Integrating Gender Equality in PAHO: Achievements and Opportunities

Monitoring Report for 2009 – 2011

(Draft 31/27/12)

Introduction

The Pan American HealthOrganization’s (PAHO) Member States approved the Organization’s Gender Equality Policy[1]in 2005 and requested the PAHO Director“to develop an action plan for the implementation of the Gender Equality Policy, including a performance monitoring and accountability system.”[2] In 2009, PAHO approved its Plan of Action (PoA) for the Gender Equality Policy.[3] The PoA provides an implementation roadmap with monitoring indicators for PAHO’s Secretariat (the Pan American Sanitary Bureau (PASB) and Member States.

As described in PAHO Directing Council Resolution DC49.R12, set out below, the PoA also ensures ownership of gender equality considerations within PAHO and designates PAHO leadership to achieve equity and “Health for All.”The Plan requires the PAHO Director to report on implementation to the Directing Council.

Resolution DC49.R12 requests the Director to:
(a) ensure the implementation of the Plan of Action and support Member States to progress in the implementation of national plans for integrating gender equality in health systems;
(b) provide knowledge on advances and best practices for achieving gender equality in health, as well as on threats to reaching it;
(c) facilitate monitoring the progress of implementation of the Plan of Action in the Secretariat’s work and technical collaboration;
(d) rely on the support of a technical advisory group and other internal and external mechanisms that include civil society participation for implementing andmonitoring the Plan of Action; and
(e) promote and strengthen partnerships with other United Nations agencies and other organizations to support the implementation of the Plan of Action

Purpose

The purpose of this report is to assess PAHO’s and its Member States’ progress in implementing the Gender Plan of Action. The report also includes recommendations from participants on improving the integration of gender in PASB and Ministries of Health (MOH). The goal of the report is to contribute to improved commitment and responses form the MOH and the PASB to better health outcomes for women, men and children of the Americas.

The PoA states that the Director will report on the progress of the Plan’s implementation on a biennial basis. This first report will cover the year 2009, when the PoA was approved, and the 2010 – 2011 PAHO biennial work plan (BWP) period. The Director requested that the PASB Office of Gender, Diversity and Human Rights (GDR) coordinate the collection and analysis of information for assessing this progress.The Director’s Technical Advisory Group on Gender Equality and Health (GH/TAG)[4]recommended that the monitoring process include representatives of PASB, the ministries of health (MOH), ministries of women (MOW), and civil society organizations (CSO).

Monitoring Strategy and Methodology

GDR developed a monitoring framework to solicit information on progress of the PASB Technical Areas, GDR Office, PAHO Country Offices, and Member States. During 2011, this monitoring plan was presented in three subregional PAHO Managers’Meetings as well as to the GH/TAG, the PASB Gender Focal Point (GFP) network and other partners.Three instruments were designed to obtain information for the strategic areas of the Gender Policy and PoA. These four strategic areas are the following:

Strategic Area 1:Strengthen the Organization’s and Member States’ capability to produce, analyze, and use information disaggregated by sex and other relevant variables.
Strategic Area 2: Develop tools and increase capabilities in PASB and MemberStates for integrating a gender equality perspective in the development, implementation, monitoring and evaluation of policies and programs.
Strategic Area 3: Increase and strengthen civil society participation, especiallyamong women’s groups and other gender-equality advocates, in identifying priorities, formulating policies, and monitoring policies and programs at local, national, and regional levels.
Strategic Area 4: In line with results-based management methodologiesinstitutionalize gender-responsive policies, as well as monitoring mechanisms that track specific mainstreaming results, and evaluate the effectiveness of gender interventions on health outcomes.

At the regional level, GDR provided information onprogress on indicators related to GDR’s work. GDR also facilitated consultations with PASB Technical Areasto collect information about gender integration in their work. At the country level, GDR encouraged PAHO Country Offices to coordinate with each Member State’s MOH,other government sectors, UN agencies, and CSO to obtain information on gender integration in country-level activities.PoA information and a monitoring questionnaire were provided to 26 country offices, including Eastern Caribbean (ECC) Office that covers 10 island countriesand territories.

