproductive health and rights, includingmeasurement challenges and the globalburden of mortality and morbidity related tosexual and reproductive health; demonstrate an understanding ofWHAT the links are between poverty, genderand sexual and reproductive health; explain WHY it is important for healthprofessionals to address poverty and genderconcerns in sexual and reproductive health; indicate HOW health professionals and thehealth system as a whole can address povertyand gender in sexual and reproductive healthprogramme; and demonstrate familiarity with some tools,resources and references available to supporthealth professionals in dealing with povertyand gender in sexual and reproductive health.Lesson plansSession 1: Exploring beliefs, values andprejudices in reproductive and sexual healthObjective: To promote exploration of participant’sbeliefs, values, assumptions and prejudices relatedto sexual and reproductive healthTime allotted: 90 minutesMaterials: flip charts, markers and masking tapePre-reading: Sections 1 and 2Activity 1: Recognizing one’s own beliefs, values,assumptions and biases in providing sexual andreproductive health servicesBefore the group convenes, write the followingstatements on a flip chart. Leave about an 18-inch gap between each statement where you canwrite the group’s responses. The intention here isto unearth and examine the differing perspectives,opinions and prejudices that are present withinany group of people. The statements are:Prostitutes are____________________.Poor women who have many childrenare ____________________________.Women who obey their husbands are_________________________________.People who abuse drugs and alcohol are_______________________________.Women who leave their children to goto work are______________________.Men who attend antenatal care withtheir wives are ___________________.Girls who gets pregnant while unmarriedare____________________________.Women from differing ethnic groupswho have large families are__________.Government officials who say thatreproductive health cannot be providedfor all, especially those who cannot payare___________________________.Facilitator’s notes

84Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsAsk each participant to write their answers on apiece of paper. In pairs, ask participants to shareand discuss their completed statements with oneanother. Then, read each statement out loud andask the paired participants to share their responses,if they wish. Try to engage the quieter members ofthe group. Ask participants to listen respectfullyto the differing points of view presented. Writethe responses under each statement. Continue todo this until the group has commented on eachstatement. Try to bring out the quieter membersof the group. Ask the group if there are differingopinions. At this time, do not ask the group todebate their remarks. Just write each responsedown. Remove the completed pages from the flipchart and fasten them on the walls of the room.Once the responses to each statement have beenwritten on the flip chart, invite the participantsto express how they are feeling about the exercise.Explain to the group that these differing opinions,biases and judgements exist in every health caresetting. It is important to unearth these opinionsand to let others hear them. Strong feelings mayemerge; the aim is to provide a safe environmentin which such discussions can be undertakenin a respectful manner. Allow the feelings to beexplored, so as to raise participants’ awareness ofthe impact of their beliefs, values, assumptions andbiases on the provision of sexual and reproductivehealth services. In this way, some of the challengesin providing gender and poverty sensitivereproductive health care can be examined.Activity 2: Brainstorming: taking actionThis exercise intends to help participants movefrom ‘issues’ to ‘action’. Ask the group to shoutout strategies they might consider in providingaccessible and respectful reproductive and sexualhealth programmes to persons from differingage, gender, socioeconomic, ethnic and culturalbackgrounds. You might wish to ask the followingquestions to prompt the group. What are the barriers to effective and respectfulsexual and reproductive health services? How can those barriers be overcome? What do you consider to be the mostdifficult barrier to overcome? What would have to be in place to overcomethis barrier? What issues would you need to take intoconsideration in planning and developing asexual and reproductive health service? What can you do as health practitioners toprovide respectful and effective reproductiveand sexual health services, particularly forvulnerable population groups?Note to the facilitator: The intent of this finalbrainstorming session is to provide an opportunityfor participants to move from their personalbeliefs, values and biases to considering strategiesfor action to provide respectful reproductive andsexual health services.Session 2: Educating the publicObjective: To develop sexual and reproductivehealth educational materials for different groupsof clientsMaterials: flip chart paper for each group andcoloured markers and/or pencilsTime allotted: 70 minutesPre-reading: Sections 1 and 2Explain to the group that they will be creatingeducational materials for a variety of targetaudiences. These educational materials can includeposters, pamphlets, advertisements, collages or anyother visual information for the general public.Divide participants into groups of four or five.Encourage them to work with people they havenot worked with before. Provide each group withone of the following educational topics:1.You have been asked to develop an advertisingcampaign to encourage adolescents to attenda sexual and reproductive health centre.Note to the facilitator: The issues thatshould be highlighted include: youth friendlyModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 852.3.4.5.advertisements, social marketing to youth,geared to the literacy level of the youth.You have been asked to create educationalmaterial to help women understandhow sexually transmitted infections aretransmitted and how they can be prevented.Many of these women are semi-literate.Note to the facilitator: The issues thatshould be highlighted include: focus onmaterial that is acceptable and accessible tosemi-literate women, attention to sensitivityof subject matter, ensuring that