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The 2023 IGWG Plenary: Breaking Barriers: Addressing Gender Inequities Facing Global Health Workers

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Background: The Interagency Gender Working Group (IGWG) hosted its 2023 Annual Plenary on Thursday, August 31 from 8:00-10:00 a.m. EDT, which explored how gender transformative programs can better address workplace inequities affecting health workers, and improve health and gender outcomes.

Gender inequities affect health workers in many ways. Gender inequities are common in health care system practices related to recruitment, retention, promotion pathways, leadership roles, earnings, and even access to full-time employment. Women represent about 70% of the health workforce but earn on average 28% less than men. Gender discrimination also affects health system leadership, governance, and occupational segregation. Women remain least represented in decision-making roles, including as physicians, administrators, and managers. Sexual and gender-based harassment, objectification, mistreatment, and violence are commonly reported by health workers around the world. Additionally, few policies and practices recognize and support the informal care that health workers, predominantly women, are expected to provide at home.

Despite evidence that gender discrimination and inequities in the health workplace are systemic, programmatic attention and funding to address these inequities are limited. However, evidence from other sectors indicates that addressing these inequities could lead to a more sustainable health system that can better address gender inequalities as a social determinant of health, and, ultimately, improve health outcomes for all.

Event overview: The 2023 Plenary highlighted research examining gender inequities faced by health workers and showcased promising practices and lessons learned from innovative programs working to address gender barriers in the health system workplace. The 2023 IGWG Plenary aimed to better equip IGWG members to examine gender inequity in their own organizations and to promote more equitable and inclusive workplaces—both within and outside the health system.

The virtual event began with a panel discussion led by experts and representatives of dynamic gender transformative programs addressing gender inequity in the health workforce.

Panelists included:

  • Dr. Amina Aminu Dorayi, Country Director, Pathfinder Nigeria
  • Seblewongel Fekadu, Gender Advisor, Jhpiego Ethiopia
  • Dr. Michelle McIsaac, Economist / Lead Gender Equity and Human Rights, Health Workforce Department, World Health Organization
  • Catherine Menganyi, Chapter Lead, Women in Global Health Kenya
  • Dr. Shabnum Sarfraz (moderator), Deputy Executive Director, Women in Global Health

Following the panel discussion, participants joined breakout rooms and shared their personal experiences addressing health workplace inequities, including challenges encountered in their work and advocacy efforts.

2022 IGWG Plenary Recording (English)

2022 IGWG Plenary Recording (French)

2022 IGWG Plenary Recording (Spanish)

Live Event Graphic

During the 2023 IGWG Plenary, a professional visual notetaker captured key takeaways from the discussion in the below graphic.

Event Slides

View slides from the event here.

Promotional Event Graphics

IGWG Gender Integration Continuum Graphic Now Available in French, Portuguese, and Spanish

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The Interagency Gender Working Group (IGWG) Gender Integration Continuum is a necessary tool to identify whether an intervention encourages gender equity to improve development outcomes, such as in reproductive health. The Gender Integration Continuum graphic is available in English, French, Portuguese, and Spanish.

Access the English version here.

Access the French version here.

Access the Portuguese version here.

Access the Spanish version here.

Lessons Learned in Gender Transformative Health Programming: A Rapid Literature Review

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In the past two decades, use of the term gender transformative by policymakers, donors, implementing agencies, and civil society actors has increased dramatically. Many health donors, bilateral and global institutions, and implementing agencies have endorsed their commitment to realizing gender transformative programs, although the definitions used by global health institutions vary.

At the same time, research on the effectiveness of gender transformative health programs as it relates to health and gender equality outcomes has increased in the past two decades. As implementers and researchers use the term gender transformative as evaluative criteria for gender equality programs, with expanding evaluation data and evidence, the need for a clear understanding of what meets the definition becomes increasingly important.

