Gender Analysis of Health

Swayamsiddha
IDRC-BAIF Gender Perspective in Health (GPIH)

aka Gender analysis of Health
A Three Day Workshop Manual
For Middle and Field level Functionaries
Contents
Section 1: Introduction.............................................................................................................................................. 4
1. Introduction ................................................................................................................................................ 4
2. Swayamsiddha & GPIH.............................................................................................................................. 5
3. GPIH Module and its evolution ................................................................................................................. 5
4. Intended audience ..................................................................................................................................... 6
Section 2: Basic Concepts........................................................................................................................................ 7
The First Dimension............................................................................................................................................. 7
The Four GPIH Tools ...................................................................................................................................... 8
The Second & Third Dimensions ........................................................................................................................ 8
Section 3: Steps & Tools......................................................................................................................................... 15
Description of GPIH Steps................................................................................................................................. 15
Step 1: Patterns of Ill-health (Who gets ill, when and where) ....................................................................... 15
Step 2: Are there adequate, affordable services available to women & men? (Health Service Analysis). 16
Step 3: Factors affecting who gets ill- women or men? ................................................................................. 17
Step 4: Factors affecting responses to ill-health ............................................................................................ 18
Where Next? From Analysis to Program Planning ......................................................................................... 19
Section 4: Prototype Workshop ............................................................................................................................. 20
Workshop Schedule........................................................................................................................................... 21
A Typical GPIH workshop.................................................................................................................................. 22
An Interactive exercise for Tool 3 & 4 review .................................................................................................. 33
Section 5: More On GPIH Tools.............................................................................................................................. 37
Section 6: Case studies .......................................................................................................................................... 40
Section 7: More Resources..................................................................................................................................... 45
WHO SEAR Gender Analysis Matrix (GAM) ..................................................................................................... 45
Working with Men in workshop setting............................................................................................................ 52
Internet Resources on Gender.......................................................................................................................... 54
Section 8: Optional Reading................................................................................................................................... 56
Major trends in the field of Health..................................................................................................................... 56
Other Gender Analysis Frameworks ................................................................................................................ 59
Appendix .................................................................................................................................................................. 69
Introduction to BAIF........................................................................................................................................... 69
Swayamsiddha Approach.................................................................................................................................. 70
Rapid Index
If you are short on time, you may scan At leisure you may wish to browse the
through following sections, before conducting following sections, for more background
a GPIH workshop: information:
What is GPIH ? Basic concepts..7
How to conduct a three day GPIH Background reading in Health – trends in
workshop? Methodology..22 last five centuries..56
Schedule for 3 day workshop..21 Energizers – interactive games to help
Case studies (English) to be used with participants refocus..62
GPIH workshop – 2 case studies in 2 Gender Analysis Matrix (WHO/SEAR) as
parts (women’s, Men’s)..40 applied to Health..45
Hindi translations of the case studies as Working with men- points to consider..52
above..64 Internet resources on Gender and
Some considerations while using GPIH Health..54
tools..37 Ready made examples for tools..33
Gender Analysis in non health
contexts..59
Acknowledgements
This manual is inspired by ‘Guidelines for the analysis of Gender & Health,
January 1999’ issued by Liverpool School of Tropical Medicine, UK. Evolution of
Gender Perspective in Health (GPIH) was a collaborative effort between
Swayamsiddha, a women’s health and empowerment project funded by the
Canadian International Agency (CIDA) and the International Development Centre
(IDRC) and implemented by the BAIF Research Foundation.
Central Project Coordination Team (CPCT), specifically Ms Savita Kulkarni and
Dr Jasmine Gogia, who were facilitating gender mainstreaming and Health
programs respectively in Swayamsiddha / BAIF during evolution of GPIH, deserve
sincere thanks for brain storming, critiquing, vetting and supporting it in so many
ways.
We must sincerely thank the nine Swayamsiddha partners and their project
teams, who shaped the GPIH with every workshop: BIRD-K, Karnataka; BIRD-
UP, Chitrakoot; CHAITANYA, Maharashtra; DHRUVA & GRISERV in Gujrat;
HMF, Andoor, Maharashtra; MITTRA, Maharashtra; RRIDMA, Rajasthan;
SPESD, MP.
Ms Katherine Hay, IDRC deserves special thanks for coming up with this idea in
the first place! Mr Martin Normandeau, IDRC provided valuable feedback and
prompt administrative support, which was vital. Ms Vandana (Central Project
Coordination Team, BAIF) helped tremendously with scheduling of workshops
and logistics under trying conditions.
The list would be incomplete if I did not thank Marian, my wife, for countless
editing, suggestions and serving as a sounding board!
Dr Satyendra K Srivastava
Health & Gender resource
satksri@rediffmail.com
1. Introduction
Section 1: Introduction
1. Introduction
‘How do you de-worm children in villages?’
‘Obviously, by making sure that the anti-worm tablets are not thrown away by
children or their guardians. We do it through a camp approach. We administer the
tablet in our presence..’
‘Where exactly?’
‘Of course in the village school. That is the place where you can catch children.’
‘Could there be some children who do not come to school? who escape this de-
worming process?’
‘Well, Yes, there are some drop outs..’
‘Who are these?’
‘Children of very poor families. Backward families…’
‘More often boys or girls?’
‘As we go to upper classes, drop out of the girls is much more due to…’
We have heard this discussion often. We have been on both ends of this discussion.
We have often wondered how gender concern can be made such an integral part of
health program planning, that operational ‘common sense’ never blinds us to gender
inequality hidden in processes and structures of programs. In other words, we have
asked: How does one analyze health issues and programs from the gender point of
view? This manual is an attempt to address these concerns.
Gender analysis as applied to Health is somewhat different to what it is in the socio-

economic sector, even though the underlying principles and intent remain the same.
In the latter setting it is to see how socio-economic interventions affect women and
men in significantly different ways; while in the former, it is to understand how
experiences of ill-health and attempts at recovery shape out differently for women
and men. Socio economic factor plays an important role in this, since gender is woven
subtly with class, caste, culture, religion etc.
This module is based on Swayamsiddha experiences from field and a series of

workshops conducted with Swayamsiddha partners dealing with rural development,
women’s issues and health. The purpose of this initiative was to integrate gender in
the health program of the project. This documentation is an attempt to reflect on this
process, disseminate the lessons learnt and provide guidelines to those who are
working in the area of Community Health.
GPIH Page 4 / 70
1. Introduction
2. Swayamsiddha & GPIH1

Swayamsiddha is a 5-year project that began in June 2000 to improve the health and
empowerment of women and girls in rural India. The project involves nine partner
organizations in six Indian states and is co-funded by the Canadian International
Development Agency (CIDA) and the International Development Research Centre
(IDRC). Overall coordination of project activities is provided by the BAIF
Development Research Foundation (BAIF). BAIF is a non-profit organization
registered under Public Charitable Trust in 1967. Various programs are implemented
by BAIF in twelve thousand villages in eight states of India. (Vide Appendix to learn
more about BAIF.)
'Swayam' means self, and 'siddha’ means 'capable'. Swayamsiddha in short, means
‘empowered’. Swayamsiddha connotes a group of self-reliant and empowered
women. In the mainstream concept of development, women's needs are often
sidelined due to gender norms, access to and control over resources. Unless women
are in a position to influence the decision-making processes, women's lives and the
structure of society would not change. Swayamsiddha aims at creating local
organizations of women and men who would explore and initiate processes for
increasing women's participation in all spheres of life. (Vide Appendix to learn more
about Swayamsiddha project).
3. GPIH Module and its evolution2

When we discussed health related topics with community women in Swayamsiddha,
we understood that along with unavailability of health infrastructure, gender norms
play a major role in women's health issues. Fasting, food habits, workload, norms
like women eat last in the house, practices regarding menstruation and pregnancy
affect women's health in a negative way. Women's self esteem, the ways women are
told to look at their body contribute to women's health hazards. Women have very
little access to money, time and they have a very limited mobility. In the beginning
of the project we realized that we have to emphasize on analysis of health issues from
gender point of view.
BAIF coordinating team based at Pune initiated number of Gender Sensitization

Training and Health training programs for the implementing staff and the community
members. The Gender Sensitization training module was instrumental in highlighting
that gender based disparity is a social structure and it is reaffirmed through various
social institutions like family, education, law, religion. Through this training people
understood the concepts of sex and gender, gender roles, gender based division of
labor, access to and control over resources and participation in decision making.
Discussion on how all this discrimination affects women's health was part of the
training program. These training programs brought out the truth - gender cuts across
1
This section was contributed by Ms Savita Kulkarni, BAIF.
2
By Ms Savita Kulkarni, BAIF.
GPIH Page 5 / 70
1. Introduction
class, caste, religion, ethnicity and other social factors. It also emphasized the need of
bringing change within to bring change in the world outside.
BAIF team initiated six health modules for the implementing teams and community
representatives. They are:
Water and Sanitation
Body mapping
Malnutrition and nutritious food
Primary treatment and First Aid
Women's health
Health communication
During all these health training program, difference between treatment seeking
behavior of women and men was discussed at length. These discussions helped to
bring gender perspective in health program.
To strengthen this perspective, we perceived a need for a separate training module

which would focus on Gender Perspective in Health (GPIH). BAIF coordinating team
and IDRC teams brainstormed to design a module based on the needs of the project.
This training module is an effort to integrate gender in health.
4. Intended audience
This GPIH resource is being offered as a ready to use training module for a three day
workshop. Program coordinators, facilitators, managers will find it useful to upgrade
conceptual, analytical and program planning skills of their health teams. They will be
able to conduct the GPIH workshop for their team / staff, often consisting of field
functionaries, supervisors, community organizers, ANMs3 and other health workers.
Some prior understanding of Gender, its basic concepts and definitions would
certainly be desirable though. (vide gender section under optional reading for a brief
discussion.)
We suggest that the participants are given a prior half a day session on following
concepts, before GPIH workshop:
Sex & Gender, difference
Gender roles
Gender based division of labor
Resources: Access & control
Gender needs: Practical and Strategic
Approaches to Development: Women in Development to Gender and
Development
3
Auxiliary Nurse and Midwife, a grassroots health functionary.
GPIH Page 6 / 70
2. Basic Concepts
Section 2: Basic Concepts

Gender analysis of Health can be thought of as an analysis which unfolds in to three
dimensions. The first dimension is the core of analysis and is about the women and men
who experience illness. The remaining two dimensions explore their surroundings.
The First Dimension
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, what prevents their
recovery?
Again, as a ‘woman’ or a ‘man’ in a particular community, what influences their chances of
recovery? Their attempts at recovery? For example, why women continue to suffer from
Anemia, even though technologically and logistically, it may appear to be a simple problem?
This is the core, the first dimension of GPIH analysis. We will come to the other two a
little later.
Figure 1
The two core questions

1. Why women or men are more 2. Why women or men find it more
vulnerable to a particular health difficult to recover from the given
problem or condition? health problem or condition?
What are the factors affecting who What are the factors affecting
gets ill - women or men? responses to ill health?
Here 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 -accessible 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 (vide Fig 2 below)4.
Figure 2
GPIH: The four steps
Step 1 Step 2 Step 3 Step 4

Patterns of Ill health. Are there enough, Factors affecting Factors affecting
Is there a gender adequate, affordable who gets ill- women’s & men’s
difference in the services available to women or men? responses to ill
distribution of ill women & men? health
health?
4
Step 1,3 & 4 are derived from Section 2 of ‘Guidelines for the analysis of Gender & Health, January 1999’
GPIH Page 7 / 70
2. Basic Concepts
The Four GPIH Tools

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
GPIH: The four steps & four tools
Step 1 Step 2 Step 3 Step 4

Patterns of Ill health. Are there enough, Factors affecting Factors affecting
Is there a gender adequate, affordable who gets ill- women’s & men’s
difference in the services available to women or men? responses to ill
distribution of ill women & men? health
health?
Tool 1: What, Tool 2: Health Tool 3: Tool 4:

Who, Where, service Factors Factors
When..(Distrib analysis – affecting who affecting
ution of Availability, gets ill- Response to ill
sickness) Accessibility women or health
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. We should be asking for example: what is it about
being a young male, as opposed to older males (and women), which makes them more
prone to smoke or drink?
The Second & Third Dimensions

Figure 4
3 1 2
Factors
affecting
Locus Context
of the
who gets
of this
factors ill? analysis
discovered and who
fails to
recover?
The Three Dimensions of GPIH
The factors affecting who (woman or man? girl or boy?) gets ill and factors affecting who
fails to recover, as above, is the first dimension of this analysis. Next comes the second
dimension: These factors discovered in step 3 & 4 above, could be operating within the
GPIH Page 8 / 70
2. Basic Concepts
households, in the communal settings / structures or they could be inherent in the bigger
institutions like markets, state policies etc. (Vide Fig 4 & 5)
Women often suffer from fungal skin infections of hand and feet. This is not due to any
biological susceptibility exclusive to women. In most cases this has to do with her daily
activity which brings her in contact with water for long duration. This is defined by her
role with in the family: cooking, filling water, caring for young etc. So the context of the
analysis – household here, becomes an important second dimension.
On the other hand, varicose veins and respiratory problems are seen in a higher number
of men working as traffic police. Most probable reason is the inadequate occupational
safety measures. Who is primarily responsible for implementation of these measures?
The employer, ie. the state government. So in this case the analysis is situated in a much
broader context: Poor state policies or its poor implementation. So in this example,
context of the analysis, could be put under Influence of states/markets/international
relations. (The blue column, Fig. 5 below.). This is the second dimension.
A third and equally important dimension is: the specific locus of these factors, the
category to which a factor belongs: Constant attending to water related chores, in case of
a housewife is related to her activities (subsistence and reproductive activities at home5).
So, ‘hands being constantly wet’ – the factor responsible for her fungal skin infection, is
located in her activities. Other loci are – environment (pollution in kitchen for women
and in mines for men, for example), access to and control over Resources (women may
have to ask men before they can spend money on their treatment), bargaining positions
and gender norms prevalent in the particular community. (Fig. 5 below, First brown
column).
In the above example, housewives’ vulnerability to fungal skin infections could also be
related to other loci: gender norms (male members of the family are not supposed to help
with these water chores), environment (inadequate drainage in kitchen), Bargaining
position (housewife is not able to demand and get a dishwasher), resources (can not hire a
housemaid). Some overlap is possible but in a specific example, we will find that the
factors lean more in the favor of one or two loci. Discerning this, will help later to plan
appropriate intervention. In the second example, traffic police men have little bargaining
power to demand good working conditions form their employer, the State government.
So, the locus of their unhealthy working conditions is Bargaining Positions.
To summarize, the context deals with the
circumstances, sometime tangible, at others
abstract (state policy eg.) of the factors surrounding
ill health. Assigning these factors to a specific locus
is different: it is an attempt to understand the nature
of these factors: Has it got to do with women and
men’s gender roles? their physical environment? or
their activity?
Second and third dimensions help us to plan interventions which take into consideration
what exactly program needs to change and where:
5
Refer to description and nature of “Activities” for a fuller understanding at page 11.
GPIH Page 9 / 70
2. Basic Concepts
women’s activity at household level?