Informationcollected was analyzed in a draft report by GDR that again was consulted with the GFP network, partners, GH/TAG members, andMembers States of the Executive Committee of the Directing Council. Comments were included for a final report to be presented to the Sanitary Conference/Directing Council in September 2012.

Monitoring Results

Despite challenges in the ongoing process of mainstreaming gender in PAHO, the impressive and comprehensive results documented in this report are a tribute to the uncompromising commitment of the PAHO Director, Dr. Mirta Roses and the Assistant Director, Dr. Socorro Gross, to equity and gender equality in health.

All four PASB Technical Areas and GDR responded to the PoA questionnaire. Of 36 PAHO Country Offices and Member States contacted, only Haiti, Jamaica, Puerto Rico, and the US did not provide results. Of the 26 separate country consultations held (one consultation, for the Eastern Caribbean, included 10 countries), eight included the participation of all partners, including civil society; 11 included only MOH and PAHO colleagues; four included other ministries and UN partners; and only two reports were provided without consultation. Please see Annex 2 for additional description of the consultation processes undertaken by each respondent.

The following summarizes the responses generated by PASB’s GDR Office, the Technical Areas, and 36 countries and territories.The results are presented according theGender Equality Policy Strategic Areas, their related Objectives and theirPoA indicators. The report concludes with recommendations provided by participants to improve the integration of gender in PAHO. Annexes and footnotes provide additional information.

Strategic Area 1: Strengthen the Organization’s And Member States’ Capability to Produce, Analyze, and Use Information Disaggregated by Sex and Other Relevant Variables.

Objective 1.1

PASB incorporates gender sensitive indicators, disaggregated by age and sex, in developing plans, programs, technical collaboration, and other initiatives.

Baseline/Indicator
Health in the Americas (publication)
• Baseline: WHO’s 2008 assessment of Health in the Americas, 2007 edition.
• Indicator: Health in the Americas, 2012 edition includes gender analysis in the Regionalvolume and in all the country chapters, using the WHO analysis tool.
Country Collaboration Strategies (CCS)
• Baseline: Proportion of 2008 CCSs includes analysis using data disaggregated by sex and age, using WHO analysis tool.
• Indicator: By 2010, all new CCSs include analysis based on data disaggregated by sex andage, and strategies to address differences.
Strategy for strengthening vital and health statistics in the countries of the Americas
• Indicator: By 2009, guidelines call for disaggregation of data by sex and age for allinformation systems.
Health analysis publications
• Indicator: By 2013, all health analysis publications will include analysis based on datadisaggregated by sex and age.

The Gender, Diversity and Human Rights Office (GDR) closely collaborates with the PASB Technical Areas, especially the Health Information and Analysis Office (HA) to integrate gender in the health information systems, tools and guidelines, and to strengthen the capacities of the PASB, governments, and CSOs for equitable decision-making, advocacy, and monitoring.

Health of the Americas: The PAHO’s publication Health of the Americaswill be completed in 2012 and launched during the 2012 Pan American Sanitary Conference. GDR is a part of the writing team and is applying the PAHO/WHO gender tools in the development and consultation of the regional and country chapters of this publication. An analysis of this flagship publication will be carried out in 2013.

Country Cooperation Strategies (CCS): Since 2009, GDR has included gender indicators in the situation analysis and development of CCS, the basis for WHO/PAHO collaboration with Member States. In 2009, GDR incorporated gender, human rights and cultural diversity directives into the WHO guidelines for developing CCS[5] and a checklist for their review. This tool was used to analyzethe 14CCSproduced from 2005 to 2008, prior to GDR’s engagement in the CCS process. Of these 14 CCS, none strongly integrated gender; 13 attained a medium score, and oneobtained a low score (see Annex 1).

After 2009, 10 CCS have been developed or completed, and GDR participated in the development of seven of these CCS. In 2012 and 2013, the post-2009 CCS will be reviewed using the WHO checklist. The results of this review will be compared to the analysis of the 2005 – 2008 CCS to determine whether gender integration in the CCS has benefited from GDR’s involvement.

