Aspiration for health - How can a focus on gender bring change in Southern Sudan

Table of Contents

Definition of terms and abbreviations

Introduction

A gender approach towards health and development

Gender empowerment reconsidered

Gender focussed PHC in an environment of war and natural disaster

Conclusion

Table of Figures

Table 1 Gender roles in the Dinka community

Case study 1 Dependancy vs Empowerment

Case study 2 Local health advice

Case study 3 Reflection on gender roles

Case study 4 Women’s participation in programm implementation

Figure 1 Summary Framework

Definition of terms and abbreviations

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Introduction

Three years after the Primary Health Care (PHC) goal of ‘health for all’ should have come into effect, research still reveals ever-increasing socio-economic disparities in global health (Bravemen & Tarimo, 2002). Concurrently, the profound gender inequity of the world’s resource distribution, a key determinant of health, contiues:

“Women are half the world’s population, yet they do two-thirds of the world’s work, earn one-tenth of the world’s income, and own less than one-hundredth of the world’s property (UN, 1985:337)”

This is true particularly in low-income countries, where the majority of girls and women are deprived of adequate health care, education and decision-making power, leading to illiteracy, malnutrition, abuse, chronic illness and premature death (The World Bank, 1994; UN, 2000). Current news headlines echo this problem: African women are 175 times more likely to die in childbirth and pregnancy than Westerners are (BBC news, 20 October 2003).

Sudan, a country marked by extreme poverty due to chronic civil war, compounded by natural disasters, also reflects these gender inequities. The few statistics available show a lower primary education enrolment ratio for girls (41.9); a high maternal mortality ratio of 1500 (per 100 000 live births) and only 10% of parliament seats are taken up by women (UN, 2003).

The denial of women’s equity and health rights has profound consequences upon the health, development and survival of children. Research across the developing world indicates that, after maternal death, more than 95% of infants died within one year, with a girl child having an even less chance of survival than a boy (The World Bank 1994; Winikoff, 1988).

Clearly, girls and women need to be the focus of all PHC initiatives if public health is to be enhanced.

Focussing upon women in order to improve health is not a recent notion, but has been promoted since the UN sponsored Women’s Decade in 1976-85 (Moser, 1993). Thus, the question arises why only minor success appear to be noticeable, and how this conceptual framework can be applied into the context of a complex emergency like in Sudan.

Therefore, this essay will firstly outline the evolution of a gender approach towards health and development, elucidating its underlying principles, objectives and achievements. It will briefly explicate the socio-economic and cultural context of a Dinka community in Southern Sudan through a ‘gender lens’ and critically reflect upon PHC programmes, with reference to the author’s personal work experience.

A gender approach towards health and development

“Development aid is less effective when women are not participating on an

equal footing.” (Oxfam Council, 1993:338)

In recent decades, a focus upon gender, which refers to the social construction of male and female relationships and their roles in society, has been pursued in order to achieve PHC’s goal of equity in health^[1] outcomes (Porter et al, 1999; Evans et al, 2002). In order to achieve this, PHC stresses the shift away from the medical model of health towards a multi-sectoral approach (McDonald, 1993). However, what does a gender approach involve?

The earliest focus upon women towards enhanced health embodied a welfare approach, based on benevolence, which only recognised specific health needs of women because of sex (biological differences of male and female) and thus aimed to meet practical gender needs such as, reproductive health, rather than challenge underlying gender inequalities (Moser, 1993). Sundari Ravindran (1995) argues that the Alma-Ata declaration largely embraced this approach, viewing women as mothers and homemakers, and subsequently concentrated upon educating mothers and promoting maternal and child health.

In contrast, the human rights-based approach, suggests that the root problem is women’s subordinate status in society, which causes unfair and avoidable differences in the health and development of women (Ostlin et al, 2002). Thus, this feminist approach aims to emancipate women from gender-oppression towards gender equity, through processes of participation and a redistribution of power. Furthermore, as women have additional communal roles that influence public health, such as production and community management, this approach emphasises legal and policy obligations such as equal wages in order to combat gender inequity (Moser, 1993). However, since the pursuit of these strategic gender-needs advocate social justice, they have often been considered too intimidating, and the gender policy has undergone conceptual changes.

Gender development schemes adjusted their focus away from women’s subordination towards general underdevelopment (Ostlin et al, 2002). Subsequently, development programmes only focused upon women’s production and income in order to eliminate poverty, rather than challenging inequitable gender rights at household, community and national level. What is more, the gender approach, which integrates the notion of women’s efficiency, adds further burdens to women’s existing workloads by taking advantage of women’s capacity for community care without appropriate remuneration (Ostlin et al, 2002). This again, led to initiatives by women in resource-poor countries themselves, focusing upon empowerment, rather than Western feminism (Moser, 1993).

Even though the ultimate aim of all these approaches could be encapsulated as enhanced well-being for women and their families, underlying ethics aims and objectives differ remarkably, and lead to multi-faceted programmes, which can make monitoring their effectiveness a difficult enterprise.

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^[1] The Alma-Ata declaration reaffirms the broader definition of health as a state of complete physical, mental and social wellbeing and not merely the absence of disease, and highlights the interplay of multiple socio-economic and cultural factors that determine public health (Hall & Taylor, 2003).