INTERNATIONALBANK FOR WORLD BANK R E T C N O E N STRUCTION PM AND DEVELO April 2006 No. 88 A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank's Latin America and Caribbean Region MAINSTREAMING GENDER IN THE HEALTH SECTOR: PREVENTION OF GENDER-BASED VIOLENCE AND MALE INVOLVEMENT IN REPRODUCTIVE HEALTH Myra Betron and Lucía Fort Background US$ 32.7 million or 1.6 percent of GDP (Morrison and Over the past decade, the prevention of gender-based Orlando in WHO, 2004). violence1 and male involvement in reproductive health have come to be viewed as key to advancing the fight Men's role in improving their own health and that of their against poverty. Research and experience have demon- families and the importance of addressing the gender strated that both issues are crucial to the objectives of inequities underlying poor reproductive health also cannot gender equality, the reduction of maternal mortality and be denied. Family planning and reproductive health issues mitigating the spread of HIV/AIDS, among other impor- have traditionally been seen as concerns for women, and tant development indicators. In fact, a 1993 World Bank reproductive health programs traditionally focus on study showed that the global health burden from gender- women. Although common sense dictates that men play an based violence, domestic violence and rape in particular is important role when it comes to reproductive health, comparable to other diseases and risk factors already Ministries of Health in developing countries almost always recognized in the global agenda, including obstructed have special maternal health or women's health divisions, labor, HIV, maternal sepsis and tuberculosis (See Figure implicitly reinforcing the notion that reproductive health 1). concerns only women. Recent findings, displayed in Box 1, underscore the fact that men not only have their own Studies have also reproductive health concerns but significantly affect the shown the nega- reproductive health of tive economic women. Men often impact of gen- decide whether der-based vio- women will receive lence. For ex- medical care, as dem- ample, in Nicara- onstrated by anec- gua in 1995, the dotal evidence from estimated value various technical as- of lost produc- sistance activities of tivity from both the World Bank's paid work and Latin America and the unpaid work, as Caribbean Region's well as the fore- (LCR) Poverty and gone value of Gender Group. lifetime earnings for women who Sexual and Reproduc- died as a result of tive Health (SRH) violence was es- practitioners and timated to be scholars have recently began to recognize 1 staff in health care centers and hospitals to Box 1: Sexual and Reproductive Health Practices of Latin effectively screen for intra-family violence and American and Caribbean Men2 refer victims to appropriate services, and to better educate and involve men in sexual and Between 28 percent and 59 percent of unmarried sexually experi- reproductive health. As a pilot project, enced men aged 15­24, and 37­65 percent of those aged 25­39, PROSALVAR also sought to help the Bank better have had two or more sexual partners in the past year. understand its operational role in preventing and Among married men aged 25­39 (including those in consensual responding to gender-based violence and in unions), 12­36 percent have had intercourse with someone other promoting the male involvement agenda. The than their wife in the past 12 months. These proportions decline to project worked to achieve these objectives 8­22 percent among married men between 40­54 years of age. through: Between 39 and 68 percent of men aged 15­24, and 65­85 percent of those aged 25­54, did not use a condom at last intercourse. Development of a guide to orient health Between 15 percent and 39 percent of men 25­54 years of age want personnel on how to detect intimate partner no more children or want to delay their next child, but are not protected by contraceptive use (their own or their partners'). violence (IPV) in the health setting and provide appropriate care for IPV survivors; Source: Alan Guttmacher Institute. 2003. In Their Own Right: Address- Two-day trainings of health personnel on ing the Sexual and Reproductive Health Needs of Men Worldwide. New the use of the guide; York:Alan Guttmacher Institute. Development of a training manual and model on topics related to sexual and reproduc- tive health for men; that men actually play a key role in the improvement of Application of the training model among health per- women's SRH, and what's more, have their own SRH sonnel in two-day workshops in the three countries to needs apart from that of women. After the 1994 promote the involvement and increased knowledge of International Conference on Population and Development, men in sexual and reproductive health; governments, non-governmental organizations (NGOs), Design and implementation of social marketing infor- and community programs around the world began to mation and education campaigns to raise community implement SRH programs that more fully incorporate men. awareness about the role of men in sexual and reproductive healthcare; The World Bank Takes Action through Learning events to exchange best practices and lessons learned by each project among staff, partici- PROSALVAR pants and World Bank staff. The Bank has hosted various conferences to address issues of male involvement in reproductive health and gender- The project contracted regional experts, each with more based violence, yet no projects in the World Bank's than ten years experience on gender-based violence and portfolio have directly addressed either topic.1 Recent male involvement in reproductive health, to develop the gender-related work in the World Bank's health projects in training materials for Nicaragua and Honduras. The Latin America has made evident the limited capacity of regional experts worked, in turn, with local trainers to help health personnel and communities to integrate