or men’s bargaining position vis a vis their employer?
ie. state policy regarding occupational health, for example.
Figure 5
Three dimensions of GPIH
(3) (1) (2)

Locus Contexts
Step 3
Factors affecting Households
Environment
who gets ill –
women or men? Communities
Activities
Influence of
Resources
states/markets/int
ernational
Bargaining Step 4 relations
Positions Factors affecting
responses to ill Available health
Gender norms health services
(Derived from ‘Guidelines for the analysis of Gender & Health, January 1999’, issued by Liverpool School of Tropical Medicine,
These loci and contexts, the columns on left and right above, acquire different meaning in
step 3 and 4. In step 3 we may wish to ascertain the factors in women’s environment,
which increases her vulnerability (compared to men and other women who work in office
for example) to respiratory infection or conjunctivitis (air pollution related to cooking, a
gender role).
While in step 4, we are looking at:

What are the responses of women and men to illness? Are they different? And if so,
Why?
Could these reasons be due to her poor bargaining position in household for example?
After falling sick, Available Health Services becomes an important context to be
considered, because sick person needs these services. This is not the case in step 3 where
we are considering the scenario before people fall sick. Similarly environment is an
important locus contributing to ill-health in 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, and
will become clearer as we continue. Let us repeat that similar questions in both
dimensions of loci and contexts can and should be asked while analyzing ill-health
among men as well as women.
GPIH Page 10 / 70
2. Basic Concepts
The following section discusses the meaning of these loci and contexts in both step 3 and
4.
Understanding the loci for Factors affecting who gets ill6

(Left column, Figure 5 above, for step 3)
Environment
“Environment” refers to women’s and men’s living and working context.
Significant Questions:
Living Conditions – Access to clean water, sanitation, ventilation, light,
hygiene etc.
Working conditions – consider issues such as distances to commute, 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.
What do women and men do?
Are there health risks associated with particular activities? How? Why?
Are there health risks associated with excessive burden of work? How?
Why?
Are there health risks associated with lack of work? How? Why?
Resources
6
This discussion is derived from Chapter 3 of ‘Guidelines for the analysis of Gender & Health, January 1999’
GPIH Page 11 / 70
2. Basic Concepts
“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.
Are there differences in women’s and men’s access to or control over
resources that affect their ability to protect their own health?
Is it different for women and men?
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 caring for their 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.
Are women and men able and willing to care for their own health? Are
there significant gender differences in women’s and men’s ability to care
for 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, expectations 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.
Are there accepted cultural norms or practices that affect women’s and
men’s health, or women’s and men’s ability to care for their health?
Understanding the Contexts7

(Right column in Fig 5 above for step 3)
The above five categories can be relevant at a number of different levels of society – and
should be considered in each of these contexts:
7
GPIH Page 12 / 70
2. Basic Concepts
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.
Understanding the loci for factors affecting responses to illness8

(left column, Fig 5 above, step 4)
Environment is not a consideration here, as explained above.
Activities
“Activities” concerns how women’s and men’s roles and responsibilities affect their
perceptions of illness and their choices concerning treatment.
Do women’s and men’s roles and responsibilities 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.
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?
Bargaining positions
“Bargaining positions” concerns how women’s and men’s bargaining positions affect
their perceptions of illness and their choices concerning treatment.
Does women’s and men’s bargaining power 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,
expectations and values which influence decisions on seeking treatment.
8
GPIH Page 13 / 70
2. Basic Concepts
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?
Understanding the Contexts9

(Right column in Fig 5 above, for step 4)
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 community
as discussed for step 3 above. However here in step 4, instead of “Influence of
states/markets/international relations” one needs to consider the kind of health care
available; this will 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 Ayurvedic/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.
9
GPIH Page 14 / 70
3. Steps & Tools
Section 3: Steps & Tools

Description of GPIH Steps
This section gives a brief description of the four steps and tools mentioned above.
Step 1: Patterns of Ill-health

(Who gets ill, when and where)
Examine sex-disaggregated information on morbidity and mortality (health outcomes
data) to delineate-
Who gets ill- women and men of different ages, socio-economic & ethnic groups?
What types of illness women and men get?
When do women and men get sick or need help (season, labor pains during night?)
Where women and men become sick (eg: snake bite in the field; exposure to indoor pollution
while cooking…)
This bird’s eye view of patterns of illness will further be enriched if caste, class,
religious, ethnic groupings and physical ability are also considered. Some rows or
columns may remain blank as the category may not be relevant for the problem being
analyzed or the information may not be available. For example, in case of worm
infestation, rows like day/night, menstruation/pregnancy etc may not be relevant. What
follows is a prototype which should be adapted to local specificities.
Tool 1 Who gets this illness? Who is affected more?
Name of 0-5 years 6-10 yr 11-18 yr >18 yr

illness/conditio Upper Lower Upper Lower Upper Lower Upper Lower
n…… class/cas class/ca class/caste class/cast class/cast class/cas class/cas class/cas
te ste e e te te te
Sex G B G B G B G B G B G B W M W M
Day/night
Summer/winter
/rainy/all
At home/fields/ Colored row & column heads can /
workplace/ should be added to, modified or deleted
others- specify in view of local realities. For ex. one
During may have more age groups, tribe
menstruation names instead of caste/ class etc. in
/pregnancy/ view of local facts and health issue
delivery/postnata being analyzed..
l
Remarks
For example, in some situations having a middle and lower class might suffice.
Elsewhere, putting up the names of popular caste or tribe may be a better idea. Other axes
of social divisions should also be considered and added to the above format: Landless /
Landowners; Muslim, Hindu, Parsi; Married / unmarried etc. Age bracketing (0-5, 6-10
etc) should also be changed depending on the issues being studied.
GPIH Page 15 / 70
3. Steps & Tools
Step 2: Are there enough, adequate, affordable services available to

women & men?
(Health Service Analysis)
List the health services and facilities, private and public, formal and informal,
traditional/indigenous and Ayurvedic/allopathic/bio medical available for treatment.
List the persons who go to the respective health care services. If it helps use
approximate percentage. For which illness do they go/for which they will never go.
Reasons for those persons going and for others not going (e.g. timing, location,
money, confidentiality, effectiveness, norm, appropriateness) to the health care
service.
Tool 2 Averag Pvt/Pub System- Fees - Clientele: Go for Will Reaso Rem
Name e lic/ Traditional/ Cash/K W/M, what never go ns for arks
of Distan Informa Allo/ Ayur/ ind Upper/Mid ailments for what not
service ce l Homeo dle/Lower ? ailments going
class etc.
For each service provider, following questions could be asked:

Timing (eg. inconvenient timings of a Government Hospital)
Location (distance, locality, lack of transport)
Money (eg. high fee structure of a private hospital, costly rituals of a faith healer)
Confidentiality (HIV + client in a Government service: how long her/his identity
remains confidential?)
Effectiveness (medicines at Government PHC could be considered useless)
Norm (are women free to go to a male gynecologist? Will an upper caste Dai attend
to a low caste client?)
Appropriateness (For delivery in a village, who is more appropriate as a service
provider – Dai or a Nurse, even if both are available?)
GPIH Page 16 / 70
3. Steps & Tools
Step 3: Factors affecting who gets ill- women or men?

Here we move on from “who gets ill” to “why certain groups of people are more
susceptible to illness than others?” This susceptibility often is more than just a question
of biological differences10. This would involve examining the important social, cultural
and economic factors that affect health and experience of sickness. This susceptibility
may vary according to the context (extreme right column in the outline above).
To facilitate analysis following grid is used, where column heads represent context and
the row heads indicate specific loci of different factors:
Tool 3
Influence of
Why do different groups of
Household Communities States/markets
women and men suffer
international relations
from ill-health
How does the
e.g. lack of health and safety
ENVIRONMENT influence legislation to protect workers
who becomes ill?
How do the ACTIVITIES of e.g. cooking on biomass
fuel increases women’s
women and men influence chances to develop
their health? conjunctivitis
e.g. male community
How do the BARGAINING members decide to use
POSITIONS of women and funds to build a meeting
men influence their health? house, not to build a well as
favored by women members
How does access to and e.g. women’s lack of income
control over RESOURCES earning opportunities may
influence the health of lead them to commercial sex Box 12
work as a livelihood strategy
women and men?
e.g. son preference may
How do GENDER NORMS mean that daughters are
influence health? fed last and receive less
nutritious food
See more examples for this grid.
10
Certain biological differences do exist – like higher mortality among male babies under six month due to
physiological reasons. But in practice socio-economic factors play a much bigger role. Also, discussion of
biological differences with ‘Health’ workers can sometimes push the workshop in an unwarranted
direction.
GPIH Page 17 / 70
3. Steps & Tools
Step 4: Factors affecting responses to ill-health

How are women and men’s responses to illness influenced by gender and other
differentials? Here too various socio-cultural and economic influences should be
considered and analyzed. Following grid is used to facilitate asking relevant questions:
Tool 4
How are men’s and
Available health (&
women’s responses to ill Household Communities
other) services
health influenced by
gender?
How do the ACTIVITIES of e.g. women are e.g. formal care schedules
responsible for caring may not fit the schedules of
women and men influence for sick family different groups of women
responses to illness members and men
e.g. a man with an
How do the relative STD may be able to
decide to seek care
BARGAINING POSITIONS
without his wife’s
of women and men influence knowledge but she
responses to illness? would need to ask him
before seeking care
How does access to and e.g. traditional healers may
control over RESOURCES accept payment in kind,
influence how women and while cash is required for
men respond to ill health? user fees at formal services
e.g. the social
consequences of
How do GENDER NORMS suffering from a
More examples for this grid
affect responses to illness stigmatized diseases such
as leprosy may be more
severe for women
A little thought makes one realize that step 3 above - Factors affecting who gets ill, will
generate useful information for preventive intervention at different levels: Information
and counseling at individual and family levels, advocacy and policy changes at
community and state level, preventive occupational interventions at home and workplace
etc.– so that women or men may not fall sick in the first place.
Similarly, analysis in step 4 - Factors affecting responses to illness, will generate useful
leads for program, so that affected groups / individuals can access services better and
recover their health with greater ease. Again, these interventions would be operational at
various levels: If the reason is – women are not able to access ready cash at household to
seek services of available Gynecologist / Nurse practitioner, then, instead of providing
more of the same services, program will have to find better/ alternative ways of ensuring
‘cash flow’ for the services or improving women’s access to cash income. In other words,
step 3 will generate information to make curative components of the program more
relevant and effective.
It is important to realize that these grids do not represent water tight compartments. Some
factors could easily ‘fit’ into more than one grid. The purpose behind using the grid is to
GPIH Page 18 / 70
3. Steps & Tools
ensure that no context or locus escapes analysis. On the other hand if some grid remains
blank, it should be accepted as such. This could be due to the fact that the group may not
have enough information about that aspect of the health problem at the moment or may
find it truly irrelevant to the issue at hand.
Where Next? From Analysis to Program Planning

Are the current programs addressing these factors, as uncovered in step 3 and 4? If yes, to
what extent? What more needs to be done? Here in this last step GPIH graduates from
analytical tool to a program tool: a tool to help review and plan the programs in a more
gender responsive way.
Figure 6
GPIH: Relevance to Program

How can they be helped to Preventive
avoid falling sick?
How can the communities component
Step 3 be helped to maintain better
Factors affecting who health?
gets ill How can the State be made
to play its role in the above?
How can sick people be Curative

helped to access services?
Step 4 How can services be made Component
Factors affecting more affordable, accessible,
responses to ill health relevant, and sensitive?
What can various actors
offer (public, Voluntary,
private, Informal)?
By the time, participants complete the GPIH analysis of the given problem, they have a
detailed list of socio-economic factors, which make women sick and keep them that way,
just because they are women. They also discover that same applies to men too in many
cases. It is also understood by now that, prior to obvious sickness, there are many shades
of health issues, conditions & sub-clinical states, which afflict women and men similarly
ie. because of their ‘gender’.
Confronted with this comprehensive list of factors responsible for production of ill-health
and its continuation, participants naturally want to know, how many of these are being
addressed by their program. Can they collaborate with other players to tackle bigger
factors, like policy issues? Can there be significant synergy between their program and
the government one? These are the questions which GPIH helps participants confront and
address.
GPIH Page 19 / 70
4. Prototype Workshop
Section 4: Prototype Workshop

The GPIH Workshop
A typical three day GPIH workshop attempts the following objectives:
1. To give participants conceptual clarity on
(a) Why gender analysis of health program is needed
(b) Basic precepts of GPIH and its four tools
2. To give participants essentials skills in using GPIH tools
3. To help participants self evaluate their health program through GPIH
GPIH workshop takes the participants through these mile stones:
Figure 7
Roadmap
8. Self evaluation of
programs 7. Use of tools in
1. Why Gender in
Health? What is Program planning
GPIH?
9. Future use in
Program planning
2. Problem Response 6. Tool 4 - Response to
illness
analysis:
What is the program
10. Workshop
and why?
feedback (End)
5. Tool 3- Factors
3. Tool 1- What, contributing to who fall
sick.
who, when, where? 4. Tool 2-Health service
Patterns of ill health analysis-
Accessibility, availability
Following is a workshop schedule which was used often in Swayamsiddha, with minor
changes to suit local factors like participant’s level of comfort with new concepts, ability
to absorb and finish group tasks and other pressures (like last bus for commuters!)
GPIH Page 20 / 70
Workshop Schedule
Day Ses Activity Purpose
sion
Day 1 1 Participants’ introduction Problem Response analysis is
Introduction of workshop objectives (Roadmap) conducted to help participants get
Recapitulation of basic Gender concepts11 & GPIH into analytical frame of mind so
definition that they look at their local issues
Problem Response analysis: Analysis of the local & programs in a holistic way.
problems and programmatic responses of the
agency.
Tool 1: Patterns of Ill-health, is introduced,
explained, discussed and adapted to local context
2 Service provider Free listing To bring out the gaps between
Constraints on accessibility and availability need and supply & dimension of
Tool 2: Health service analysis, is introduced, quality of health services
explained and discussed
3 Tool 3: Factors affecting who gets ill - is Important to make participants
introduced through a case study about a woman’s understand that tool3 (and 4) are
health issue not meant to capture only
4 Tool 3 is used again to analyze another case study, women’s vulnerability to certain
this time involving men’s health issue health issues; Hence use of 2 case
studies.
Day 2 1 Tool 4: Factors affecting response to illness – Two case studies are used to
introduced using a woman’s case study emphasize that tools have no
inherent bias for any sex and that
in true spirit of gender, men’s
2 Tool 4: Factors affecting response to illness –
repeated using a man’s case study this time problems should also be analyzed
in depth from gender perspective.
3 Tool 3 practiced for a new local health problem This practice session emphasizes:
maintaining inter/ intra tool
4 Tool 4 practiced for a new local health problem linkages and coherence and
The significant differences
between tool 3 & 4
Day 3 1 Recap of 4 tools
2, 3 Group work: Take a local health issue and do a Important to see if the analysis is
complete analysis from tool 1 to 4. making a logical use of various
Group work: Plan an intervention (specific bits of information generated by
activities) based on this analysis the different tools; Is there
Compare present program against the ideal coherence in the entire process?
comprehensive intervention planned by you Is the intervention planning
Brain storm- How these tools can be used in future making use of the preceding
program planning exercises? analysis?
4 Open session for questions / suggestions

