UHCP GENDER EMPOWERMENT AND SOCIAL INCLUSION ANALYSIS.pdf

GENDER EMPOWERMENT AND SOCIAL INCLUSION ANALYSIS

UNIVERSAL HEALTH CARE PROJECT: 2024-2028

Executive Summary

The Universal Health Care Project (UHCP) has examined the differential impact of the project that will affect women and girls, men and boys, and gender-diverse individuals, including sex-disaggregated and gender-sensitive data across all activities and addendums. This gender analysis was conducted at the project development stage to identify the underlying gender norms and factors that will bolster health programming through improved understanding of family planning / adolescent reproductive health (FP/ARH), tuberculosis (TB), HIV, health systems strengthening (HSS), community-based drug rehabilitation (CBDR), and global health security programming consistent with USAID objectives and goals. Key issues identified include the intersectional vulnerabilities faced by girls, women, boys, and men, that shape their exposure to health risks, hazards, and health seeking behaviors. Highlighted too, are the significant unmet need for comprehensive health care among gender-diverse individuals. The

UHCP will programmatically integrate these considerations along with other issues and interventions identified.

Project Description

The UHCP will address challenges facing the health system in the Philippines by focusing on health systems strengthening (HSS), improving the quality of service delivery, and the adoption of positive social norms and behaviors. The goal of the UHCP is to strengthen national and local health systems in line with the Philippine Development Plan 2023-2028 and the country’s

Universal Health Care Law with a focus on enhancing the quality and coverage of health services, effective local ownership, and the management of health priorities. Project activities will implement focused health systems interventions to achieve key U.S. government objectives for TB, FP/ARH, HIV, and GHS. The UHCP will contribute to a sustained and coordinated multi-sectoral approach focusing on locally-led development and will pivot towards a more transformative model that seeks to address critical social determinants of health, including education, skills development, and employment, as well as animal and environmental health, to mitigate future impacts of macro- and microshocks to health systems. The UHCP will address key health objectives of the US and Philippines governments through a strategic composite of bilateral, regional, and global USAID implementing mechanisms.

Background

As part of the design of the new round of health projects, the Office of Health (OH)/USAID

Philippines conducted a gender analysis to understand the country’s gender situation, the implications of gender roles and power dynamics, and their impact on the access to quality health services of women, men, persons with disabilities and people of diverse sexual orientations, gender identities and expressions (SOGIE). Mainly guided by USAID’s Integrating

Gender Equality and Women’s Empowerment in USAID’s Program Cycle1 and the 2023 Gender

Equality and Women’s Empowerment Policy2, and the recently updated U.S. government

Gender Based Violence (GBV) policy3, OH reviewed relevant documents on health and gender equality. Based on the findings, this analysis provides recommendations for improving gender integration and impact in the Universal Health Care Project.

Highly considered in this gender analysis are the DOH’s Gender and Development policies. With

USAID support, the DOH is developing its strategic Gender and Development framework and agenda that is more inclusive, incorporating the needs of people with diverse SOGIEs and persons with disabilities. The DOH is also using the National Objectives for Health and health across the lifecycle to include children, adult women, men, and teens.

A renewed focus on youth is a prime consideration. The Philippines is one of the countries with a demographic dividend window of opportunity: young adults aged 15-24 comprise 19 percent of the population including 10.3 million adolescent girls (10-19 years old)4. According to the

National Economic and Development Authority (NEDA) one of the national social emergencies in the Philippines is teen pregnancy. A UNFPA study in 2016 showed that adolescents who began childbearing before turning 18 are less likely to complete secondary education which impairs their ability to join the workforce. The net estimated impact of teen pregnancy due to lost opportunities and future earnings can be as high as 33 billion pesos annual loss for the economy5.

5Education, Earnings and Health Effects of Teenage Pregnancy in the Philippines. 15 July 2016.

4Philippines Statistic Authority. Updated Population Projections Based on the Results of 2015 POPCEN.

3 United States Strategy to Prevent and Respond to Gender-Based Violence Globally 2022

2 2023 Gender Equality and Women's Empowerment Policy

1ADS Chapter 205 Integrating Gender Equality and Women’s Empowerment in USAID’s Program Cycle https://philippines.unfpa.org/sites/default/files/pub-pdf/Education%2C%20Earnings%20and%20Health%20Effects%20of%20Teenage%20Pregnancy%20in%20the%20Philippines.pdf https://psa.gov.ph/content/updated-population-projections-based-results-2015-popcen.%20October%202019.

https://www.state.gov/reports/united-states-strategy-to-prevent-and-respond-to-gender-based-violence-globally-2022/ https://www.usaid.gov/document/2023-gender-equality-and-womens-empowerment-policy#:~:text=The%20U.S.%20Agency%20for%20International,effective%20and%20sustainable%20development%20outcomes.

https://www.usaid.gov/sites/default/files/2023-04/205_1.pdf

A 2023 OH Gender Assessment of current implementing partners’ GEWE performance reveals that USAID/OH indicators are more focused on the “Reach” aspect of the

“reach-benefit-empower-transform”(RBET) gender inclusivity continuum; thus, the UHCP is envisioned to be more gender transformative by selecting GEWE/GBV indicators that cover the

“Benefit-Empower-Transform” parts of the continuum.

