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GPIH tries to answer two questions:
· What makes women and men more vulnerable to a given health problem or issue? (Why men, being ‘men’ are more prone to develop heart problems for example? Why being a ‘woman’ makes her vulnerable to certain types of water related skin problems?)
· Having fallen victim to these problems or conditions once, what prevents their recovery, again, being ‘woman’ or ‘man’ in a particular community? or influences their chances of recovery? Their attempts at recovery? (Why is it so difficult for women to get rid of Anemia, even though technologically and logistically, it may appear to be a simple matter?)
Figure
1
But we are presuming that these health problems (or issues / conditions) affect women or men disproportionately, ie. that there is a gender differential in the incidence of various health issues. We are also presuming that there are enough health services available to both women and men. So the first step is to establish (or question) these two assumptions, before we can ask the above two core questions. Broadly, this constitutes the four steps in gender analysis of Health.
Figure 2
The GPIH tools can be derived directly from the four steps above and are matrix based. The matrix design is meant to stimulate discussion and ensure exhaustive analysis.
Figure 3
All the four tools can and should be adapted to local realities and should go beyond gender differentials to include other axes of social inequities like, age, caste, class, ethnicity, creed, physical ability etc.
Next, factors affecting who (woman or man? girl or boy?) gets ill, could be operating within households, in communal settings / structures or they could be inherent in the bigger institutions like markets, state policies etc. So the context of the analysis becomes an important second dimension of GPIH, as shown below. (Fig. 4, last shaded column)
A third and equally important dimension is: the specific locus of these factors – What is it about women’s and men’s activities, their access and control over resources for example which makes them vulnerable to a certain health problem or condition? Other loci are – environment (pollution in kitchen for women and in mines for men, for example), bargaining positions and gender norms prevalent in the particular community. (Fig. 4, First shaded column).
These factors and contexts, the columns on left and right above, acquire different meaning in step 3 and 4. In step 3 we wish to ascertain the factors at household level, in women’s environment, which increases her vulnerability (compared to men) to respiratory infection or conjunctivitis (air pollution related to cooking, a gender role).
While in step 4, we are looking into the factors, which make it harder for her (compared to men) to procure treatment because of her poor bargaining positions in households. So, while discussing responses to illness, Available Health Services becomes an important context to be considered, not so in step 3 where we are considering scenario before people fall sick. Similarly environment is an important factor contributing to ill-health (step 3) but has no relevance in step 4- factors affecting response to ill-health.
These little but significant differences can be seen in the tool 3 and tool 4 matrices. Let us repeat that similar questions in both dimensions of factors and contexts can and should be asked while analyzing ill-health among men. The following section discusses the meaning of these factors and contexts in both step 3 and 4.
Understanding the Factors (Left column, Figure 4 above)
Environment
“Environment” refers to women’s and men’s living and working context.
Significant Questions:
· Living Conditions – Access to clean water, sanitation, ventilation, hygiene?
· Working conditions – consider issues such as use and design of equipment, ventilation, exposure to noise, hygiene arrangements, working hours, terms and conditions, holiday entitlements, exposure to risk.
· Geographical location and climate
· General social and economic conditions
· Not just physical dimension but also psycho-social environment eg. harassment at workplace.
Activities
“Activities” refers to what women and men do at home and at work. Different societies assign different roles to women and men:
· “Productive” roles i.e. paid work or production of goods (or services) for subsistence or sale
· “Reproductive” roles i.e. domestic tasks including cleaning, cooking, caring for children and sick people.
· “Community” roles i.e. participating in various tasks associated with managing community organizations and operating and maintaining community services.
Different activities carry different risks of infection, physical and mental stress and illness.
Significant Questions:
· What do men and women do?
· Are there health risks associated with particular activities?
· Are there health risks associated with excessive burden of work?
· Are there health risks associated with lack of work?
Resources
“Resources” refers to gender differences in women’s and men’s access to and control over resources such as money, transport, time, information, political power and influence.