At the 20-year anniversary of the Gender Integration Continuum, the Interagency Gender Working Group has developed a research brief addressing the following questions:

  • How effective is gender transformative programming?
  • What program elements are key to successful programs?
  • What questions or limitations have emerged about the implementation of gender transformative programs?
  • What lessons and conclusions can we take away from programming that aims to change gender and social norms, advance gender equality, and sustain improvements in health?

This research brief summarizes the methods, findings, and conclusions of a rapid literature review of systematic reviews of evaluated gender transformative health programs. It sheds light on how best to achieve gender equality and health outcomes through gender transformative programming. The brief also provides recommendations for program implementers, policy advocates, and funders for improving the effectiveness and sustainability of gender transformative health programs.

Read the Research Brief Here

From the IGWG Newsletter

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Resources

Gender and Data Resources Related to COVID-19

Data2X

With the help of partners and friends, Data2X has compiled a running list of resources and current reporting on gender and gender data as they relate to COVID-19 preparedness and response around the world, including the current and anticipated impacts of the pandemic.

Access the list of resources Click to visit home page.

Flattening the Curve: Finance and the Pandemic of Gender-Based Violence

UNICEF

As the global pandemic of VAWG is addressed with the combined efforts of many organizations and individuals—recognizing specifically the many women’s networks on the frontlines—it is also important to focus on the opportunities COVID-19 presents for economic and financial systems as active partners to build solutions and mitigate violence. This blog article looks at how UNICEF and Criterion Institute have been exploring pathways to engage systems of finance in addressing GBV in crises.

Read the blog here.

COVID-19 and Ending Violence Against Women and Girls

UN Women

This brief highlights emerging evidence of the impact of the recent COVID-19 pandemic on VAWG. It makes recommendations to be considered by all sectors of society, from governments to international organizations and to civil society organizations, to prevent and respond to VAWG at the onset, during, and after the public health crisis, with examples of actions already taken. It also considers the economic impact of the pandemic and its implications for VAWG in the long term.

Read the report here.

A Practical Approach to Prevent, Address and Document Domestic Violence under COVID-19

MADRE

With 90 countries in lockdown and nearly four billion people sheltering at home from the COVID-19 pandemic, domestic violence has become an epidemic within an epidemic. In response, UN Secretary General Guterres called for a global “ceasefire” on domestic violence, lending high-level support to this long-standing demand. To have meaning, the Secretary General’s call must be coupled with action at the local level—where domestic violence occurs. This is where local women’s organizations can play a crucial role. The international interventions that follow should look to women’s groups working on the frontlines of the crisis to lead.

Read the report here.

COVID-19 Sex-Disaggregated Data Tracker

Global Health 5050

To understand the role gender is playing in the COVID-19 outbreak, countries urgently need to begin both collecting and publicly reporting sex-disaggregated data. In this tracker you can find graphs on sex-disaggregated data, data disaggregated by age and sex, and data on associated health risks and comorbidities that may influence the risk of severe COVID-19 infection or death in men and women.

Access the tracker here.

News Articles

Women and the Frontlines of COVID-19

Forbes

With almost 80% of women operating on the frontlines of the COVID-19 pandemic, the long-term effects on them are of increasing concern. With other potential risks such as child care implications and domestic violence, women are more likely than men to say their lives have been disrupted because of the coronavirus. The article looks at the short- and long-term implications for gender equality during and following COVID-19.

Read the article here.

Domestic Violence Is on the Rise With Coronavirus Lockdown. The Responses Are Missing the Point

The Intercept

In the weeks since populations worldwide have been directed to “stay home” to prevent the novel coronavirus’s spread, cases of domestic violence have surged. According to statistics released, U.S. law enforcement agencies have seen domestic violence cases rise up to 35% in recent weeks. This article highlights the correct responses needed by national and local governments, along with nongovernmental organizations, to address the global rise in domestic violence during the pandemic.

Read the article here.

