M&E of Gender and Health

Learning Objectives
Define gender & related terms
Identify why gender is important to Health outcomes
& programming
Identify criteria for how gender is addressed in
programs
Identify donor gender M&E requirements
Identify measures of different gender factors
Apply gender indicators to programs to integrate
gender into M&E
Activity: Vote with your feet!1

This will help us explore gender

concepts
Our own beliefs on gender make a
difference
We need to keep this in mind
when we ask people to address
gender

1 USAID Training of Trainers: Gender and Reproductive Health 101

 Definitions1

Sex: Biological difference between males &

females
Gender: What a society believes about the
appropriate roles, duties, rights, responsibilities,
accepted behaviors, opportunities and status of
women and men, in relation to one another
These beliefs vary between places & change
over time in the same place.
1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
 Definitions1: Gender Equality

Equal treatment of women and men in laws and

policies, and equal access to resources and services
within families, communities and society at large.
Comes from written and unwritten norms, rules, laws
and shared understandings.
Pervasive across societies
Most prevalent form of social inequality
Cuts across other forms of inequality such as class,
caste, race and ethnicity.
1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
 Definitions1: Gender Equity
Stress is on fairness
Refers to the absence of unfair/avoidable or
preventable differences in health between women
and men
Different/unequal needs of & barriers affecting
women and men in accessing/benefiting from
health-care programs must be considered in
program resource allocation & design
Includes and should be inherent to program
monitoring and evaluation
1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
Why do we think about gender &
health?
Gender inequality is associated with:
High child mortality, high rates of stunting and wasting
Lower rates of health care utilization for maternal, child, and
reproductive health services (including STI/HIV)
Higher rates of maternal mortality
Higher rates of gender-based violence
Gender Inequality is a driver of the AIDS epidemic world-
wide
Bottom line: High gender inequality is associated with
lower health outcomes
Gender and HIV/AIDS
Programming
Gender equality must be at the core of all our actions.
Together we must energize the global response to
AIDS, while vigorously advancing global equality
-Michel Sidib, UNAIDS Executive Director
Gender-related inequalities compromise the health of
women and girls and, in turn, affect families and
communities. Gender-based violence is a serious and
widespread human rights violation, as well as a key
driver of the HIV epidemic.
-Deborah von Zinkernagel, Principal Deputy Global AIDS
Coordinator (OGAC)
Gender and HIV/AIDS

Numerous studies document the relationship

between gender inequality and HIV/AIDS outcomes:
Increased risk of transmission/higher prevalence
Less knowledge about HIV/AIDS
Higher levels of risk-associated behaviors due to
vulnerability
Association with the incidence of intimate partner
violence, which in turn influences the risk of HIV
Less utilization of programs & services
 Gender inequalities & HIV/AIDS
Programs1
Women may not have the power to negotiate condom use
with partners
So: risk reduction counseling that does not empower women
may be less effective than programs providing skills to
negotiate safer sex
Women often fear that abandonment or violence would
occur if they disclosed their HIV status to their partners,
and this is a barrier to HIV testing.
In many societies, women need permission from partners
and families to seek health care, which reduces their
access to health services, including those for HIV.
1 WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
 Definitions1: Gender & health
programming
Gender integration: Strategies applied in
program assessment, design, implementation &
evaluation that take gender norms into account &
compensate for gender-based inequalities
Gender Mainstreaming: incorporate a gender
perspective into programs, its activities and into
their M&E

1 USAID Training of Trainers: Gender and Reproductive Health 101

 Gender and health programming:
Gender integration continuum1

1 USAID Training of Trainers: Gender and Reproductive Health 101

Gender norms: accommodating or transformative?
At a New Delhi bus stop
Gender norms: accommodating or transformative?
 How can health systems address
gender inequality? 1
Sex-disaggregated data available
Collected or possible to collect, but not reported or
left out by design
Quality & ongoing training involved for M&E
system staff
Gender-focused monitoring & evaluations to
measure progress and impact
Involvement of stakeholders at all levels

1Payne, Sarah (2009). How can gender

equity be addressed through health
systems? WHO, policy brief #12
 Gender-based analysis1
Understanding how experiences of women and men differ
and are similar
Considers roles and responsibilities of men & women
have in society re: power & decision-making
Healthdifferences in
Health status & determinants
Care utilization in view of needs
Ability to pay for services
Participation of women & men in health management
Bottom line: GBA reveals influences, omissions &
implications of work in health policy, programming &
planning.

