Moser, Caroline

Tinker, Anne

English

Digital Commons @ American University Washington College of Law

GENDER PLANNING: DIFFERENT POLICYAPPROACHES TOREPRODUCTIVE HEALTHCAROLINE MOSER*ANNE TINKER**MS. MOSER. I am neither a lawyer nor a health expert, so reallyI am somewhat of an imposter in this symposium. I have worked,however, on gender issues in developing countries over the last twodecades, particularly on the development of a rationale to integrategender into planning. I would like to focus, therefore, less on thelegal framework for women's reproductive rights per se, and more onthe entry points for the implementation of a rights-based framework forreproductive health. In an operational agency, this is a primaryconcern.Which health-based issues are the most appropriate entry pointsfor action? To answer this question I will introduce the methodolog-ical framework for gender planning that I have developed. AnneTinker, my colleague, will then examine the extent to which she hasfound it a useful framework in terms of World Bank work in thehealth sector. In this way, together, we will identify whether suchmethodological tools are useful in deconstructing complex issuesrelating to reproductive health. This symposium has provided us withan interesting opportunity to try and work collaboratively, fromdifferent perspectives, on the same issue.I want to start by raising three sets of issues. First, whose rights arewe talking about, and whose needs? How are these identified? Arethey global, national, or local in nature? How far are womenthemselves involved in the definition of these rights?Second, how do we achieve change? Is it best achieved top down,through what has been termed "equity," through changes in the legal* Senior Urban Social Policy Specialist, Urban Development Division, World Bank.** Senior Health Specialist, Population Health and Nutrition Department, World Bank.1113THE AMERICAN UnrsIy LAW RmEW [Vol. 44:1113framework? Or is it best achieved bottom up, through what has beentermed "empowerment?"Finally, are we talking about women, or are we talking aboutgender? There is a very big difference between these two concepts.The last decade has witnessed an important debate concerning theshift from what is called "women in development" (WID), whichfocuses on women as a special group-often in isolation-to a"gender and development" (GAD) approach. This focuses on gender,by which we mean not men or women, but the relations betweenthem-and the way these are socially constructed. When we look atwomen as victims, for example, are we looking at women on theirown? Or are we not looking at the relationship between men andwomen? I am uncertain whether this symposium is concerned withthe issue of rights for women, or about gender rights-rights thatrelate to men and women and the relationships between them.I want to introduce three tools that I have developed over the lastdecade working on gender planning, elaborated in greater detail intwo recent publications.' I have worked not only as an academic butalso as a trainer, not only with multilaterals and bilaterals but alsowith nongovernmental organizations (NGOs). I have tried totranslate complex feminist debates into practical planning lan-guage-to make it more accessible to development practitioners.The first tool I find useful is to differentiate between the differentroles and relations men and women have in the household and insociety. Men generally have the primary productive role; women, incontrast, tend to have three roles. They have a reproductive role,which obviously links to caring for family health needs. Most poorwomen also have a productive role as well. Finally, women have whatI have called a community managing role. This relates to the unpaidwork women undertake within their communities, managing the deliv-ery and maintenance of social services, particularly in the area ofhealth and nutrition. At the community level, men also have animportant role, generally in local politics. Gender divisions of labor,therefore, exist not only within the household, but also withincommunities.The implications of this are twofold. First, women balance threeroles and responsibilities, with important implications for time man-agement. Second, much of the work undertaken by women is not1. Seegenerally CAROLINE MOSER, GENDER PLANNING AND DEVELOPMENT: THEORY, PRACrIcEAND TRAINING (1993); Caroline Moser, GenderPlanning in the Third World: Meeting Practical andStrategic Gender Needs, 17 WoRLD DEv. 1799, 1799-1825 (1989).1114REPRODUCTIVE HEALTH PLANNINGvalued-only productive work with its exchange value tends to havea value. My particular interest in community managing relates to theunpaid nature of such work. Many of you will have seen primaryhealth care programs with paid, mainly male, doctors and unpaid,mainly women, community workers with responsibility to implementwhole programs.If men and women have different roles in the household andsociety, then logically they also have different needs. The second toolin gender planning relates to gender needs, and the distinctionbetween practical and strategic gender needs. Practical gender needsare the needs that women themselves identify in their socially ac-cepted roles in society.If you ask a woman what she needs, she may reply, for example,that she needs water. In fact, her whole household needs water.Because in her reproductive role, however, securing water is herresponsibility, consequently she identifies this as her need.Strategic gender needs are very different. These are the needs