Lessons From African Feminists Mobilizing Against COVID-19

Earth Institute, Columbia University

The Women, Peace, and Security program hosted a webinar with its Peace and Social Change Fellowship participants, who are leaders of grassroots women’s organizations across Nigeria, Uganda, Democratic Republic of the Congo, Lesotho, and Sudan. The webinar discussed how women are mobilizing their communities to respond to the growing threat of COVID-19. Their strategies offer wisdom on practical ways to care for oneself and one another and on building societies grounded in solidarity, equity, and care for communities.

Read the article here.

Global Lockdowns Resulting in ‘Horrifying Surge’ In Domestic Violence, U.N. Warns

NPR

Citing a sharp rise in domestic violence amid global coronavirus lockdowns, António Guterres called on governments around the world to make addressing the issue a key part of their response to the pandemic. Speaking late Sunday he said, “for many women and girls, the threat looms largest where they should be safest—in their own homes.”

Read the article here.

The Coronavirus Is a Disaster for Feminism

The Atlantic

Pandemics affect men and women differently, as they often magnify all existing inequalities. Working from home in a white-collar job is easier; employees with salaries and benefits will be better protected; and self-isolation is less taxing in a spacious house than a cramped apartment. But one of the most striking effects of the coronavirus will be to send many couples back to the 1950s. This article details the impact of the virus on women’s independence across the world.

Read the article here.

The Coronavirus Fallout May Be Worse for Women Than Men— Here’s Why

World Economic Forum

Women make up the majority of workers in the health and social care sector—70% in 104 countries analyzed by the World Health Organization. As the fight against COVID-19 continues, an increasing number of women around the world are on the frontlines, disproportionately affected and burdened by the outbreak. Many of them will be expected to work longer hours while juggling domestic responsibilities such as childcare.

Read the article here.

DO’s & DON’Ts for Engaging Men & Boys

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What: What should you do, and not do, when engaging men & boys in health promotion and gender equity? This 2-page resource brings together recent best practices and lessons learned for male engagement across health areas. It is intended to guide decision-making about programs, policy, media coverage, research, and funding priorities.

Who: Developed by the USAID Interagency Gender Working Group’s Male Engagement Taskforce, which is co-chaired by Myra Betron of the Maternal and Child Survival Program and Jhpiego, Julie Pulerwitz and Ann Gottert of Population Council, Dominick Shattuck with Breakthrough Action/JHUCCP, and Natacha Stevanovic of Georgetown University’s Institute for Reproductive Health. The intended audience for the guidance consists of donors, implementing partners and researchers.

Why: Men and boys have their own distinct health needs and vulnerabilities, and engaging men can benefit everyone—including women and girls. The reality is that inequalities in social value, power, and opportunities of men and women have provided men with many advantages, while at the same time men are disproportionately affected by many health challenges (e.g., homicide, alcohol abuse). Confronting both issues requires a careful balance, and this guidance seeks to provide practical suggestions around how to do this.

Read more: here

Involving Everyone in Gender Equality by Synchronizing Gender Strategies

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Authors:
Doris Bartel
Margaret E. Greene

Where Are We Now?

Much has changed since 2010 when the Interagency Gender Working Group (IGWG) published the breakthrough report Synchronizing Gender Strategies: A Cooperative Model for Improving Reproductive Health and Transforming Gender Relations. This report introduced a new concept of synchronized gender strategies, defined as working with men and women, boys and girls, in an intentional and mutually reinforcing way, to challenge restrictive gender norms, catalyze the achievement of gender equality, and improve health. The report revealed some of the existing tensions between programs focusing on women’s empowerment or on men’s engagement. In showcasing program examples using a gender-synchronized approach, the report also highlighted some key elements of gender-synchronized health programs. These elements included intentionality in reaching out to men and women to promote mutual understanding, aiming for equalizing power dynamics, preventing and responding to gender-based violence (GBV), promoting flexible gender roles, and advocating for gender equality as measures of program success.

