By Urvashi Gandhi
Health is one of the most critical parts of the Sustainable Development Goals to which all governments and agencies across the globe have committed to achieving by 2030. Women and girls are an important part of health programs and services, as they are not just consumers of services but also a part of service delivery. Health programs have been built on universal principles and frameworks, with the aim of reaching the maximum number of individuals. But sometimes these programs are more focused on reproduction and maternal health, including service delivery, and neglect to include women and girls as individuals, or acknowledge their personal agency. This critical aspect should be an integral part of ideating, planning, policy-making, programming and implementation.
It is important to look at some of these nuances that are related to gender norms and address them so that women and girls from the most marginalized communities may also benefit.
Gender is a key determinant of health inequities. Gender influences the relationships between people, and the distribution of power in those relationships, thus impacting health-seeking behaviors of individuals. It also intersects with socio-economic status, marital status, age, ethnicity, disability, sexual orientation, etc. One can see its manifestation when married adolescent girls find it difficult to negotiate safer sex or pregnancy with their partners and/or have no access to information and services for contraception. This makes them vulnerable.
Gender discrimination is based on gender norms, which are ideas about how women and men should be and act. It governs the behaviors of individuals while accessing health related services and information. Internalized early in life, gender norms can establish a life-cycle of gender socialization and stereotyping. Gender norms thus influence the health and well-being of women and girls across three domains:
- How women and girls themselves and their families view their health needs
- How much agency and decision-making women exercise over their bodies and the choices they make
- What challenges they face in accessing health-related information and services
An example of gender norms is seen in the importance given to the notion of virginity for girls; virginity is directly related to the perceptions of purity, family honor, and marriageability of a girl. Fears over sexual violence, abuse or harassment exist and are seen as risks to this purity. Therefore, to preserve this purity, adolescent girls are married off before the age of 18 years or just as soon as they turn 18. A UNICEF report shows that while child marriage rates halved in 2018, this still meant that nearly 1.5 million girls got married before the age of 18. And for these adolescent girls who are married off early, there is a huge taboo in accessing information on sexual and reproductive health services. The taboos extend to adolescent girls and women attempting to express desire and negotiating with their partners, including for sexual and/or reproductive choices. The norms and taboos make adolescent girls and women more vulnerable to risky sexual behaviors, unprotected sex and unwanted/unplanned pregnancy, and/or unsafe abortions. This, in turn, influences their health-seeking behavior and also has a long-term impact on their health.
In terms of family planning, despite the above taboo, statistics show that there is almost an overall dependence on women. According to the National Family Health Survey – 4, the male versus female ratio for sterilization stood at 1:52, with “female sterilisation being the most popular contraceptive method”. This directly impacts the health and agency of many women.
Similar situations come up time and again in a woman’s life, which impact her health. These situations limit her choices, access to contraception, when and if she would want to have children, how many children she would want and even her ability to say yes or no to sex with her partner.
In rural areas, Frontline Workers (FLWs) are the key service providers and their training is critical for the kind of information that is shared with the communities where they work. It is important to address the FLWs’ own biases and prejudices regarding adolescent girls accessing sexual and reproductive health information and services. It is also important to build their capacities on how to promote a healthy dialogue on issues related to sexual and reproductive health and identifying violence with young people in communities where they work.
Gender norms also do not prioritize women’s and girls’ health needs, but see them merely in their reproductive role to give birth to a healthy next generation. India has very strong laws on sex selection and also relatively progressive laws on abortion. Yet, women and girls find it extremely difficult to make an informed choice, and/or access quality services in a non-judgemental manner. Son preference is high and has resulted in a lower child sex ratio during the past few decades. According to the 2011 census, the current sex ratio is 940 women per 1,000 men.
This mind-set continues to see control over women’s choice to abortion being affected and/or limited by her marital family’s choice. Their decisions are mostly determined and influenced by what their husband’s family wants.
Laws, services and policies alone will not create this change; the need is to change the mind-set of people, of how they view the health of women and girls, the choices women have and make and the agency they have. It is important to change and challenge norms by working towards and making the health needs of women and girls a priority.
Here is what we believe global development professionals must do to change this scenario:
- Look at the health of women and girls holistically and don’t just focus on the reproductive cycle (menstruation to menopause). A similar message needs to travel from the policy-making level to the grassroots level.
- Consider various aspects of health, including emotional, mental and physical.
- While drawing up programs, schemes and policies on women and girls health, involve them during the planning, decision-making and implementation process. Base interventions on the lived experiences of women and girls.
- Make health services more accessible by basing them on intersectional identities. For the most marginalized girls and women, use lenses like gender, disabilities, class, race and more.
- Work towards changing the mindset of frontline workers who are involved with the last-mile delivery of services and are the ones who work directly with women and girls.
- Ensure easy access to complete, correct, unbiased and confidential information & services related to sexual and reproductive health and rights for everyone so that they can make informed choices and decisions about their own bodies.
By applying the above mentioned points, we would be investing in the health of women and girls as individuals, and not just as potential mothers who can give birth to healthy children. We need to start young and share with adolescents on how to take care of themselves for their overall health and well-being.