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Lin - Gender Sensitive
Lin - Gender Sensitive
Lin - Gender Sensitive
1661-8556/07/0100S27-8
DOI 10.1007/s00038-006-6049-7
© Birkhäuser Verlag, Basel, 2007
(1999) defines gender-sensitive indicators as those that enable (Abdool & Vissandjee 2000; Eckermann 2000). A narrow fo-
us to identify, examine and monitor gender-related changes in cus on patterns of disease has resulted in limited development
society over time. In a discussion on indicators in the biennial of indicators which reflect broader concepts of health, health
report, Progress of the World’s Women, the United Nations seeking behaviours and positive strategies for achieving health
Development Fund for Women (UNIFEM 2000) defined gen- (AbouZahr & Vaughn 2000; Tudiver et al. 2004). The report-
der-sensitive indicators as those constructed so as to compare ing of these indicators seldom provides information on a sex-
the position of women and men at a point in time and over disaggregated basis, even when the original data collection
time, and therefore focus on gender gaps (i. e. the gap between makes such a differentiation (Licuanan 1999). In addition,
men and women, particularly based on their socially con- some authors argue that the lack of participation by women
structed roles). Gender-sensitive indicators should also facili- and engagement of communities in indicator development
tate comparison between different groups of women (UNIFEM has resulted in indicators which may not measure aspects of
2000) and be able to identify and assess whether equity is be- health, equity and progress relevant to women (Austen et al.
ing achieved (Abdool & Vissandjée 2001). 2000; Beck 1999).
To examine equality and equity in health, gender-sensitive These critiques point to the need to develop frameworks for
indicators need to include a comparator (or denominator) health indicators that: (1) take into account the broad determi-
which is an appropriate norm, reference group, or standard to nants of health; (2) include gender as a central component for
be used to compare the situation of women and men, girls and analysis (Abdool & Vissandjee 2001); (3) not only focus on
boys, or indeed the situation of different groups of women health outcomes, but also on the social and economic proc-
and girls. The presence of such a comparator is one of the esses which influence health and well-being (Coleman 2003;
defining qualities of a gender-sensitive indicator. This means Tudiver et al. 2004); (4) are sensitive enough to detect gender
that gender-sensitive indicators go beyond ‘gender statistics’ differences in health experiences (Tilley 1996); and (5) enable
(e. g. 60 % of women in country X are literate, as opposed to the consideration of equity in the analysis of health system
30 % five years ago) through their inclusion of a pertinent performance, and include measures for issues of importance
norm, reference group or comparator (Beck 1999). to women, or men (such as the relational and technical aspects
However, comparing information about the status of women of health care).
to that of men may be insufficient because it restricts the fo- It should be noted, however, that these critiques of existing
cus to areas where such comparisons can be made. This limits health indicators in the literature do not point to the need to
the measurement of women’s progress to areas where men develop new data collection and surveillance systems. Rather
have already achieved ‘success’ and potentially gives an in- the challenge is how to modify current health information
complete picture of women’s experiences, goals and interests systems to ensure that they can adequately reflect gender eq-
(Austen et al. 2000). Equally, a full analysis of the situation of uity issues, if not other equity concerns.
women (and men) may also require the use of sex-specific There are three key domains discussed in the literature in re-
indicators because some conditions (such as maternal mortal- lation to making health indicators gender-sensitive. These
ity) are only experienced by one sex, and it is important to are: (1) conceptual issues about both the theoretical concepts
know about absolute levels of achievement as well as gender used to understand health and illness, and those that describe
gaps (UNIFEM 2000). gender relations within the household, community, work-
place, and the economy; (2) technical issues associated with
What makes health indicators gender-sensitive? indicator and data definition, data collection, and basing indi-
Health indicators can be described as statistics or parameters cator development on the availability of existing data rather
that provide, over time, information on trends and changes in than constructing new structures to build gender-sensitive in-
the condition and status of health (Tudiver et al. 2004). The dicators; and (3) processes for developing and using indica-
frameworks and theoretical constructs used to understand tors.