Laws, Policies, Regulations and Institutional Context

The Government of the Philippines (GoP) introduced policies including the Universal Health

Care (UHC) Law and the Philippines Health Agenda to increase access to healthcare and ensure

“the best health outcomes for all” which includes broad general coverage of Filipinos relying on the Philippine Health Insurance Corporation, also known as PhilHealth.6,7,8 While the Universal

Health Care Law takes on a health-for-all approach, decision-makers, and stakeholders must respond to the specific needs of women and girls, men and boys, and gender-diverse individuals, starting with the recognition of how healthcare is paid for and accessed. Health system strengthening under the UHC Law is being led by the DOH and other relevant partners.

Building the capacity of policymakers and decision-makers to develop gender-responsive legislation, policies and regulations, as well as continuing to develop the quality of health services will build trust in the health system. At the policy level, members of government have the power and authority to make decisions regarding health care. Equal access to quality health care will build trust in the health system, motivate, and empower women and girls, men and boys, and gender-diverse individuals, particularly the underserved, in their health-seeking behavior.

In addition to national government laws and policies that provide a legal mandate for equal coverage of health services for Filipinos, other factors play a role in health care access including the interaction between women and men and health care providers. Gender and power and decision-making dynamics within the home could be factors in health-seeking behavior.9 Men also have challenges accessing health care and their health needs and the barriers they face are different from women. For example, men do not regularly access health care because the clinic hours usually conflict with their work schedules.10 According to the National Tuberculosis

Prevalence Survey 2016, slightly more women (60%) than men (58%) had PhilHealth coverage.11

11National Tuberculosis Prevalence Survey 2016: Philippines

10Health Policy Project, The Fade Away Effect: Findings from a Gender Assessment of Health Policies and Programs in the Philippines. December 2014.

9 USAID Philippines, Health Gender Analysis, February 2017.

(https://www.tbdiah.org/resources/publications/national-tuberculosis-prevalence-survey-2016-philippines/

8 Congress of the Philippines, Republic Act 7875. “National Health Insurance Act of 1995.”

7 Congress of the Philippines, Republic Act 11223. “Universal Health Care Act.”

6 Department of Health, Republic of the Philippines, Administrative Order No. 2016-0038. Oct 26, 2016. “Philippine Health Agenda 2016-2022.”

https://ntp.doh.gov.ph/download/national-tuberculosis-prevalence-survey-2016/ https://www.healthpolicyproject.com/pubs/345_FORMATTEDPhilippinesGPMReport.pdf https://www.healthpolicyproject.com/pubs/345_FORMATTEDPhilippinesGPMReport.pdf https://www.tbdiah.org/resources/publications/national-tuberculosis-prevalence-survey-2016-philippines/ https://doh.gov.ph/sites/default/files/policies_and_laws/Ra07875.pdf https://doh.gov.ph/sites/default/files/health_magazine/RANo11223_UHC.pdf https://ntp.doh.gov.ph/download/the-philippine-health-agenda-2016-2022/

Presumably , this disparity has been addressed with the passage of the UHC Act which provides social health insurance coverage for all, but challenges persist to operationalize the universal coverage. On the other hand, excise taxes for tobacco use and alcohol may have a protective effect especially for men, since the tax burden is assumed to decrease use of these harmful products (e.g., may have good effects for men to prevent the risk of having lung diseases including TB). Gender differences also affect fairness in financial contributions.12 Initially, social health insurance was available only to the employed sector financed from payroll tax.13 Given their culturally-driven productive role in the household, men are more likely to be employed in the formal sector and are able to pay contributions for social health insurance, and if available, private health insurance/HMOs and hence can access care that is covered by the insurance.

Women who are culturally assigned to be in the reproductive sphere and are more often doing unpaid labor at home or employed in the informal sector would have limited access to health insurance. This scenario may push more women to pay user fees when accessing care and will greatly disadvantage their access to services such as reproductive health services. Currently, there are limited social insurance benefits for unmarried women, despite protections for single parents under RA 8972, and those with more than four children.

