Introduction

1.1 Women's health in context

Health is not only a medical issue, confined to natural and biological factors which can be addressed by medical interventions. Rather, good health or illness are products, not only of biology, but of the social, cultural, economic and political environment in which we live and act. Health, thus, cannot be viewed in isolation from the context within which it is defined.

Good health is far more than just the absence of illness. Many factors affect our health, including how we live, what we do, the people with whom we choose to interact, and the nature of these relationships. Feeling unhealthy is not only associated with suffering from an infection or disease, but more often with feeling tired and overworked, being under stress, and living in a hostile atmosphere. Feeling healthy is closely associated with feeling relaxed, productive, and useful; being creative, living in healthy, active, and pleasant surroundings, and amidst supportive relationships with people whose company we enjoy.

Why should women's health demand a special focus? There is a perception that both sexes are equally vulnerable to disease, within a given context and setting. However, once we acknowledge that illness has a social dimension as well as a biological cause, it becomes imperative to address the impact of gender relations on health. Given the different social realities for men and women, their experiences of health and their health needs must also be different. Gender analysis shows that differences based on social and cultural relations ('gender'), exist between men and women that go far beyond the differences based on biology ('sex') (Oakley 1971).

Women have a vastly different status from men in every society: one of subordination. Women typically have less control over resources; the 'sexual division of labour', which is regarded by most societies as natural, burdens women with multiple demanding roles. Equally important is the fact that women and men undergo very different processes of socialisation; these give them such disparate social identities that they have different perceptions and definitions of good health and ill health. Consequently, not only do men and women have differing health needs, health problems, and access to health services, but also varying perceptions of health itself.

People's health problems are not only based on biology, but on structural factors, including socioeconomic status, and their own status as individuals within their households and communities. Both the cause of women's ill-health, and women's ability to obtain health care, are related to these factors. Some of the reasons why it is important to focus specifically on women's health needs are as follows:

• Women have special health needs because of their biological role as bearers of children.

• The sexual division of labour, which places multiple roles on women's shoulders, tends to make women more vulnerable to certain diseases than men.

• Certain conditions, such as sexually transmitted diseases, are more difficult to detect in women.

• Women may have greater difficulties in using health services.

• Women's specific health issues are neglected by health services.

1.2 Women's life-cycle and their health

Traditional frameworks for the analysis of women's health tend to concentrate exclusively on the childbearing years, and, further, on problems directly related to pregnancy and childbirth, but women's health needs extend throughout their life cycle, and beyond their reproductive role. Besides the special health needs related to reproduction and childbearing, women are also exposed to most of the health hazards that affect men. Reproductive health problems are compounded, or sometimes even caused, because of the heavy manual labour undertaken by rural poor women. Control over female sexuality dictates an early marriage for women, followed by early and frequent childbearing, often while shouldering an active productive role, and managing a household plagued by poor living conditions and chronic shortages.

Often, the roots of health problems which women experience later in life lie in their neglect in childhood. Discrimination against the female child starts early in many cultures: girl children are less welcome than a male 'heir'. The girl is socialised to accept her subordinate position, and is given fewer material and nonmaterial resources than the boy. If the household is poor, this may mean undernourishment for the girl, less health care, and illiteracy. Early malnutrition causes stunting, leading to poor development of the girl's pelvic bones, and this considerably increases the risk of obstructed labour in pregnancy.

Women's productive roles may begin as early as four or five years old; girl children typically help at home from a very early age: cooking, cleaning, fetching water and fuel, and caring for younger children. This places them at risk of burns, and other accidents in the course of domestic work. By the time they are eight or nine years old, children in rural communities are often regular workers in the farm. They may be exposed to respiratory infections because of working in marshy and water-logged fields; and poisoning from pesticides and fertilisers is a growing problem. Another common health problem is infection by parasites such as hookworms. Infections may be contracted from animal bites, and there is a risk of accidents with equipment. Occupational health hazards associated with industry are burns, eye problems due to intricate work, lack of relaxation, exhaustion, poor posture and back problems. Sale of girls for prostitution exposes them to sexually transmitted diseases, including HIV/AIDS.