We know that the concept of synchronized gender strategies continues to resonate with colleagues working in health and development. But as many have noted, the field has progressed since 2010, and the report needs updating. Many new examples of gender-synchronized projects have been implemented and evaluated. What have we learned from these programs?

In 2017, the IGWG supported a review of the evidence and experiences of gender-synchronized strategies since the 2010 report was released. The aims were to analyze the findings of numerous new program evaluations and to explore interventions that intentionally consider gender and sexual diversity.1 The effort included a literature review and consultations with a range of experts from a variety of backgrounds within the health and development sectors as well as from the violence prevention community.

Lessons Learned From New Evidence

Many new gender-synchronized health programs with published evaluation findings emerged. Examples of these programs are shown below. Many of the key elements outlined in the original 2010 report were evident in the programs. For example, newly identified programs all intentionally reached out to men and women, and boys and girls, and sought opportunities to promote dialogue about the advantages of loosening rigidly defined gender roles. Many explicitly aimed to prevent GBV, and several included interventions to shift the balance of power and provide men and women opportunities to collaborate for a common cause.

One example is the SASA! Initiative in Uganda from Raising Voices, which aims to prevent HIV/AIDS and domestic violence by focusing on power imbalance in intimate relationships. An evaluation through a four-year randomized control trial (RCT) showed that women in intervention communities were significantly more likely to report joint decisionmaking, open communication, and the ability to refuse sex with their partners. Analysis of the qualitative data revealed the importance of working with women and men together, through modeling collaborative male and female leadership and enhancing exchange of ideas and perspectives of men and women.2 A learning report from Raising Voices shows that the gender-synchronized approach provided deeper understanding about the gender constraints and privileges experienced by others. Including women and men in discussions provided the opportunity to discuss these issues together and led to greater gains and diffusion of new ideas about workloads, decisionmaking, and violence among men and women.3

Like SASA!, the Bandebereho program implemented in Rwanda by Promundo and partners incorporated gender-synchronized elements in group critical reflection and dialogue sessions for couples. The sessions provided a structured space for men and women to question and critically reflect on gender norms and how these shape their lives. In discussion groups, men and women rehearsed equitable attitudes and behaviors with supportive peers. This exchange provided an opportunity for men and women to internalize new gender attitudes and behaviors, and apply them in their own lives and relationships. The intervention also included community activities and campaigns related to fatherhood and care-giving. The project utilized an RCT evaluation design with data on gender roles and domestic violence gathered from male participants and their female partners. Compared to the control group, women in the intervention group reported significantly lower levels of physical and sexual violence and more male accompaniment to antenatal care, while men and women reported significantly less violence against children, greater male participation in household tasks, and less male dominance in decisionmaking. 4

The Gender Matters (Gen.M) curriculum implemented in Texas by EngenderHealth also yielded some positive results.5 Boys and girls in the treatment group were significantly more knowledgeable about contraceptive methods and where to obtain them, and were more likely to strongly agree that female birth control should always be used during sexual intercourse than young people in the control group. But there was no evidence that Gen.M affected attitudes toward traditional gender ideologies (in large part because youth in the treatment and control groups held relatively egalitarian attitudes) or in sexual refusal skills.

The Primary-School Action for Better Health program in Kenya showed that a gender-synchronized approach can be effective for primary school ages, utilizing in-service teacher training to improve pupils’ health knowledge, self-efficacy, and condom use.6 The evaluation showed that boys and girls reported significantly more communication with their parents and teachers about HIV and sexuality, greater self-efficacy related to abstinence and condom use, and greater condom use as well as decreased sexual activity. Gains were gender specific, with boys reporting increased condom use while girls were more likely to report decreased or delayed sexual activity. This intervention was operational in 11,000 of the country’s nearly 19,000 primary schools by 2006.