Workshop feedback
11
Difference between Gender and Sex; Gender relations; Access / control over resources; Practical &
Strategic gender needs. The difference between working for women and working on gender;
GPIH Page 21 / 70
A Typical GPIH workshop

Here we briefly describe a typical 3 day GPIH workshop and its methodology.
Pre-requisites
Physical: a hall for 15-20 people to sit and also to subdivide in to 2-3 groups;
Charts, markers, board etc.
Participants: Mixed (women, men) groups, from diverse backgrounds (ANMs, Rural
animators, field workers, supervisors and program managers) work fine; Analysis
benefits immensely by the variety of information coming from such a group.
Number of participants, ideally about 12-15, but could range from 10 to 20.
Level: Some prior knowledge of gender issues is helpful. General awareness of health
issues is also useful. Participation of people who supervise, review and plan health
programs like Field supervisors and program coordinators, can be very useful.
Methodology has to be highly participatory since it deals with deep seated values, beliefs
and project work. Intense discussions have to be interspersed with energizers, games or
other type of activity which helps to change the rhythm of the workshop.
Day one
First Session
Introduction to GPIH, Problem Response analysis and Tool1
1. Introduction of participants: some creative method which doubles as an ice-breaker
too, if the group is not very familiar or comfortable with one-another.
2. Facilitator next introduces GPIH by asking a question:
What is Gender? What is its relevance to your work?
A simple definition of GPIH, and its relevance to their work, is then introduced, built on
their responses.
Attempts to understand socio-economic reasons why a woman (or
man) tends to be less healthy or more sick than the others OR
being sick, finds it more difficult than others to get well…
GPIH is a framework for looking at health issues and health programs
from a gender point of view – a gender lens to look at Health – a planning
tool.”
3. Workshop roadmap is put up on a wall and discussed. This helps participants
understand the major milestones to be achieved over next three days.
4. Problem Response Analysis
A volunteer is requested to come forward and free-list the problems (inclusive of health
ones) in the area. When a comprehensive list is ready on the chart / board, she is asked to
list her organization’s response to these issues. Problems and responses are thus listed in
two columns on the board by the volunteer, often prompted and helped by colleagues.
GPIH Page 22 / 70
Facilitator asks her to draw arrows between those problems & responses, which have a
linkage and explain them. This exercise gives the facilitator a glimpse of the local
context, helps the participants to get going (and more vocal) and will get the group tuned
to the wider understanding of health- central to the unfolding GPIH. The resulting list
could be something like this:
Problem Response Analysis
Problems Program response
White Discharge RCH Education
Malaria control Mosquito net
Malnutrition Kitchen garden
Nutrition day celebration
Water Interventions
Water borne diseases Awareness, Chlorination
Water fetching over long distances Hand pump, span pump
Unavailability of primary treatment Nature cure, Health check up program, Herbal
cure inputs to SHGs
Infant and maternal mortality Training of field functionaries, TBAs, Growth

monitoring, Immunization
Drudgery of SHG women Washing platform, Cattle tank, Ball bearing,

portable stove, tree plantation
Sometimes, participants are also able to bring out undesirable effects of an intervention
from health perspective: Ball bearing may increase the efficiency of grinding stones at
home but in some instances it may attract larger amounts of grain to be ground and may
aggravate low back pain of the housewife. This exercise helps participants to move away
from immediate causes of ill health and sets the stage for a broader socio-economic
analysis.
The participants are asked to free list health problems in their area. Tool 1 is now
introduced. Handouts in regional language must be provided to facilitate comprehension
and discussion. Various labels of tool 1 (column and row heads) are explained. The group
is asked how many of these labels are appropriate for their area. They are encouraged to
make suitable changes in the handout given to them.
Small group activity: Once the tool 1 grid is finalized to reflect local specificities, two or
three small groups are made and are given 1-2 health problems to analyze, from the list of
local health problems. They have to discuss and fill up tool 1, using whichever method
they feel comfortable with. Some groups would use just a plus mark to indicate that the
problem is common among young children of Kokna tribe during winters for example.
Another group may represent it on a scale of 0 to 5, where 0 means ‘no incidence’ and 5
means ‘very common’. Ensuring uniformity here serves no purpose and could inhibit the
group.
In the plenary, they present their findings where feedback is moderated and enriched by
the facilitator. Another way to accomplish this in less time: Display all the outputs (Tool
GPIH Page 23 / 70
1 charts) at once on a wall, where the groups offer comments and question each other’s
outputs, moderated by the facilitator. This exercise emphasizes the importance of
knowing in depth the profile of the segment of the population being most affected by the
problem. The question to help this is:
How do you know that the said problem is rare among other groups? Why do we want to
know this? How will it affect the program planning?
Second Session:
Health Service Analysis: Tool 2
The group is asked to free list various service providers catering to their community -
private and public, formal and informal, Ayurvedic/ traditional/indigenous and
allopathic/bio medical. It is emphasized that to plan well, one needs to know, who is
affected by the problem (tool 1) and also what services are available to them currently.
The latter is the subject of tool 2– health service analysis; this tool is introduced now.
Why some people / groups may not be able to utilize certain services is discussed:
constraints on accessibility and availability of health services.
Questions to stimulate discussion are:
What segments, communities or groups go to these various health care services? For
which illness do they go? for which they will never go?
Reasons for those persons going and for others not going to the health care service?
Does it have anything to do with the timing and location of services, money needed to
avail it, confidentiality offered or practiced, effectiveness of the service, prevalent
norm, appropriateness regarding it?
Again, 2-3 subgroups take up 1-2 service providers and do an analysis; A typical output
may resemble following in part:
Tool2 Dist Pvt/P System fe Cliente Go for what Will never go Reasons for R
Name anc ub/ e le. ailments? for what not going e
e ailments m
1. 2. 3. 4. 5. 6. 7. 8. 9. 10
BAIF 0 Volu Ayur+ 2 All, Fever, Diarrhea, TB, Snake Only basic
PTC km ntary Allop Rs women Dressing of bite, skills
more wounds, Body Delivery, available
than pain, Skin disease, Accidents
men Burns
Limdha 5 Pvt Allop 20 All Fever, Vomiting, TB, Delivery, Needed
Pvt km - Diarrhea, Dressing Accidents, facility/
Doctor 50 Snake bite drugs not
Rs available
Bhagat 0 Infor Ayur + 5- Kotwal Mental health Accidents, Limited role
km mal Tantrik 10 iya, problems, snake Delivery, TB (faith
Rs Vasava bite, fracture, Joint healing)
pain, Jaundice
GPIH Page 24 / 70
Third Session:
Introduction to Tool 3
First case study (part 1) translated in the regional language is distributed, and discussed in
small groups. Facilitator makes sure that everyone has understood the story and finds it
believable. Next, the group analyses the reasons operating behind Phalguni’s backache.
Facilitator introduces tool 3 and explains various labels (row & column heads, context &
loci) and how to fill the format. In this plenary session conducted by facilitator, small
groups (as made previously) brain storm and list the reasons. They are asked next, which
reasons should go into which box – and why. This generates interesting debate among
groups, where facilitator has to moderate and help people with suitable examples for
various boxes. For example: what could be a suitable example for box 12 (tool 3)?
In the unorganized agriculture sector, for the same work women tend to get less daily
wages. Why? Is there a gender norm that man’s work must be treated as of more intrinsic
value? Who benefits and who perpetuates it? The market? How does it contribute to her
vulnerability to sickness?
Participants may struggle to understand this interplay of row and column heads and
would need suitable examples to illustrate the point. A typical output of this session may
look like this:
Tool 3: Reasons behind Phalguni’s backache (case study 1, part 1)
Why do different At Household level At Community level Influence of
groups of women and States/markets
men suffer from ill- international relations
health
How does the Forest has shrunk (community Natural resources
ENVIRONMENT responsible for it) (forest, water) under
influence who becomes Communal Water source far from state control which has
ill? village not cared.
How do the ACTIVITIES Phalguni has too much domestic
of women and men work, to be done in bent posture
influence their health?
How do the More children (Phalguni cant More children (society norm) state unable to prevent
BARGAINING decide family size) Poor path to forest and water early marriages
POSITIONS of women Early Child bearing Forest path not being priority of
and men influence their Husband refused to buy solar panchayat
health? cooker
How does access to To carry excessive weight over No access to panchayat funds to Contraception not
and control over long distances (no access to repair path provided / promoted by
RESOURCES influence draught animal?) Women in panchayat not able to state
the health of women sway decisions Unsuitable Policy of
and men? world bank, bypassing
Phalguni’s village
How do GENDER More children being born Early Child bearing
NORMS influence Excessive workload on women Boys not helping in domestic
health? Boys not helping in domestic chores
chores Women having “sankoch12” & not
using the new contraption
(harness) to carry load
12
Sankoch – problem of shame; predominantly, women’s issue.
GPIH Page 25 / 70
Fourth Session:
Use of Tool 3 to analyze a men’s case study
The facilitator asks – what is Gender?
The response mostly brings up the correct theme: inter-relationship between roles
ascribed to women and men by the society. Building on this reply, facilitator states that
men too must be vulnerable to certain health problems just because they are men! So, let
us analyze another case study to understand this phenomenon in some depth. Part 1 of the
second case study Better sex ratio in a mountain village is shared in small groups. Tool 3
is used to analyze various reasons responsible for higher mortality among men in
Kuthalsain as above. Following is a sample output:
Tool 3: Higher mortality among men in Kuthalsain (Case study 2, Part 1)
Why do different groups of At Household level At Community level Influence of
women and men suffer from States/markets
ill-health international
relations
How does the Poor Land, poor water Media promotes
ENVIRONMENT influence resources forces them to “manly”
who becomes ill? dangerous jobs professions like
Army
How do the ACTIVITIES of Taking ‘jhula’ down from high State offers no
women and men influence trees other job, career
their health? men having to work in remote
forests
Driving on mountain roads
How do the BARGAINING
POSITIONS of women and
men influence their health?
How does access to and Poor facilities for higher Poor facilities for
control over RESOURCES education in the region higher education by
influence the health of state in the hills
women and men?
How do GENDER NORMS Appeal of “manly” Appeal of “manly” Armed forces
influence health? professions professions recruit men, not
Pressure on men to Men running grocery are women
earn at any cost and looked down upon
provide for children’s Driving after drink due to peer
higher education pressure
In summing up, we ask- what use is this tool 3, to overall planning process?
To prevent people falling sick, what our program needs to do – that is what it tells us ie.
Information of a preventive nature.
Day Two
First Session:
Introduction to Tool 4
GPIH Page 26 / 70
A rapid participatory recap is conducted with the help of participants. Tool 4 as handout
is distributed and a question is asked: In what way is it different from tool 3 and why?
The similarity is obvious. Differences come up as the participants go over it a few times:
third column has changed from Influence of States/markets/ international relations to
Available health services. First row for Environment is missing.
Both these changes are understood if one looks at the name and the purpose of the tool.
Tool 3 deals with the scenario before falling sick while tool 4 deals with circumstances
coming into play after falling sick. Environment (eg. ill ventilated kitchen) has a role in
contributing to sickness but is no obstruction to its treatment. After falling sick, available
health services influence outcomes; while state policy and market forces may contribute
to people’s vulnerability to falling sick in the first place.
The participants are now given part two of the first case study- Backache in women. In
small group task, it is discussed and constraints on Phalguni’s return to health are sorted
out. Next, groups brainstorm as to which constraint belongs to which box of tool 4 and
why. Questioning why is important since at times, one factor may have more than one
interpretation and assigned to two boxes.
Once this exercise is over, we sum up by asking, why this information is important for
program planning: This tool generates information useful for ‘curative’ content of the
health intervention. Here is a sample output:
Tool 4: Factors making Phalguni’s recovery difficult (case study 1, part 2)
How are men’s and Household Communities Available health services
women’s responses to
ill health influenced by
gender?
How do the ACTIVITIES Too much work load- PHC timing clashes with her
of women and men no time for self care schedule
influence responses to
illness
How do the relative Phalguni cant go to
BARGAINING PHC on her own;
POSITIONS of women depends on husband
and men influence to take her
responses to illness?
How does access to White discharge and White discharge was taken PHC is 10 Km away
and control over Backache was taken as an insignificant problem Only one bus service was
RESOURCES influence as an insignificant by Phalguni there.
how women and men problem by Phalguni To link backache with white Timings of Bus and PHC being
respond to ill health? To link backache discharge erroneously inconvenient
with white discharge Superstition about cure Health Team of the NGO visits
(lack of correct info) (lack of correct info) – the village only once a week.
Superstition about community promotes it Location of the PHC unsuitable
cure among women
How do GENDER Cow has to be Phalguni had to stay back The only doctor available was a
NORMS affect milked by woman for daughter in law’s male
responses to illness Young child will eat delivery
only from her hands Phalguni cant show her
GPIH Page 27 / 70
Phalguni had to stay back to a man (doctor)

