Chapter five: moving from rhetoric to action.

Sustainable improvement in the health systems of developing countries depends foremost on a nation's commitment to the health and well-being of its people. Foreign assistance can play a critical role, however, by focusing policy concern and ensuring that adequate resources are available. Foreign assistance agencies can have an impact on women's health far beyond their monetary contributions by making policymakers aware of the social and economic gains to be realized from lowering rates of female death and disability. Perhaps most important, international agencies can help by sharing lessons gleaned from other countries' experience and by supporting interventions that have proven to be the most cost-effective.

World Bank Programs in Women's Health and Nutrition

World Bank lending for health, population, and nutrition has increased fivefold over the past six years. Between 1986 and 1993 the World Bank allocated nearly $5.7 billion to more than 100 health, population, and nutrition projects with women's health components. These projects represent 90 percent of the Bank's projects in this sector since 1986. Nearly half the projects with women's health components are in Sub-Saharan Africa, one-fourth in Asia, and one-fifth in Latin America. The following are the main areas in which the Bank has supported activities since 1986.

* Safe motherhood. In Indonesia the Bank is supporting the expansion of safe motherhood services to the village level. In Zimbabwe the Bank and other assistance agencies are collaborating to upgrade maternity care facilities, improve referral systems, and train nurse-midwives. In China the Bank funds training in maternal health care for female physicians and assists in making emergency obstetric services more accessible to poor women.

* Family planning. A Bangladesh project supports family planning and maternal and child health services provided by female outreach workers. In Ukraine, where there are 1.5 abortions for every birth, the Bank is discussing a project with the ministry of health to strengthen maternal and child health services and provide contraceptive supplies to reduce women's reliance on abortion.

* STDs and AIDS. In Lesotho the Bank is supporting prevention, diagnosis, and treatment of STDs and AIDS for women of reproductive age, as well as research on effective ways to extend services to commercial sex workers. Brazil's Bank-assisted National AIDS/STD Control Program includes mass media campaigns, education in the workplace, disease surveillance, and research.

* Adolescent sexuality. The Bank has assisted the governments of Lesotho and Nigeria in developing school-based family life education programs and mass media campaigns to persuade adolescents to delay childbearing. Indonesia's population project includes clubs for young people and family planning messages on television, radio, and video aimed at youths.

* Nutrition. Projects in India seek to meet the protein-energy and micronutrient needs of children and lactating women through supplements. In Niger the Bank is supporting the use of labor-saving devices to reduce energy expenditure, and in Malawi an effort is under way to increase food production and income generation in order to increase women's protein intake.

* Gynecological cancers. Programs in Brazil, Chile, Ecuador, Romania, and Venezuela include detection and early treatment of cervical and breast cancer.

* Gender sensitivity in disease control. In India the Bank has financed an innovative program to ensure gender sensitivity in disease-control efforts. The Leprosy Elimination Program provides training for female health and public education workers on the sociocultural factors that impede the identification and treatment of leprosy in women and on ways to promote self-care among women.

* Other sectors. Bank projects also address the broader socioeconomic determinants of women's health. In Bangladesh and Burkina Faso, World Bank-assisted education projects include actions to improve female enrollment in schools. The Bank-financed Human Resource Development Project in Senegal includes a public education program for men and religious leaders aimed at countering negative attitudes toward family planning. In Ghana a Bank transport project provides supplemental food for women laborers.

Newer Bank projects focus more directly on women's health needs and are more comprehensive. For example, the Women's Health and Safe Motherhood Project being developed in the Philippines includes services related to maternal health, family planning, STDs, AIDS, and cervical cancer. The project provides support for NGOs working on women's health issues in the areas of communication, training, logistics, information systems, and partnerships with other agencies. Programs on such emerging issues as violence against women are also being developed.