thatwomen identify because of their position in society. These are theneeds, then, that assist women to achieve greater equity in theirrelationship with meft in society. It is very important to recognizethat such needs vary widely not only within different contexts, but alsobetween different classes and ethnic groups.The third tool relates to the underlying policy approaches towomen in development. Over the past twenty years these havechanged, not in isolation but reflecting changes in macro-leveleconomic and social policy approaches to Third World development.Five different approaches can be identified. In describing each, theimportant question concerns the extent to which they provide anentry point for health concerns. Are there different entry points indifferent contexts, utilizing different policy approaches?Of the five approaches, the earliest and most popular is the welfareapproach. This is based on three assumptions: first, that women arepassive recipients .of development, rather than participants in thedevelopment process; second, that motherhood is the most importantrole for women in society; and third, that child rearing is the mosteffective role for women in all aspects of economic development.This approach focuses entirely on women in their reproductive role,and identifies the mother-child dyad as the unit of concern.The second approach is equity, originally introduced during the1970s. This approach recognizes that women are active participantsin the development process, who through both their productive andreproductive roles provide a critical, if often unacknowledged1995] 1115THE AMERICAN UNIvRSrIY LAW REvIEW [Vol. 44:1113contribution to development. This is a "top down" approach. Itfocuses particularly on reducing inequality between men and womenand meeting strategic gender needs through legislative measures. Inchallenging women's subordinate position, the equity approach hasbeen considered threatening. It was widely criticized by many as West-ern feminism, and was not popular with many governments.It was quickly replaced by the antipoverty approach, a "toned-downversion of the equity approach"2 in which the economic inequalitybetween men and women is linked not to subordination, but topoverty. The focus here shifts to women's productive role, toreducing income inequality, with the prioritization of income-generating projects and increased access to productive resources.The fourth approach is the efficiency approach, now the predomi-nant WID approach, particularly since the debt crisis of the 1980s.Here the emphasis shifts away from women and towards development,on the assumption that increased economic participation for womenis automatically linked with increased equity. Efficiency recognizesthat development needs women, even if women's condition is notnecessarily improved by development.3 The efficiency approachaddresses a diversity of practical gender needs relating to women'striple role, but often assumes elasticity of women's time and theircapacity to extend their working day to undertake both paid andunpaid work.The final approach is the empowerment approach. Differencesbetween empowerment and equity are important to identify. If theequity approach aims to meet strategic gender needs through "topdown" state legislation, the empowerment approach, in contrast,addresses strategic gender needs through the "bottom up"interventions of women's organizations. The origins of the empower-ment approach are derived less from Northern research and morefrom the feminist movement and grassroots organization experienceof women in the South. It identifies power less in terms of domina-tion over others (with the implicit assumption that a gain for womenimplies a loss for men) and more in terms of the capacity of womento increase their own self-reliance.I want to end by emphasizing that although these five differentapproaches were developed during different historical periods, all arestill in use. One policy approach is not necessarily a priori "better"2. Mayra Buvinic, Women's Issues in Third World Poverty: A Policy Analysis, in MAYRA BUVINICET AL, WOMEN AND POVERIY IN THE THIRD WORLD 14 (1983).3. See P. MAGUIRE, WOMEN IN DEVELOPMENT: AN ALTERNATIVE ANA Isis (1984) (mimeodocument).1116REPRODUCTIVE HEALTH PLANNINGthan another. They have different underlying rationales for develop-ment; they relate to different women's roles; they address differentpractical and strategic gender needs; consequently, they provide alter-native entry points for addressing women's reproductive healthissues.MS. TINKER- What are some of the entry points for policy andplanning in reproductive health, using a gender analysis framework?First is the welfare approach, which focuses on women's roles asmothers. The objective is to reduce fertility, promote breastfeeding,and improve family health. With the emphasis, however, on women'sreproductive role, women's other roles are not addressed, includingalternatives to childbearing or combining work with breastfeeding andchildcare, for example.The second approach is based on equity, where women's inferiorsocio-economic status-relative to men-is the focus. The objectiveis to reduce discriminatory practices affecting women's access tohealth services. The emphasis is on laws and policy dialogue. TheWorld Bank has been discussing with India, for example, the age ofmarriage, and with some African countries, the laws and policiesrelated to female genital mutilation. As we all know, however, whilethe law sets the standard and can provide an enabling