Girls who begin their productive and reproductive duties early will lack the opportunity to attend school. Girls are expected to adhere to sex-role stereotypes, as 'mother's helpers' and 'little ladies' in community gatherings, and may face more constraints on playing and having fun. This lack of relaxation or stimulation through learning also causes mental stress and fatigue. All in all, the workload of many female children throughout the world exposes them very young to continual and excessive physical stress, which will last throughout their lives into old age. In adolescence, young women continue the roles begun in childhood, only do more work than before. They carry out heavy agricultural work, and are exposed to respiratory and parasitic infections. These have implications for their health during pregnancy and following delivery: severe infection can lead to miscarriages.

As members of a community, there may be serious restrictions on women's sexual behaviour. which have consequences for their reproductive health. Girls and women are isolated during menstruation in some communities, making it difficult to maintain menstrual hygiene, and thus causing severe infections.

Productive work does not stop during pregnancy, and this places women at a higher risk of pregnancy-related complications, and maternal mortality. Farm-work performed knee-deep in water, and the consequent exposure to infection through micro-organisms, may result in urinary tract infections as well as gynaecological problems. Women often suffer from hyperacidity and gastritis, due to lack of time to eat or eating at irregular intervals. For women of childbearing age, repeated births, begun too young or continuing too late in a woman's life cycle, occurring too often or too soon after one another, add to the risk of maternal mortality. Births may be unsupervised by health personnel, and repeated abortions may have numerous health consequences such as anaemia, reproductive tract infections, pelvic inflammatory diseases, uterine prolapse, and urinary incontinence.

Societal norms that tacitly permit multiple sexual partners in men expose women who are their partners to the risk of sexually-transmitted diseases and HIV/AIDS. Women's subordination and powerlessness within conjugal relationships, and the acceptance by society of male violence as 'normal', has resulted in sexual and other violence within the family being a major health concern – both physical and psychological – for women. Repeated reproductive tract infections and exposure to the risk of sexually transmitted infections greatly increase women's risk of contracting cervical cancers, a major killer among women from developing countries.

Social violence against women includes practices that are directly injurious to women's health and lives, such as female infanticide, restricted mobility, and discrimination against widows. Ear piercing, tooth filing, and tattooing at puberty for beautification, are all part of the socialisation of young girls into norms of female beauty, and the acceptance of male control of female sexuality. An extreme manifestation of a male-dominated society is female genital mutilation, which denies women the right to sexual pleasure. Quite apart from this, female genital mutilation is the source of severe reproductive health problems, including severe pain during intercourse, and obstructed labour. Incest and sexual abuse in girls is not well researched, but, according to the limited data available, it seems to be widely prevalent. Female infanticide and foeticide, and childhood marriages are other problems to take note of. In addition, in situations of ethnic, racial and communal violence, and armed conflict, women are subjected to enormous mental and physical traumas, such as rape and sexual abuse, widowhood, and having to head the household all alone.

Towards the end of their lives, it is rarely possible for women living in poverty to retire and cease work. Towards the end of their reproductive span, women may suffer from a host of health problems related to menopause, such as excessive and irregular bleeding; hot flushes and mood changes owing to hormonal changes, and a feeling of vulnerability. A lifetime of deprivation and hard productive and reproductive labour, leaves women ailing from numerous problems such as arthritis, back problems, osteoporosis; and further deterioration of existing conditions such as prolapse of the uterus and bladder and urinary incontinence.

In many cultures older women have a greater say and role in the community, bringing greater confidence. However, older women are also more likely to be widows, dependent on others for their livelihood, which may mean greater vulnerability than ever before. It is not uncommon to find destitute old women in communities who do not even have two meals a day, nor health care, at a time when their need for such care is the greatest. In communities where resources are scarce, well-being of the elderly is usually a last priority, and that of old women without resources, least of all.

The consequence of biological vulnerability, and gender-based discrimination in a context of poverty, is ill health for women. When they feel ill, women seldom get health care promptly, because of lack of time and money; the socialisation which reinforces women's self-neglect; women's lack of decision-making power; and in many cultures, the restriction on their mobility, which makes it impossible for them to seek health care without the permission and accompaniment of male members of the household. For poor communities, there are yet another set of problems related to lack of transport facilities, and distance from a health facility, which, although affecting both sexes, have far-reaching consequences for women who have already lost much time before the decision to seek health care was taken.