materialsare culturally acceptable to the women andthat the diagrams and drawings will be easilyunderstood.Management is promoting the involvementof men in your reproductive and sexualhealth programme. You have been askedto create a poster or other visual aid toencourage men’s involvement.Note to the facilitator: The issues that shouldbe highlighted include: acceptability tomen, social marketing that attracts men andsensitivity to cultural norms and practices.You have been asked to develop educationalmaterial to help people in your communityunderstand the value of family planning.Note to the facilitator: The issues thatshould be highlighted include: acceptabilityto women and men, social marketing thatattracts women and men, sensitivity tocultural norms and practices, clear messagesabout the value of family planning and theinvolvement of both women and men.You have been asked to develop educationalmaterial on gender-based violence. Many ofthe women who live in your community aresemi-literate.Note to the facilitator: Highlight methodsof challenging views and attitudes about6.gender-based violence, by using, for example:statistical evidence in picture form of theincidence of gender-based violence in thecountry or community; drawings thatillustrate the different forms of violenceagainst women; safe places for women togo; NGOs active in addressing gender-basedviolence; and, emergency numbers of policeand health facilities.During a recent reproductive health survey,it was noted that teenage pregnancies hadrisen sharply. You have been asked to developeducational materials to raise awareness ofthis problem and to develop some preventionmessages.Note to the facilitator: The issues thatshould be highlighted include: statistics ofteenage pregnancies, reasons for increasein teenage pregnancies, cultural andsocial pressures for teenagers to engage inunprotected sexual intercourse, methods ofcontraception and places where teenage girlswould be welcome for contraceptive andsexual counselling, education and services.Give each group flip chart paper, coloured markersand/or pencils. Ask them to draw, write or considerother creative methods of providing effectivemessages to these target groups of people.Presentation of educational materialsAs the groups are working on their educationalmaterials, write the following questions on a flipchart at the front of the group. What is the main message you are trying toportray? Why do you consider this to be the mostimportant message? What issues did you consider as you thoughtabout reaching this target group? If you were asked to develop othereducational materials (of any kind), whatother methods would you like to include? Why do you think these methods would beparticularly useful?Facilitator’s notes

86Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsAsk each group to present their educationalmaterials. A nominated spokesperson should leadthe presentation; however, other group membersshould be encouraged to participate. Specialattention should be given to the questions writtenon the flip chart.This activity is intended to help participants comeup with creative ways to reach target groups, justifytheir choices, and consider the appropriateness ofthe educational material.Session 3: Role-play: overcoming barriershindering access to sexual and reproductivehealth servicesObjective: To explore ways of addressing barriersimpacting access to sexual and reproductive healthservicesExpected learning outcome: Through role-play,participants will actively engage in overcomingbarriers that may hinder client access to sexualand reproductive health services.Time: 65 minutesPre-reading: Sections 1, 2 and 3include: poverty, marginalized women,health concerns (STI and HIV/AIDS), andaccess to abortion.Scenario 2: A 15-year-old girl comes to ahealth centre and asks to talk to a nurse. Sheexplains that she is to marry in three weeksand that she is afraid.Note to the facilitator: The issues thatshould be highlighted in this role-playinclude: immaturity, coercion, powerlessnessof young women, cultural norms andignorance of sexual and reproductive health.Scenario 3: A husband comes to a familyplanning clinic with his wife. He explainsthat he wants to know what the healthworkers have been telling his wife, as he isinsistent that they not use family planningmethods of any kind.Note to the facilitator: The issues thatshould be highlighted in this role-playinclude: male dominance, women’s lackof power and control, male control overcontraception and birth spacing, overcomingaccess barriers.Divide participants into three large groups.Explain to the participants that role-playactivities provide a safe environment withinwhich to practise methods of addressing barriersto sexual and reproductive health services.Each group will role-play one of the followingscenarios:Scenario 1: A client who is a known womansex worker enters a health clinic in animpoverished, urban community and asksfor a pregnancy test. You have treated thiswoman before for an STI and have beenencouraging her to have an HIV test. Sheappears to be distraught about the pregnancyand abortion is illegal in your country.Note to the facilitator: The issues thatshould be highlighted in this role-play Scenario 4: A woman from a remote areaarrives at a health centre in town after havingridden on a bus for two hours to seek care.She complains of pain in her abdomen anddifficulty passing urine.Note to the facilitator: The issues thatshould be highlighted in this role-playinclude: problems of accessibility in ruralhealth, delayed access to health services andpossible complications due to difficulty inhealth-seeking practices, as well as methodsof overcoming health service access barriers.Scenario 5: Two young boys come toan evening sexual health clinic. They arelaughing and joking with one another. Whenthe health care worker asks how the youngboys can be helped, they look embarrassedModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 87and say that perhaps they do not need anyhelp after all. They prepare to leave.Note to the facilitator: The issues thatshould be highlighted in this role-playinclude: improving access to sexual andreproductive health services for youngmen, cultural bias against acknowledgingadolescent sexuality and respect for youngpeople in adolescent health services.Read these case scenarios out to the whole group.Allow