The table below highlights potential GESI issues and gaps within this section, as well as related recommendations or mitigation measures. Similar tables are included for each section that follows.

Potential GESI Issues/ Gaps

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations/ Mitigation Measures

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Women employed in the informal sector are not able to access social health insurance and its benefits.

Support better targeting/ identification of the potential beneficiaries for subsidized premiums in the indigent and informal sector.

Limited insurance benefits for unmarried women and those with more than four children.

Advocate for policy changes in PhilHealth to optimize benefits of unmarried women;

Support implementation of the Solo Parent’s

Welfare Act.

13 Medical Care Act of 1972

12 Witter, S., Govender, V., Ravindran, T. and Yates, R., 2017. Minding the gaps: health financing, universal health coverage and gender. Health Policy and Planning, 32(suppl_5), pp.v4-v12.

Access to reproductive health services is hampered by user fees.

Enhance benefits for better access to reproductive health services.

Cultural Norms and Beliefs

The communication of health messages can also influence women and men differently and this access to information is a link to access to health resources and services. Cultural norms and beliefs also play a significant role in health-seeking behaviors and outcomes and there needs to be a more detailed exploration of the experiences of both men and women including the

“dynamism of the social relationships and interactions of other critical social, cultural and environmental determinants of health.”14 Higher treatment adherence and cure rates among women are linked to local cultural norms that socialize them to being more compliant to treatment regimens. Gender norms, roles and practices must be considered if health policies and programs are to serve all genders equitably. Traditional gender roles and practices create differences between women’s and men’s health outcomes, preferences, decisions and behaviors.15

While biological sex alone can directly produce certain health outcomes without the influence of gender (e.g., prostate cancer for men, ovarian cancer for women), gender inequalities and norms can inevitably give rise to consequences in health, social, and economic outcomes through differences in 1) exposure to health risks and hazards, 2) health behaviors, and 3) access to healthcare.16 These pathways are not independent of each other, but rather intersect and are described in this section and how they result in differential health outcomes.

Men and women experience differential exposures to health risks and hazards just by their socially assigned gender role and corresponding responsibilities. In employment, men usually are employed in occupations that require heavy physical work such as mining, construction, manufacturing, and defense, while women usually take on work in care and service professions.

These gender classifications in employment allow them to have differential exposure to occupational-related disease and trauma. Men are more susceptible to accidents, traumatic injuries, and exposure to harmful chemicals. Women, on the other hand, may be more vulnerable to threats of physical and sexual abuse and mental health concerns from caring for children and the chronically ill. For women in the workforce and the informal sector, these are

16 Heise, L., Greene, et al. “Gender inequality and restrictive gender norms: framing the challenges to health.” The Lancet, 393(10189), pp.2440-2454.

15 Health Policy Project, The Fade Away Effect: Findings from a Gender Assessment of Health Policies and Programs in the Philippines. December 2014.

14 Allotey, P. and Gyapong, M. Gender in tuberculosis research. International Journal of Tuberculosis and Lung Disease 12(7): 831-836, 2008.

https://pubmed.ncbi.nlm.nih.gov/31155275/ https://www.healthpolicyproject.com/pubs/345_FORMATTEDPhilippinesGPMReport.pdf https://www.healthpolicyproject.com/pubs/345_FORMATTEDPhilippinesGPMReport.pdf https://pubmed.ncbi.nlm.nih.gov/18544213/ compounded by the double burden they bear and the health risks associated with having to solely manage the household.

Health behaviors of both men and women may also result in differential health outcomes.

Norms of masculinity where men are expected to show strength and take on risk-taking behaviors can be deleterious to their health. These behaviors consist of poor health-seeking behavior (only seeks care when already serious), smoking, alcoholism, substance use, reckless driving, etc. Among risk-taking behaviors is the participation in risky sexual behaviors, for example engaging with multiple partners, inconsistent use of contraception, and sexual coercion, which may all lead to sexually transmitted infections. Since women are the likely recipients of these actions, and because of the power imbalance between them, women are also at great risk of detrimental effects from these behaviors.

Factors such as health behaviors and power imbalance between men and women largely affect ability to access health care. While men feel that they should portray toughness during illness, women are presumed to be the caretaker in the family and should be able to put family members first ahead of their needs. The power imbalance between men and women affects decision-making in the household when it comes to finances, allotment of time, and authority.

Although norms are changing, traditionally men have the power to decide where to allot finances and their time, and because of this, women tend to have less autonomy in seeking care for their own health. Aside from women in the household, marginalized populations such as sex workers, people living with HIV, and gay men and other men who have sex with men (MSM) may tend to avoid seeking care because of stigma from health providers. At the service delivery level, the perceived power of the health care providers could impact men and women differently and also influence their decisions and behavior regarding health care.