Most of the gender-synchronized programs and evaluations were shaped by heteronormative assumptions. The review was able to identify few examples of gender-synchronized programs that intentionally considered gender and sexual diversity. Programs that address the gaps in services or health of gender and sexual minorities have largely been narrowly focused on HIV prevention or efforts to advocate for their rights rather than integrated into health, development, or violence prevention programs. We noted few resources to engage, support, and enhance gender role expectations with or alongside gender and sexual minorities, and few programs that integrated these concerns into interventions for an entire community. Only one project evaluation report showed evidence of attitudinal shifts among adolescents related to their understanding of gender and sexual diversity.7

The literature review also noted other gaps. There was little analysis of whether or how gender-synchronized strategies contributed to the positive results of the project, whether health or gender-specific outcomes. Most programs focused on people’s attitudes and behaviors, but few included components to shift the gender bias and discrimination in systems and structures such as national policies, health services delivery, or school-based practices. The Primary-School Action for Better Health in Kenya was not specifically focused on gender, but successfully used a systems approach to scale the intervention.

Stakeholder Feedback

The feedback from the stakeholders’ consultations showed that many in the health development field find the concept of synchronized gender strategies a useful frame for designing new programs. Among projects promoting women’s reproductive health, gender synchronization has encouraged project staff to be intentional about the dynamics of (heterosexual) couple communication and decisionmaking about family planning and other reproductive health concerns.

As was true in 2010, some tensions still exist among stakeholders, particularly in the context of GBV mitigation. There are some who feel that in practice some programs lack sufficient critique and emphasis on changing the systems and structures that provide more privilege to males (for example, addressing gaps in transportation systems, school, or work environments that could protect women and girls from sexual harassment and assault).

Reflections

This review has been helpful in understanding how far the field has progressed and illuminating the continued need for evidence of the specific contribution of gender synchronization. While it’s encouraging to see that many of the new evaluations revealed significant improvements in women’s decisionmaking, role sharing in workload in the household, and communication between couples, parents and children, and even teachers and pupils, the causal pathways remain unclear.

The authors noted evidence that highlights how gender-synchronized interventions that fully address power dynamics and privilege can help gain traction in the prevention of intimate partner violence. These exemplars provide insights for how they might support the prevention of GBV in other contexts.

The authors found that conceptually, gender-synchronized strategies remain relevant with a strong logic for implementation. The review confirmed that many of the key elements identified as core to gender synchronization were included in the programming examples reviewed. Yet some gaps were also identified. In practice, programs can sometimes offer and inadvertently reinforce an idealized vision for women and for men that lack examples of diversity outside heterosexual married couples. Just as the review found few examples of programs that intentionally consider gender and sexual diversity, specific populations have been under-represented and opportunities to work with more diverse populations may have been missed. Did the authors overlook these projects? Or are gender-synchronized programs that include a focus on gender or sexual identity missing from the field?

This review affirmed that the space for discussions on gender inequality and power dynamics is still not safe in many communities. People speaking out on issues of gender inequality are often silenced or threatened. In our review we noted a lack of discourse about how to assess safety or how to move the conversation forward in a way that is contextually appropriate.

Recommendations and Next Steps in Gender-Synchronized Programming, Evaluation, and Research

Based on the findings of our analysis, the authors see a need to expand the diversity of voices contributing to the discussions about lessons and challenges in gender-synchronized programming. The review currently lacks key insights from community organizations and advocates for marginalized groups, particularly LGBTI persons about how gender-synchronized strategies might be applied with greater inclusion of diverse populations. Developing a shared conceptual understanding of these issues by diverse groups working on women’s empowerment, men’s engagement, HIV, health, and rights of gender and sexual minorities will promote greater trust and willingness to collaborate. This shared understanding and collaboration could contribute to advance the human rights of marginalized and vulnerable populations and improved health outcomes for everyone.