Increasingly, population projects are adding reproductive health services to existing family planning programs. In Indonesia a new Bank-financed population project builds on the government's successful family planning program with the aim of broadening community-based health services to meet women's needs. The project includes training midwives to provide maternal health care at the village level, providing contraceptive information and services to adolescents, and educating the public on reproductive health and the role of women in society. This expansion represents a shift from the government's earlier strategy, which was more narrowly focused on increasing contraceptive acceptability and use and--since 1986--on promoting private sector provision of family planning services.

Partnership among Assistance Agencies

Substantial and lasting improvements in women's health will require a multisectoral approach. Assistance agencies should coordinate their inputs to maximize each agency's strengths and capabilities. Country programs could benefit from assistance agencies' comparative advantage in such areas as training, technical support, institutional development, and logistics management.

Within the United Nations system, WHO serves as the lead technical agency on health. WHO has prepared technical guidelines on many topics related to women's health, such as essential obstetric services and the Mother-Baby package (WHO forthcoming), and it is currently developing a counseling guide for healthy women. Many of the recommendations in this book are derived from who's work. The United Nations Development Programme (UNDP) supports broad poverty reduction programs, the United Nations Children's Fund (UNICEF) addresses the problems of girls, and the United Nations Population Fund (UNFPA) provides family planning and related services. The World Bank, another member of the UN family, is the largest single provider of international financial assistance in the health sector. In addition, the Bank's strengths include its sectoral and economic analysis examining issues and appropriate strategies and its ability to engage in policy dialogue with core government ministries on resource allocation to support priority programs.

Bilateral agencies are also making important contributions to women's health. The Swedish International Development Authority (SIDA), which gives high priority to sexual and reproductive health, has collaborated with the World Bank and other assistance agencies in country programs, SIDA has developed a strategy on sexual and reproductive health that encourages governments to ensure the availability of essential reproductive health services. Several other bilateral assistance agencies have made reproductive health care a priority in their assistance programs.

International NGOs have national affiliates with close ties to the communities they serve, which often puts them in a good position to ensure that information is made available, controversial issues are addressed, and community needs are recognized. International NGOs can increase awareness, serve as a bridge between national organizations and international resources, stimulate debate and action, assist in the formulation of policy and development of programs, conduct research, and provide technical assistance. International organizations of health professionals such as physicians, nurses, and midwives can be helpful in establishing norms and standards for service delivery and disseminating information on effective approaches and new technologies.

Collaboration among assistance agencies has helped to advance women's health programs. For example, the Liter-Agency Group for Safe Motherhood supports safe motherhood programs. World Bank pilot projects in Bangladesh, Indonesia, and Zimbabwe have strengthened coordination among multilateral, bilateral, and nongovernmental organizations, improving the delivery of maternal health and family planning services. United Nations-sponsored international conferences on women, social development, and population provide a forum for discussing women's health policy and an opportunity for bringing concerns to the forefront of the development agenda and to the attention of a wide international audience.

An Agenda for Women's Health and Nutrition

International agencies can take six major steps to promote improvements in women's health and nutrition: persuade governments to give higher priority to women's health and nutrition; identify an institutional base for women's health and nutrition programs; promote greater use of gender-based data and pilot studies; support cost-effective women's health interventions; increase attention to changing health-related behaviors; and involve women in program planning and implementation.

Knowledge, policy support, and program development related to women's health problems vary greatly among countries. For example, strategies to address issues of new but increasing concern (such as gender violence, management of unsafe abortion, and STDs among adolescents) arc relatively untested and could benefit from external assistance to support consciousness-raising, policy analysis, and pilot programs.

Influencing Policy Priorities

In many developing countries women's health and nutrition rank low among national priorities, even within the health sector. Assistance agencies can help make the case for greater attention to women's health on the basis of the multiple economic and social payoffs described in Chapter 1. Arguments to increase funding for women's health and nutrition programs should stress the far-reaching effects of a woman's poor health and the availability of cost-effective interventions.

Women represent a disproportionate share of the poor and so deserve particular consideration in programs to mitigate the potential adverse effects of structural and sectoral adjustment, particularly in the areas of nutrition and health. Related external assistance could take traditional forms, such as foodprice subsidies and food distribution, or more innovative forms, such as social, health, nutrition, and education interventions designed to reach female children, adolescents, and adults.