environment,behavior is much more difficult to change.The use of amniocentesis or ultrasound for the purpose of sex-selective abortion, which is being practiced in India, China, andKorea, for example, is equity confounded. When it is outlawed asdiscriminatory, it deprives women of the right to choose.Third, women are disproportionately poor and their potentialunderutilized. The objective of the antipoverty approach is to increasetheir contribution to development and reduce economic constraintson access to health services. Examples of this approach include ironsupplementation in the cotton mills of China or the tea plantationsof Sri Lanka, so that women are no longer anemic, and as a result aremore healthy and more productive.Another example of the antipoverty approach is the safety-netprotection for poor women. The Bank-assisted project in China, forexample, will ensure that women with life-threatening pregnancy-related complications will be treated regardless of income level. Theyare now being turned away at matemal hospitals because they cannotpay. The antipoverty approach does not deal adequately with thefundamental issue that women are generally paid less for equal work,1995] 1117THE AMERICAN UNIvERsrrY LAW REVIE [Vol. 44:1113and that much of their work, which is reproductive and domestic, isnot renumerated.Fourth, women's health is cost effective. With the efficiencyapproach, the objective is to achieve high impact at low cost. TheBank and the World Health Organization have undertaken disease-burden studies and cost-effectiveness analyses of different interven-tions to improve the health of adults and children. They found thatamong all interventions for adults, the most cost-effective were thereproductive health interventions for women aged fifteen to forty-four. This approach is supply-driven, emphasizes technology, and isvery effective with ministers of finance and planning.The cost-effective argument needs to be tempered with adequateregard to social and cultural issues that affect women's access to, anduse of, services, such as the sex of the provider and the opportunitycosts for the woman to seek care. The value of her time, for example,has to be considered, given her many responsibilities.The final approach is empowerment, which views women as potentialpositive agents of change. Health, particularly in combination witheducation, can increase self-reliance and potential. The objective isa multifaceted life-cycle approach, emphasizing women's involvementin improving their health. Focus-group discussions and the involve-ment of women and nongovernmental organizations are part of theplanning process. A more integrated approach is taken, whereby, forexample, adolescent fertility is viewed in the context of education,employment, and self-esteem. Nontraditional issues, such as violenceagainst women, are receiving increasing attention.This approach requires a longer-term strategic view, more coordina-tion between sectors, and the sharing of power, which can be verythreatening. Governments and assistance agencies, generally cen-tralized, hierarchical, and drawn on sector lines, are not generally setup to support this approach.The U.N. Population Conference in Cairo endorsed this approach,by asserting that the achievement of population stabilization andoverall development goals really depends on empowering women.Currently, the fastest growing sectors in the Bank are health andeducation, with a particular emphasis on women. The Bank'sassistance program now represents an expanded approach, whichviews reproductive health more broadly than population and also seesthe linkages between health and education. In fact, there are now100 projects with women's health components in the Bank, ascompared to six similar programs only five years ago.1118REPRODUCTIVE HEALTH PLANNNGWomen's NGOs are becoming more involved in our project-development work. For example, in the Philippines, the result of thesafe motherhood working group to help develop a women's healthproject, which has recently been negotiated with the Government, isa study on violence against women. This is what the women wanted.It was not in the initial plan.Our current discussions in India are very much focused on abroader approach to population, shifting away from targets forcontraceptive prevalence to quality of care and enabling women totake greater control over their lives. A number of our recentpublications reflect this change, such as A New Agenda for Women'sHealth and Nutrition and a paper we commissioned on Violence AgainstWomen: The Hidden Health Burden.All of the entry points to improving women's health can contributeto the planning process. Some traditional planners, however, havetended to adopt too much of a "top down" approach to solving whatthey see as the development problem, of which women are considereda part. The empowerment approach, on the other hand, involveswomen in the solution, recognizing them as agents of change fortheir own health, as well as the health of their families and communi-ties.1995] 1119

Transcript: Gender Planning: Different Policy Approaches to Reproductive Health Conference on the Interventional Protection of Reproductive Rights: The Utility and Limits of Rights Based Approaches

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Transcript: Gender Planning: Different Policy Approaches to Reproductive Health Conference on the Interventional Protection of Reproductive Rights: The Utility and Limits of Rights Based Approaches

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