health will critically influence the indicators developed, as In other words, making health indicators gender-sensitive
will assumptions about men, women and their roles. Tradi- will, ideally, involve: identifying an appropriate conceptual
tionally, the use of a biomedical approach combined with par- framework for understanding health which both links health
ticular assumptions about women, has imposed a number of determinants and health outcomes and includes gender as a
limitations on existing indicators for health. These include the central component; and applying the lessons about gender-
many health indicators which focus on illness/disease rather sensitive indicators to the development and use of indicators
than on health and well-being (Eckermann 2000; Nayar 2002; to the extent possible (that is, both the technical and process
Abdool & Vissandjee 2000) and/or assume gender neutrality aspects of indicator development).
Gender-sensitive indicators: Uses and relevance Int J Public Health 52 (2007) S27–S34 S29
© Birkhäuser Verlag, Basel, 2007
National or provincial Policy Most efficient means in accordance Distributional/gender impact, costs, potential harm,
government with community values community values, and benefits of current and
proposed policies
Region/ community Regional plan, community Efficient and effective means to Health needs of different population groups,
development achieve shared social ends (including community values, resource use and impact across
gender equity) programs
Service/ organisation Program development, Efficient means to meet institutional Institutional client base (including diverse population
institutional priorities interests groups), expertise needed, program costs and outputs
Using gender-sensitive health indicators the circumstances associated with equity/equality, and
progress towards achieving equity/equality and outcomes).
Why use gender-sensitive health indicators? The choice of indicators may also depend on the level at
Gender as a determinant of health is well recognised. Many which they will be used – local, community, national, region-
authors (Coleman 2003; Standing 1997; Beck 1999) have ar- al or international – which raises the issue of how best to ag-
gued for consideration of the social, structural, and power re- gregate and organise indicators at differing levels to inter-con-
lationships that shape the lives of women and men in relation nect in a meaningful way that can potentially lead to action
to health. Similarly, arguments have been made about the im- toward improvements for women. This might mean that dif-
portance of reducing health inequities created through avoid- ferent indicators are required for different levels of activity
able disparities in health and its determinants, between groups and ideally that women, as the ‘affected community’, should
of people who have different levels of underlying social ad- be involved in determining which indicators are most mean-
vantage (Gomez 2000) (original emphasis). ingful for a particular level.
The key reason for using gender-sensitive health indicators is It is important to recognise, however, that different levels of
to provide a rigorous information base for policy actions that decision-making (and different decision-makers) are attempt-
can improve health outcomes (Coleman 2003) and thereby ing to solve different problems and that there is a need for
reduce unjust health inequities resulting from the social con- appropriate evidence. Table 1 illustrates the types of evidence
struction of gender. This requires the development of indica- that interest decision-makers at different levels, and gender-
tors that contribute to improved understanding of the path- sensitive indicators should be part of the evidential basis for
ways between inequity and disease so that effective decision-making.
interventions can be designed to operate at the “optimal points Indicators can also be used for all aspects of a policy cycle –
in these processes and pathways [where they] can interrupt from identification of problems, to setting policy objectives,
and reverse the potential for disease onset”, represent good to implementing policy and evaluating policy outcomes. At
return on investment, and do not cause harm to some groups each level there should be a logical set of questions to inform
while assisting others (Coleman 2003). indicator selection. These include: What is the issue to be ad-
The development and use of appropriate gender-sensitive in- dressed? What changes are we trying to effect? How will we
dicators to monitor equity/inequity trends in health status and know if we have succeeded? What activities need to occur to
healthcare access and utilisation can support policy by an- bring about change? What resources will be required? Thus,
swering the key questions: “Is the gap in health status improv- monitoring will require indicators about inputs, processes,
ing or worsening over time?” and “How are policies and inter- outputs, and outcomes.