each group to choose one of the scenarios,ensuring that two groups do not choose the samescenario. Ask the groups to select two or threevolunteers to act out the situation. One volunteerwill role-play the health care professional; theother(s) will act as the client(s). For each role-play,the actors should go beyond the given scenario.That is, each group should further develop thescenario.Volunteers should practise their role-plays forabout 15 minutes and then receive feedback fromtheir groups. Volunteers should not be given toomuch time to practise as this usually makes themnervous.Bring the participants back together. Ask onegroup to read the scenario and then to role-playthe situation, including their creative additions tosituation. The role-play should take about sevenminutes.After each role-play, congratulate the volunteersand then ask the following questions of the entiregroup: What were the important issues that theactors brought out? How did you think the actors overcameaccess barriers to provide helpful support,advice and/or treatment? What did you think was most helpful in thisrole-play situation? Why? What might you have done differently? Why? How might this role-play influence how youpractise health service delivery in the future.Why?Debriefing should take about 10 minutes for eachgroup. It is important that all participants fullyengage in the debriefing session. Ask participantsto imagine themselves in each situation and toconsider how they would work with the client(s).The intention is to help each participant considerhow she/he would use “good practices” toaddress access barriers, and why they think suchpractices are “good”. Encourage participants,even reluctant ones, to critique the role-play ofothers. Explain that critiquing is a way to exploredifferent options and approaches within a safeenvironment.Repeat this exercise two more times until eachgroup has performed a role-play and the othershave had an opportunity to critique their“practice.”Session 4: Submission to the Commission onHealth Care ReformObjective: To develop strategies to influencepolitical decision-makingTime allotted: 80 minutesPre-reading: Sections 1, 2, 3 and 4Setting the activityTime allotted: 20 minutesExplain to the participants that they have beenasked to present a submission to a governmentcommission that is touring the country. Thecommission is listening proposals from healthprofessionals to determine which services andprogrammes should be universally accessible inthe country’s new health reform agenda.Instruct participants to develop a seven minuteverbal presentation that will convince thecommission that sexual and reproductive healthcare should be a core programme in the country’snew health care system. Stress that the commissionwill be hearing from many special interest groups,so their submission has to be very persuasive,Facilitator’s notes

88Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsbecause not all health programmes can becomecore programmes in the reformed health caresystem.Divide participants into groups of six to eightparticipants, some of which have not workedtogether before. Each group is to prepare asubmission. It is likely that groups will preparefairly similar submissions; however, the intent isto see how each group presents its submission andwhere they put particular emphasis. You mightwant to pose the following questions to help thegroups consider their submissions. What are some of the most persuasive waysof getting your points across? What issues do you consider the mostimportant and therefore need to emphasize? How would you prioritize these issues? How would you organize your submissionto provide organized flow with maximumimpact? What would be your opening and closingremarks? What lasting impressions would you want toleave the commission members?Give the participants 20 minutes to prepare theirsubmission. They should access informationfrom the pre-readings required for this learningactivity.Note to the facilitator: Explain to the participantsthat the commission’s chairperson (you, asfacilitator) will cut off the presenters if they gobeyond their seven minute time allocation. If theparticipants were ever required to present to a realcommittee, it is very likely that they would becut off if they went overtime. At the end of eachsubmission the commissioners (the rest of thegroup) will have five minutes to ask questions ofthe group submitting the presentation. Make sureyou set a stage that is quite formal. Such formalitywill mirror the reality of the atmosphere thatusually pervades such submission presentations.In this way, participants have an opportunityto experience the formality that usuallysurrounds presenting submissions to a powerfulcommission.Presenting the submission and question timeAsk each group to choose a spokesperson topresent the submission to the commission. Therest of the participants will act as commissionersand should take notes during the presentations.Following each seven-minute presentation(remember to be strict on this time frame), the“commissioners” should pose probing questionsto the presenter and his or her group. Remindthe group that the commission has to choose corehealth care programmes from a wide and disparateselection of programmes and services, and thateach special interest group will be presentingsubmissions. For that reason, the commissionerswill have to ask questions that will lead them tomake the right choices for the country’s reformedhealth care system. As such, the responses tothe commission’s probing questions will be asimportant as the submission itself. The overallintent is for participants to experience the politicalprocess that is often used to allocate resources anddetermine core programmes. They will experiencethis process by acting as activists and advocatesin promoting sexual and reproductive health as acore health care programme.DebriefingAfter the groups have presented their submissionsand the questions posed by the commissionershave been answered, gather the entire group fora debriefing session. You may wish to use thefollowing questions (or some of your own) as aguide: What has been your overall experience withthis learning activity? What stands out for you most? What did you like most about the way thepresentations were conducted? What did you learn from the questions thatwere posed by the commissioners? What would you have done differently nowthat you have experienced being both apresenter and a commissioner? What overall lesson will you take withyou into your work as a health carepractitioner?Module on Sexual and Reproductive Health