1PAHO (2009). Guidelines got gender-

based analysis of health data for
decision making. PAHO.
 Data required for GBA1

Quantitative
Collecting, reporting & analyzing health indicator and
surveillance data that are disaggregated by sex
Data on socioeconomic determinants of health, health
status, outcomes , treatments used, incidence of
morbidity & mortality, decision-makers, formal &
informal health providers all collected and reported by
sex
When possible, further disaggregation by geographic
location, age, income, ethnicity & education

1PAHO (2009). Guidelines got gender-

based analysis of health data for
decision making. PAHO.
 Data required for GBA1

Qualitative
Information about personal experiences and
perspectives
In depth information about motivations, attitudes,
behaviors, choices etc.
Gets to the why of what quantitative data shows but
often cannot explain
In this case, meaning and contextualization of gender
roles & norms and why people act the way they do
within the health system

1PAHO (2009). Guidelines got gender-

based analysis of health data for
decision making. PAHO.
Gender M&E & Health
New international push led by USG, UN and others to
address gender in programmatic streams
Demand for gender integration or mainstreaming as
prerequisite for activity/program planning
Adhere to donor requirements
Now: gender should be part of M&E Plan, reflecting how gender
is addressed in the program
Conceptual Framework, Logic model, indicators, data use
Who is demanding this?
USG Global Health Initiative, gender strategies of USAID,
WHO, World Bank
HIV/AIDS: PEPFAR, UNAIDS, GFATM,
 Gender & Health M&E1
Monitoring
Indicators that measure gender-specific outputs
Indicators that track progress and effectiveness of gender-
specific elements of programming
Disaggregated data collection and analyses
Data collection in areas such as attitudes and behavior that
reflect gender norms
Evaluation
Measuring impact on outcomes that relate to gender-specific
programming
Elements that address gender equality
Data used to demonstrate progress and impact, influences
demand for richer data

11 USAID IGWG 2009, A manual for integrating

gender into reproductive health and HIV programs
 HIV/AIDS, VAW and Gender M&E 1
Programs should include strong M&E component to
contribute strengthening evidence on intersection between
GBV & HIV
Monitor gender equality and reducing VAW incidence as
positive process, with outcome indicators related to HIV
risk
Monitor possible increase in VAW as potential adverse
outcome of HIV-related interventions
Improve reporting: need systematic way to address extent
and progress or deterioration in type and level of VAW,
including violence against sex workers & other key
populations

1WHO 2010. Addressing Violence against

women and HIV/AIDS: What works?.
Bilateral & Multilateral Agency Gender
Strategies: USG GHI
First principle of GHI: women, girls & gender
equality principle
Gender-related inequalities & disparities
disproportionately compromise womens and
girls health
Country strategies should include gender
assessments & analysis, and women, girls &
gender equality narrative
Bilateral & Multilateral Agency Gender
Strategies
PEPFAR: 2 Pronged approach
Gender integration in all program areas (prevention,
care & treatment)
Programming along 5 strategic, cross cutting areas:
Increase gender equity in activities/services
Reduce violence and coercion
Address male norms & behaviors
Increase womens legal protection
Increase womens access to income/productive
resources
Bilateral & Multilateral Agency Gender
Strategies
WHO guiding principles
Addressing gender-based discrimination is a prerequisite for
health equity
Leadership and ultimate responsibility for gender
mainstreaming lie at the highest policy /technical levels of
the WHO
Programs must analyze the role of gender and sex in areas
of work and for developing appropriate gender-specific
responses in all strategic objectives on a continuing basis
Equal participation of women and men in decision-making at
all levels of WHO is essential in order to take account of
their diverse needs
Performance management should include monitoring and
evaluation of gender mainstreaming.
 Bilateral & Multilateral Agency
Gender Strategies
World Bank Group Gender Action Plan (GAP)1
Rationale: Progress is lagging on womens economic
opportunities
Gender equality as smart economics, a 4 year plan that
invests in the improvement of women's access to :
Jobs
Land rights
Financial services
Agricultural inputs
Infrastructure.