Potential GESI Issues/ Gaps

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations/ Mitigation Measures

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Men and women experience differential exposures to health risks and hazards just by their socially assigned gender role and corresponding responsibilities.

The design of interventions to increase access to health services must be cognizant of these gender differences.

Women are presumed to be the caretaker in the family and are expected to be able to put family members first ahead of their needs.

They tend to also have less autonomy in seeking care for their own health.

Advocacy efforts and interventions to reach out to clients must be designed to actively seek out women and to respond to their needs.

Health Systems Strengthening

In terms of HSS, two areas where gender norms and factors are important considerations are in service delivery and health human resource. For service delivery, “three delays”in health care have been recognized, namely, delays in deciding to seek care, identifying and reaching a health facility, and receiving adequate and appropriate treatment. The Department of Health established service delivery networks, now known as health care provider networks (HCPN), to provide maternal and child health, FP/ARH, HIV, and TB services using a life-cycle approach at all levels, including community, rural health unit, provincial and regional. Although these networks are intended to cover all aspects of health, such as health service delivery, financing, and demand generation, these still need to be improved to recognize that poor health outcomes are not only due to economic and human resources concerns, but also to socioeconomic and other inter-related factors, including gender.

Gender sensitivity, diversity, and social inclusion are some of the barriers in accessing services in these networks. While there are efforts to improve sensitivity of these facilities, the reality is that many are still not fully inclusive or responsive to the diverse needs of patients. Women, LGBTQI+ individuals, and other marginalized groups often face discriminatory treatment or barriers to care, including lack of privacy, stigmatization, and inadequate services. A culture of machismo and gender bias prevails in many healthcare settings and can manifest in various forms of discrimination, such as dismissive attitudes towards women's health concerns, non-inclusive language, or lack of sensitivity to the needs of LGBTQI+ clients. In particular, key populations opt to access health services including screening and treatment in CSO run facilities which are more sensitive to their needs.

The DOH has demonstrated commitment to gender equality by adopting and implementing various gender-sensitive activities. There are some areas that would benefit from increased attention with a gender lens, beginning with human resources for health. Absence of gender equality benchmarks for the different categories of health staff and levels of the health system impacts its current hiring, retention and promotion process. The majority of health human resources at primary health care facilities are women, which may prevent men from seeking consultation. An observation from USAID’s demand-generation activity, Usapan (group discussion) for men and couples, showed that men participate more in discussions if the facilitator is a man. On the other hand, more men are appointed in executive and managerial positions in the public health sector. Second, the supply chain system is not sensitive to the needs of specific health facilities and does not reflect the needs for health commodities for men, women, girls and boys, and gender-diverse individuals. Supply chain managers lack sensitivity to gender differences in distribution decisions to support gender-equitable access to medical commodities.

Potential GESI Issues/ Gaps

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations/ Mitigation Measures

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Women and LGBTQI+ individuals face discriminatory treatment or barriers to care, including lack of privacy, stigmatization, and inadequate services.

Integrate gender sensitive practices in the continuous quality improvement initiatives;

Pilot mechanisms to promote incentives for

LGBTQI+ and women friendly health facilities.

Gender imbalance in the health workforce. Explore the institution of gender equality benchmarks for health staff on current hiring, retention and promotion processes of health human resources.

UHC does not include the needs of People of

Diverse SOGIE.

Need to develop a PhilHealth and service delivery package for LGBTQAI+ needs such as gender affirmative care.

Family Planning/Adolescent Reproductive Health

The Responsible Parenthood and Reproductive Health Act of 2012 (“RPRH Law”) contains provisions that create difficulty for women and girls in accessing reproductive health care.

Adolescents and youth under the age of 18 require parental consent to access family planning commodities and women require spousal approval for bilateral tubal ligation.17

The National Demographic Health Survey (NDHS) 2017 found three important “delays” that prevent women and girls in accessing health care including in (a) the decision to to seek care, 17 “Responsible Parenthood and Reproductive Health Act of 2012” RA 10354.

https://rpo8.popcom.gov.ph/responsible-parenthood-and-reproductive-health-rprh-general-information/ especially among low status women and those who fear of being ill-treated in health facilities;

(b) identification, transportation to, and financial access of health facilities; and (c) receipt of adequate and appropriate treatment that avoids disrespectful care and abuse. Additionally, women and girls may go through early or forced marriage at the age of puberty. Though the

Philippines passed a law that criminalizes early or forced marriage in December 2021, the law is being contested in some parts of the country.18 Gender-based violence is experienced by 1 in 4

Filipino women.19 Furthermore, there is low male engagement in reproductive health and family planning programs.