· Access refers to the ability to use or access a resource.
· Control refers to the ability to make decisions about how a resource will be used.
Significant Questions:
· Are there differences in women’s and men’s access to or control over resources that affect their ability to protect their own health?
Bargaining Positions:
“Bargaining Position” concerns the extent to which women and men are in a position to act in their own best interests when it comes to protecting their own health. This depends on personal perceptions of best interests, but it also depends on an individual’s ability to make decisions, command resources and, at times, influence the behavior of others.
Significant Questions:
· Are women and men able and willing to protect their own health? Are there significant gender differences in women’s and men’s ability to protect their own health?
· To what extent can women and men make independent decisions regarding their health and its protection? Are there gender differences in their ability to negotiate with others about their health protection?
Gender Norms
“Gender Norms” refers to norms and beliefs about women’s and men’s capacities, characteristics, roles and interests. Norms are prescriptions or guidelines for social behavior which are usually implicit, or unspoken. A social norm is not necessarily actual behavior and norms behavior are not necessarily simply the most frequently occurring pattern, but are influenced by the interests and values of the most powerful groups in society.
Significant Questions:
· Are there accepted cultural norms or practices that affect women’s and men’s health, or women’s and men’s ability to protect their health?
Understanding the
Contexts
The above five categories can be relevant at a number of different levels of society – and should be considered in each of these contexts:
· Household – refers to family groups and what goes on in the home
· Communities – refers to groups of people whose association may be based on geographical locations, working activities, ethnic or cultural links.
· States, markets and international relations refer to the wider contexts – national and international laws, Government structures and services, the private sector, NGOs and the services they provide. This focus goes beyond health sector policies and services.
Activities
“Activities” concerns how women’s and men’s roles and responsibilities affect their perceptions of illness and their choices concerning treatment.
Significant Questions:
· Do women’s and men’s roles and responsibilities affect their willingness/ability to admit to being ill, and to seek treatment?
Bargaining positions
“Bargaining positions” concerns how women’s and men’s bargaining positions affect their perceptions of illness and their choices concerning treatment.
Significant Questions:
· Does women’s and men’s bargaining power affect their willingness/ability to admit to being ill, and to seek treatment?
Resources
“Resources” concerns the ways in which women’s and men’s access to and control over resources affects their perceptions of illness and their choices concerning treatment.
Significant Questions:
· Do women’s and men’s access to and control over resources affect their willingness/ability to admit to being ill and to seek treatment?
Gender Norms
“Gender norms” includes local perceptions of health and illness as well as norms and values which influence decisions on seeking treatment.
Significant Questions:
· How do local perceptions of illness and local norms concerning illness and treatment affect women’s and men’s willingness/ability to admit to being ill, and to seek treatment?
The above four categories concern men’s and women’s choices and behavior in response to illness. These decisions are largely made in the context of households and family groups, in the context of community norms. However it is also important to recognize that the kind of health care available will also affect decision making regarding health and treatment.
Available Health Services
In most contexts, people are able to seek care from a variety of sources which may include formal public and private health services, traditional health services of various kinds, chemists, drug-sellers, healing practices etc. In each context, it is important to identify the range of services available for health care. Where people seek care will depend on their perceptions of the relative accessibility and acceptability of the different services and these perceptions will be affected by the gender related factors in the categories as listed above.
Consider the following aspects:
· What are the various health services and facilities, private and public, formal and informal, traditional/indigenous and allopathic/bio medical available for treatment?
· Consider ways in which gender differences in each of the categories listed above might affect women’s and men’s choices concerning where they go for health care treatment.
· Gender differences in men’s and women’s activities will affect choices concerning health care treatment on the basis of location and timing of services
· Gender differences in men’s and women’s bargaining power may affect decisions on the basis of value for money, confidentiality and perceptions of effectiveness.
· Gender differences in men’s and women’s access to and control over resources may affect decisions on the basis of cost and location.
· Gender differences in perceptions of health and norms concerning health care will affect perceptions of quality and appropriateness.