back for DIL’s
delivery
Second Session:
Use of Tool 4 to analyze a men’s case study
Tool 4 is used to analyze second part of the second case study, dealing with Ramesh’s
accident and subsequent events. Methodology is same as above. But the group often
needs help in grasping the insidious nature of male socialization (psychological part),
leading to certain lifestyles (smoking, drinking, gambling, go getter attitude etc) and
preference for certain occupations; Subtle but proven connection between heart diseases
and bottled up emotions in case of men is often used as an example. Specifically, while
concluding, facilitator asks:
Which events would have taken a different turn in this case study, if Ramesh was to be
replaced by a woman, say his wife, everything else being equal?
Here is a typical output:
Tool 4: Constraints on Ramesh’s recovery (Case study 2, part 2)
How are men’s and Household Communities Available health services
women’s responses to ill
health influenced by
gender?
How do the ACTIVITIES of Place of accident
women and men influence being too far away
responses to illness form the village
How do the relative Ten thousand Rs Forest produce – being illegal for
BARGAINING POSITIONS were needed for Ramesh
of women and men treatment No transport being available in the
influence responses to night
illness?
How does access to and Ten thousand Rs Ten thousand Rs were Hospital being 40 km away
control over RESOURCES were needed for needed for treatment Dealing in Forest produce
influence how women and treatment Village did not have a (Ramesh’s occupation) – being
men respond to ill health? Village did not have transport means illegal, Hospital will have to report
a transport means No qualified doctor being to police
in the village No transport being available in the
night
No qualified doctor being in the
village
How do GENDER NORMS Men running grocery store
affect responses to illness are looked down on
An interesting debate occurs around the question: Can woman give consent for
amputation of her leg, if necessary? Who is freer to do so- woman or man? Unmarried
woman or married woman? What if it is uterus (hysterectomy) and not her leg? This
brings out subtle norms governing these choices in different strata / communities of
society.
GPIH Page 28 / 70
A rapid recap of tool 3 and 4 is done. Participants are asked: which boxes in tool 3 & 4
will be the most difficult and most easy to address through a program. This further results
in a discussion about how we use information generated by these tools for program
planning and about strategic and practical gender needs: Factors listed in the row for
gender norms, may be most difficult to change, but will have to be addressed in the long
term interest of women and men, affected by them. Often different answers will come up
depending on the background, beliefs and attitudes of the participants. It would be useful
to emphasize that there are no standard “correct” answers.
Another way to recap tool 3 and 4 is to give the group a number of Zopp cards with
caselets written on them and ask them to arrange them on a big chart with tool 3 or 4
outline. This is a more interactive and spontaneous way of finding out how much
participants have grasped and what their difficulties still are.
Third Session:
More practice with Tool 3
Two or three health problems are given for analysis with tool 3 for practice, as small
group task. Often the problem may already have been used for tool 1 analysis (who,
where, when). The group is reminded that the problem should not be analyzed from the
point of view of general public. Rather, if on day 1, tool 1 analysis has shown the
problem to be commoner among young Warli13 girls in off road villages during
monsoons, then tool 3 analysis must keep these specifics in mind. It will be their (Warli
young girls) activity and environment which should come up in tool 3 grid, if it makes
them vulnerable to the given health problem. It is important to remind the group that all
the tools are inter-related and should not be seen & used in isolation.
In the plenary session, groups review each others’ grid and offer a critique, moderated by
the facilitator. Again, asking why a certain factor has been put in a particular box, would
bring out a mass of information, which the group may have discussed but may not have
put down on the chart.
Fourth Session:
More practice with Tool 4
Same health problems as above are given for analysis with tool 4 now, as small group
task. Besides the above precaution that this exercise must take cognizance of preceding
analyses, facilitator also emphasizes the fact that while tool 3 highlights the factors which
make one vulnerable to a particular health problem, tool 4 deals with constraints which
come into operation after falling sick and makes it difficult for her or him to seek help.
One deals with factors before falling sick, the other after- to put it simply. Forgetting this,
some participants tend to produce similar lists of factors both in tool 3 and 4. In the end
we summarize the purpose of both the tools: help plan preventive (tool 3) and curative
(tool 4) contents of a Health intervention.
Day 3
13
A tribe in Maharashtra
GPIH Page 29 / 70
First Session:
Recap of the four GPIH tools
A rapid recap of the four tools is conducted. Next, the participants are divided in to small
groups, depending on their numbers. On previous days, participants had learned &
practiced one tool at a time, often overlooking the inter-connections. Now in small
groups, a common health problem is given for complete analysis from tool 1 to 4, leading
to intervention planning, as a holistic exercise. If there are two groups, consider giving
one a woman’s issue like Leucorrhoea and the other, a man’s issue like Urethral
discharge (‘Dhaat’) or Alcoholism.
After each step, findings are shared or presented and peer reviewed. If some of the
analysis was already done in the previous sessions like Health service analysis (tool 2), it
is not repeated and used as it is. Finally, all four analyses are displayed together and the
group tries to see
Is the center of the analyses all through, the same affected segment of the
population? Same women? men? children? Tribe?
or has it drifted to some general loose group like ‘the community’?
Have the tools been used properly?
Is the analysis deep enough? What is it about their activity, environment etc which
makes them vulnerable?
Second Session:
Planning an Intervention based on the analysis
The same small groups are now asked to develop a comprehensive, even ideal
intervention plan in the light of the preceding analyses. They are given the following
heads to be kept in mind:
What activity actually will be done? (its contents)
Who will be responsible for it? Who will participate in it?
When will it be conducted? For how long? Frequency?
Who will be its focus? (Target group? participant)
Will any special methodology be used?
This often takes the form of a grid as below:
Intervention Plan for TB : Objective- To reduce the prevalence of TB in 3 years by half
Activity Who will be Where, for When, Other / What help
responsible whom frequenc method needed
y
1. Base line survey Local team Project One A survey Help from
to register all (F,M) villages month form will be Village key
families with All family complete used, Door to person, Trg,
cough > 6 wks survey door PHC
2. Primary data From PHC PHC, CHC, 15 days Meeting with Project leader
collection (PHC, Baif staff Dist hosp, Will MO, CMO, AC, PC
Dist Hospital, inform them Interview
Pvt practitioners) also
GPIH Page 30 / 70
3. Health check up PHC-MO, In a central 1 mo Health camp; CHC, PHC,

camps CHC-MO, village after Lab Village school,
staff; BAIF survey; investigation Key person,
doctor & Jan-Feb Panchayat,
Staff NGO, local
institutions,
4. Complicated PHC-MO To CHC, Dist 15 days Transport GO, NGO
cases referral Hosp After arrangements
camp (PHC)
5. Treatment; PHC ANM, Village, Door If + in Door to door, PHC
Arrangement of NGO to door screening ANM,
medication camp Balwaadi
worker, SHG
Now all the tools and intervention plan are put together for peer review; the facilitator
and the group look for convergence and consistency in the two: the analyses and the
proposed intervention. Do they justify each other? Any deviation is discussed. This is one
of the most important steps in the entire workshop:
For example: if tool 1 shows that the problem affects warli young girls in the off road
villages, does the intervention plan try to focus on them? If tool 2 shows that most
affected people go to Bhagat in their area, does the health education campaign try to work
with Bhagat or bypass them? If tool 3 & 4 mentions that one of the problems are- women
do not have enough privacy to practice personal hygiene or recommended treatment (eg.
Sitz bath) – is this being addressed somehow in the intervention?
Next, the group is asked to self evaluate their current efforts against the problem just
analyzed. They compare their current program against the proposed intervention plan and
rank various activities / components on a scale of 0 to 10 and add it up to work out an
overall percentage. This process too ends in a peer review. The group is encouraged to
think in terms of how programs can be planned better next time rather than rejoice or
worry about the score their program has received.
We may not be able to do everything for a given issue on our own due to resource
constraints. But is the short fall being met by other players? Do we need to collaborate
with other agencies?
A group produced following table in a GPIH workshop:
S.N Self evaluation of Program Activities Out of 10
1. Base line survey for skin problems 7
2. Basic curative treatment for skin 5
problems
3. Preventive health education – hand 4
washing, nail cutting, bathing, fungal
infections, causation through dirty water
4. promotion of Low cost bathroom 8
construction
5. Nail cutter distribution- schools, SHGs 3
6. Ensuring clean water availability 9
GPIH Page 31 / 70
7. Hand pump repair, Spring development 8

Total 62.8%
Third Session:
Adapting the GPIH tools for program planning needs
The group brainstorms on how to actually go about using these tools during program
planning; Questions to ask are:
Can these tools be actually used in your organization?
How? To what purposes?
What will they have to do in order to use them?
What changes will the tools have to undergo, to be ready for use?
The facilitator moderates this session and jots down the ideas on a chart; And later
critically evaluates these ideas and shares them with the group in a sum up exercise. The
group often comes up with deep insights at this point. It would be worthwhile to find out
what the normal planning cycle / process being used is.
The facilitator tries to emphasize- that there is nothing mysterious about the tools: the
matrix format helps us to think critically (and generously) and that the matrix can be
adapted.
Fourth Session:
Conclusion and Feedback
An open session for any and all questions. A brief recap is conducted. Workshop
feedback is taken. Participants are thanked and workshop concludes.
GPIH Page 32 / 70
An Interactive exercise for Tool 3 & 4 review

Some preparation will be necessary for this exercise. Facilitator should make many Zopp
cards containing following (or other) examples for tool 3 and tool 4. An empty frame of
tool 3 and 4 is made on a big chart. The participants in small groups are asked to place
the cards on the chart in the relevant boxes. After handing the Zopp cards, facilitator
should withdraw. Depending on the group’s strength, they may be given a deadline of 10
to 20 minutes.
This often generates intense debate within the group, where cards are often re-read,
discussed and shifted around. The facilitator, who sits at some distance quietly, gets an
insight into how much participants have grasped and what they may still be confused
about. These ‘caselets’ can also be used as readymade examples to help the group
understand rows and columns (loci and context of the factors) while discussing these
tools.
Examples for Tool 3 : Factors affecting who gets ill

At Household level At Community level Influence of States/markets
international relations
How does Many rural families have ill Many liquor shops have opened In view of the large revenue
the ventilated small kitchens. up in Village X. Drunk men keep received from tobacco trade,
ENVIRON Women while cooking are harassing women passing by. state government does not put
MENT exposed to smoke for long This generates considerable ban on this and related industry
influence periods. As a result they may anxiety among women working (Gutka etc). Men often fall pray
who suffer more often from outside home. to aggressive advertising and
GPIH Page 33 / 70
becomes respiratory problems and eye smoke. This gives rise to men
ill? infections. suffering more often from lung
Homes of poor families may cancers. Poor women too are
be poorly ventilated and have known to smoke / chew
little sun light entering. tobacco.
Women spending long hours
in such homes may suffer
from TB and general ill health,
more often than men.
How do Women’s hand (and feet) Men work outside home and State promotes recruitment of
the remain wet most of the time hence are exposed more to young men from Hills in to
ACTIVITI due to their water related mosquito bite, than women in armed forces. This career
ES of chores / activities like kitchen. exposes young men to alcohol,
women washing, cooking, caring for Men work outside home and STD/HIV, injuries and premature
and men children etc. So they suffer therefore are more exposed to death.
influence from fungal infections of skin certain kind of accidents or Harvesting herbs & other
their and nails more often than dangers like road traffic produce from the hills is ‘illegal’
health? men. accidents. and therefore men do it in a
risky fashion.
In absence of strict regulations
in rural areas, young men get
driving license, without
adequate skills or experience.
This leads to frequent
accidents.
How do Women cant insist on having a Maintenance, repair, renewal of Women legislators are not able
the labor saving or healthier water resources in a village to bargain with state / their own
BARGAIN device to use at home even receives less priority than other parties to review ineffective
ING when easily available - like issues of interest for men. laws dealing with women’s
POSITION kerosene oil stove, smokeless Women in Panchayat are not issues (dowry, violence,
S of stove, water filter, pressure able to bargain for these issues. inheritance, maintenance after
women cooker etc. This would mean As a result women may have to divorce etc)
and men that they have to keep on continue with unhealthy ‘Women and Adolescents
influence working for long hours and or workloads, chores. should not be employed in
their continue with unhealthy Commercial sex worker can not dangerous trades’ is poorly
health? conditions or postures, bargain effectively with client to implemented in rural areas by
leading to backache, tiredness care for their own health the state. So women workers
and general ill health. through use of condoms. are often exploited by the
Women cant insist on safe sex employer, exposing their health
and therefore is exposed to and well being to risks.
unwanted pregnancy and
STDs.
How does Women have less access to Information/ Communication State provides more
access to channels of information (radio, resources (TV, Phone) available information on family planning,
and TV, News paper) and therefore to panchayat are often limited safe delivery, ante natal care
control may not be able to protect to use by men. This reduces etc. Access to health
over their well being through women’s capacity to effectively information fulfilling needs of
RESOUR preventive steps. care for their health. adolescent girls, boys, men, old
CES In case of poor families with women and men is limited in
influence few mosquito nets, women’s rural areas. These groups are
the health access to nets may be limited less able to maintain their well
of women and her exposure to mosquito being in absence of such
and men? bite may be higher. information. Rural women may
GPIH Page 34 / 70
Women’s access to torch, not know about self breast

footwear and nutrition (milk, examination and therefore
meat) could be less than that report breast cancers late.
of men, giving rise to related
problems or vulnerability
(snake bite, accidents, worms,
malnutrition)
How do Wife is not supposed to ask Women are not supposed to State follows the unstated
GENDER husband to use condom or opt report violence by husband (or norms and will not provide
NORMS for sterilization. in laws). Much violence goes contraceptive info & services to
influence Women supposed to eat last unreported therefore. single women. This gives rise
health? which affects her nutrition. Son preference in community to risky / septic abortions.
Wife supposed to fast often for forces women to opt for many Media / Market promote a
the well being of husband. pregnancies. macho image of men to sell
Wife must serve husband and Only son can care for parents, cigarettes, alcohol etc. Men feel
others even when they are not daughter. Daughters are they must fit in to that image
suffering from Infectious therefore less cared for. and thus fall prey to these
disease like TB. She can pick Men can work bare body, unhealthy life styles.
up infection easily. women not. More chances of
mosquito bite to men.
Examples for Tool 4: Factors affecting Response

Household Communities Available health services
How do Unlike men’s work, women’s Men in Army, hesitate to report Hospitals don’t open at the time
the chores never seem to end. certain health problems (eg. of rural women’s (and men’s)
ACTIVITI Have no fixed routine. Seeking poor eye sight), for fear of convenience. Rural women are
ES of care for her health problems losing promotion. free in the evening, when
women receives last priority. Men, being men, go for risky / hospital OPD is closed.
and men Women with dermatitis are dangerous occupations (like
influence often asked by the doctor to mining) even at the risk of their
response keep away from water. This is health.
s to impractical for her. So, cure
illness takes long time.
How do Husband can go for treatment If wife has TB, husband might Health department prefers male
the of chronic ailments (TB, leave her at her parent’s place; doctors for chasing national
relative Leprosy) and STDs, but wife may even desert her and ‘targets’. Women being in the
BARGAIN will have to get husbands remarry. Community doesn’t weak bargaining position are not
ING consent in most cases. object. So women don’t easily able to demand and get lady
POSITION accept that they have TB. This doctors, ANMs in the required
S of interferes with their treatment numbers. This limits their
women and follow up. chances of early diagnosis and
and men proper treatment.
influence
response
s to
illness?
How does Women don’t have access to Large spending on health from Health department offers no
access to cash. So they go for treatment MMD savings, can not be made control to rural women where
and to faith healers. without consulting men / ANM, her work and posting etc
control husband. This can delay are concerned. So whatever
over appropriate health care to ANM does, rural women can do
RESOUR women in emergencies. little about it. This often results
CES Men often fight at PHC and are in poor services to women
GPIH Page 35 / 70
influence therefore given better care than needing them.

how women get. Indigenous healers in rural area
women Men get emergency evacuation often accept fee in kind (grain,
and men more easily organized in oil etc). Other service providers
respond community, since they move would not or can not accept fee
to ill around and have a network of in kind. This forces women into
health? favors given and received. accepting services from the
former.
How do Women are not supposed to Unescorted women’s mobility is Women health professionals are
GENDER discuss sexual symptoms. supposed to be restricted to supposed to be good only as
NORMS This delays correct diagnosis home. This prevents her from ‘gynecologist’ and never given
affect of STDs, Breast / cervical seeking health care at an early senior administrative posts.
response cancer etc. stage. Thus, health services never get
s to Men, playing the stereotypes, the chance to become women
illness refuse to accept that they are friendly.
unwell. This delays diagnosis Consent form for operation and
of their problems like High other medical procedures
blood pressure etc. request for husband’s signature.
Sexual dysfunction (eg. This sometimes delays the
Impotence) in men is a difficult treatment.
topic to be shared with wife or
doctor. Men suffer for long
before owning these
problems.
GPIH Page 36 / 70
5. More on Tools
Section 5: More On GPIH Tools