ventions working to narrow the gap?” (Evans et al. 2001). It is important, however, to recognise that policy, program,
and legislative processes do not rely on indicators alone. Data
Linking indicators to decision-making can contribute towards the development of shared meaning in
A suite of indicators, rather than single indicators, are often the decision-making process. For example, surveillance data
chosen for monitoring purposes. The purposes for which indi- can contribute in a number of ways, according to Tudiver et
cators are to be used will influence the type of indicators that al. (2004). These include: (1) identification of ‘sentinel
are most relevant, while the conceptual framework used for events’ that require immediate policy action (such as disease
understanding health and illness will also shape how suites of outbreaks); (2) tracking disease incidence and health behav-
indicators are chosen. Additionally, different types of indica- iours over time to effectively target policy and program de-
tors can be used for different purposes (i. e. to identify both velopment; (3) monitoring policy implementation and as-
S30 Int J Public Health 52 (2007) S27–S34 Gender-sensitive indicators: Uses and relevance
© Birkhäuser Verlag, Basel, 2007
sessing the effectiveness of interventions; (4) monitoring funding; (2) the contextual factors of individuals and organi-
cross cutting issues (such as working conditions) that are rel- sations involved (i. e. personal disposition, attitudinal stance,
evant to many aspects of health; (5) examination of social situational requirements, program demands, and research ori-
trends to identify if they correlate with other determinants entation); (3) dissemination efforts that include considered
and influence the development of healthy public policy; and strategies, methods, targets; and (4) linkage systems between
(6) highlighting policy and program failure and identifying data producers and users that enable widespread adoption and
the lessons learned. implementation and are cost effectiveness (Oldenburg et al.
1997).
Informing research, policy making, legislation and program Contextual factors may be the most important determinant of
development whether indicators will be used to inform policy making. In a
There are a number of key issues to consider when using indi- study about factors that influence evidence-based decision-
cators to inform research, policy, legislation and program de- making in the Canadian health system, Tranmer et al. (1998)
velopment; and to raise awareness and monitor systems per- found that multiple positive and negative factors were at work.
formance. These include: (1) consideration of the types of Decision makers often find the evidence difficult to interpret,
decisions that have to be made and who makes them; (2) indi- not specifically relevant to the policy being considered, not
cators are only one input; (3) indicators need to lead to or link timely enough, and contradictory in relation to other expert
with gender based analysis; (4) indicators have to engage the opinions. The values and beliefs, professional or educational
broader community; and (5) the focus should be on indicators backgrounds, and the organisational imperatives of the deci-
that promote action. To achieve these intended purposes there sion makers were also important influences.
is a need to strengthen capacity at all levels to implement sys- The above suggests that a particular aim in building an effec-
tems for monitoring gender equity in health. This involves tive system for using indicators for policy development and
having the right data, having quality data, and having a social monitoring is to ensure that the stakeholder community has
process to review the data. access to information and is empowered by access to data.
The value of good quality and conceptually sound indicators Given that health policies and programs are not solely the re-
is limited if there is not an appropriate monitoring system for sult of the deliberations of decision-makers, but also reflect
examining gender-sensitive indicators. Such a system requires the input of civil society interest groups, policy development
not only adequate infrastructure for collection and collation and monitoring processes for the purpose of achieving gender
of valid and reliable data but also a participatory process equity in health are not only of interest to consumers and
through which the meaning/s of indicators are reviewed, im- community groups, but also a mechanism for their empower-
plications for action are distilled, and decisions are taken to ment. Thus, regardless of the philosophical basis of public
effect greater equity. Such an ongoing system of monitoring policy-making, the use of indicators has become an important
will also contribute to the identification of emerging issues part of consumer empowerment.
that need to be researched or acted upon. The most cost-effec-
tive system would be to build on (i. e. genderise or gender-
sensitise) existing infrastructure for data collection and analy- Successful applications of gender-sensitive
sis, as well as link in with mainstream policy and management health indicators
decision-making. There are several international examples of the use of gender-
sensitive indicators as part of policy and program develop-
Using indicators as a social process ment and implementation. National governments, interna-
If indicators are to be used by decision-makers, the impor- tional agencies, research and advocacy bodies have
tance of effectively communicating the data cannot be under- undertaken various efforts to develop and use gender-sensi-
estimated. Not only should the data be timely (for purposes of tive health indicators for tracking progress towards equity,
specific decision-making), it also needs to be accessible. This including gender equity. Four examples of the practical ap-
means being effectively communicated or presented, readily plication of gender-sensitive indicators are described below.