men into them become familiar with the material to subsequently family planning and reproductive health programs or to train the health personnel in a series of two-day workshops respond effectively to domestic violence cases.2 Midwives in each country. In Bolivia, given the distinct socio-cultural at women's birthing centers in Nicaragua, for example, milieu, the training differed slightly in that trainings on have been challenged with trying to convince men who gender-based violence were preceded by a session cover- oppose family planning of the economic difficulties of ing the basics of the issue and the component on male raising large families.3 Moreover, sheer lack of knowledge involvement in reproductive health was designed by local and capacity prevents health providers from screening for experts on masculinity and health. and providing proper treatment to gender-based violence survivors. Results on the Ground The Integral Health Project for Men and Women, or PROSALVAR was much more modest than traditional PROSALVAR as it is commonly known, was designed to World Bank projects both in terms of time and money help build a response to these apparent gaps in healthcare invested. The design and implementation was completed in projects in the LCR through pilot activities in three Highly a year and a half with extremely limited resources. Still, the Indebted Poor Countries: Bolivia, Honduras and Nicaragua. project was able to achieve noteworthy results. Financed by the Bank-Netherlands Partnership Program, the project's main objectives were to build the capacity of In La Paz, Bolivia, despite the challenges of working in a fragile political state (at times paralyzed by citizen demon- 2 strations), the project was able to train 196 health providers incorporate the lessons of the male involvement model was on screening and care for IPV and held workshops on the more challenging. Although one of the goals was to train basics of gender-based violence for 376 members of the health providers in health centers to reach out to the community, including health workers, municipal officials, community and increase male demand of SRH services, an police and NGOs, as well as 290 health providers on impact evaluation of the project in Honduras found that masculinity and sexual and reproductive health. Applying a doctors participating in the training workshops still con- social science model that sought to break down stereo- sider the fact that men do not seek health services as a types related to masculinity that are detrimental to health, barrier to involving men in SRH services.4 This continued the project increased awareness among health providers resistance implies a need for broader reforms that deploy and staff in the Ministry of Health, which now has plans to healthcare workers in the community to address SRH. develop protocols to attend to male clients particularly in Future activities could also help these community health the area of sexual and reproductive health. workers in finding ways to incorporate male involvement in SRH into their work. In Honduras, despite limited experience in the project's focus areas at the start of the intervention, the project A systemic approach to reforming services for victims of produced a profound effect. Most notably, all health IPV is essential for long-term sustainability. Reproduc- centers in the metropolitan health region of Tegucigalpa are tive health programs addressing IPV in recent years5 have now required to screen for intimate partner violence among found that the most effective way to improve health women seeking reproductive healthcare. The project services to better address IPV is through a systemic trained a total of 203 health providers in the metropolitan approach, or system-wide reforms (See Box 2). In the area of Tegucigalpa. Moreover, the sustainability of these case of PROSALVAR in Bolivia, the lack of support for the reforms seems to be ensured by the incorporation of the incorporation of IPV services by upper management, production of screening guidelines and forms into the which also should have been involved in the trainings, budget of the health region. The Secretary of Health has made clear the need for a systemic approach. In already demonstrated commitment to scaling up efforts, Honduras, although upper management enforced new and interest by other donors is making it a real possibility. policies that require health providers to screen for IPV, the resulting increased caseload of IPV victims threatens to In the health regions of Masaya and Jinotega in Nicaragua, overburden family counseling units to which the victims the project trained 222 health providers on detection and are referred.6 More holistic reforms should ensure care for IPV survivors and 213 health providers on male adequate norms, policies and resources to allow health roles in sexual and reproductive health. The strong providers to effectively apply the knowledge acquired in tradition of civil society's participation in development the trainings. coupled with the history of inter-institutional collaboration to address violence against women in Nicaragua facilitated the inclusion of NGOs and other institutions, such as the police, in the training workshops. This multi-institutional Box 2: What a Systemic Approach to and multi-sectoral representation, along with Nicaragua's Reform Involves relatively advanced system of response to IPV, resulted in a Reforms involving a systemic approach to improving rich exchange of information and collaborative planning on IPV services typically include: how to improve a multi-sectoral coordinated response to Changes in norms, policies and protocols; violence against women. Both sets of trainings resulted in Infrastructure upgrades to ensure private consul- plans of action to be carried out by participants that tations, training all staff (including managers) on involved follow-up training for colleagues and others in the screening of IPV, safety planning for victims, and community. provision of emotional support; Strengthening of referral networks with other IPV Lessons Learned services; and, Increased availability of emergency services, such Community participation models are especially effective as Sexually Transmitted Illnesses (STI) prophy- when addressing issues related to gender but take time to laxis and emergency contraception. adapt. Not only do they help diffuse and reinforce change in attitudes by reaching a wider audience, but participants Source: Bott, Sarah, Andrew Morrison and Mary also appreciate being actively involved in discussions and Ellsberg. 