Important considerations while using them
General Comments
Should the message be aimed at Field functionary level or program manager level? In
a mixed group, it is often difficult to decide where to pitch the message. No easy
answers. But ensuring that small groups made for different exercises or activities are
truly balanced helps. Participant to participant learning takes place in the small groups.
Emphasize implications for planning after each and every tool. Participants tend to
forget and the tool becomes stand alone concepts. Asking questions like: If you
planned on the basis of this tool, what particular aspects will be emphasized or get
changed in your plan & implementation?
For planning, it is important to view all four tools together. If tool 1 shows up that the
problem affects Kotwalia young males, then subsequent tools and intervention must
not lose this focus. When viewed in isolation, the planned intervention may not take
advantage of all the useful bits & pieces of information generated by all four tools.
In true spirit of Gender, it needs to be emphasized that tools can and must be used both
for women and men’s problems. Thus using two case studies, one ‘female’ other
‘male’ is helpful.
Self assessment of their programs at the end should be least directive.
Specific Comments
Tool1
Emphasize the need to make column and row heads exhaustive, comprehensive. Group
may not realize the need for doing so in the beginning. For example, a group may see no
need to include Parsis (Zoroastrians) as one of the column heads in tool 1 on following
grounds:
They are a very small minority in their project area.
They are often well educated.
They are rarely poor in their project area.
After some discussion the group may realize that their knowledge of the community in
question may be limited: that some Parsis may have started marrying into local tribal
communities and these new ‘Parsi’ families may suffer handicaps similar to tribals.
Again in certain contexts, like metros, Parsis may attract more violence, since old couples
often live alone in apartments. So keeping these facts in mind, tool 1 should be adapted to
local situation.
Tool 2
Following terms, as constraints on using a particular service should be explained with
examples:
GPIH Page 37 / 70
5. More on Tools
Timing: Housewives may be free in the afternoon but OPD of the public hospital
may be closed by that time; Women doctor or the ANM posted in the village may
not be available in the evening or in the night, as they may be commuting from the
nearby city. On the other hand, village herbalist might be available most of the
time.
Location: Distance can restrict women’s access to health service (may not be able to
ride cycle, may not have access to it or to bus fare, may not be free to travel alone
or may not have sufficient time to travel); The locality where a service provider is
based, could again pose problems for women, especially if traveling alone, due to
social atmosphere (crime) or due to caste restrictions.
Money: Village herbalist may be more affordable than the RMP doctor. Treatment
and necessary investigations like X Ray, sputum test may not be completed due to
lack of funds. Some institutions, insist on a safety deposit (Rs 2000/- or so) at the
time of admission. Rural people who can not raise large cash at once, may not
prefer them, even though they may be offering good treatment.
Confidentiality: Men suffering from sexual dysfunctions will hesitate to consult the
doctor in the nearby facility. Muslim women may wish to procure contraceptives
quietly and may not trust government ANM. In certain occupations, men may wish
to hide their ailment from their employers (vision problems of a public transport
driver). Even if employer has provided suitable health services (as in armed forces),
such employees may seek help elsewhere. This limits their options considerably.
Effectiveness: People have their own perception about the efficacy of a particular
service in their area. A gynecologist in a government hospital may be seen as good
enough only for family planning services. A complicated delivery may be referred
to a private lady doctor. The rationale for such perceptions may not be obvious at
first sight and should be explored at length.
Norm: Are women free to consult a male gynecologist? Is an ‘upper’ caste midwife
free to deliver a Harijan woman? Is a Christian tribal free to participate in pre-
conversion healing rituals of his tribe? We discover that many services may or may
not be availed due to the gender, caste or social norms.
Appropriateness: For delivery, do women go to village midwife or the lady doctor?
We will discover that in addition to all the above factors, there is something like an
appropriateness factor operating in many such decisions. Everything being equal,
women may go for delivery to village midwife, not to the lady doctor, as it is
considered appropriate in their community. When infants cry too much in the
evening, older women in the family will often cast off the ‘evil eye’ with the help
of a few chilies, even if modern health care is easily available. This is considered
the appropriate response for this particular problem.
Tool 3 & 4
Explain labels especially for tool 3 and 4 well. State and market, and their influence on
individuals are somewhat abstract concepts. Some examples from their own context
which can help are: Why migrant labor in your region comes from a certain part of the
GPIH Page 38 / 70
5. More on Tools
country? Why is Gujrat a dry state? What happens if this policy changes? How will it
affect people’s health?
Similarly ‘activities’ represent economic/ subsistence activities; child eating mud or
men playing cards is not an activity in that sense.
It is important to realize that these grids do not represent water tight compartments.
Some factors could easily ‘fit’ into more than one grid. The purpose behind using the
grid is to ensure that no context or locus escapes analysis. On the other hand if some
grid remains blank, it should be accepted as such. This could be due to the fact that the
group may not have enough information about that aspect at the moment or may find it
truly irrelevant to the issue at hand.
Keep examples ready for various boxes (T3, T4) while introducing the tools.
Examples illustrate the point and help comprehension greatly.
Sometimes participants tend to use broad labels (ignorance, poverty etc) while
analyzing factors for T3 and T4, instead of isolating specific factors in depth and
detail; This creates confusion later when the factors have to be put into the grid.
“Poverty” per se could go in to various boxes, depending on the way, it is understood
or explained: Poverty can lead to lack of toilet in the home (box 1, tool 3). It could
refer to extra workload on woman in a poor household, which cant afford buying fuel
wood, fodder etc and hence the woman has no time to practice personal hygiene (Box
4 and 10, Tool 3). So broad labels like Poverty could be assigned to all the boxes,
which would prevent further analysis and pin-pointing of the real factors.
In Tool 3 and 4, people tend to forget the difference (before sickness, after sickness).
This has to be stressed a few times.
Some participants stretch logic too far to put a factor in a particular box. This could
have merit in some cases. One discovers quite unusual ways of looking at an issue. A
PHC having just a male doctor – is that the outcome of insidious gender norm
operating among service providers? Initially, we thought that it reflects gender norm of
the community not the service provider / policy maker - since community tends to
send more boys than girls for medical career, leading to scarcity of lady doctors. It is
the community which frowns on women being attended by a male doctor, even though
the woman in question may have accepted it as a matter of course. After a lengthy
debate, we agreed that a subtle gender norm does operate among service providers too:
Many District Health officers would prefer male doctors for ‘tough postings’ as they
are considered more ‘efficient’ where fulfilling national targets are concerned.
The participants who have some experience in health sector (like ANMs) may want to
discuss “biological factors” more than the other factors; this can veer the discussion in
to an area which offers little scope for intervention. It is important to de-emphasize
biological determinants of illness and move on to social factors.
GPIH Page 39 / 70
6. Case Studies
Section 6: Case studies

1. Backache in Women (Part 1 for Tool 3)
Phalguni Devi lives in a village in the hills. She is a mother of six children. Her youngest
son is about ten years old. Her own age is about 44. Her husband is a peon in district
cooperative bank in a small town ten km away from her village. She has been suffering
from backache for last ten years.
Her schedule through the day is quite busy even now, though for the last two years she
has had a daughter in law to help. While Kamla, her daughter in law, brings fodder and
fuel from the forest, five km away, she brings water, from a spring about 500 yards away.
Their village participated in a Swajal (worldbank) scheme to provide potable water and
basic sanitation to all the villages; but during the initial planning phase, it was discovered
that her village did not have adequate water resources round the year which could be
tapped for a gravity fed supply scheme. Their village could benefit only by lifting water
from a nearby river. Swajal scheme was taking up only gravity fed water schemes at the
time, so her village was bypassed.
Her gram panchayat every year receives small funds form District Development Office,
for construction activities under Jawahar Rojgar Yojana. For last five years, these funds
have been spent for repair and maintenance of the 1.5 km footpath, which links the
village to the main road; This is the spot where an occasional bus stops and a few tea
shops are located. The path going to the forest or the dilapidated spring, have never
received any attention, even though in many village meetings two women panchayat
members have mentioned it as a pressing problem.
Women’s life in her village revolves around water, fuel and fodder for cattle. With
overuse, forest cover has been shrinking and now, they have to walk further, to fulfill
their needs for fuel and fodder. Since every trip takes about three hours, women try to
collect as much fodder as they can carry. Sometimes, this exceeds their “carrying”
capacity and then either they leave part of their collection in some secluded corner of
forest or just take more rests and carry on.
Once an army man in her village who was on leave, showed them how to make a harness
out of broad canvas tape, to carry heavy loads on their backs, rather than head; It was
adjustable and being flat did not bite into the flesh. But everyone laughed at this fancy
contraption and no one used it.
Traditionally, men in these villages have either gone to armed forces or joined local
politics or become contractors for petty government construction jobs. Even those who
do not have a job, would rather go to the tea shop at the road and discuss various socio-
political issues. Actually collecting water, fuel and fodder – is considered women’s job.
Young boys, mostly school drop outs, help with grazing cattle in forest, at the most. Men
GPIH Page 40 / 70
6. Case Studies
go to forest only occasionally – for hunting wild boar or barking deer for meat, during
festivals.
The last time when Phalguni was taken along with a group of seven women members of
Self Help Group, to the nearby city, they saw a solar cooker. It had a mirror which
reflected all the heat to cooking pots and cooked tasty food in a few hours with out fuel or
smoke. It appeared so simple, that she thought she could handle it easily. Also, due to
government subsidy, it cost only Rs 800/-. But she did not have the money at that time.
Afterwards when she spoke to her husband, he advised her to wait for a few months.
Backache in Women: (Part 2 for tool 4)

She has been suffering from backache for quite some time. Since it was a common
problem among women, she never bothered about it. Some women in the village thought
that it was related to problem of “white discharge” and hence difficult to cure. Later on,
she attributed it to her advancing age. Some more years passed. But one winter, it became
so bad, that she could not get up from her bed.
This village is visited every fortnight by a medical team from a local voluntary agency. A
RMP doctor (“quack” according to some) also lives in the village. But as is the custom
among women, a Jagari (faith healer) was consulted. Jagari offered special worship on
her behalf to Raj-Rajeshawari, the local goddess; He asked Phalguni to keep some special
offered rice grains under her pillow and also gave her a thread to tie on her right big toe.
In exchange he took only some rice and wheat.
Her husband offered to take her to the PHC, in the small town ten kilometre away where
he worked, as peon. But Phalguni declined. She knew that Bhuri, her cow, would not give
milk to any other hand. Her youngest son, Makanu, also was no better. He would not eat,
unless she sat in front and fed him with her own hands. Even though it was only ten
kilometers away, but she had heard from other women that it would easily take one whole
day. There was just one bus returning to her village in the evening. PHC was located 3
km out of the town and its timings were such that she knew that last bus would be
missed, and they would have to return only the next day.
What actually made her uncomfortable about going to the hospital, was what she had
heard from Ashadhi, her friend in SHG: The male doctor there did not agree to write
medicines without examining patients, even if they were women. How could she show
her back to a stranger?
Despite all these fears, a year ago, when pain became unbearable, Phalguni decided to
take her chances and go to the doctor at PHC. A day was decided. But, that very day
Kamla, her daughter in law, started her labor pains! What could be done now? Nothing.
She had to cancel her trip and stay back.
GPIH Page 41 / 70
6. Case Studies
Over last one year, a strange thing has been happening. Phalguni has been getting
visitations from the local goddess – Raj-Rajeshawari, every few months. She throws her
limbs around, makes strange sounds. Then she collapses on the ground and sleeps for the
rest of the day. These episodes of visitation by the goddess have come in close proximity
with the bouts of backache. They have left her dazed but somewhat better and relieved.
Many other women, suffering from backache, touch her feet during these episodes and
have claimed improvement.
GPIH Page 42 / 70
6. Case Studies
Better sex ratio in a mountain village? (Part 1 for tool 3)

If you live in Kuthalgaon, there is a fair chance that you will not celebrate your 50th
birthday – if, and this is an important if, you are male.
Sometime back, a local NGO did a census study in this village of 2400 people. They were
happily surprised that unlike the plains, in this mountain village, there were 1014 females
for every 1000 males. Some people were suspicious of this finding and wanted to look
deeper. It was discovered that 15% of female population was 50 yrs or older, while only
11% of male population was in that age group.
This entire region has poor land and irrigation resources: soil is rocky, uneven and
agriculture is dependent on rain exclusively. There are no practical alternatives to rain.
So, agriculture here has never produced surplus, which could be sold in distant markets.
Some small farmers are able to produce only about six month’s grain requirement from
their fields. To fulfill the needs for cash income, every family tries to send a son to the
army. Those who can not qualify for army, become drivers on the narrow tortuous
mountain roads.
Then, there is a third category of men who follow adventurous path to big money. Some
of them collect rare herbs - jhoola illegally from forest. Jhoola sells for Rs2000 to 3000
per kilogram in places like Delhi. It is a fungus, which grows on the high branches of
Oak and Cedar trees in dense and moist forest. Sometimes forest department guards arrest
them. But what can really spoil or end their career, are accidents: attacks by wild animals
and slipping & falling from a tree. Often when this happens, they are 2-3 days trek away
from their villages.
In this category, there is another group, which traps wild animals for their skin and other
parts (like bear’s spleen, tiger’s teeth) for smuggling. Last time, Ramesh got caught in a
trap set by some other hunter, was mauled by a bear and was brought half dead to the
village on the third day.
Among all these occupations, the most honorable is joining the army. But there too lurks
the danger. In last Kargil war, Kuthalgaon alone lost five young men. Two received
Gallantry awards and three received Battalion honors. The region has the tradition of
honoring its brave. A fair – Kargil Mela- has been instituted in the memory of these five
young men, to be held on the first of Ashadh, every year. Still most young men dream of
studying up to class ten and then enroll for Garhwal Rifles (Army).
Drivers come next in the scale of desirable professions. You don’t need much education.
First, one has to be a cleaner on some vehicle and work hard for at least 3-5 yrs. Then,
one gets a chance to get the steering and drive on some unfrequented path. For about Rs
3000, you can get the commercial vehicle driving license without a proper driving test!
GPIH Page 43 / 70
6. Case Studies
Drivers are notorious for drinking. Some drink when they get a major booking during
marriage or “yatra” season. Suddenly, they are rich and the occasion has to be celebrated
with friends. Some get drunk, after finishing a long and hard drive on bad roads. And
there are others, who feel that without a couple of pegs they would not have courage to
drive at all. Then there are also cases of drivers being forced by the merry making
marriage party to have a peg or two, before driving the Barat (bride groom’s party) to the
bride’s village. No wonder, accidents occur.
When the local NGO did a focus group discussion with a group of men from the village,
they agreed that money by itself was not that important. But to have nothing to do and
stay at home was worse than going to the forest, army or on the roads and taking one’s
chances. Some men who run a grocery shop at home, are pitied. Infact two of them opted
for it because they were medically unfit to carry out their duties in the army and were
sent home. Now, even their families find it a burden to have them around all the time.
Further they said, that somehow they have spent their life in Kuthalgaon but they would
rather see their children get out and move in a better world. For children to get good
education, money is needed. You can not get it from agriculture.
Better sex ratio in a mountain village? (Part 2 for tool 4)