1 World Bank.
http://web.worldbank.org/WBSITE/EXTERNAL
/TOPICS/EXTGENDER/0,,contentMDK:22386
117~pagePK:210058~piPK:210062~theSiteP
K:336868,00.html
 Bilateral & Multilateral Agency Gender
Strategies
UNAIDS Action Framework for addressing women, girls,
gender equality and HIV1
Knowing, understanding &responding to the effects of the
HIV epidemic on women/girls.
Translating political commitments into scaled-up action
addressing rights & needs of women /girls in the context
of HIV.
An enabling environment for the fulfilment of womens and
girls human rights and their empowerment, in the context
of HIV.

1UNAIDS Action Framework: Addressing

Women, Girls, Gender Equality and
HIV1. The Action Framework (2009)
Measuring Gender
Gender differentials in HIV incidence, prevalence, and
service utilization/delivery
Complex construct unlike many risk factors
Gender equality measures that have been used for
quantitative analyses in HIV/AIDS studies
Norms for women and men, including attitudes about
gender-based violence (GBV)
Beliefs about roles
Relationship factors
Womens autonomydecision making power in various
areas
Independent access to economic resources
Experience of GBV
Example of complex gender equality
measure: GEM Scale
Objective is to measure attitudes towards gender
norms in intimate relationships among men
Used to predict multiple partners, family planning
use, IPV & more in varied contexts (Brazil, India,
China, Uganda etc.)
24 items, 2 sub scales: Inequitable gender norms,
Equitable gender norms
Requires asking 24 (can be more or less, depending
on context) items, then performing a statistical
analysis
Push for harmonized gender &
health indicators
HIV field is ahead of the rest
New guides are coming in the next year
All part of the new demand for gender-aware
programming streams, based on old knowledge
Harmonized indicators for violence against
women and girls (guide on the resource list)
Areas of measurement:
Gender in the context of HIV
Prevalence: gender differentials
Treatment: who gets treatment
Behavior: risk and care seeking
Knowledge: differentials in levels and patterns
(what people know)
Gender Equality Measures (as on previous
slides)
Programmatic Reach: target populations &
coverage
Areas of measurement:
Gender in the context of HIV
Gender Based Violence (GBV): prevalence and
health service related
Stigma/Human Rights: Attitudes, laws and policies
Humanitarian Emergencies: situation for women and
girls
Most at Risk Populations (MARPS): people in sex
work
Orphans and Vulnerable Children (OVC)
 Sample gender & HIV indicators
Prevalence
% of young women who are HIV infected
Numerator: # of antenatal clinic attendees (aged 1524) who test
positive for HIV
Denominator: # of antenatal clinic attendees (aged 1524) tested
for HIV
Treatment
% of adults &children with HIV known to be on treatment 12 months
after initiation of ART. [disaggregated by sex & age]
Numerator: # of adults and children still alive & on ART 12 months after
initiating treatment
Denominator: Total number of adults and children who initiated antiretroviral
therapy who were expected to achieve 12-month outcomes
Sample gender indicators for health
programs
Behavior: risk
%of young people who have had sexual intercourse before age 15. [disagg.
by sex & age]
Numerator: # respondents (1524) reproting age at which they first had sexual
intercourse as under 15
Denominator: Number of all respondents aged 1524 years
Knowledge:
% of people who correctly respond to prompted questions about preventing
maternal to child transmission of HIV through ART & avoiding
breastfeeding
Numerator: # of respondents who say that HIV transmission from women who
have tested HIV positive can be prevented by the mother taking drugs during
pregnancy &avoiding breastfeeding
Denominator: Total respondents in survey
Sample gender indicators for
health programs
Gender Equality Measures
Proportion of people who say that wife beating is an acceptable
way for husbands to discipline their wives
Numerator: Number of respondents in an area (region, community, country)
who respond "yes" to any of the following questions:
Sometimes a husband is annoyed or angered by things that his wife does.
In your opinion, is a husband justified in hitting or beating his wife if
she is unfaithful to him
disobeys her husband
argues with him
refuses to have sex with him
does not do the housework adequately
Denominator: Total number of people surveyed
Sample Indicators
Programmatic Reach:
% sex workers reached by HIV prevention programs
[disaggregated by sex & age]
Numerator: #of SWs who replied yes to both:
Do you know where you can go if you wish to
receive an HIV test?
In the last twelve months, have you been given
condoms (e.g. through an outreach service, drop-in
centre or sexual health clinic)?
Denominator: Total number of respondents surveyed
Sample Indicators: Violence against
women
VAW/G:
%of health units that have documented & adopted a
protocol for the clinical management of VAW/G
survivors
Numerator: # health facilities in the geographic region
of study (country, region, community) reporting that
they have both documented and adopted a protocol
for the clinical management of VAW/G survivors
Denominator: Total number of health units surveyed
in the geographic region of study
 Sample Indicators