2005. Preventing and Responding to Gender- learning, as demonstrated by the experience in Nicaragua. Based Violence in Middle- and Low-Income Countries: a However, a community participation model cannot simply Global Review and Analysis. World Bank Policy Re- be imposed upon communities that have little experience search Working Paper No. 3618. with it. In Honduras, for example, where community- driven development is a newer concept, finding ways to 3 Linking IPV and male involvement in SRH components ers and health officials, but greater investment in both time allowed for some breakdown of prejudices of proponents and money are necessary to achieve sustainable impacts. of these sometimes opposing camps. Many working in the field of intimate partner violence (also known as Notes violence against women, as women are the most frequent victims) often view the male involvement field as a threat 1In 1993, the United Nations General Assembly defined to already meager resources for women's programs, and violence against women as "Any act of gender-based tend to focus on male involvement more as a method to violence that results in, or is likely to result in, physical, address IPV. The project has helped widen that perspec- sexual, or psychological harm or suffering for women, tive to include other reproductive health issues, like HIV/ including threats of such acts, coercion, or arbitrary AIDS and family planning. In Honduras, where the men's deprivations of liberty, whether occurring in public or health program had been totally isolated from the Depart- private life." ment of Mental Health that traditionally handles IPV, the 2Data are from seven countries in LCR: Bolivia, Brazil, project helped mainstream the issue as a public health Dominican Republic, Haiti, Mexico, Nicaragua and Peru. problem rather than stigmatizing it as a "mental health" 3Male Roles in Adolescent and Reproductive Health, June issue. In fact, studies consistently show that IPV is a 10, 1998 and The Development Implications of Gender- learned behavior with grave reproductive health and Based Violence, November 9, 2004. human rights impacts, which the project helped bring to 4The PROGENIAL program in Central America provided the attention of primary staff in the health ministry. support for gender mainstreaming in World Bank projects in various sectors, including health, Changing norms, atti- and contributed to the body of tudes and behavior re- knowledge on gender issues faced lated to gender does not in health. happen overnight. 5Ruiz-Abril, unpublished. Training 6 on gender- ESA Consultores. (2005) based violence and male "Evaluación del Proyecto involvement in sexual PROSALVAR en Honduras: and reproductive health Capacitaciones en Masculinidad y involves a process of Salud Reproductiva". Unpublished changing deeply en- final report submitted to the World trenched social and cul- Promundo Bank. tural gender norms, 7See for example, Bott, Sarah, which certainly cannot Alessandra Guedes, and Ana Instituto be done through a two- Guezmes. The Health Service Re- day workshop. Unless projects and programs invest sponse to Sexual Coercion/Violence: Lessons from IPPF/ adequate amounts of time and money, activities that seek WHR Member Associations in Latin America. In: Non- to change behavior (and perhaps even attitudes) with consensual Sexual Experiences of Young People in Devel- respect to gender norms may be doomed to failure. oping Countries: A Consultative Meeting, New Delhi, Recent interventions' research has shown that "sensitiza- September 2003. Conference Proceeding. Population Coun- tion on gender," or the process of unlearning gender cil and Family Health International. stereotypes, requires continual reiteration perhaps for as 8ESA Consultores. (2005). "Evaluación del Proyecto long as six months.1 Nonetheless, whereas many initia- PROSALVAR en Honduras: Capacitaciones en Violencia tives hardly move beyond theoretical discussions of contra la Mujer". Unpublished final report submitted to the gender, PROSALVAR was able to identify and test World Bank. concrete actions that health providers can use to address 9Pulerwitz, Julie, Gary Barker, and Márcio Segundo. 2004. both issues, and to make evident the need for such "Promoting healthy relationships and HIV/STI prevention attitudinal and behavioral change. for young men: Positive findings from an intervention study in Brazil," Horizons Research Update. Washington, DC: Overall, PROSALVAR was able to raise awareness of the Population Council. implications of intimate-partner violence, IPV, and about About the authors stereotypes and myths related to gender norms and masculinity, especially with respect to reproductive health. Myra Betron, a Consultant in the Poverty and Gender Group The project made some initial steps toward incorporating of the LCR, was in charge of organizing and coordinating the issues of gender-based violence and male involvement, the PROSALVAR project in the field. Lucía Fort is a Senior namely raising awareness. This awareness-raising Gender Specialist in the Poverty Reduction and Economic prompted change in some actions, especially when rein- Management Unit and Regional Gender Coordinator for the forced with changes in policies and protocols by manag- Latin America and Caribbean Region of the World Bank. 4