The authors call for future evaluation designs that can show whether and how gender-synchronized strategies contribute to impact in health and gender equality. The community also needs to consider a refined definition, theory of change, and key program elements of gender-synchronized interventions. Language is important. The community needs to be precise in how it describes the gender-synchronized interventions and project goals to avoid misunderstanding. For example, speaking of “including both women and men,” may unintentionally reinforce the idea that only these two groups exist, and always/only in relation to each other. It is important to frame the work as deconstructing harmful aspects and rigid expectations about masculinity and femininity.

The authors call on organizations implementing gender-synchronized programs to apply more inclusive approaches, and in particular to make sure that programs better reflect and incorporate gender and sexual diversity. Improving conditions for vulnerable groups requires engaging the socially dominant groups in the process of reflection on gender roles, norms, and power dynamics in their own lives. And at the same time, programs must be intentional in incorporating vulnerable groups when they are also working with the people in the socially dominant category. A more inclusive process could help to build consensus around a vision for health and healthy relationships (not just sexual relationships), and to aim for equalizing power dynamics and expanding opportunities within and among the roles that all people play in society.

The authors note that many people face stigma or experience threats for challenging social injustices; this could be more explicitly acknowledged and addressed as a new core element of gender-synchronized approaches. The authors honor the courage of those who have stood up and spoken up to help create positive change towards gender equality in their own communities. It’s time for programs with gender-synchronized approaches to proactively include risk-monitoring systems and ways to better protect those working for change.

The authors believe that gender synchronization has relevance across sectors, with future opportunities for adaptation, implementation, and learning. They call for intentional dialogue and exchange of ideas about gender-synchronized strategies in different programmatic and geographical contexts, so that all can gain clarity about the goals and outcomes of gender-synchronized work.

Doris Bartel is an independent consultant and former co-chair of the IGWG Gender-Based Violence Task Force.
Margaret E. Greene was an original author of the 2010 report Synchronizing Gender Strategies: A Cooperative Model for Improving Reproductive Health and Transforming Gender Relations and is the CEO of GreeneWorks.

References

1 Gender and sexual diversity (GSD) is an umbrella term that acknowledges diversity among sexual orientation, gender identity, gender expression, and sex characteristics. Gender and sexual minorities include, but are not limited to, lesbian, gay, bisexual, transgender, and intersex (LGBTI) people.

2 Nambusi Kyegombe et al., “The Impact of SASA!, A Community Mobilization Intervention, on Reported HIV-Related Risk Behaviours and Relationship Dynamics in Kampala, Uganda,” Journal of the International AIDS Society 17 no.1 (2014).

3 Raising Voices, “Stronger Together: Engaging Both Women and Men in SASA! to Prevent Violence Against Women,” Learning From Practice Series, no. 4: Research Perspectives (Kampala, Uganda: Raising Voices, 2015), accessed at www.raisingvoices.org/wp-content/uploads/2015/09/LP4.StrongerTogether.FINAL_.dec2015.pdf.

4 K. Doyle K et al., “Gender-Transformative Bandebereho Couples’ Intervention to Promote Male Engagement in Reproductive and Maternal Health and Violence Prevention in Rwanda: Findings From a Randomized Controlled Trial,” PLoS ONE 13, no. 4(2018): e0192756.

5 U.S. Department of Health and Human Services, Office of Adolescent Health, Final Impacts of the Gender Matters Program (September 2016), accessed at www.engenderhealth.org/youth/wp-content/uploads/2018/03/gendermatters_finalimpactreport.pdf.

6 Eleanor Maticka-Tyndale, Janet Wildish, and Mary Gichuru, “Quasi-Experimental Evaluation of a National Primary School HIV Intervention in Kenya,” Evaluation and Program Planning 30, no. 2 (2007): 172–86.

7 Andrea Lynch, “Health + Equality + School Engagement: Scenarios USA Reinvents Sex Education,” Qualité (New York: Population Council, 2014), accessed at www.popcouncil.org/uploads/pdfs/qcq/QCQ21.pdf.