Potential GESI Issues

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Adult Women And Men

Due to the unequal power relations between men and women:

● Men are the foremost decision makers including about fertility options (e.g. number of children that the family should have and whether the family will practice FP or not);

● In relation to poverty, since men are the ones who get paid for productive work, low income women’s health is the least of women’s priorities .

● Strengthen existing initiatives like the

DOH’s Men’s Health Program.

● Prioritize interagency collaboration, partnerships, and linkages across national and subnational levels.

● Establish convergence between various government agencies (e.g.

collaboration with TESDA, DOLE, DTI, and DSWD to address social determinants of health such as unemployment and promote economic empowerment for women and girls; collaboration with DepEd and CHED for education; collaboration within DOH and with POPCOM, NNC, and DepEd.

Adults And Adolescents

Women, girls, boys, men, and LGBTQI+ individuals do not report GBV incidents due to self-stigma that they're tagged as abused.

Bolster existing GBV response, for example:

using effective reporting through the use of

HEADSS tool for all adolescents to cull out

GBV incidents and support DOH’s

19 National Demographic and Health Survey, NDHS 2017

18 https://www.pna.gov.ph/articles/1164695 https://www.pna.gov.ph/articles/1164695

Potential GESI Issues

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

WCPU/WCPP program to include GBV cases among LGBTQIA+

Not all health facilities use the existing psycho-social tools for adolescents thus, sexual violence may not be reported (e.g., HEADSS is used only for pregnants and at risk youth).

A standard tool should be developed for health facilities to screen GBV and create a mechanism for referral and management.

Adolescents

● Feeling of invincibility (feeling excused from the disease) resulting in health issues (e.g. STIs, pregnancy) especially at the age of exploration.

● Social stigma about family planning, mental health, and shame from feeling abused.

In addition to strengthening convergence between and among government agencies and LGUs, bolster whole-of-society approaches (e.g. sustainable partnerships with NGOs, CSOs, academia) to provide age-appropriate services and information.

For Adults and Adolescents:

Bolster DOH Program for Young Parents, Family health cluster programs, Infectious and non-communicable disease programs, among others, and mainstream

GEWE and GBV in all these DOH Programs.

Tuberculosis

Globally and in the Philippines, the prevalence rate for TB is higher for men than women. In

2017 approximately 10 million people developed the disease including 5.8 million men, 3.2 million women and 1 million children worldwide. TB incidence rate in the Philippines for adults

(>15 years) is 641,000 or 174,000 females and 467,000 males.20 The TB numbers indicate clear gender disparities in how the disease impacts men and women differently and the importance of addressing the gendered dynamics of TB.

Several theories have been identified including socio-cultural factors, norms and beliefs, gender differences in health-seeking behavior, gender roles at home and in the workplace, occupational risks, the stigmatization of the disease, and access to information and resources. For example, gender norms in some cultures may keep women closer to home whereas men’s social and occupational interactions may expose them to the disease.21 In many countries, men are more likely to drink alcohol, smoke or be imprisoned which also puts them at higher risk.22

In addition to these lifestyle factors there is a difference in how women and men seek out treatment and how they interact with the health care provider (HCP). There have also been studies demonstrating gender differentials between delaying and adhering to treatment.23 This indicates that the gendered behavior of the individual together with the health care system and

HCP interactions with patients contribute to the different health outcomes of women and men.

The needs of marginalized groups such as LGBTQI+ individuals and persons with disabilities, may also experience poor patient care, poor and inefficient health services, stigma, and discrimination in health facilities. Transgender individuals may face significant barriers due to insensitivity or lack of awareness on the part of the provider, or due to outright discrimination or ridicule. All genders experience stigma regarding TB, and this can also be a barrier to accessing health care. Men, in particular, may be constrained by socially and culturally defined notions of masculinity which may also constitute a barrier to accessing services.

According to the 2016 prevalence survey, more females consulted a healthcare worker (e.g., with self-reported screening symptoms) and males elected to self-medicate, took no action or consulted a non-health care worker. The analysis of reasons for certain health seeking behaviors did not elicit a major difference between males and females. TB policies are gender blind. GEWE is not considered by program managers as a barrier to diagnosis and treatment. The National TB

Program gathers sex-disaggregated patient data, but the data is not considered in planning for finding missing TB cases. Case detection or finding missing cases is key to TB prevention and treatment.