comprehensible to the intended audience and able to engage a
wide range of stakeholders and interested parties. As data do Gender-based analysis
not speak for themselves, their uptake into decision-making – A program to promote the equitable use of eye services
requires attention to a range of social and organisational fac- and reduction of eye disease and blindness in Tanzania,
tors, including: (1) organisational elements, infrastructure, India, Egypt, and Nepal found that by using gender-sen-
administration, culture, communication, policy making, and sitive indicators, an assessment could be made of the as-
Gender-sensitive indicators: Uses and relevance Int J Public Health 52 (2007) S27–S34 S31
© Birkhäuser Verlag, Basel, 2007
sociation between gender and blindness, the identifica- built into data collection. For example, the New South Wales
tion of potential reasons for differences, and the local Bureau of Crime Statistics and Research and the Women’s
factors associated with use of eye services. The key find- Coordination Unit worked with the police to design forms so
ings were that women consistently have lower rates of that useful data was collected as part of the apprehended vio-
utilization of cataract surgical services compared to men; lence order (AVO) process.
women bear about 75 % of trachoma related blindness; When the statistical data and its analysis became available, it
the barriers that restrict the use of eye care services by was used by advocates, both within government and outside,
men and women are different due to differences in gen- to achieve greater reform through increased services, im-
der roles and behaviours; and that young girls who be- proved practices and attitudinal change. The data and analysis
come blind due to congenital cataract are much less was also used to formulate policies such as the 1992 National
likely than young boys to be brought to hospital for sur- Strategy on Violence Against Women which was developed
gery. with community representatives and endorsed by the Council
These findings were used to develop strategies that re- of Australian Governments (COAG).
duced travel access problems and the cost of surgery, In 1996, the Australian Bureau of Statistics conducted a major
improved awareness, access, and acceptance of eye care Violence Against Women Survey, which was followed in
services, set up 20 different referral sites in reach of eve- 1997 by the COAG initiated Partnerships Against Domestic
ry village, reduced hospital-based barriers to the utilisa- Violence, a whole-of-government approach that reduces and
tion of services; and to introduce counselling for eye prevents domestic violence in Australia through 12 strategies
disease patients to improve their decision making and monitored by 13 indicators. Phase 1, which included more
acceptance by family members – particularly for elderly than 100 projects across Australia, was completed in June
females (Courtright 2004; Courtright 2003). 2001. The subsequent Phase 2 ended in June 2005 (Partner-
– In Botswana, a multi-sectoral, gender-sensitive public ships Against Domestic Violence 2002).
health response to the HIV/AIDS epidemic was imple- In 2003, the Victorian Health Promotion Foundation conduct-
mented following the use of several indicators that re- ed a detailed study of intimate partner violence to measure the
vealed the increasing vulnerability of women to HIV/ attributable burden of disease. This study found that for wom-
AIDS; the disproportionately high risk rates for young en under 45 years of age, such violence was responsible for an
people, particularly young women; the lack of access to estimated 9 % of the total disease burden (VicHealth 2004).
comprehensive information and services by women and
girls; and the risk of marriage, sexual coercion and vio- Accountability
lence leading to a greater chance of infection. In 2004, the Report Card, the third in a series assessing the
As AIDS is seen as a development rather than health is- overall health of women in the USA found that there had been
sue, strategies to empower women and girls were imple- a failure to meet national goals. The Report Card is distribut-
mented. Based on prevention, testing and treatment, they ed to policy makers and women’s health advocates nation-
included the encouragement of abstinence and postpone- wide. The Report Card is an advocacy tool that uses a broad
ment of sex, normalization of condom carrying, integra- definition of health and evaluates 34 health status indicators,
tion of voluntary counselling and testing into other health 67 health policy indicators, and assesses the nation’s progress,
services, an annual “Miss HIV Stigma-Free” and a pro- or lack thereof, state-by-state, in reaching key benchmarks
gramme to prevent mother-to-child transmission of HIV related to the status of women’s health. It also provides an
(AZT and infant formula) for HIV positive pregnant important overview of key disparities in the health of women
women (de Korte et al 2004; Watson (undated)). based on race, ethnicity, sexual orientation, disability status,
and other factors. The 2000 and 2001 Report Cards prompted
Policy advocacy activities such as legislative hearings, town meetings, forums,
Over the past 30 years Australia has acknowledged that vio- and new materials on women’s health across the country. The
lence against women is a major social issue and significant Report Card also measures women’s health by looking at their
health determinant for women and their children. During the economic security in the states. The 2004 Report found that
1970s and early 80s women’s advocacy groups used qualita- little progress had been made in this area, with Alaska being
tive data to bring the issue to the attention of policy makers the only state with a minimum wage that allows a family of
and decision makers which led to the establishment of the first three to reach the federal poverty threshold (National Wom-
services and some policy changes. As reforms and programs en’s Law Center and Oregon Health and Science University
were implemented, indicators and their measurement were 2004).