2 Identifying women's health needs: an analytical framework

2.1 Introduction

It can be seen from the above that, while biological factors and poverty or low socioeconomic status of the household are important factors influencing women's health, they are not the only determinants of women's health status. It is important to disentangle the consequences to women's health of poverty on the one hand, and of intra-household inequities on the other. Women's subordination to men, and their lack of power to take decisions governing their lives, largely determine women's experience of ill-health and inability to obtain the health care which could help them.

Aspects of women's lack of power can be seen in male control over female sexuality and reproduction; the compulsion upon women to bear a high number children; son preference; women's multiple roles and heavy work load; their lack of control over resources; and their exclusion from decision-making. All these factors underlie and complicate common female health problems. Poverty only exacerbates the threat to women's health which already exists due to gender-based discrimination.

The factors influencing women's health (their socioeconomic situation, their biological needs, and sexual discrimination against them) are intertwined. Each of the factors impinges on the other. How do we go about initiating changes in this situation? The key to disentangling this complex web may lie in starting with women themselves; creating greater opportunities for them to interact, and to reflect on their situation; and facilitating their empowerment, to change their situation of oppression, as women, as poor people, and as members of a marginalised group or community. Factors affecting women's health operate at individual, household, community, national and international level.

2.2 Household level factors

• Women's resource base (their assets, skills, etc);

• women's use of wider household resources, and their status in terms of autonomy, control over resources, power, and decision making authority;

• demographic variables such as age and parity.

Such factors influence women's 'illness burden' (how frequently and seriously ill a woman is, and for how long), and, to a significant extent, women's 'health-seeking behaviour' (any action a woman takes to regain good health when she falls ill). The 'health outcome', also known as a woman's 'health status', is determined by the interaction of her illness burden and her health-seeking behaviour.

Health-seeking behaviour is strongly influenced by the community's 'health culture', that is, the attitudes of the community to health and illness, and to fertility and its control, including beliefs about the aetiology of various health problems, traditional healing resources commonly used, and attitude to formal health services. Practices and beliefs surrounding menstruation, pregnancy, childbirth, and menopause would feature prominently among these.

Physical, economic, and social access to health services, and the prioritisation and quality of different aspects of health care provided, are other important influences on women's health-seeking behaviour.

All factors at the household level are influenced by community level factors.

2.3 Community level factors

• Community structure: stratification, divisions, power distribution, resource-bases and resource distribution within the community;

• women's status within the community: authority, autonomy, participation in decision making, rights to use of and control over community resources;

• health services available to the community.

The first set of factors has to do with the number and amount of resources at a community's disposal, and their distribution across various social groups. The second set of factors deal with resource availability to women within each social group. An understanding of both first and second sets of factors is essential to an understanding of the consequences of being a woman who belongs to a very poor social group. These two sets of factors governing women's access to health care demand different strategies for action.

The nature of health services available to the community is related to the community's resources. For example, an urban community or a wealthy social group is likely to have better quality and more appropriate health care facilities available to it than would a poor or socially marginalised community.

2.4 National and international factors

The current process of transnationalisation of commerce and production, the growing interdependence of economies across the globe, and continuing inequality in the balance of power between countries of the North and South, significantly influence national economic policies and the performance of national economies. For instance, a slump in export prices of an agricultural commodity may result in a loss of jobs and intensification of poverty for a Southern community which depends principally on production of that commodity for export.

The indebtedness of Southern countries, and the Structural Adjustment Programmes (SAPs) which many countries have been compelled to embark upon, have resulted in massive cuts in social expenditure, including health expenditure, and in the destruction of small-scale economic ventures in many countries, which are now viewed as 'uncompetitive'. Agricultural subsidies, that helped populations to survive, have suffered, and many people have lost their usual means of survival and are increasingly forced to seek other livelihoods. All considerations have an impact on factors operating at the community level: many communities have found their resource base eroding, or experienced a redistribution of resources among particular social groups. These changes have had adverse effects on poor women in terms of resources and health services.