When Ramesh was brought half dead from the forest last year, the village quack who had
worked in the city, saw him and said – if he is to be saved he must be taken to the Trauma
hospital in the city, 40 km away. At least Rs ten thousand must be sent along with him.
Ramesh was hesitant since he knew that trapping of wild animals is a legal offence and if
the hospital authorities informed the nature of his injuries to the police, he could be
questioned. But his brother took the initiative and took his (Ramesh’s) wife’s ornaments
and raised a loan of another Rs five thousand from the village.
It was evening and the last bus had already left. Gopal the taxi driver, from the next
village was contacted, who offered his services free since he and Ramesh used to go to
the same village school as children. They were fast friends.
Ramesh was admitted in the intensive care unit. During the night, doctors decided that his
left leg must be amputated below the knee to save his life. Ramesh gave his consent for
the doctors to go ahead.
After two weeks in the hospital, Ramesh returned to the village, on crutches but alive.
Gram panchayat, decided to allot him a grocery shop in the village square, so that he can
generate at least his own pocket expenses.
GPIH Page 44 / 70
7. More Resources
Section 7: More Resources

An alternative Gender & Health Analysis framework
WHO SEAR Gender Analysis Matrix (GAM)14

GAM is used to analyze and infer role of GENDER in determining the sex differences
observed in health related data. This matrix has three columns and three rows and makes
no attempt to separate factors operating before and after people fall sick. It also takes up
Biological & Physiological factors.
GAM Exposure & Outcomes & Access &

Variables Vulnerability Impact Utilization
Biological &
Physiological factors
Social factors (Class,
caste, education,
Occupation, rural
/urban, tribal, ethnic
groups …)
Qualitative analysis of
observed difference for
role of Gender
First two rows are filled with sex disaggregated data (as far as possible) and third row is
used to question and analyze the observed differences from gender point of view. For
example:
GAM: Exposure & Outcomes & Access &
TUBERCULOSIS Vulnerability Impact Utilization
Variables
Biological & Prevalence of TB among TB is the single most The health
Physiological factors women & men is 2:1 significant cause of facilities that
death among women women use
in the world. provide only
maternal & child
health AND family
planning services
Social factors (Class, Women are more

caste, education, vulnerable:
- Under-reporting,
Occupation, rural - more likely to pick up
14
GAM was not used in the series of the workshops conducted with Swayamsiddha partners, but is being
offered just as additional resource.
GPIH Page 45 / 70
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/urban, tribal, ethnic infection as care provider

groups …) to infected husband and
other relatives
Qualitative analysis of When Husband is State has more

observed difference for diagnosed as positive focus on
for TB wife is ‘Population
role of Gender expected to care for control’ and
him. But when she is women are seen to
diagnosed, she is be the convenient
more likely to be point of
denied care, intervention for
sometimes even such programs.
deserted.
Exposure & Vulnerability refers to epidemiological aspects of incidence and prevalence

of sickness / problems in women & men; also to different levels of exposure among them.
Outcome & Impact deals with severity of an illness, its outcomes including disability,
death and burden of disease. Are there sex differences in this respect? Sexually
transmitted diseases may impact women and men differently. STDs are often silent
(without symptoms) among women. But Infertility caused by STDs may have a greater
stigma for women than men; On the other hand ‘impotence’ may have deeper impact for
men than women.
Access & Utilization: Access includes distance and time involved in getting the services.
Utilization deals with seeking behavior of women and men. Women may seek care late.
Men may not seek help for sexual dysfunctions and often resort to faith healing or
‘quacks’. Gender roles affect access to information through differences in literacy,
mobility, access to schooling and also through targeting of technologies. For example,
fertility regulation is targeted at women while use of EKG is targeted at men more than
women.
The third row – qualitative analysis for the role of gender – is meant for analysis and
inference drawn from the data in the upper two rows. Are the observed differences due to
biological factors or due to social / gender factors?
Next step is to utilize this information to review existing programs and policies and make
suitable changes or recommendations. What follows are two examples for Tuberculosis
and HIV/AIDS.
GPIH Page 46 / 70
7. More Resources
Gender Analysis of Tuberculosis using WHO SEAR Gender Analysis Matrix

Variables Exposure and Vulnerability Outcomes and Impact Access and Utilization
Biological Epidemiological data show that Deaths: Statistics reveal that TB is The health facilities that
& tuberculosis, particularly the single most significant cause of women usually use
physiologi pulmonary tuberculosis, is more death among women in the world. It provide only maternal
cal factors common among males than is the largest killer of women in the and child' health and
among females. According to reproductive age group (15-44 years) family planning services.
reported statistics the prevalence in the South East Asia Region. Pregnancy: Although
of tuberculosis is two males to Tuberculosis killed half a million exact data are not
one female. women in the Region in the year available, indications
Tuberculin test data show that 1997. from Africa show that
more males than females have a tuberculosis is the major
Pregnancy: Although exact data are
positive result to the test. Annual cause of morbidity and
not available, indications from Africa
reports of new cases of mortality in pregnant
show that tuberculosis is the major
tuberculosis sent to the WHO women.
cause of morbidity and mortality in
from all countries - industrialized
pregnant women.
as well as developing - show
nearly twice the number of males Progression of disease and case
compared to females. fatality:
The reason for this could be Progression of disease is faster and
because women may exhibit case fatality higher among women
lower delayed type than men TB patients. In a
hypersensitivity (DTH) responses prospective cohort study in
than males. It is not clear why Bangalore, India, among those aged
older men have a higher risk of 10-44 years, the progression rate of
progression from infection to tuberculosis in females was 130%
disease in comparison to women higher than that in males. This
of older ages. Cellular immunity seems, to indicate that though the
may diminish more quickly in men percentage of women infected may
than in women. be less, once they get infected the
Age differences: Statistics show disease progresses faster among
that upto the age of 14 years there women. The faster progression from
is very little difference in infection to disease in women could
prevalence rates among males also be responsible for the low
and females but the gap widens tuberculin positive results in
after this with 20-70% higher in screening programmes.
males than females. Hormonal Co infection with HIV: Both HIV and
changes could be responsible for tuberculosis occur in reproductive
this. age groups. Co infection with HIV is
The low level of notification of common in new cases of
female tuberculosis patients in tuberculosis. There is a difference in
the reproductive age(1535 years) the sero prevalence in male and
indicates the presence of gender female TB patients in different parts
disparities in notification. In of the world. In Africa the sero
younger children, there is no prevalence of HIV is higher in female
difference in reporting between TB patients than in male but in Asia
male and female children. the reverse is true. In a study in
Older women aged 35 and above Cameroon it was seen that 24% of
have higher levels of under female TB patients and only 12.5% of
reporting and so 'higher levels of male TB patients who were tested
under diagnosis. This could be were sero positive. Estimations show
because women of this age group that during the 1990s around 8% of
GPIH Page 47 / 70
7. More Resources
are not in contact with health all new TB cases were attributable to
services because they are not co-infection with HIV. Coinfection
having children. with HIV will also lead to an
increased development of drug-
resistant mycobacteria.
Social: Though epidemiological evidence Social stigma does not allow women Women face problems in
Class, shows that ~ the number of cases to discuss TB with others. seeking medical help
caste, is higher in men compared to Women are sent back to the natal and symptom reporting.
educatio women social cultural realities home when found to be infected due Due to delay in
n, indicate that women are more to the expense for treatment. diagnosis, treatment is
occupatio vulnerable to infection due to a Moreover illness reduces their started late and
n, rural \ variety of reasons. Women are potential for earning and carrying out complications are more
urban, also vulnerable to infection as household tasks. likely
tribal service providers for infected Information about disease is low Once diagnosis is made
groups husbands, in-laws, children and among women due to illiteracy. there is unwillingness as
other family members.. Women with TB are more likely to be the part of women to
'W'hen TB control programmes deserted or divorced and men may spend money and time
set 70% case ~ detection as a marry again pushing women into on continued treatment
target, the undetected cases are further dependency condition. as they need to leave the
more likely to be female due to While Male TB patients continue to home for availing
the low notification of female be supported and cared for by their treatment many times.
cases. spouses and other family members, Cultural constraints
Women do not report to health the same does not hold true for prevent women
centres when they have women TB patients, especially the' accessing services
symptoms. young' married ones. especially for long term
Women TB patients are sometimes treatment in
secluded within the family and care tuberculosis. Demands
of own family and children is denied on women's time at
due to perceived danger of infection. home and low access to
Women TB Patient is more likely to money and travel
spread the disease to children. facilities withhold
women from taking
treatment.
Married women are
concerned more about
rejection by husbands
and families than about
adherence to treatment
The requirement of an
initiative from the patient
to seek health care
(under DOTS) may be
insensitive to the
conditions of women
and poor people in
developing countries.
Too many visits to
health centers for
services.
Qualitative Case studies show that when the

analysis of husband is diagnosed as positive for
observed tuberculosis the wife is expected to
GPIH Page 48 / 70
7. More Resources
difference care for him. But when the wife is

for role of diagnosed, she is more likely to be
gender denied care and treatment and
sometimes even deserted.
GPIH Page 49 / 70
7. More Resources
Gender Analysis of HIV / AIDS using WHO SEAR Gender Analysis Matrix
Variable Exposure and Vulnerability Outcomes and Impact Access and Utilization
Biologic Age and risk of exposure: Opportunistic infections are Most school based AIDS
al & Low age at marriage, child prostitution severe in women education starts only in
physio- and rising number of street girls Pattern of opportunistic secondary schools or
logical increases exposure and risk of HIV infections and their severity colleges when it is already
factors infection among girls. differ in women and men. too late and most girls have
AIDS rate among women reaches a However studies of HIV left studies and are already
peak in late twenties, indicating that disease progression in women married and have entered
many girls are I infected in their late are limited. into a sexual relationship.
teens. Effect of HIV on pregnancy Even among highly
There is increased susceptibility to HI\' Most of the opportunistic educated women knowledge
for women under 18 years because the infections are life threatening of HIV/AIDS is more often
vaginal mucous membrane in young in pregnancy. TB is a major gained through friends and
women does not acquire a cellular opportunistic infection in HI\' relatives and this
density that acts as an effective barrier and this combined with knowledge is more likely to
until after 18 years of age. pregnancy increases risk to be inaccurate.
women. Prohibitions on access to
Post menopausal women are also
Children born to HIV positive sex and related information
vulnerable because after menopause
women may be sero positive. for women further hampers
the vaginal mucous membrane
Women may thus avoid access to information and
becomes thinner and weaker and is
pregnancy and are more likely services.
more vulnerable to HIV.
to seek abortion placing Services do not encourage
Men are older in marital and sexual
themselves at risk. women for testing due to
relationships and could be already
Treatment of pregnant women fear of repercussions.
infected. Men tend to want to have
to reduce Mother to child Testing is associated more
sexual relations with younger women
transmission affects the with pregnancy giving a
exposing them to infection.
health of the women. . false indication that it is not
Sex and risk of exposure:
serious among other
The epithelial quality of the vaginal women.
mucous membrane is more vulnerable The risk approach which
to infection than the penis. targets only same sections
of community is biased.
Male to female transmission is 2 - 4
Treatment of women and
times more effective than female to
men not done.
male due to the large vaginal surface
Treatment for women is
and the cell content of semen.
focused on pregnant
Semen remains in the vaginal tract or women showing that it is
rectal tract for a longer period than the health of the unborn
vaginal fluids on the penis. This baby which is to be
increases the risk of exposure to protected while the infected
women. woman is neglected.
Opportunistic infection in
Semen is more infectious than vaginal
pregnancy are treated only
fluid. HIV requires cells to be
after weighing their effect
transmitted. Semen is very rich. in
on the foetus.
cells and so it is more infectious
Condom use is promoted
Wives of migrant laborers, truck with women more often than
drivers, wives of drug abusers, men by health and family
defense and marine personnel are at planning staff.
higher risk The promotion of condom
as an effective preventive
GPIH Page 50 / 70
7. More Resources
method is not gender

Frequency of sexual intercourse and
sensitive since it is a male
multiple partners among commercial
controlled method and
sex workers places them at higher
women are not 10 a position
risk.
to negotiate for the use of
Use of spermicides could lead to condom in the context of
higher vulnerability of vaginal surface. unequal social and sexual
relations.
Women's lower educational
and literacy level, lower
attendance at school further
reduces their access to
mass media through which
AIDS awareness campaigns
are often promoted
Social: Women suffer more than men from HIV positive women face a social Women’s responses to HIV
Class, STDs which increases the risk of HIV surveillance are different
caste, infection through heterosexual death: than men's. Women are less
educatio relations. In many cases STDs are Women especially sex likely to come for testing or
n, asymptomatic in women, which workers are often stereotyped treatment due to social
occupati impede early detection and timely as transmitters of HIV and stigma. Therefore, in
on, rural treatment. STDs. Therefore the stigma surveillance data there is
\ Women receive proportionally more attached to seropositivity is under-estimation for
urban, blood transfusion than men, and have particularly severe for these women.
tribal a higher risk of contracting HIV / AIDS. women as it may lead to loss
groups Women sex workers are at greater risk of livelihood.
of infection due to the high risk Married women who are
behavior of their partners, rather than seropositive may be blamed
their own. Multiple sex partners and and abused by their husbands
low use of condoms puts many of and even abandoned or
these women at risk through their divorced. Given the limited
relationships with high risk male property rights of women and
partners. their economic dependence
Gender and risk of exposure on men this could result in
destitution.
Women constitute 75% of the new
Single women who are known
cases of infection. Women are at
to be HIV positive are unlikely
greater risk socially and
to find a partner. Widows
psychologically than men.
whose husbands have died of
The social and psychological
AIDS are unlikely to be
constructs of gender and sex roles
remarried. Such women are
restrict women from taking steps to
thus particularly vulnerable
protect themselves against risky
where employment
sexual behaviour by male partners.
opportunities are rare and
Knowledge and awareness gaps are
inheritance rights are weak.
more likely in women leading to higher
HIV positive women who
rate of vulnerability. ,
become pregnant face further
Education and awareness is less
psychological and social
among women.
pressure. The child may be
Married women traditionally have faith
seropositive. Fear for the
in the fidelity of the husband that he
future of the child and may
will not engage in extra marital
pressurize them into having
relations. She is shocked when she is
an abortion.
detected as HIV +ve.
Women are primary care
GPIH Page 51 / 70
7. More Resources
givers at the household and

community levels. The burden
of caring for the sick relatives
often falls on them. This will
be doubly difficult if women
themselves have AIDS.
Psychological trauma.
Working with Men in workshop setting