6. Tools, resources and referencesIntegrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsModule on Sexual and Reproductive Health

90Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals6. Tools, resources and referencesToolsTable 12: Integrating gender and poverty into quality assurance programmesIndicator Yes No Plans for action and timelineInstitutional policies and practicesDo agency policies that prohibit gender-based discrimination exist?Do agency policies that prohibit the abuse of power and sexualharassment in the institution exist?Do policies and procedures to ensure gender-based equity in thepromotion of staff exist?Do mechanisms that prohibit spousal consent exist?Is there a declaration in the institution’s mission that promoteswomen’s empowerment?Provider practicesDo staff address clients by their name?Are records kept of consultations and counselling where staffexplored sexual and reproductive health?If records are kept, based on the total client load, do the recordsindicate that most clients receive such consultations?Are consultations geared to the client’s educational level? Arepictures and diagrams used, for example?Do staff provide details on treatment to clients?Do staff have adequate time to conduct a consultation?Do staff provide time for clients to ask questions and expressconcerns?Do staff explain procedures undertaken on clients?Do staff know the agency’s mission?Convenience to clientAre the agency hours convenient to clients?Is child care provided at the agency?Client satisfactionDoes the agency have methods to collect data on client satisfaction?Does the agency have policies to ensure client confidentiality andprivacy?If yes, is this policy upheld?Is the waiting area large enough to accommodate all of the clients?Is the waiting area inviting to clients?Do clients report feeling comfortable asking questions andclarifying doubts?Do clients report sufficient time with staff?Client accessibilityAre all clients able to access the agency, regardless of their ability topay?Continued on next pageModule on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 91Table 12 (continued)Indicator Yes No Plans for action and timelineIs there a waiver system for people who cannot afford the services?Can clients reach the agency, i.e. without transportationdifficulties?Are people who are vulnerable or marginalized because of race, age,gender, economic status or living arrangements able to access theservices?Use of gender-sensitive languageDo staff use non-discriminatory language?Do staff use inclusive language?Health communicationDo communication materials on sexual and reproductive rights(including women’s rights) exist?If yes, are they readily available for clients?Do materials on sexual and reproductive health issues exist?If yes, are these materials easily understood by clients, regardless oftheir level of education?Do other forms of information exist, e.g. videos, posters, groupeducation sessions, peer education, use of various media?Monitoring and evaluationIs staff performance monitored?Do staff have periodic evaluations?Is the overall function of the agency evaluated by clients and staff?Do mechanisms exist to make programmatic changes based on theinformation gathered from clients and staff?Adapted from Cardich R. et al. Manual to evaluate quality of care from a gender perspective. International Planned Parenthood Federation,Western Hemisphere Region, 2000.Box 33: Gender sensitivity checklist for programme implementationDoes your programme …Yes Noprovide child care for participants during programme activities?provide transportation for participants in an effort to encourage attendance?occur at a time and place that are convenient to all participants, especially women and girls?encourage community members, especially women and girls, to participate inpeer education (e.g. leading segments of the workshop discussions, demonstrating condom use)?encourage people living with HIV/AIDS, especially women and girls, to participate inprogramme implementation?provide access to information about HIV/AIDS to all participants equally?encourage discussion about socially assigned gender roles affecting women, men, adolescents andelderly?enable women and men, and girls and boys to understand one another’s needs?attempt to ensure that women and men, and girls and boys are listening to the needs of oneanother (have participants represent one another in role-play, have participants summarize andrepeat the issues raised in discussion, etc.)?Continued on next pageTools, resources and references

92Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsBox 33 (continued)Yes Noencourage discussion of the various social factors, such as economics, political and social structurethat put women or men more at risk for HIV/AIDS?encourage discussion of how gender inequality affects HIV/AIDS prevention, transmission,treatment and care?address the financial difficulties brought on by HIV/AIDS, which often disproportionately affectwomen and girls (e.g. laws that do not allow women to inherit land from their husbands, theneed for widows to seek out new forms of income to support their families, the burden of healthcare costs that often become the responsibility of women)encourage discussion of the power imbalances between women and men, and between girls andboys, and how these imbalances affect the transmission and prevention of HIV/AIDS (e.g. thedifficulties women face in insisting that their partners use condoms, the ability to choose whenand with whom to have sex, etc.)encourage discussion of how empowerment of women and girls could help lessen their vulnerabilityto HIV/AIDS? (It is crucial to include men and boys in this discussion so they can support theirwives, sisters and mothers as opposed to becoming threatened by their empowerment.)work to eliminate the power imbalances between women and men and between girls and boys?address the issue of violence against women and girls?provide opportunities for women and girls to become empowered through HIV/AIDS education(e.g. enhance the self-confidence of women and girls by encouraging them to attain new skills,take on more