VAW/G:
Proportion of people who agree that rape can take
place between a man and woman who are married
Numerator: # of people who agree with the statement:
When a husband forces his wife to have sex when she
does not want to, he is raping her1
Denominator: Total number of people surveyed

1 wording of this question needs to be

carefully developed in order to use
language that conveys the meaning
within the cultural context
Sample Indicators
VAW/G:
Proportion of youth-serving organizations that include trainings
for beneficiaries on sexual and physical VAW/G
Numerator: # of youth serving organizations that train
beneficiaries on VAW/G issues. Training curriculums aimed at
youth should include components covering:
Acts of VAW/G that affect youth along with the health
and social consequences
How power, coercion and gender issues place youth at
risk for VAW/G
Where are how youth can get help if they have
experienced an act of VAW/G
Denominator: Total # of youth serving organizations surveyed.
Sample Indicators
HIV Stigma/Human Rights:
%of people 15-49 expressing accepting attitudes towards people living
with HIV [disaggregated by sex, age, & education
Numerator: Number of women and men aged 15-49 who report
accepting attitudes towards people living with HIV
Denominator: All respondents 15-49 who have heard of HIV
Humanitarian Emergencies:
# of women & girls reporting incidents of sexual violence per
10,000 population in the emergency area
Numerator: # of incidents of sexual violence reported by
women and girls in the specified period
Denominator: The total camp/area/country population during
the same time period.
Gender & HIV Indicator resources

VAW/G compendium
https://www.cpc.unc.edu/measure/publications/ms-08-30

HIV indicator Registry (UNAIDS)

http://www.indicatorregistry.org/
Go to: browse indicatorsneed to identify the gender indicators
here

Gender scales
http://www.c-changeprogram.org/content/gender-scales-
compendium/index.html
Coming Resources
Gender and HIV menu of indicator options
Set of harmonized, agreed-on indicators
Technical advisory group of global donors & independent
experts, including
UN: UNIFEM, UNAIDS, WHO, UNFPA
USGs GHI: USAID, PEPFAR
World Bank, GFATM
Organized by areas of measurement-intersection ofHIV/AIDS
and gender
New gender and health source:
Resource guide for gender data and statistics (WHO,
IGWG/USAID & MEASURE Evaluation)
Activity:
Integrating gender into M&E
Look at your program objective(s) & think about how
gender can be addressed
Modify the activities that stem from that objective(s)
Using any of the indicator resources listed above in your
group work projects:
Look at one or two of the resources & match an area of
measurement that is relevant to your modified activities
Select 1-2 indicators that you can use to reflect how gender
is addressed that can be tracked in both the outputs and
outcomes (or modify ones already there)
Fill in a matrix for these indicators
If time allows, look for another area
MEASURE Evaluation is funded by the U.S. Agency for
International Development (USAID) through Cooperative
Agreement GHA-A-00-08-00003-00 and is
implemented by the Carolina Population Center at the
University of North Carolina at Chapel Hill, in partnership
With Futures Group International, John Snow, Inc., Macro
International Inc., Management Sciences for Health, and
Tulane University. The views expressed in this presentation
do not necessarily reflect the views of USAID or the United
States government.