Multilateral and multisectoral agencies such as the World Bank reed to extend the policy dialogue beyond the ministry of health to include the ministries of finance, planning, education, and women's affairs, and to other sectors as appropriate. For most women's health issues, policy discussion should also include key decisionmakers and influential groups outside the government, such as health professionals, women's groups, and business leaders.

Creating an Institutional Base

International assistance agencies can designate an individual, department, or committee to take responsibility for women's health and nutrition programs and request that the ministries of health establish a similar institutional base. Such a base can give greater visibility to related programs, coordinate relevant activities, initiate or modify programs, and promote collaboration with other sectors. Because women's health and nutrition programs encompass a variety of service delivery modes and require collaboration with agencies outside the health sector, an institutional base can ensure program direction and coherence.

Encouraging Targeted Research

Without gender-disaggregated data, women's health problems can be easily overlooked. International agencies can support analyses that differentiate between males and females and can request that routine data reports include such differentiation. Disaggregation by age group is also important for program targeting.

Assistance agencies should support studies designed to broaden knowledge of women's health problems, encourage policy dialogue, improve the data base for project design and implementation, and mobilize resources in support of women's health.

In its sectoral work, the World Bank often compiles background material to support discussions on health policy and to assist governments in developing programs. In Brazil, for example, sectoral work documented the dimensions of women's health problems (including inadequate prenatal care, high rates of unsafe abortion, and unnecessarily high rates of cesarean section). In India and Uganda, sector analyses helped to identify women's health problems and constraints on women's use of health services.

Supporting Cost-Effective Services

Foreign assistance agencies can help governments match health services for women to each country's women's nutrition and health status profile. In most developing countries, assistance is needed to expand women's health and nutrition interventions on a national scale and to incorporate new components such as STD services and education on nutrition and safer sex.

Assistance agencies need to examine their own policies and program priorities in light of the cost-effective approaches identified in World Development Report 1993 (World Bank 1993b). For example, few assistance agencies support abortion management, promotion of contraceptives to adolescents, and cervical cancer services. Missing the opportunity to include these services in assistance programs means high economic and social costs. In reorienting their women's health programs, assistance agencies should incorporate a life-cycle approach and give more emphasis to early prevention of disease and efforts to change behavior.

Promoting Behavioral Change

International assistance agencies can play a major role in influencing health agencies to give greater attention to preventive services and to become more involved in behavioral change interventions outside the traditional health care delivery system. Assistance agencies can facilitate links between health agencies and public and private institutions in other fields, provide funds and technical expertise for undertaking behavioral change interventions, and support mechanisms for exchanging information on effective strategies.

Increasing Women's Participation

Assistance agencies can do much more to involve women in health programs. Key areas for action include ensuring that in their own professional staffs women are adequately represented; including women on project planning, monitoring, and evaluation teams; encouraging health ministries to put more women in decisionmaking positions; involving women's organizations and female experts in all phases of program planning and implementation; incorporating mechanisms for soliciting women's feedback; and promoting the procurement of supplies and advisory services from female-owned businesses and women's cooperatives.

Assistance agencies can help to identify areas in which women's inputs would be useful and then facilitate their involvement. In addition, assistance agencies can insist that collaborating agencies publicize job vacancies, new contracts, and other opportunities so that women can compete for them. Links with women's groups, and particularly with women's income-generation projects, should be explored. For example, women's groups could create clinic signs, banners, badges, and other promotional materials.

Regional Problems and Priorities

Although women throughout the developing the world share common health problems, the key concerns vary from region to region. So, too, do the priorities for action.

Sub-Saharan Africa

Sub-Saharan Africa has the world's highest fertility and maternal mortality rates. Maternal health problems are exacerbated by poor prenatal and delivery care and by unsafe abortion, which accounts for 20 to 40 percent of all maternal mortality in the region. African countries also have some of the highest adolescent pregnancy rates in the world. By age 18 more than 40 percent of females in Cote d'Ivoire, Mali, and Senegal have already given birth (Population Reference Bureau 1992).