23 Philippines TB Prevalence Survey, 2016

22 IMPACT Assessment

21 USAID Health Program Gender Analysis

20 WHO Global TB report 2022

Power dynamics and control over decision making are key factors in how TB is addressed and managed. The USAID Philippine CDCS noted continued inequality in household family and decision making. This would have an impact on health seeking behavior if women are trying to encourage their husbands to get tested or adhere to treatment or want to get tested and treated themselves. Pursuing the collaboration with the private sector component and targeting informal workplaces (i.e., construction, mining) has the potential to connect more who are working in high risk occupations with TB services. Another key area for gender is working with the clinics and health care providers to integrate more gender sensitivity into patient centered care, which is also part of the NTP’s medium term strategy. Having a clear understanding of gender roles, relations and dynamics and why more men than women are resistant to seeking

TB testing, diagnosis and treatment will be an important part of the gender analysis.

Potential GESI Issues

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Men are more predisposed to have TB than women.

Gain an understanding of the differences in exposure among the genders, identifying settings that may put men as special risk (e.g., mines and prisons).

Poor health seeking behavior of men and children and defiance in seeking TB care

Develop gender responsive social and behavior change communications that addresses determinants to health seeking delay.

Stigma and discrimination towards transgender people accessing TB care.

The implementation of education programs and capacities aimed at health-care providers, individuals with TB, and at-risk community members, may reduce TB stigma, although little data exists on the effectiveness of these strategies.

Power dynamics may disadvantage women Gain an understanding of gender and children in delaying access of women and children to TB services.

relations, the division of labor, and who has access to and control over resources.

HIV/AIDS

The impact of the ongoing HIV epidemic disproportionately affects key populations — specifically transgender women, gay men, and other men who have sex with men (MSM), who comprise more than 80 percent of cases in the national HIV surveillance registry.24 Despite an increasingly differentiated approach to service provision (e.g., community-led facilities and public sector sundown clinics) access to health services for key populations and HIV-positive individuals, especially transgender women and young key populations, remains poor.25

Curbing the exponential increase in new infections demands a response that goes beyond biomedical approaches (i.e., test-and-treat, PrEP). This will have to factor in the complex intersectional vulnerabilities that trans women and MSM face. These in turn drive the synergistic epidemics of HIV, STIs, mental health, and substance abuse, among others, found among these populations. Acceptable and holistic HIV service packages for trans women that include hormone replacement therapy and mental health are generally not available.

The Philippine HIV and AIDS Policy Act provides a clear policy framework to protect people living with HIV from stigma and discrimination. Yet, evidence shows the pervasiveness of stigmatizing attitudes among health providers.26 Moreover, Filipino gay, bisexual, transgender, queer or questioning, intersex and non-binary identities — most affected by the ongoing epidemic — face stigma and discrimination in various spheres27. These attitudes are largely fueled by homo- and sex-negative norms. The absence of punitive policies and the more tolerant societal attitudes towards them28 mask the challenges these populations must overcome. Young same-sex attracted Filipino men are twice as likely to think about suicide

28 Manalastas, E. J., Ojanen, T. T., et. al. Homonegativity in Southeast Asia: Attitudes Toward Lesbians and Gay Men in Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam. Asia-Pacific Social Sciences Review, 2017, 17 (1), 25-33. Copy at http://www.tinyurl.com/ybmug67r

27 UNDP, USAID (2014). Being LGBT in Asia: The Philippines Country Report. Bangkok.

26 Lopez SMJ, Ramiro VR, Roxas EA. Measuring Stigma and Discrimination towards People Living with HIV among Health Care Workers in a Tertiary, Government Teaching Hospital in the Philippines . Acta Med Philipp [Internet].

2017Dec.29 [cited 2023May8];51(4). Available from:

https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/502

25 Regencia, Z.J.G., Castelo, et al. Non-uptake of HIV testing among trans men and trans women: cross-sectional study of client records from 2017 to 2019 in a community-based transgender health center in Metro Manila, Philippines. BMC Public Health 22, 1755 (2022). https://doi.org/10.1186/s12889-022-14158-w

24 HIV, AIDS, and ART Registry of the Philippines, DOH-EB, December 2022 https://lawphil.net/statutes/repacts/ra2018/ra_11166_2018.html https://pdf.usaid.gov/pdf_docs/PBAAA888.pdf https://pdf.usaid.gov/pdf_docs/PBAAA888.pdf https://pdf.usaid.gov/pdf_docs/PBAAA888.pdf https://pages.upd.edu.ph/ejmanalastas/publications/homonegativity-southeast-asia-attitudes-toward-lesbians-and-gay-men-indonesia-malaysia https://pages.upd.edu.ph/ejmanalastas/publications/homonegativity-southeast-asia-attitudes-toward-lesbians-and-gay-men-indonesia-malaysia https://pages.upd.edu.ph/sites/default/files/ejmanalastas/files/manalastas_2013_fil_gay_suicide_risk.pdf https://pages.upd.edu.ph/ejmanalastas/publications/homonegativity-southeast-asia-attitudes-toward-lesbians-and-gay-men-indonesia-malaysia https://pages.upd.edu.ph/ejmanalastas/publications/homonegativity-southeast-asia-attitudes-toward-lesbians-and-gay-men-indonesia-malaysia http://www.tinyurl.com/ybmug67r https://doh.gov.ph/sites/default/files/statistics/EB_HARP_December_AIDSreg2022.pdf compared to heterosexual29 men and depression, anxiety, and stress rates have been found to be higher among sexual minority women30.

