Q&A: MSH Gender Specialist Gives Her Perspective on the New HIV/AIDS Care and Support Program in Ethiopia

The new HIV/AIDS Care and Support Program (HCSP), funded by the US Agency for International Development, represents the largest national expansion of HIV & AIDS services at the community and health center levels in Africa. Dr. Belkis Giorgis, the program’s NGO Capacity Building/Gender Advisor, discusses the challenges that Ethiopian women face and MSH’s family-focused, gender-sensitive approach to AIDS. To extend the reach and impact of our activities, MSH recognizes the importance of including senior staff such as Dr. Giorgis in our health programs to address the socioeconomic and cultural realities that men and women confront.

What are the major health challenges facing Ethiopian women today?

The major health challenges facing Ethiopian women are linked to poverty: lack of food, safe water, and access to health care services. Ethiopia ranks among the world’s poorest countries (105th among 108 developing countries on the Human Poverty Index of the UN Development Program). Health indicators such as infant and maternal mortality reflect this: there are 77 infant deaths per 1,000 live births, and 850 mothers die for every 100,000 births. Only 6 percent of women in Ethiopia deliver at a health facility, the fertility rate is 5.3, and early marriage is the norm. Cultural and religious traditions promote and sustain inequalities. For example, nearly three-quarters of women are circumcised, some undergoing the most severe types of genital mutilation. Gender-based violence such as rape and abduction have been identified as major problems for girls. Educational, training, and employment opportunities for women are limited. Women also work long hours, carrying fuel wood, transporting water, engaging in agricultural production, and caring for children. Despite these conditions women not only survive but are the backbone of their families.

Are there efforts already being undertaken by local women’s groups? What kind of support do they need?
Ethiopia is a big country with a population of close to 80 million, comprising nearly 80 nationalities, so it is difficult to make general statements about the role of local women’s groups. In each region, there are differences in how women organize themselves and help other women. The cultural and religious contexts within which these groups operate differ. Given this background, there are numerous informal associations based on religion and other cultural formations that allow women’s participation and help them cope with day-to-day realities. During crises such as famines, these groups help women a lot. As in other countries in Africa, mutual help continues to be strong. Ethiopia has strong religious traditions, both Islamic and Christian, and there are vibrant informal associations based on religious beliefs that help women and families. This support is not only financial but also psychosocial. All you need to see is how communities rally around to help families when someone dies. Recently, there has been a growth of strong self-help groups that organize to obtain resources that allow them to increase their income. These groups need support to build their capacity to access mainstream development projects. Since Ethiopia was never colonized, the legacy of social welfare groups based on Western models that we see in other countries is lacking. So these groups need assistance to organize themselves while maintaining the traditional concepts of self-help and mutual support.

How does meeting these challenges fit into the Ethiopian government’s priorities?

The government recognizes the negative situation of its women and has taken actions to address it. The constitution guarantees women equal rights, and family laws have been revised to provide greater equity for women in cases involving marital property and custody rights. Nearly one-third of representatives in Parliament are women. A women’s policy agenda has been adopted and is being implemented through the Ministry of Women’s Affairs. A reproductive health policy has been adopted, and it clearly articulates the rights of women. The government has recognized that education is the key to the empowerment of women. Hence schools are being built and girls are encouraged to attend. As they reach secondary school, however, they tend to drop out because they contribute to household labor, get married, or are afraid to walk to school. Affirmative action policies are in place for girls who make it to the university level. Even with all this, it will take a long time to reverse centuries of oppression. Almost half (48 percent) of young women (ages 15–24) are not literate, compared with about one-third (37 percent) of young men.

How does the HIV/AIDS Care and Support Program fit into these priorities and needs?

The HCSP fits well within these priorities since women are not only disproportionately affected by HIV & AIDS but are the major providers of care. Their vulnerability to HIV as a result of biological differences is exacerbated by the fact that they cannot negotiate safe sex from their partners or husbands, in addition to being victims of coercive sex. When you see the figures on prevalence, it is clear that young women have the highest prevalence. The figures for prevention of mother-to-child transmission (PMTCT) of HIV are very low in Ethiopia because prenatal care coverage is low. So pregnant women who lack access to health care but are HIV positive do not have the opportunity to get PMTCT services. HCSP is working at the health center level because it is more accessible to women who do not have the resources to go to hospitals for antiretroviral treatment. The comprehensive nature of HCSP also helps both men and women obtain prevention, treatment, care, and support services. HCSP is focused on families rather than individuals, to create an environment in which women are likely to benefit and can access care and support.

What role do you play in MSH’s work?

As a gender specialist with a background in public health (especially reproductive health), I am involved with other team members in training staff about gender and reviewing the work they are doing in every technical area to determine if there is an opportunity to integrate issues related to gender. For example, if we are conducting prevention activities, our messages have to address the needs of women and the situation they are in. In the treatment area, the gender team works with issues of quality as they relate to the needs of both women and men. In care and support, we work with families while being cognizant of the burden women carry in taking care of themselves and their families.

What does it mean to “mainstream gender?"
Mainstreaming gender means that, in any activity you undertake, you consider, understand, and value the roles of males and females and determine how your activity will have a positive or negative impact. For example, when women have responsibilities they have to fulfill daily and lack transport services, integrate services at the health center so they can get multiple services at one time. If you are working to prevent gender-based violence, involve males, because their socialization encourages them to think that women are inferior and have no rights

How does one measure the impact of gender-related interventions?
The indicators used to measure gender are not well understood except when we disaggregate data by sex. Second, indicators need to be measured over the long term. Each intervention is linked to another one, and the process is cumulative rather than a one-time intervention that will yield immediate results. Success depends on so many other factors that you may not be able to link one intervention to an outcome that you can say is directly related to that intervention. But you can definitely determine that there are positive outcomes that make it easier for women—and indirectly for males and the whole society. If a woman is healthy and productive, she contributes to family welfare.

How do men respond to such interventions?

Men respond to interventions positively when they support their own aspirations. Males can be partners and should not be viewed as adversaries. If we forge alliances with men for the interventions we plan, we have a better chance of success. While inequality affects women directly, it also affects men in that it benefits neither to live in a society that relegates women to an inferior position.

From your research and other experience, what will be the lasting benefit of HCSP’s work?

The lasting benefit will be a behavior change among beneficiaries and providers of services. Experience has taught me that unless we tackle gender issues with cultural sensitivity, which allows men and women to examine how their roles affect their lives positively and negatively, people do not have the opportunity to change. Gender is not an abstract concept and must be contextualized in the framework of poverty, culture, and religion. It is not men against women or women against men—it is more of a coming together of both sexes to work for a common good. Both men and women want to be healthy, have healthy families, and see their children educated for a better life. The socialization process that defines the roles and responsibilities of males and females will change over time, and perhaps the next generation will have an easier time of accepting the fact that inequality exacerbates poverty, squanders resources, and impedes progress. In the meantime, programs, like HCSP, are designed to minimize obstacles to helping women and men prevent transmission of HIV and get treatment, care, and support if they are affected by HIV & AIDS.

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