STDs and HIV/AIDS are a major cause of disability and death among African women and account for more than half the STD burden among women in developing countries. Infertility and cervical cancer, often caused by STDs, are common in some countries. Female genital mutilation is practiced in several countries of the region.

Priorities for improving women's health in Africa include increasing access to maternity care, family planning, safe services for abortion management, and STD services, and preventing genital mutilation, HIV infection, and violence against women. To deliver the necessary clinical and preventive services--and especially to extend services to rural areas--many countries will need to strengthen their health care infrastructure. Special initiatives for adolescents are needed because of the large numbers of young females at risk and the great potential for improving health through the postponement of sexual activity and childbearing, safer sex practices, and good nutrition.

South Asia 

Throughout most of South Asia, women of all ages suffer the effects of gender discrimination. Discrimination and neglect are estimated to cause one in six deaths of female infants in Bangladesh, India, and Pakistan. In some areas gender-specific abuse is common, including sex selection through abortion, female infanticide, and injury and death associated with wife abuse and dowry demands Other forms of discrimination, such as giving less food to female household members, restricting their access to health services, and imposing more physical work on girls and women, are also common. Women's lower status is also evident in lower school enrollment and retention rates.

Many women lack access to health care, especially maternity care, contraceptives, and safe services for abortion management. South Asia has a higher proportion of growth stunting among girls and anemia among pregnant women than any other region. Only one in three women receives prenatal care or has a trained attendant at delivery. Consequently, rates of death and disability associated with pregnancy and childbirth are high. STDs are widespread, and HIV infection is on the rise.

The key component of an agenda for women's health in South Asia is for health care providers to combat the effects of discrimination by expanding access to health services through such measures as training female health providers, conducting community education and outreach programs, and publicizing the importance of protecting female health. Expanding and improving the quality of women's health services are also important Health programs need to give greater attention to the nutritional status of young girls and adolescents, as well as to detection and prompt referral of pregnancy-related complications. Intersectoral initiatives are needed to address the problems of early marriage and violence against women.

East and Southeast Asia

In certain countries, such as Laos and Cambodia, women's health conditions resemble those in South Asia or Africa. In other parts of East and Southeast Asia, women are attaining levels of health, education, and social status typical of middle-income countries. In East Asia 95 percent of women benefit from trained assistance during delivery, although less than half of all deliveries take place in institutions. There are considerable regional and urban-rural differences, however, reflecting the influence of lifestyle and economic status on disease patterns. For rural women, infectious diseases are a major cause of death, while urban women have higher rates of cardiovascular and cerebrovascular diseases and cervical and breast cancer. East Asia has the highest incidence of cervical cancer among the developing regions.

Maternal morbidity and mortality rates remain high in several countries in the region because adequate maternity care is not widespread (WHO 1991a). Contraceptive prevalence is relatively high in Indonesia, the Republic of Korea, Malaysia, and Thailand, but in some countries, such as the Philippines, a full range of contraceptive methods is not available. HIV/AIDS is growing more rapidly in Southeast Asia than in any other part of the world (USAID 1991). Increasingly, girls in their early teens are entering prostitution, often because of economic hardship or force.

Smoking and alcohol abuse among women are growing concerns in some parts of East Asia, as multinational tobacco firms increasingly target advertising to women. Women's health status is also influenced by discriminatory practices, such as sex selection in China and the Republic of Korea and female genital mutilation in parts of Indonesia and Malaysia.

Priorities for women's health services are likely to vary considerably within the region, depending on the existing health infrastructure and policies. In countries with limited services, health agencies will need to concentrate on expansion and improvement to ensure access to maternity care, family planning, and safe abortion services. Most countries in the region need to give additional attention to early prevention of disease among young and adolescent girls, especially by stressing the dangers of unprotected sex, tobacco use, and substance abuse. Where resources permit, cancer screening and treatment should be provided.