responsibilities as desired, become local leaders in health promotion)?encourage and acknowledge the support that women and girls can provide to one another?address the double standard that exists between women and men in relation to sexual activity(e.g. men being allowed to engage in sex outside of marriage while women are not, men beingexpected to have sexual experience before marriage while women are not)?address the issue of sexual abuse (e.g. rape, incest)?address adolescent sexuality and the effect it may have on HIV/AIDS?address the issue of equal access to education for boys and girls?address the reproductive and sexual health needs of children and adolescents?facilitate awareness in adults of the reproductive health needs of children and adolescents?encourage adults to address the reproductive and sexual health needs of children and adolescents?provide demonstrations to all participants on how to use both male and female condoms andencourage all participants to practise their use?encourage discussion about the possible difficulties associated with condom useexperienced by both women and men?address how HIV/AIDS affects how women and men make reproductive choices?encourage the involvement of both women and men in family planning?address how to avoid HIV transmission from mother to child (both before and after birth)?address the need to improve the quality of health services for women and girls?address the various health care changes that occur over a lifetime and how those changes affectHIV/AIDS treatment and prevention? (For example, a woman’s health needs and HIV/AIDSsusceptibility may change significantly as her body changes through adolescence, childbearingyears, and menopause.)encourage men and boys to participate equally in HIV/AIDS prevention efforts?encourage men and boys to help with domestic tasks as HIV impacts women’s lives? (Greaterassistance with domestic tasks may be needed if a mother, sister or wife becomes ill, if she has tocare for infected loved ones, if she has to begin to generate the family income.)encourage men and boys to become more involved in the care of their families?Source: Joint United Nations Programme on HIV/AIDS n.d.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 93ResourcesWorld Health Organization offers comprehensive family planning resources, tools and information( Nations Population Fund ( has a wide range of resources and informationfor diverse sexual and reproductive health issues.Joint United Nations Programme on HIV/AIDS ( has a number of resources andpublications on HIV/AIDS and other STIs, including links to organizations working on HIV/AIDS.Eldis ( provides a searchable database of research and organizations working in thearea of sexual and reproductive health. Eldis has also produced a key issues guide to sexual andreproductive health and rights ( ( communicates development research on health, including sexualand reproductive health.BRIDGE (, which supports research on gender and development, hasproduced a number of useful publications that summarizes available evidence on gender and sexualand reproductive health, including a recent publication on women living with HIV/AIDS and genderand sexuality.Alan Guttmacher Institute ( is a NGO dedicated to reproductive healthresearch, policy analysis and public education.The Population Council ( is an international NGO based in the United Satesof America that carries out research, including reproductive health issues.International Centre for Reproductive Health ( aims to improve the acceptability,accessibility and quality of sexual and reproductive health services.Center for Gender, Sexuality and Health ( promotesresearch and training on sexuality, sexual rights and sexual education.The South and Southeast Asia Resource Centre on Sexuality website ( a wide range of information on sexuality.Working with menEngenderHealth published a Men’s Reproductive Health Curriculum ( that aims to provide health providers with the skills and sensitivityrequired to work with male clients and provide reproductive health services for men.Involving men is a key theme of UNFPA’s Promoting Gender Equality programme. A number ofresources are available at:’s Engaging men in gender equality: positive strategies and approaches – overview andTools, resources and references

94Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsannotated bibliography includes a number of references, resources and experiences on involvingmen in gender and development work. This publication is available at: and reproductive rightsWorld Health Organization maintains a number of resources on health and human rights, includingthose specific sexual and reproductive health. These can be found at: Swedish Association for Sexuality Education published Breaking through: a guide to sexualand reproductive health and rights, which is available in PDF format on the Internet ( Office of the United Nations High Commissioner on Human Rights has consideredinternational human rights treaties with regards to HIV ( The Commission on Human Rights has appointed a Special Rapporteur on the right to health( on Sexual and Reproductive Health

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110Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health ProfessionalsENDNOTES1World Bank 2004.2United Nations Development Programme 1995.3Vlassoff et al. 2004. In: United NationsMillennium Project 2006.4Gillespie 2004.5DeJong 2000; Germain and Kidwell 2005.6United Nations Population Fund 2004c; Baume etal. 2001.7Paragraph 7.2 in United Nations Population Fund1996 and repeated in paragraph 94 of UnitedNations 1995.8Glasier et al. 2006; United Nations MillenniumProject 2006.9Glasier et al. 2006.10Paragraph 7.3 of United Nations Population Fund1996 and repeated in paragraph 95 of UnitedNations 1995.11Wellings et al. 2006.12United Nations 1995.13Glasier et al. 2006; World Health Organization2001d.14World Health Organization 2001d.15This working definition of sexual health was putforward by members of a technical consultationon sexual health, which met in January 2002, andhas since been refined by an international workinggroup. As a working definition, it is not attributedto WHO.16UNDP/UNFPA/WHO/World Bank SpecialProgramme of Research, Development andResearch Training in Human Reproduction,Department of Reproductive Health and Research,World Health Organization 