It can be difficult to help some men participants see the logic of gender issues for obvious
reasons. It is like stepping outside yourself and viewing the world with a different set of
eyes. Sometimes, it is women participants, who can not find sympathy with the new
perceptions proposed in a gender workshop. Following guidelines and thoughts have
helped us:
1. Having a woman-man team as facilitators often helps by demonstrating to
participants what it means to rise above ‘biological sex’ and work in a gender
equitable fashion.
2. Treating participants with consideration and gentleness, instead of coming down
on them like a truck load of bricks! Instead of silencing an interlocutor from a
higher intellectual, academic or ethical stance, it is better to let participants mull
and think over an issue and come to some conclusions on their own.
3. Small groups should always be mixed groups. Men in senior administrative
positions or in senior age bracket should be judiciously counterbalanced with
other participants who could help them explore their beliefs gently.
4. It is important to emphasize that GPIH is essentially neither pro-women nor pro-
men. But it brings out vulnerabilities of both, in the matters of sickness and
recovery. Therefore using case studies taking up both women and men’s health
issues is important.
5. Sometime a senior male participant would be participating so actively as to leave
little scope for women participants; talking to him on the side, explaining
importance of everyone’s joining in discussion helps. This works with any
participant, women or men.
6. Men sometime find it daunting that they are supposed to be ignorant about
women’s issues! On the other hand, women too may be less well informed about
men’s issues (Why men suffer from heart ailments disproportionately? Why is it
so difficult for men to discuss sexual problems with their wives or regular
doctors?). Raising such discussions purposely and bringing up these dark spots in
their awareness brings everyone, women and men, on to the same democratic
plane.
7. Sharing (self disclosure): When a male facilitator shares part of his own journey
(Ten years ago, it never struck me..) it helps men participants realize that all of us,
being the product of our times and culture, could be gender biased to varying
extents and that there is nothing shameful in accepting this fact.
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8. Asking men to play the role of women in a role play or take up women’s stand
point in a discussion, often initiates a helpful internal dialogue in the participant.
9. Participants often look up to facilitator as some kind of role model. This brings a
tremendous responsibility on facilitators to constantly review their behavior from
the gender point of view and always behave in a gender sensitive manner. Even if
one asks for a glass of water from a field supervisor, who just happens to be a
woman, it could strengthen gender stereotypes in participants’ minds!
10. One should always be aware of one’s role as a facilitator, as a helper in a process
of questioning of deeply held beliefs, without taking strong moral postures. In
GPIH, by and large, we start from observed data (who gets TB more often? who
gets sterilized more often?) and therefore it should be possible to emphasize
objectivity in such discussions. But often, this discussion would lead to deeper
values / biases: When the data says that men suffer more from TB why should I
believe that it is the other way around and that women are being under reported in
state statistics?
It might be possible to remain objective while handling questions as above and

offer data from a different source. But there may be rare occasions when
facilitator may have to directly address the hidden biases. On such rare occasions,
we found that ‘Caste’ in our Indian context could be used as a good parallel to
help people understand:
A hundred years ago, an alien from Mars visited a village in India. It found
everyone happy and content. It spoke to villagers at length and even the villagers
said that they were happy and content. Everything was fine.
Was everything really fine in that village a hundred years ago?

Today we know that, Dalits have lived a life of misery and oppression in our
villages for long. How is it that the alien never found out anything about the
ticking caste bomb in our villages, the rampant caste oppression?
Alien knew nothing about caste. So it didn’t see anything like caste oppression.
We know about it because we have talked about it, we have listened to Ambedkar
and Gandhi on this issue with an open mind. Eyes see what mind knows.
So when we say, everything is fine between women and men in the Indian family,
Indian society or our organization - could it be that we too are like that alien?
Could it be that the next hundred years will show us something different?
Certainly, we end by asking questions and don’t force conclusions.
11. Trainer authority: Striking a balance in our role as a non-authoritarian partner in

the process of enquiry & learning and a trainer with certain authority (and
responsibility) to discipline the learning process will always be difficult. How
GPIH Page 53 / 70
7. More Resources
much is too much - of authority being exercised even unconsciously? It would be

helpful to check whether15:
Learners are constantly looking at the facilitator and talking to her/him during
a general discussion.
Learners expect the facilitator to make choices for them.
Learners expect all their questions to be answered by her/him.
Learners appear eager to win her/his approval.
Learners seem hesitant to critique and display low initiative.
Workshops around Gender, can sometimes slip into clash of values. Ensuring that
we as facilitators are not seen to be forcing anything, can be important for the
learning process to continue both with women and men.
Internet Resources on Gender

Internet has considerable resources on ‘Gender and Health’, Gender analysis and related
issues. But one needs time, patience, discrimination and search skills to get to what one is
actually looking for. We list the best (in our estimation) ten sites here for beginners. Let
us also remember that information changes, shifts and gets outdated quite rapidly on the
web. Also the boundary between what is free and what is for a fee, is blurred sometimes.
1. PAHO (Pan American Health Organization)

http://www.paho.org/genderandhealth/
http://www.paho.org/English/DPM/GPP/GH/Mainstreaming.htm
2. UNDP
http://learning.undp.org
3. WHO
http://www.who.int/reproductive-health/pages_resources/listing_gender.en.html
http://www.who.int/gender/other_health/en/
http://www.who.int/gender/en/
4. Tropical School of Medicine, Liverpool, UK

http://www.liv.ac.uk/lstm/hsr/GG-1.html
5. Women’s Health Bureau, Health Canada

http://www.hc-sc.gc.ca/english/women/exploringconcepts.htm
6. ELDIS
http://www.eldis.org/gender/
7. Institute of Development Studies - BRIDGE

http://www.ids.ac.uk/bridge/page2.html
15
From ‘A manual for Participatory Training Methodology in Development (PRIA)’.
GPIH Page 54 / 70
7. More Resources
8. Harvard School of Public Health

http://www.hsph.harvard.edu/Organizations/healthnet/
9. Women’s Health, New Zealand

http://www.womens-health.org.nz/
10. Worldbank
http://www.worldbank.org/gender/
When looking for something unusual (gender differences in Malaria for example), try
following search engines. Start with a broad query (Malaria), then search with in results,
and refine the search by using key words like – gender, gender analysis, differences,
women, sexual, vulnerability etc.
http://www.google.com/
http://hotbot.lycos.com/
http://www.metacrawler.com/
The pages, which one opens, may not highlight the key words one is looking for. If it is a
long document, press ‘Control + F’ (in Internet explorer, other browsers have equivalent
shortcuts) and use the key word to do a rapid textual search, to confirm relevance of the
document. At poor connectivity, it helps to switch off graphics and focus exclusively on
text in most browsers.
GPIH Page 55 / 70
8. Optional Reading
Section 8: Optional Reading

This section offers optional reading for users of this manual.
Major trends in the field of Health

This section is addressed to the facilitator who may want to get a glimpse of important
developments in the field of Health, gender concerns being the latest one. Our
understanding of ‘Health’ and health care practices have undergone massive changes in
the last five centuries, often reflecting paradigm shifts in other fields of human
knowledge like Science, Economics and Theology. What follows is a brief description of
these major shifts. This will help the facilitator develop a larger conception of health
system– a prerequisite to understand that it has been changing over the years.
Mechanistic World View: Between 1500 and 1700AD, a radical shift took place in the
way people looked at the world and in their whole way of thinking. It could be
summarized as –
Material universe and everything in it, including human body is a machine. It can
be understood by studying the parts. There is no purpose, life or spirituality in matter.
Life or even consciousness could be explained through physico-chemical properties of its
constituents.
Such beliefs originated with Descartes in 17th century, as a major departure from the
organic world view sanctioned by the Church and Aristotle in the middle ages. The
inherent belief in this departure was: manipulation and exploitation of ‘nature’ is not only
scientific but is sanctioned by ‘science’. Such attitudes and beliefs percolated into
medical science and practice as well-and can be seen to be behind such modern
controversies like “womb on hire” and human cloning.
Reductionism: This was closely linked with the above and consisted of the belief that all
aspects of complex phenomena can be understood by reducing them to their constituent
parts, ie. the ‘whole’ is nothing more than the ‘sum’ of the parts. Over emphasis on such
thinking led to dichotomies such as Body versus Mind and Curative versus Preventive
care in time. It also led to fragmented thinking in medical profession and focus on
treating the ‘sick organ’ rather than the person as a whole16.
Biomedical Concept of Health: The developments in rational, observable sciences

strengthened the medical profession’s belief that the human body was a machine, disease-
a consequence of the breakdown of this machine and doctor’s task – repair of the
machine. Thus Health, in this narrow view, became the ultimate goal of Medicine.
The criticism leveled against this is that it has minimized the role of the environmental,
social, psychological & cultural determinants of health. The biomedical model for all its
spectacular success in treating diseases, was found inadequate to solve some of the major
16
The Turning Point by Fritjof Capra: p 59.
GPIH Page 56 / 70
8. Optional Reading
health problems of mankind – malnutrition, accidents, drug abuse, mental illness,

environmental pollution17.
Germ Theory (Pasteur, 19th Century): In practice it meant, that we live in an ocean of
dangerous germs and disease is a consequence of an attack from the outside, rather than
of a breakdown within the organism. This led to over emphasis on antibiotics and
antiseptics. Role of other factors behind health and its maintenance got de-emphasized in
the process: role of one’s own immunity, healthy life styles, environment etc. Such
attitudes have been promoted by an aggressive drug industry.
Public Health Vs Curative Health: The great dichotomy

Industrial revolution in mid 19th century England gave rise to slums, overcrowding and
filth. Frequent Cholera epidemics led an English lawyer (Chadwick) to investigate the
health of the inhabitants of the large towns and suggest ways to improve their living
conditions. His report led to a great sanitary awakening which spread to Europe and
America. This was also the beginning of ‘public health’ in modern era.
The division between Curative and Preventive medicine (also Public Health) was evident
at the close of the 19th century. After 1900, medicine moved faster towards
‘specialization’ (even super-specialization) and rational scientific approach to disease.
Closely linked was the growing phenomenon of excessive dependence on sophisticated
(and costly) technology and drugs. It could be said that curative medicine gravitated
towards rich man’s diseases while preventive health was left to deal with poor man’s
problems.
Women and Health / Medicine

It appears that organized religion and political institutions like state, systematically kept
women out of healing traditions18 or restricted their role to ‘lowly’ nursing and midwifery
fields19. This exclusion was effected through excluding her from formal education,
insisting that her role was within the home, not outside and through licensure/ regulation
and also at times through persecution & violence.
Witchcraft trials and witch hunts in medieval Europe was one example how state and
organized religion joined hands to push ‘medical women’ out of the public arena for
centuries. Men took the central role of being the physician. The rationale was: nursing
required feminine qualities of nurture and caring while clinical decision making required
rational intellectual acumen associated with men.
Only in the mid nineteenth century did women begin to be admitted to recognized
medical schools. Even today more men opt for the medical profession and the few
17
Preventive & Social Medicine by Park & Park. 13th ed.
18
Even in Ayurveda, it seems that women had little or peripheral roles. See another article describing these
systematic processes in west: http://www.umanitoba.ca/outreach/manitoba_womens_health/wominmed.htm
19
Read “The Woman’s Health Movement: Past Roots” by Dr P.H. Helen I. Marieskind in “Seizing our
Bodies”. This interesting essay traces women’s role in health from ancient times to present.
GPIH Page 57 / 70
8. Optional Reading
women who do so, often end up specializing or practicing Gynecology, Obstetrics,

Pediatrics – branches dealing with women’s reproductive role and the new born.
It is believed that patriarchy was at play on a subconscious plane while modern science
evolved over the last five centuries. The purpose of this science was subjugation of
nature. Nature was often thought and spoken of as woman. Nature in Bacon’s view20, had
to be “hounded in her wanderings,” “bound into service” and made a slave. She was to be
“put in constraint,” and the aim of the scientist was to “torture nature’s secret from her.”
This deep seated bias against women (and feminine qualities) can be seen in the
following practices, beliefs:
Women often end up in poorly paid nursing jobs. Clinical decision making and
treatment part is systematically kept out of their purview.
Family planning programs have targeted women more than men.
There are more family planning options for women than men, discovered by
scientists and offered by the State in their Family welfare programs.
Doctor-State- Drug Industry nexus has often condoned use / trial of questionable
technology/ contraceptives on women’s body. (Dalkon shield21, Ultrasonography/
amniocentesis for female feticide, unwarranted hysterectomies, Caesarians etc)
Countercurrents in Health/ Medicine

In India, awareness on women’s issues in modern times started as a major social reform
movement in 19th century, led by Ram Mohan Ray, Vidyasagar and others- in the
vanguard of Renaissance in Bengal. It passed through the political current of the nation,
during the independence struggle. It had a resurgence in post emergency phase (1970s) as
evolution of many women’s organizations and movements (Chipko & anti-arrak/liquor
movement in south). 73rd and 74th Constitutional amendments assuring one third seats for
women in the local governance structures, MTP and PNDT acts similarly in the field of
health were the outcomes of long advocacy efforts of women’s groups22.
Women’s movement in India has affected field of health in many ways, some of which
are:
Violence against women is increasingly being recognized by health service
providers and authorities.
Organized resistance by women’s organizations and activists, to unethical and
aggressive promotion of contraceptives
Increasing advocacy against use of medical technology against women (Depo-
provera, Norplant, Amniocentesis etc)
20
Early 17th Century English philosopher who proposed a theory of scientific knowledge based on
observation and experiment that came to be known as the inductive method and influenced scientific
thinking for long.
21
‘A case of corporate malpractice & the Dalkon Shield’ – Mark Dowie, Tracy Johnston, in ‘Seizing our
Bodies’.
22
Based on an essay – ‘The women’s movement in India: A brief History’ by Sreela Das Gupta.
GPIH Page 58 / 70
8. Optional Reading
Exclusive focus of service providers on reproductive role of women (RCH, Family

planning services) is being challenged; General health care, adolescent needs and
topics like menopause, sexuality, gender and ‘male responsibility’ are being
included increasingly in the purview of interventions being planned now.
Absence of Female service providers in state health services is being recognized as
of a serious quality concern.
Other Gender Analysis Frameworks23

GPIH is one gender analysis framework. There are many more, oriented to fields other
than Health. Following section discusses Gender analysis and GA frameworks in a
broader context.
Introduction to Gender Analysis Framework

Women's participation in development has constantly been a matter of debate and
concern for many. Policies and approaches have undergone many changes over the
period. The debate between Women In Development (WID) and Gender And
Development (GAD) approaches has passionate followers. Within both these approaches,
a variety of approaches and perspectives exist. Almost everybody accepts that men and
women are differentiated in this world. However, there is no consensus about the causes
of this differentiation and discrimination. Gender Analysis Framework (GAF) is a tool,
which tries to find out the causes for discrimination between women and men. At the
same time, it tries to give direction to reducing this gender-based discrimination. To
summarize, we can say that to use GAF means to ask right questions and understand right
direction.
Gender Analysis Framework is a tool, which is used by different development

organizations for planning, implementing and monitoring their interventions. The
primary use of GAF is to inform policy makers. Gender relations affect the solution of
any problem and hence the impact of any development initiative. This also could be
called a methodology to identify constraints and challenges in integrating gender. In
short, Gender Analysis Frameworks are useful in integrating gender into development
initiatives. Not only development practitioners but also teachers and trainers use it for
documenting impact of policies, approaches and programs. Different tools have been
evolved based on the needs and situations. So, there is no one GAF as such and the body
of tools have grown complex in the last few years.
Development practitioners are part of the society and societal construction of gender
influences them largely. Development programs are generally influenced by patriarchal
norms - and therefore such initiatives could not bring desirable changes in the lives of
women. On the contrary, many such efforts have re-enforced gender norms and gender
inequities. To those who are convinced about women's rights, GAF provokes them to
think and analyze the context in which they are working. GAF provides a range of
23
Ms Savita Kulkarni, BAIF, contributed this section on Gender Analysis and GA frameworks.
GPIH Page 59 / 70
8. Optional Reading
insights to its readers and users. Of course, GAF needs very sensitive handling -
otherwise it is just a dry and futile exercise.
Brining gender concerns into the forefront of the development initiatives (and hence into
the existing institutions and organizations) is necessary. This is not only a technical
process but it involves challenging and changing existing power structures and
relationships. Understanding GAF is necessary but not sufficient to bring changes in
gender relationships.
Key concepts in GAF

