Health policies and interventions need a cross-cutting gender equality and women’s empowerment component if they are to tackle the real issues that women face.
Persistent social and gender inequalities lie behind the fact that women and girls in many developing countries are at an increased risk of ill health than men and boys. Their low status in health systems reflects their wider status in society. Women’s health programmes and policies are increasingly recognising this and starting to develop integrated approaches that address gender equality and women’s empowerment.
As the Lancet Commission found in 2015: “Gender-transformative policies are needed to enable women to integrate their social, biological and occupational roles and function to their full capacity, and that healthy, valued, enabled, and empowered women will make substantial contributions to sustainable development.”
For some years, priorities in women’s health worldwide have been changing from the narrow focus on maternal and child health to an expanded view of women’s health that includes a more complex life-course approach, one that looks beyond women’s sexual and reproductive health.
Integrated approaches include tackling the health challenges that women share with men, and as well as those challenges that affect women disproportionately due to a range of social determinants, including gender equality, social justice and culture. Not only is an increased focus on community health systems needed – but also a crosscutting gender equality and women’s empowerment component in health programming is essential if health policies and interventions are to take on the complexity of the barriers to accessing health care that women face throughout their lives.
Interventions addressing women’s health should therefore go beyond access to health care and health systems, but include education, social protection, and actions aimed at empowering women and girls in all aspects of life, as well as interventions fostering social change and gender equality within communities.
Things are changing and the Global Goal on gender equality will go some way towards supporting changes. Health interventions are widening their focus, but to date there are very few examples of integrated approaches where gender equality and women’s empowerment are central to a health system-level intervention.
One of these is the Women for Health (W4H) programme, which has been operating in five states of northern Nigeria (Jigawa, Katsina, Yobe, Zamfara and Kano) since 2012. The W4H programme is funded with UK aid from the UK Government and managed by Health Partners International in partnership with Save the Children and Grid Consulting, Nigeria. WISE Development input into the initial programme design phase of the programme.
The programme aims to increase the number of female front-line health providers and support their deployment to rural health facilities. The gap in the female health workforce is largely a rural phenomenon and efforts to deploy female health workers from urban areas, or from other parts of the country have had limited sustainable success to date. Consequently, one of the main initiatives of the W4H programme is to attract female students from rural areas to the Health Training Institutes who are more likely to accept and stay in a rural posting where they can have greatest impact on maternal, infant and child mortality.
Increasing the number of female students entering and graduating from health training courses is a key challenge. Before the programme began, student drop-out and failure rates were very high. Rarely do rural women and girls understand the requirements to enrol on health training courses, nor have the entry level qualifications in sciences. Few rural girls have female role models to guide them in education or further training. The quality of teaching and learning needed to be improved, and much work was required to create a supportive learning environment for female students.
Also important were the attitudes and aspirations of the students, their families, and communities. Some female students treated health training as a ‘waiting room’ for marriage, while others lacked the encouragement and moral support from family members that they may need to continue their studies. The programme began with a gender audit which revealed that, in general, Health Training Institutes did not specifically consider the needs of female students and that the institutions needed to change.
Community mobilisation in rural areas has enabled community sponsoring of young women to attend Health Training Institutes and they are tied into an agreement that guarantees them three years employment in their home community. Young women from rural areas are supported through a foundation programme at the Health Training Institutes, which improves their levels of qualifications and science knowledge enough to enter the full course for midwifery or community health worker. A carefully designed multi-dimensional approach which brought the Health Training Institute management on board and supported them in the development and management of their own gender management plans has significantly increased the gender responsiveness of the Health Training Institutions.
This approach and the significant advocacy by the programme led to the following appointments and changes: one female provost (Katsina) and a female principal of an School of Health Technology (Kankia), as well as 13 female vice principals; all schools now have female Head of Departments and female representation on management and decision-making bodies; and gender components have been mainstreamed into all Health Training Institutes’ operational plans.
In addition to this, 19 schools have established a counselling system for female students (especially important for rural women who are sometimes hundreds of miles from their communities) which has created a mechanism for students to raise issues with the Institutions’ management. Fulfilling their family responsibilities is a reality for women which can affect their ability to pursue further education and 13 schools have established crèches and 10 have employed nannies, enabling young mothers to take part in the foundation programmes.
All Health Training Institutes have improved security around female hostels and some have appointed female security guards.  Moreover, with support from a female architect, appropriate accommodation for female students, including married female students, has been constructed in over half of the institutions.
To achieve W4H objectives within the northern Nigerian context has required enormous attitudinal changes and significant complex cultural, gender, economic and organisational challenges have had to be overcome, both within communities and in the Health Training Institutes. From W4H we have learned that a multi-level approach, that addresses practical, social and cultural barriers to women’s inclusion in education and employment, is required for success.
 Mary Surridge, Ladi Wayi, Nana Lyamgohn, Mariam Maina And Alawiyatu Usman (2013) Women for Health Programme, Gender Audit Report
 Mary Surridge and Zainab Moukarim (2014) Women for Health Progress Report on the Increased Gender-responsiveness of Health Training Institutes (HTIs)s