Legislation protecting them from stigma and discrimination has yet to be passed by Congress.

This hampers their ability to claim their right to health and access to health services; in addition to creating self-stigma and mental health issues. Moreover, standing Philippine policies requiring parental consent for minors to access HIV pre-exposure prophylaxis and antiretroviral treatment compound the challenges that young key populations face.

Though HIV cases among women remain low, the shame and silence that surround homosexuality and the low knowledge of basic information on HIV prevention31 and sexual health in general put female partners of gay men and other men who have sex with men at risk.

Lack of economic opportunities for some women engaged in sex work also force them to engage in risky sexual practices.

The vibrant community movement in the Philippines mirrors the pivotal role communities continue to play in the design, implementation, and monitoring of HIV programs.32 Community consultations conducted under the ongoing PEPFAR program underscore the fragility of their sustainability and the inadequacy of resources to support their work. This challenge is particularly more acute for organizations engaged in advocacy, relative to those providing services. There is clamor from the community for increased technical assistance to enhance organizational capacity that will support their operations.

Potential GESI Issues

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Transgender women, gay men and other men Integrate mental health and holistic trans

32 Ayala, G., Sprague, L., et. al. Peer- and community-led responses to HIV: A scoping review. PLOS One, 2021, 16(12): e0260555. https://doi.org/10.1371/journal.pone.0260555

31 Philippine Statistics Authority (PSA) and ICF. 2022. 2022 Philippine National Demographic and Health Survey (NDHS): Key Indicators Report. Quezon City, Philippines, and Rockville, Maryland, USA: PSA and ICF.

30 Alibudbud, R. Gender in mental health: Comparing the rate and social factors of depression, anxiety, and stress among young heterosexual and sexual minority women in the Philippines. Journal of Lesbian Studies, 2023;27(1):74-88. doi: 10.1080/10894160.2022.2091731.

29 Sexual Orientation and Suicide Risk in the Philippines: Evidence from a Nationally Representative Sample of Young Filipino Men. Philippine Journal of Psychology, 2013, 46 (1), 1-13 https://pages.upd.edu.ph/sites/default/files/ejmanalastas/files/manalastas_2013_fil_gay_suicide_risk.pdf https://pubmed.ncbi.nlm.nih.gov/35757983/ https://pubmed.ncbi.nlm.nih.gov/35757983/ https://doi.org/10.1371/journal.pone.0260555 who have sex with men face complex intersectional vulnerabilities.

programming into HIV services. Build support networks to help mitigate self-stigma among

PLHIV and key populations. Establish referral pathways for those requiring substance abuse and other types of support.

Provider stigma and discrimination against key populations negatively impacts health-seeking behavior.

Address provider stigma and discrimination through training and provider behavior monitoring, linked to community-led monitoring.

Limited capacity to address the differentiated preferences and needs of key populations within a traditional primary healthcare model.

Use human-centered design to address barriers to key populations’ uptake of services and to create targeted messaging to increase demand for services.

Female partners of MSM have low awareness and knowledge on HIV transmission and prevention and do not recognize their risk and need for HIV testing.

Mainstream and update public sector HIV awareness campaigns that are anchored on value-based and sex-positive messaging to include HIV transmission, prevention, and treatment components.

Stable resources and funding streams to support community advocacy and service delivery and the corresponding capacity to efficiently manage resources are inadequate.

Expand organizational assessments and sustain organizational development efforts to enhance programming and facilitate more efficient operations of community-led organizations.

Global Health Security and COVID-19

Overall, gender issues surrounding health security in the Philippines reflect broader gender disparities and inequalities , including gender based violence. As the COVID-19 pandemic imposed mobility restrictions and lockdowns, cases of GBV sharply rose. Before the pandemic, one in every four Filipino women had experienced domestic violence (NDHS, 2017). During the pandemic, the Philippine Commission of Women reports that violence against women and children tripled even as official police reports showed declining numbers reflecting gross underreporting.33 GBV is a significant health issue as women who experience violence may be

33 CNN Philippines Reports of violence against women, children to PH Commission on women almost tripled during pandemic. 2020. https://cnnphilippines.com/news/2020/12/12/pwc-violence-women-children-pandemic.html https://cnnphilippines.com/news/2020/12/12/pwc-violence-women-children-pandemic.html less likely to report and seek medical attention, which can have serious health consequences, including increased risk of sexually transmitted infections and unintended pregnancies.