S32 Int J Public Health 52 (2007) S27–S34 Gender-sensitive indicators: Uses and relevance
© Birkhäuser Verlag, Basel, 2007
standards); building on indicators proposed through key inter- ment and related social processes. Strengthening existing data
national consensus and reporting frameworks, including The collection and surveillance systems is the most cost-effective
World Health Report, Human Development Report, State of approach.
the World’s Children, Millennium Development Goals, Bei- Key elements of an effective infrastructure include: adequate
jing Platform for Action, International Conference on Popula- and sustainable infrastructure for collection, analysis and re-
tion and Development (ICPD), and CEDAW; using proxy in- porting; capacity-building mechanisms and processes in place
dicators when collecting additional data is not feasible; and to train and support enhanced understanding of meaning and
having designated jurisdictional focal points, located within action potential of the set of leading health indicators that in-
appropriate settings, with accountability for data collection tegrate gender perspectives; capacity building at provincial,
and dissemination. regional and community levels; creation of a continuing so-
Reporting: The development and use of gender-sensitive cial process for accountability by developing mechanisms to
health indicators is a relatively new phenomenon. The chal- bring together key stakeholders at both national and global
lenge then is how to achieve an optimal reporting system that: levels to review and discuss action requirements arising from
has a regular reporting time frame, offers sufficient specificity leading health indicators; and an accountability process for
(including, where possible, sex, ethnicity, age, socioeconomic regular review and evaluation of the whole leading health in-
status); monitors and understands risk and protective indica- dicators system, including data elements and definitions, col-
tors (including highlighting action potential, in a way to in- lection methods, analysis and reporting, data access and dis-
crease monitoring and understanding); provides quantitative semination, and accountability processes.
and qualitative indicators and analyses which ensure that lo- These principles and strategies could lead readily to more so-
cal contexts are explicitly taken into account in the reporting phisticated forms of indicators, as well as to a range of pos-
system; enables analysis and reporting of trend data on the sible research questions. For the policy-maker and the health
core set of indicators; enables analysis and reporting by ap- services manager, however, it is important to focus on the de-
propriate peer groupings for comparative performance as- cision contexts, and ensure there is a small, manageable group
sessment (WHO Kobe Centre 2003); has a manageable set of of indicators that can be the basis for meaningful dialogue
core indicators nationally but can also develop optional mod- between key stakeholders.
ules that allow for harmonization and comparison across peer
communities or regions; ensures data collection and dissemi- Acknowledgements
nation processes are ethical; sets benchmarks for performance The information contained in this article is based on Develop-
monitoring where possible; and has an accessible, appealing, ing Gender-Sensitive Health Indicators: Relevance and Prac-
user-friendly reporting style that engages stakeholders. tices, a report funded by Health Canada. The views expressed
Infrastructure and capacity building: It is also important to herein are not necessarily those of the Government of Canada.
have an appropriate infrastructure to support the development The authors wish to thank Su Gruszin (Public Health Infor-
of indicators, collection of data, monitoring and reporting mation Development Unit University of Adelaide) for her
processes, as well as the social processes associated with on- contribution to the paper, and Susan Chaplin for her editorial
going linking between use of indicators for policy develop- assistance.
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