The Middle East and North Africa

Fertility rates in the Middle East and North Africa are among the highest in the world, almost equal to those of Sub-Saharan Africa. High fertility and early childbearing contribute to poor health among women. Contraceptive prevalence rates are low, and access to health care is poor. Cultural norms prevent many women from using existing health services. Female genital mutilation is practiced in some areas. Women's low status and low literacy levels, as well as lack of information and data on women's health issues, are major obstacles to improving female health.

The main priority in the region is to increase women's access to health care by better meeting their needs for female health care providers, convenient locations, and information on healthy behavior. Better maternity care is another pressing need in most countries. Women could also benefit substantially from improved access to contraception and a broader choice of methods.

Latin America and the Caribbean

In many Latin American countries, noncommunicable diseases cause more deaths and disability to women than communicable diseases and maternal and perinatal causes combined. Nevertheless, maternal mortality ratios in the region are higher than in other areas with comparable income levels, due in large part to unsafe abortion. Fertility is moderately high in most countries. Services are often inefficient and of poor quality. Tertiary and higher-level health facilities are overutilized for maternity care, and some countries have abnormally high rates of cesarean section deliveries, which adds to women's health risks.

Unwanted pregnancy, particularly among adolescents, is a serious problem. Although abortion is illegal in most countries in the region, abortion rates in some areas are among the world's highest. STDs are also a growing concern. Although the aids epidemic is in the early stages, the number of cases among women is projected to rise sharply by the year 2000 (PAHO 1993). Violence against women is increasingly recognized as a source of poor mental and physical health.

As the proportion of older people rises, problems such as cardiovascular and cerebrovascular diseases are becoming more significant among women. Breast cancer is increasingly common, particularly in the higher-income countries. Cervical cancer is also on the rise. Women's risk of disease is raided by such factors as high rates of smoking, obesity, and anemia; almost one in three women in the region is anemic (PAHO 1993).

The agenda for improving women's health in Latin America includes ensuring that low-income women have access to health care services, especially maternity care and family planning; developing strategies to meet the reproductive and sexual health needs of adolescents; addressing the problems of unwanted pregnancy and unsafe abortion; and promoting healthy behaviors, such as good nutrition, safer sex practices, and avoidance of smoking and obesity. Some countries will need to give more attention to specific problem areas such as overuse of tertiary health care facilities, unnecessary medical procedures, HIV/AIDS, violence against women, and inadequate assistance to women beyond reproductive age, including management of cervical and breast cancers.

Eastern Europe and Central Asia

Women's health status in Eastern Europe and Central Asia is lower than might be expected, given high levels of female education and a reasonably well developed health infrastructure. Shortages of drugs and supplies are common, as are outdated health care practices that are not always cost-effective. Although almost all women receive prenatal care, excessive emphasis is placed on diagnostic tests and not enough on counseling and prevention. Abortion, which is legal in many countries in the region, is the most common method of fertility regulation because contraceptives are largely unavailable; in fact, there are more abortions than live births. The needs of divorced, widowed, and elderly women require greater attention. In several countries women's health status is worsening, and their access to such services as legal, state-subsidized abortions is being threatened.

Key initiatives in a women's health agenda for the region include making family planning information and services more widely available to reduce reliance on abortion, providing more training to improve clinical practice, ensuring that adequate drugs and supplies are available, increasing the emphasis on preventive health care (particularly avoidance of tobacco, the value of exercise, and good nutrition), and addressing the needs of women beyond reproductive age.

Moving Forward

The task ahead is to apply what we know about women's health needs to concrete actions. We know that many women's health problems could be prevented or mitigated through low-cost interventions. We know that these interventions can work in low-income settings. We know that investments in women's health have multiple payoffs for the national economy, the community, individual families, and the next generation. What remains to be done is to pierce the veil of indifference and inertia that inhibits women's health and nutrition programs. Given a mandate for change, agencies and individuals can advance new initiatives and support more effective allocation of existing resources. For the countless millions of women struggling to meet their families' daily needs and make a better life for themselves and their children, such changes cannot come too soon.