2004.17Hunt 2004.18UNDP/UNFPA/WHO/World Bank SpecialProgramme of Research, Development andResearch Training in Human Reproduction,Department of Reproductive Health and Research,World Health Organization 2004.19Ibid.20Ilkkaracan and Jolly 2007.21Griffen 2007.22Swedish Association for Sexuality Education 2004.23Paragraph 96 of United Nations 1996.24Swedish Association for Sexuality Education 2004.25World Health Organization 2001d.26These working definitions were elaborated as aresult of a WHO-convened international technicalconsultation on sexual health in January 2002, andsubsequently revised by a group of experts fromdifferent parts of the world. They are presentedhere as a contribution to ongoing discussionsabout sexual health, but do not represent anofficial WHO position, and should not be used orquoted as WHO definitions.27UNDP/UNFPA/WHO/World Bank SpecialProgramme of Research, Development andResearch Training in Human Reproduction,Department of Reproductive Health and Research,World Health Organization 2004.28Griffen S 2007.29United Nations Millennium Project 2006.30Ibid.31Murray and Lopez 1998. In: United NationsMillennium Project 2006.32Vlassoff et al. 2004. In: United NationsMillennium Project 2006.33Bearinger et al. 2007.34Ibid.35United Nations Population Fund 2006b.36Glasier et al. 2006.37Ronsmans et al. 2006.38World Health Report 2005b.39Glasier et al. 200640Ibid.41World Health Organization 2005c.42Ronsmans et al. 2006.43Ibid.44WHO defines “unsafe abortion” as a procedurefor terminating an unintended pregnancy eitherby an individual without the necessary skills orin an environment that does not conform to theminimum medical standards or both. Grimes et al.2004.45Grimes et al. 2004.46Ronsmans et al. 2006.47United Nations Millennium Project 2006.48World Health Organization Regional Office forthe Western Pacific 2005b.49World Health Organization Regional Office forthe Western Pacific 2005c.50World Health Organization Regional Office forthe Western Pacific 2006.51For more information on child health, please seeWorld Health Organization Regional Office forthe Western Pacific 2007b.52World Health Organization Regional Office forthe Western Pacific 2005h.53UNICEF 2003 in United Nations MillenniumProject 2006.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 11154Vlassoff et al 2004. In: United NationsMillennium Project 2006.55United Nations Population Fund 2006b.56Rahman et al. 2003. In: Hutton 2006.57United Nations Population Fund 2002.58Glasier et al. 2006.59EngenderHealth 2003.60Raju and Leonard (eds.) 2000.61Hawkes 1998.62Glasier et al. 2006.63World Health Organization Regional Office forthe Western Pacific 2006.64Cleland et al. 2006.65Ibid.66World Health Organization Regional Office forthe Western Pacific 2005d.67United Nations Population Fund 2002.68Glasier et al. 2006.69Alan Guttmacher Institute 1999. In: Glasier et al.2006.70United Nations Millennium Project 2005b. In:United Nations Millennium Project 2006.71Labrecque 2005.72United Nations Millennium Project 2006.73Ezzati et al. 2002.74Vlassof et al. 2004. In: United NationsMillennium Project 2006.75Glasier et al. 2006.76Ibid.77Glasier et al. 2006; Bearinger et al. 2007.78World Health Organization Regional Office forthe Western Pacific 2005.79Chen et al. 2007.80World Health Organization Regional Office forthe Western Pacific 2004.81Glasier et al. 2006.82Joint United Nations Programme on HIV/AIDS2007.83World Health Organization 2004d.84Joint United Nations Programme on HIV/AIDS2006a.85Joint United Nations Programme on HIV/AIDS2006b.86A generalized epidemic is one where the adultHIV prevalence exceeds 1% in the generalpopulation and HIV transmission mostly occursthrough heterosexual sex.87World Health Organization 2005b.88World Health Organization 2004b and 2005b.89International Council on Management ofPopulation Programmes 2001.90Diamond 2000.91Department for International Development 2000.92For more information on how poverty isconceptualized and measured, please refer to thefoundational module on poverty in this series.93The vulnerability of many Pacific islanddeveloping nations to external shocks (includingnatural disasters and market failures) and theirsmall resource base have led to their inclusionamong least developed countries. For moreinformation on least developed countries, visit thewebsite of the United Nations Office of the HighRepresentative for the Least Developed Countries,Landlocked Developing Countries and SmallIsland Developing States: et al. 2003.95Bloom et al. 2002.96Pitanyanon S et al. 1997. In: Bloom et al. 2002.97Wong et al. 2003.98UNFPA 2003. In: Australian Agency forInternational Development and United NationsDevelopment Programme 2005.99Bennett 2000.100Wan and Zhang 2006. In: Joint United NationsProgramme on HIV/AIDS 2006a.101World Health Organization 2000b.102UNICEF 2002.103World Health Organization Regional Office forthe Western Pacific 2007.104World Health Organization Regional Office forthe Western Pacific 2005f.105World Health Organization Regional Office forthe Western Pacific 2005h.106Sandoval 2000. In: World Health OrganizationRegional Office for the Western Pacific 2005h.107Lacey et al. 1997; Krueger et al. 1990.108Tran et al. 2006.109United Nations Children’s Fund 2003.110Panis and Lillard 1994.111World Health Organization 2000b.112World Bank 2002. In: United Nations Children’sFund 2003.113United Nations Children’s Fund 2001.114Carr 2004.115Government of Mongolia and United NationsDevelopment Programme 2003.116Pokin and Solon 1976. In: Adair and Guilkey1997.117Senaur 1988. Children born earlier in the birthorder are similarly observed to be favoured in theintrahoushold allocation of calories.118King and Mason 2001.Endnotes

112Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals119United Nations Administrative Committee onCoordination Sub-Committee on Nutrition 2000.120Soucat 2002.121Glasier et al. 2006.122Wagstaff and Claeson 2004.123Darmstadt et al. 2005.124World Health Organization 2005c.125Ibid.126World Health Organization Regional Office forthe Western Pacific 2005b.127Government of Papua New Guinea and UnitedNations in Papua New Guinea 2004.128Health Action Information Network 2005.129United Nations Population Fund and PopulationReference Bureau 2005.130Cleland et al. 2006.131Ibid.132Carr 2004.133Gwatkin et al. 2007b.134Asian Development Bank and World HealthOrganization 2002.135Mehrotra and Delamonica forthcoming. In:United Nations Development Programme 2003.136United Nations 1996. In: Asian DevelopmentBank 2003a.137United Nations Development Programme 2003.138Government of Mongolia and United NationsDevelopment Programme 2003.139Government of Mongolia 2003.140Health Action Information Network 2005.141United Nations Development Programme 2001.142United Nations 2002.143Gibson and Rozelle 2002.144World Health Organization Regional Office forthe Western Pacific 2007.145Passey et al. 1998.146World Health Organization 2000a.147World Health Organization Regional Office forthe Western Pacific 2005c.148Gwatkin et al. 2007a.149Gwatkin et al. 2007b.150Department of International Organizations,Ministry of Foreign Affairs, the People’ s Republicof China and the United Nations Country Teamin China 2005.151Government of Solomon Islands and UnitedNations Development Programme 2002.152World Health Organization Regional Office forSouth-East Asia 2000.153Lao People’s Democratic Republic 2003.154Gao et al. 2001.155Lui et al. In: Evans et al. (eds.) 2001.156Ravindran 2005.157Borghi et al. 2006.158Moses et al. 1992. In: Nanda 2002.159Mirsky 2001.160Kaufman and Jing 2002.161Kowalewski et al. 2002. In: Borghi et al. 2006;Borghi et al. 2003. In: Borghi et al. 2006.162Toan et al. 2002.163$1 = 6500 kip164World Health Organization 2000a.165Doyal 2001.166World Health Organization Regional Office forthe Western Pacific 2007.167United Nations Country Team Viet Nam 2001,World Bank 2001.168World Health Organization 2000a.169Delvaux et al. 2003.170Seth et al. 2005.171Ganatra et al. 2004.172World Health Organization 2000a.173Schoemaker 2005.174World Health Organization 2000a.175Id21 2002.176Government of Solomon Islands and UnitedNations Development Programme 2002.177World Health Organization 2000a.178World Health Organization, Department ofGender and Women’s Health 2003a.179World Health Organization 2000a.180Gakidou and Vayena 2007.181Passey et al. 1998.182Chalker et al. 2000.183Schuler et al. 2002.184World Health Organization 2000a.185World Health Organization Regional Office forthe Western Pacific 2005i.186Organisation for Economic Co-operation andDevelopment and World Health Organization2003.187World Health Organization Regional Office forthe Western Pacific 2007.188Department for International Development 2001.189National Institute of Statistics, DirectorateGeneral for Health (Cambodia) and ORC Macro2001; Gwatkin et al. 2007a, 2007b and 2007c;Asian Development Bank and World HealthOrganization 2002.190Asian Development Bank 2003b.191World Health Organization Regional Office forthe Western Pacific, 2005j.192Kaufman and Jing 2002.193Gwatkin et al. 2007b.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 113194World Health Organization 2000a.195Ibid.196Government of Mongolia 2003.197Malnutrition was defined as a body mass index(BMI) of less than 18.5 (based on weight inkilograms divided by height in metres squared).Carr 2004.198Government of Mongolia 2003.199National Institute of Statistics, DirectorateGeneral for Health (Cambodia) and ORC Macro2001.200World Health Organization Regional Office forthe Western Pacific 2007.201World Health Organization 2000a.202Gakidou and Vayena 2007.203United Nations Population Fund 2006b.204World Health Organization Regional Office forthe Western Pacific 2005c.205Ibid.206United Nations Population Fund 2006b.207UNDP 2003. In: ActionAid 2003.208Glasier et al. 2006.209Bailey and Bruno 2001. In: Greene and Merrick2005.210Buvinic 1998. In: Greene and Merrick 2005.211Greene and Merrick 2005.212Haberland et al. 2004. In: Greene and Merrick2005.213Jensen and Ahlburg 1999. In: Greene and Merrick2005.214National Research Council and Institution ofMedicine 2002. In: United Nations MillenniumProject 2006.215Katz et al. 2003. In: Filippi et al. 2006.216Islam and Gerdham 2006.217Gertler et al 2003. In: Greene and Merrick 2005.218United Nations Population Fund 2005.219World Health Organization, Department ofGender and Women’s Health 2006a.220Bearinger et al. 2007.221Lawn et al. 2005.222Division for the Advancement of Women, UnitedNations, 2005.223Sims 1994.224Mueller, Rogerson and Reeder 2002.225Gray et al. 2005. In Ronsmans et al. 2006.226Segal 1990.227World Health Organization Regional Office forthe Western Pacific 2005h.228Upadhyay et al. 2006. In: World HealthOrganization Regional Office for the WesternPacific 2005h.229World Health Organization Regional Office forthe Western Pacific 2005d.230Ford and Koetsawang 1991.231World Health Organization Regional Office forthe Western Pacific 2005d.232United Nations Population Fund 2004b.233World Health Organization 2000a.234Ilkkaracan and Jolly S. 2007.235Greig 2006. In: Griffen 2007.236Griffen 2007.237Human Rights Watch 2004.238Ilkkaracan and Jolly 2007.239Reproductive Health Outlook 2005c.240Reproductive Health Outlook 2005b.241World Health Organization Regional Office forthe Western Pacific 2005i.242United Nations Population Fund 2004b.243Li 2004.244Family Health International 1998.245Reproductive Health Outlook 2005a.246World Health Organization Regional Office forthe Western Pacific 2007.247World Health Organization Regional Office forthe Western Pacific 2005h.248United Nations Population Fund 2004b.249Wellings et al. 2006.250World Health Organization Regional Office forthe Western Pacific 2005i.251World Health Organization Regional Office forthe Western Pacific 2007.252NSC/UNFPA 2002. In: World HealthOrganization Regional Office for the WesternPacific 2005f.253Chhun et al 1995. In: World Health OrganizationRegional Office for the Western Pacific 2005d.254Cabigon 1999. In: World Health OrganizationRegional Office for the Western Pacific 2005h.255World Health Organization Regional Office forthe Western Pacific 2005g.256World Health Organization Regional Office forthe Western Pacific 2005h.257World Health Organization Regional Office forthe Western Pacific 2005f.258For more information please refer to the Moduleon Gender-Based Violence.259Centers for Disease Control and Prevention 2000.260Glasier et al. 2006.261Reproductive Health Outlook. 2005c.262Gwatkin et al. 2007b. Among children sick withfever in 2002, 45.0% of boys and 47.7% of girlswere seen medically. When suffering from acuterespiratory infections, 55.1% of boys and 54.4%Endnotes

114Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionalsof girls were seen medically.263Gwatkin et al. 2007c.264Muller et al. 1998.265Kaufman and Jing F 2002.266Gakidou and Vayena 2007.267World Health Organization 2000a.268Path Foundation 1999.269This study analysed the results of a random sampleof 3327 rural and urban women who gave birthbetween 1 May 1983 and 30 April 1984 in 33sample barangays, combined with the results ofa survey of public and private health facilities inthese 33 barangays. Wong et al. 1987.270See, for example, Thorson et al. 2000 to learn howwomen’s lack of mobility affected their access tocare for tuberculosis in Viet Nam.271Gao et al. 2001.272Asian-Pacific Resource and Research Centre forWomen 2005.273United Nations Population Fund 2002.274Beegle, Frankenberg and Thomas 2001. In:Wagstaff et al. 2003.275The survey was conducted by the NationalNutritional Council and Department ofAgriculture of the Philippines, with the assistanceof the International Food Policy Research Institute1988.276World Health Organization 1996.277World Health Organization 2000a.278Gakidou and Vayena E 2007.279Asian-Pacific Resource and Research Centre forWomen 2005; World Health Organization 2000a.280Care Cambodia 2002. In: Asian-Pacific Resourceand Research Centre for Women 2005.281Joint United Nations Programme on HIV/AIDS2005.282Mirsky 2001.283Kaufmann and Jing F 2002.284United Nations Population Fund 2004b.285Sychareun 2004.286World Health Organization Regional Office forthe Western Pacific 2005f.287World Health Organization Regional Office forthe Western Pacific 2005i.288CARE International 2003. In: World HealthOrganization Regional Office for the WesternPacific 2005d.289Government of Solomon Islands and UnitedNations Development Programme 2002.290Reproductive Health Outlook 2005a.291Grimes et al. 2006.292World Health Organization Regional Office forthe Western Pacific 2005i.293World Health Organization Regional Office forthe Western Pacific 2007.294World Health Organization 2003b. India, Nepaland Pakistan are also exceptions to the globaltrend.295United Nations Population Fund 2004a.296Joint United Nations Programme on HIV/AIDS2007.297Government of Cambodia, 2008.298Government of the Philippines, 2008.299Government of Viet Nam, 2008.300Government of Malaysia, 2008.301Government of Papua New Guinea, 2008.302World Health Organization Regional Office forthe Western Pacific 2006.303World Health Organization Regional Office forthe Western Pacific 2005h.304World Health Organization Regional Office forthe Western Pacific, United Nations PopulationFund, United Nations Children’s Fund 2006.305World Health Organization Regional Office forthe Western Pacific 2005d.306World Health Organization Regional Office forthe Western Pacific 2005h.307World Health Organization Regional Office forthe Western Pacific 2005d.308World Health Organization Regional Office forthe Western Pacific 2005h.309Reproductive Health Outlook 2005c.310EngenderHealth 2003.311World Health Organization Regional Office forthe Western Pacific 2005d.312World Health Organization Regional Office forthe Western Pacific 2005h.313United Nations Millennium Project 2006.314Evans et al. 2001.315World Health Organization 2001d.316World Health Organization and Stop TBPartnership 2001.317Hunt P 2004.318Swedish Association for Sexuality Education 2004.319The Yogyakarta Principles 2007.320World Health Organization 2002b. Generalcomment on the right to the highest attainablestandard of health, article 12 ICESCR.321Population Action International 2004.322Glasier et al. 2006.323Fathalla et al. 2006.324Glasier et al. 2006.325United Nations Millennium Project 2006.326Ibid.Module on Sexual and Reproductive Health

Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals 115327The Partnership for Maternal, Newborn and ChildHealth 2007.328The notable exception was the United States ofAmerica.329Sinding 2004.330Global Health Council 2004.331United Nations Population Fund 2006a.332United Nations Population Fund 2006a.333Sinding SW 2004.334World Health Organization 2006d; UnitedNations Millennium Project 2006.335United Nations Millennium Project 2006.336World Health Organization 2006d.337Gwatkin 2002.338United Nations Millennium Project 2006.339World Health Organization 2006a.340For more information on the Commission onSocial Determinants of Health, please see: Health Organization 2004. A reviewof PRSPs undertaken by the World HealthOrganization found that, although the valueof a cross-sectoral approach to health is oftenrecognized in the health section of PRSPs, littleevidence is available to show that this concern istranslated into strategy.342Danguilan/UNIFEM 2005. In: United NationsMillennium Project 2006.343Dehne et al. 2000.344World Health Organization 2006b.345World Health Organization 2006d and 2006b.346Government of Mongolia 2006.347World Health Organization 2006b.348Ibid.349United Nations Millennium Project 2006; WorldHealth Organization 2006d.350World Health Organization 2006a.351Ibid.352de Pinho et al. 2005. In: Ravindran and de Pinho,eds. 2005.353Musgrove et al 2001. In: Ravindran 2005.354Östlin 2005.355Ravindran 2005.356World Health Organization 2006c.357Östlin 2005.358UNRISD 2000. In: Ravindran 2005.359Filippi et al. 2006.360Campbell et al. 2006.361World Health Organization 2006d.362United Nations Millennium Project 2006.363Fathalla et al. 2006.364World Health Organization 1997b.365United Nations Millennium Project 2006.366World Health Organization 2006a.367Fathalla et al. 2006.368World Bank 2003.369Family Health International 2004. In: WorldHealth Organization 2006a.370David Lowe Consulting-Asia 2003.371Borghi et al. 2006.372Gertler and Boyce 2001, and Morriss et al. 2004.In: Borghi et al. 2006.373Borghi J et al. 2006.374United Nations Population Fund 2004b.375Ibid.376Molesworth 2006.377United Nations Population Fund 2004b.378Molesworth K. 2006.379World Health Organization 2006a.380Ibid.381World Health Organization 2006d; UnitedNations Millennium Project 2006.382Ilkkaracan and Jolly S. 2007.383United Nations Population Fund n.d.384United Nations Population Fund 2004a.385Wellings et al. 2006.386Ibid.387Dehne and Riedner 2005.388United Nations Population Fund 2003.389Warwick and Aggleton 2002.390World Health Organization 2006e.391Joint United Nations Programme on HIV/AIDS1997.392United Nations Population Fund 2004b.393World Health Organization 2005a.394Ibid.Endnotes

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