Disaggregating health information in guidelines and health analysis publications:The Gender Equality Policy calls for all health information produced by the Organization and its Member States to be desaggregated by sex and age and to be analyzed with a gender perspective. The table below provides self-reported information on data disaggregation of publications and guidelines produced by PASB’s four Technical Areas: Sustainable Development and Environmental Health (SDE), Family and Community Health (FCH), Health Surveillance Disease Prevention and Control (HSD), and Health System and Services (HSS).

Technical Areas: Number and percentage of guidelines with disaggregated data by sex, age, and ethnictiy, 2005-2010

Technical Areas: Number and percentage of publications with disaggregated data by sex, age, and ethnictiy, 2005-2010

Project / Total Publications / Disaggregated by:
Sex / Age / Ethnicity
Number / % / Number / % / Number / %
SDE / 15 / 11 / 73% / 11 / 73% / 5 / 33%
FCH / 15 / 12 / 80% / 13 / 87% / 4 / 27%
HSD / 28 / 23 / 82% / 25 / 89% / 6 / 21%
HSS / 7 / 5 / 71% / 4 / 57% / 4 / 57%
TOTAL / 67 / 49 / 73% / 48 / 72% / 15 / 22%

Source: GDR consolidated data.

Between 63% and 100%, of the guidelines and publications produced by the Technical Areas disaggregated information by sex, but considerably fewer did so by ethnicity. Disaggregation is a necessary step for identifying health disparities, but it alone is not sufficient for understanding why these disparities exist. A gender and equity analysis can complement disaggregated information by indicating how to address inequalities in health. While it is positive that the Area addressing surveillance and disease (HSD)consistently disaggregates its information in its guidelines,a gender and ethnicity perspective is not always applied in HSD’s publications. Moreover,it is of concern that the guidelines and documents aimed at improving health systems and services (HSS) were less likely to disaggregate information by sex, thus missing an opportunity to address the different needs of women andmen in seeking these services.

Objective 1.2

National and local producers and users of health statistics with the capability to produce, analyze,and use gender-sensitive information for decision-making, advocacy, monitoring, and evaluation.

Indicators
Tools on gender and health analysis
• Indicator: Number of tools on gender and health analysis available and accessed on gender and health knowledge platform
National health profiles on women and men
• Baseline: Number of existing health profiles.
• Indicator: By 2014, trained producers and users of information in ten countries develop orimprove national health profiles on women and men and use them for planning and advocacy(survey of workshop participants).
Contribution of unpaid home-based health care to national health expenditure
• Indicator: In 2013, three countries will have quantified unpaid home-based health-careprovided by men and women as contribution to total national health expenditures.
National mechanisms for analysis and monitoring gender equity in health
• Baseline: Number of health or gender observatories that have received PAHO support to include gender and health indicators.
• Indicator: By 2013, three national or local observatories on gender have integratedhealth/gender indicators and have published issue papers regarding advances in gender equality in health.

Tools on gender and health analysis:

PASB Gender, Diversity and Human Rights Office: GDR has developed a number of tools for training producers and users of health information in integrating a gender and intercultural perspective in health information systems and use. It has also produced a number of gender and health evidence publications, described later under Objective 1.3. Since 2009 and in collaboration with HSD/Health Analysis Office and country-based gender focal points(GFP), GDR has carried out capacity building workshops with participants from MOH, women’s machineries, national statistics offices and CSOs from seven countries (six Andean countries, Guatemala, Paraguay, and Surinam. As a result, the Andean countries have developed a set of gender and health indicators that will be incorporated into the health information system promoted by theAndean integration entity CAN (Comunidad Andina de Naciones).

PASB Country Offices and Member States:The information collected from Member States was self-reported and quite varied. Some countries included guidelines and publications produced only by PAHO and the MOH, while the majority included information on gender produced by other partners, including the ministry of women, other UN agencies and CSO.