Other gender issues relating to global health security in the country include the diverging health-seeking and help-seeking behaviors between men and women, access to reproductive health services which put women at risk for maternal mortalities and morbidities and unintended pregnancies, and gender imbalance in the health workforce which have been covered in the different sections above.

Potential GESI Issues

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Gender-based violence during health emergencies tends to increase. Global health emergencies often exacerbate existing gender inequalities. Women, girls, boys, and gender-diverse individuals may face heightened risks of sexual exploitation.

Risk communication and community engagement (RCCE) in response to epidemics should integrate key messages on gender and gender based violence.

During health emergencies, women, girls, and gender-diverse individuals may face barriers such as financial constraints, cultural norms, lack of education, and limited decision-making power.

Since GHSA is a new activity, collect sex-disaggregated data and conduct gender-focused research to identify specific vulnerabilities; this will inform policies and improve health interventions.

Health emergencies can disrupt RH and maternal healthcare services, putting the well-being of women, girls, gender-diverse individuals, and infants at risk.

Ensure access to family planning, safe childbirth, postnatal care, and essential reproductive healthcare for women, men, boys, girls, and gender-diverse individuals.

This is crucial in sustaining overall health security, diversity, inclusivity, and resilience.

Women and gender-diverse individuals are often underrepresented in decision-making

Women and gender-diverse individuals should be involved and represented in and leadership roles in global health security.

Their experience and expertise are essential for comprehensive and inclusive responses.

decision-making at several levels. This is crucial in addressing gender-specific health needs.

Community-Based Drug Rehabilitation

The 2015 Nationwide Dangerous Drug Board (DDB) Survey on the Nature and Extent of Drug

Abuse in the Philippines revealed that there are 1.8 million current users of drugs and that around 4.8 million Filipinos have used drugs at least once in their lifetime34. While most persons who use drugs (PWUDs) are predominantly male, with a ratio of 7 males to 1 female, both genders face barriers to accessing drug treatment and recovery services in the country. While access to services is a major challenge, stigma is also a key factor in requesting such services.

Women, in general, have a much more difficult task in requesting the same due to stigma, confidentiality and a fear of police action. LGBTQI+ individuals experience an even greater stigma and discrimination than men.

Gender equality in accessing drug treatment and recovery services is realized when women and men and girls and boys enjoy the same rights, resources, opportunities and protections. This requires that disadvantages faced by girls/ women and gender diverse individuals are addressed and requires the engagement of all stakeholders to make progress towards justice and equality.

Shifts in gender equality require not only awareness and behavior change, but also changes in the fundamental power dynamics that define gender norms and relationships. In the Philippines however, national and local programs and activities for people who use drugs (PWUD) are designed for men, and women are treated as a special population.

Researches have also shown that women who use drugs respond to drugs differently, and have unique obstacles to effective treatment as simple as not being able to find child care or being prescribed treatment that has not been adequately tested on women. Women have unique needs that should be addressed during substance use disorder treatment. Gender-based violence is another issue faced by women in the context of drug treatment. The UNODC

Guidelines report that women are at a greater risk of being victims of sexual abuse and violence compared to men and one out of every three girls and women are victims of violence. Effective treatment should incorporate approaches that recognize sex and gender differences, 34 Dangerous Drugs Bureau (2016) as reported in https://www.rappler.com/nation/146654-drug-use-survey-results-dangerous-drugs-board-philippines-20 https://www.rappler.com/nation/146654-drug-use-survey-results-dangerous-drugs-board-philippines-2015 https://www.rappler.com/nation/146654-drug-use-survey-results-dangerous-drugs-board-philippines-2015 understand the types of trauma women sometimes face, provide added support for women with child care needs, and use evidence-based approaches for the treatment of women.

Potential GESI Issues

(Who participates/who is involved/who benefits/why others are not engaged in the activity)

Recommendations

(What can be done in the context of this activity to broaden participation – women and girls, men and boys, and gender-diverse individuals)

Women and LGBTQI+ individuals who use drugs are even more stigmatized and have more difficulty accessing health services.

Social and behavior change communications to reduce drug demand should integrate key messages on gender and gender based violence.

Women have unique needs in substance abuse treatment that are not addressed.

Interventions and programs should recognize the special needs of women in community based drug rehabilitation.

Women who use drugs are more likely to experience gender-based violence.

Social and behavior change communications to reduce drug demand should integrate key messages on gender and gender based violence and where to access help.