Understanding following concepts is pre-requisite for using GAF.
Sex and Gender: Sex refers to biological differences between women and
men, which do not change and are universal. Gender refers to social
construction of roles and expectations that are learned through various social
institutions. They can change over a given time. Gender is about roles,
responsibilities, expectations, privileges, and power for women and men in a
particular society. This set of ideas are also termed as Gender norms.
Gender Roles/ Gender Based division of labor - In all societies, women and
men are supposed to perform certain tasks. This is a learned behavior and all
the members of the society are expected to understand and follow it. In some
cases, exceptions are accepted but it has a limitation. Productive work means
that work by which the person can earn income. Reproductive work is unpaid
work, which needs to be repeated. It includes support and service. Some
people also call it social reproduction, though this is done at the family level.
Community Management means maintaining community resources such as
water, education, social relations etc. This is unpaid work and is supposedly
done during the free time.
Needs
a: Practical Gender Needs are those needs which when satisfied help women
and men to perform gender roles effectively and efficiently. For example,
providing handpump, smokeless chulha to women is to address Practical
Gender Need. b: Strategic Gender Needs/Interests are those by addressing
which we can bring in changes in power relations, distribution of benefits and
control over resources. When this happens, we say that there are Changes in
gender relations.
Access to and control over resources: Resources are of different kinds: human
resources (labor, education etc.); material resources (land, water, house, food
etc.) and intangible resources (information, political participation etc.). Access
could be defined as opportunity to avail services from a particular resource.
Control is capacity and opportunity to take decisions about use, sharing, and
sale of a particular resource.
GPIH Page 60 / 70
8. Optional Reading
Empowerment: is power within. There are different kinds of power relations

in the society. Power is control. Power means who decides and whose
interests are served with priority. Empowerment is the ability to do, to
accomplish, to perform with full mastery of oneself. For this, one has to earn
freedom from gender norms and other bondage.
Women in Development (WID): It includes number of approaches, which

were evolved for women's participation in development. They are Welfare,
Equity, Efficiency, Anti Poverty and Empowerment.
Participation: is defined as equal accesses to and control over decisions and

policies, planning, implementation and monitoring.
Choosing a suitable GAF

There is not a single standard GAF but there are many. One needs to choose GAF
according to one's needs and skills. Some of the frameworks focus on gender roles and
some focus on social relations, which entails gender analysis. Some of the tools in a
given framework might be irrelevant to you. One needs to modify and evolve different
tools for the well thought purpose. We should be aware that just by using GAF, gender
does not automatically get integrated in programs, projects and organizations/institutions.
Some of the well-known GAFs are as follows:
1. Harvard Analytical Framework

2. People Oriented Planning Framework (POP)
3. Moser Framework
4. Gender Analysis Matrix (GAM)
5. Capacities and Vulnerabilities Analysis Framework
6. Women's Empowerment (Longwe) Framework (Equality and Empowerment
Framework)
7. Social Relations Framework (SAF)
These frameworks were developed in different contexts and for different needs.
What is the immediate output?

By using GAF, at least the following output is expected:
1. Understanding about women's and men's relative situation in the given context.
2. Principle activities done by women and men and their implications.
3. Priorities of women
4. Practical Gender Needs and Strategic Gender Interests
GPIH Page 61 / 70
9. Energizers & Hindi Resources
Section 9: Energizers & Hindi Resources

In our experience a discussion on gender generates genuine discomfort in some, boredom
in some others and intense mental agitation in most. Sustaining a meaningful dialogue
over a long period of time during workshop can be difficult. Field functionaries, often
concerned and dealing with tangible realities of day to day work, may find it difficult to
remain focused through out a long conceptual discussion.
Energizers and other breaks in the rhythm of an exercise, like asking participants to get
up and sit in such a way that everyone gets light or can be seen or heard, can be
extremely useful to provide participants a breathing space and refocus. Cramps in the leg
can be a real distraction for older participants from the field. These little games /
activities also ensure that participants do not go back to their comfortable niches, seats
and slip into passivity.
In our experience, any activity or energizer, which makes participants get up, move,
think, shout & LAUGH, is of infinitely more value than the few minutes it might take out
of the workshop schedule. With some practice it might be possible to conclude such
activities in under ten minutes and return to workshop theme.
There are many energizers available to facilitators. Many more can be invented by
creative facilitators. We mention here just four, which we used frequently under different
circumstances and found quite useful.
1. Boom Out: Participants stand in a circle. Facilitator explains the rule:

- Numbers will be counted aloud by the participant starting from 1.
- But numbers containing “4” or divisible by “4”, like 14, 16, 20 etc. will be
replaced by a loud ‘BOOM’.
- If you make a mistake, you come and stand in the center. Person next to you, will
continue from the next number. If Anil was at number 14, and said “14” or
anything other than “BOOM” or took a lot of time thinking about it, Anil will be
out and will go to the center. Meera, next to Anil, will carry on and say “15” – not
“14”.
Apparently, from “40” onwards, participants will be booming out till “50” is reached.
When played fast, it makes everyone exceptionally alert and awake and generates a lot of
fun.
Variations: The trigger number can be even 2 or 3. Word BOOM can be replaced by any
fun word. Another variation is ‘Double speed Boom out’. Here, the person booming out,
raises right or left hand bent above head and pointing to side. Whichever side the hand
points, numbering moves in that direction. We used it frequently, 3-4 times in a 3 day
workshop, starting from simpler versions and ending with double speed variety.
Remember: This game can be played only with those who know number tables.
2. AAI Bole (Mother says): The group stands in a circle. The facilitator casually asks:
Whom do you always obey? Do you all obey your mother?
GPIH Page 62 / 70
The answer is invariably ‘yes’. Aai in Marathi means mother. The facilitator now says:
OK, we will find out how obedient you are - and goes on to explain the rules:
Facilitator will use two kinds of commands. One with a prefix (AAI - BOLE), other
without it. Only the first kind of command has to be obeyed – because mother is giving
it! Commands themselves are simple but repetitive and funny:
Close Right eye.
Raise Left hand.
Twirl your left ear.
Open your mouth.
Raise both hands. etc
Every now and then, two kinds of commands are mixed and given in close proximity,
with a result that one that should be obeyed, is ignored or the other way around.
Participants make these mistakes and are requested to stand in the center or to one side.
Finally a small number of very alert participants are left who have survived all the tricks
and refuse to get out. Facilitator now uses a clever, if slightly unethical, ruse:
“OK, friends. Most participants are out. Just three of you are left in this large circle. Why
don’t you all come closer so that I can see you better?”
Everyone moves into a tight circle, and everyone is declared out, since this wasn’t
mother’s command! Obviously, this ruse works only once with a group!
3. Long ago, there was a king…

This is a number game which can be played in a hall. The facilitator stands in the center
and tells a story loudly. Participants move around her in a circle. Whenever there is a
number mentioned in the story, participants have to stop and make small groups
consisting of that many members. The story can ramble any which way with random
numbers: ‘The king had four queens… One queen had two princes .. and so on’. Those
who don’t fit in any group, get out and sit in the center. Eventually just 2 participants are
left. They could be congratulated and asked to recap tool 3 and 4!
4. Naani - Paani24
The group stands in a circle with the facilitator in the centre. Members have to jump in
‘water’ (one step ahead) when they hear Paani or leap back to original position, which
represents maternal grandmother’s home (Naani) on the other command. To confuse
participants, the facilitator may jump in the wrong direction with Naani or Paani
command. This jumping back and forth rapidly can be quite useful in a post lunch
session!
Games number 2,3 and 4 are quite suited to participants from rural background.
The following section provides Hindi translation of the case studies.
24
Savita introduced us to this very interesting but simple game, among many others.
GPIH Page 63 / 70
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GPIH Page 64 / 70
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GPIH Page 68 / 70
10. APPENDIX
Appendix
Introduction to BAIF25
BAIF, a leading voluntary agency in India, was started by Manibhai Desai, a disciple of
Gandhi ji, in 1967. Its mission is to “create opportunities of gainful self employment for
rural families especially disadvantaged sections, ensuring sustainable livelihood, enriched
environment, improved quality of life and good human values”. To achieve this mission,
the approach followed in the program is
Family as a unit of development
Multidisciplinary program for assured livelihood
Blend of development with Research and Training
Working through People’s organizations
Women Empowerment and
Environmental Protection
(See http://www.baif.com for more information on BAIF).
Swayamsiddha Background
‘Swayamsiddha’, is a comprehensive project to empower women by addressing their
special health and socio-economic development needs. BAIF contemplated a project
focused on women’s health and empowerment, in order to focus interventions on gender
integration and to consolidate the scattered and diverse but rich field experiences.
Swayamsiddha Objectives:
The General Objective of the project is: “To improve rural women’s (and girls’) health,
and empower them to address their own needs by initiating gender responsive collective
actions and institutionalizing processes in 10 selected project areas in 7 states in India,
building on ongoing work of BAIF and selected NGOs.”
Swayamsiddha project builds on a 10-year history of collaboration between IDRC and

BAIF and is designed to reach about 75 villages and provide benefits to the women
members of community-based organisations as well as their families. By the conclusion
of the project, it is anticipated that there will be an improvement in the health of rural
women and girls, as a result of their empowerment to address their own socio-economic
and development needs. To support the changes that are needed for these improvements
to occur, the project has specific objectives:
development and strengthening of networks among concerned organisations;
improved availability of reproductive health care information within the villages;
greater awareness of the need for gender equity and changes in the allocation of
work that is traditionally based strictly on gender;
25
Contributed by Ms Savita Kulkarni, BAIF; also the following section.
GPIH Page 69 / 70
10. APPENDIX
improved access by women to physical and natural resources and financial

services; and
Better understanding of how to plan and implement sustainable programs that will
improve the health of women and girls. [adapted from Project Implementation
Plan, 30 April 2001]
Implementation:
The project was started its implementation in July 2000. This project is being
implemented at 9 locations in 6 states by 9 Partner Organizations.
No State Area Implementing Organization

1 Gujrat Vansda (Valsad) DHRUVA*
2 Gujrat Nanodara(Ahemadabad) GRISERV*
3 Karnataka Tiptur (Tumkur) BIRD-K*
4 Maharashtra Junnar (Pune) CHAITANYA
5 Maharashtra Jawhar (Thane) MITTRA*
6 Maharashtra Andur (Osmanabad) Halo Medical Foundation
7 Madhya Pradesh Lateri (Vidisha) SPESD*
8 Rajsthan Ghatol (Banswada) RRIDMA*
9 Uttar Pradesh Chitrakut BIRD-UP*
(Marked with * are BAIF states societies.)
Swayamsiddha Approach
Gender integration, Action Research, Health, Ecosystem Approaches to Human Health,
Institutionalization and Networking are some of the major components of this project
along with rigorous Monitoring and Evaluation.
It is expected that this project will create a significant impact and generate substantial
learning on approaches and strategies for initiating gender responsive development
process, which will specially address women’s health and empowerment issues.
The project has been designed to integrate gender equity into the project activities and
approaches. Gender equity was a critical component in the project design from the outset.
Throughout the design stage there was a clear attempt to identify and address gender
biases in developing outcomes, identifying barriers, and selecting activities. In framing
many of the project objectives care has been taken to move beyond a WID approach (or
simply targeting women) to a more integrated understanding of gender and equity.
The implementation approach is to initiate empowering processes with groups of local

women and men. Formation of community level organizations and building the capacities
of women and men.
GPIH Page 70 / 70

Gender Analysis of Health

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Gender Analysis of Health

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Swayamsiddha

IDRC-BAIF Gender Perspective in Health (GPIH)

Gender analysis as applied to Health is somewhat different to what it is in the socio-

This module is based on Swayamsiddha experiences from field and a series of

2. Swayamsiddha & GPIH1

3. GPIH Module and its evolution2

BAIF coordinating team based at Pune initiated number of Gender Sensitization

To strengthen this perspective, we perceived a need for a separate training module

Section 2: Basic Concepts

The two core questions

GPIH: The four steps

Step 1 Step 2 Step 3 Step 4

The Four GPIH Tools

GPIH: The four steps & four tools

Step 1 Step 2 Step 3 Step 4

Tool 1: What, Tool 2: Health Tool 3: Tool 4:

The Second & Third Dimensions

women’s activity at household level?

(3) (1) (2)

While in step 4, we are looking at:

Understanding the loci for Factors affecting who gets ill6

Understanding the Contexts7

States, markets and international relations

Understanding the loci for factors affecting responses to illness8

Understanding the Contexts9

Available Health Services

Consider the following aspects:

Section 3: Steps & Tools

Step 1: Patterns of Ill-health

Tool 1 Who gets this illness? Who is affected more?

Name of 0-5 years 6-10 yr 11-18 yr >18 yr

Step 2: Are there enough, adequate, affordable services available to

For each service provider, following questions could be asked:

Step 3: Factors affecting who gets ill- women or men?

See more examples for this grid.

Step 4: Factors affecting responses to ill-health

Where Next? From Analysis to Program Planning

GPIH: Relevance to Program

How can sick people be Curative

Section 4: Prototype Workshop

GPIH workshop takes the participants through these mile stones:

4 Open session for questions / suggestions

A Typical GPIH workshop

Infant and maternal mortality Training of field functionaries, TBAs, Growth

Drudgery of SHG women Washing platform, Cattle tank, Ball bearing,

Phalguni had to stay back to a man (doctor)

3. Health check up PHC-MO, In a central 1 mo Health camp; CHC, PHC,

7. Hand pump repair, Spring development 8

An Interactive exercise for Tool 3 & 4 review

Examples for Tool 3 : Factors affecting who gets ill

Women’s access to torch, not know about self breast

Examples for Tool 4: Factors affecting Response

influence therefore given better care than needing them.

Section 5: More On GPIH Tools

Section 6: Case studies

Backache in Women: (Part 2 for tool 4)

Better sex ratio in a mountain village? (Part 1 for tool 3)

Better sex ratio in a mountain village? (Part 2 for tool 4)

Section 7: More Resources

WHO SEAR Gender Analysis Matrix (GAM)14

GAM Exposure & Outcomes & Access &

Social factors (Class, Women are more

/urban, tribal, ethnic infection as care provider

Qualitative analysis of When Husband is State has more