As shown in the following charts, countries reported having developed between 1 to 19 (Bolivia) guidelines for integrating gender in health information, policies, programming, and they reported between 1 and 20 (Peru, Uruguay) publications(see Annex 2). Countries that disaggregated information by sex, predominately reported including a gender analysis. Most countries reported that this information was used for decision making, advocacy, monitoring and also for training. Most of these publications dealt with violence against women, HIV and sexual reproductive health, or health situation analysis, while only two countries included communicable diseases (Argentina, Nicaragua).

Percentage of countries and territories with publications that include data disaggregated by sex and age, 2005 - 2010

Source: PAHO/GDR. Self-administered survey of 36 countries

Percentage of countries and territories that use their gender sensitive health publications for planning, monitoring and advocacy, 2005 – 2010

Source: PAHO/GDR. Self-administered survey of 36 countries

Nineteen countries reported having guidelines for health analysis, programming and monitoring.[6] As illustrated in the graph below, the majority of these guides called for disaggregating information by sex, while less than half included ethnicity.

Percentage of countries and territories with data disaggregated

by sex, age and ethnicity, 2005 - 2010

Source:PAHO/GDR, Self-administered survey of 36 countries

National health profiles on women and men:The following countries reported having published gender and health profiles during 2005 - 2010: Bolivia, Costa Rica, Honduras, Mexico, Peru, Panama and Uruguay. Colombia, Nicaragua and Trinidad and Tobago reported that gender analysis was included in their country’s health situation reports.

Unpaid home-based health care and national health expenditure: The PAHOGender Equality Policycalls for recognizing the importance of home-based health care that is predominantly provided by women and is unpaid. WithPASB advocacy,Colombia, Peru, Ecuador, Uruguay and Costa Rica have included this care in time use surveys. Costa Rica is publishing the analysis of unpaid care. Ecuador, México and Colombia are developing satellite health accountsthat quantify this contribution within the framework of National Accounts.Additionally, Chile, Costa Rica, Mexico and Perureported policies and/or publications on unpaid health care and gender. (See also, Objective 1.3.)

National mechanisms for analysis and monitoring gender equity in health: Observatories are made up of civil society organizations (CSOs)and academicians and are key partners for using and producing gender and health information for analysis, advocacy and monitoring equality. GDR has setup a network of 35observatories in Latin America that address gender and health, and has established an electronic discussion list of over 70 participants, including GFPs, to exchange publications and other information.In 2009, GDR, the MOH of Chile, and the Chilean Observatory on Gender Equality and Health brought together representatives of eight observatories and their health sector counterparts to identify ways to strengthen collaboration and support.[7]

During the PoA monitoring consultations,countries reported existing observatories that address gender and health, and other observatories that possibly included gender analysis, especially violence observatories, which addressgenderbased violence. PAHO provides technical collaboration to the human resources and violence observatories, as well as to the gender and health observatories in Chile, Uruguay and Guatemala.

Country / Gender and Health Observatory / Other Observatory related to Health
Argentina / Observatory on Sexual and Reproductive Health- CSO
Bolivia / Observatory on Gender and Equity – CSO, MOH
Brazil / Observatory on Gender Equality- CSO
Colombia / National Observatory on Gender issues – National women’s machinery
Mexico/US Border / Observatory on Violence
El Salvador / Observatory on Violence in three cities that addresses gender based violence –CSO, MOH, Women’s machinery/ISDEMU
Ecuador / Observatory on Sexual and Reproductive health (under construction)- CSO / Observatory on Children and Adolescents
Guatemala / Observatory on Sexual and Reproductive Health – CSO, MOH / Observatory on Violence, Observatory on Human Resources
Honduras / Four Observatories on Human Resources, one on Violence
Mexico / Observatory on Maternal Mortality – UN, SCO, Ministry of Health / Observatories on Violence in all states
Paraguay / Observatory of External Causes
Peru / Four Women’s observatories (Ayacucho, Apurimas, Piuria, Pano) / Three Observatories: Quality, Cultural Diversity, Human Resources
Uruguay / Observatory on Sexual and Reproductive Rights - CSO

Objective 1.3