Facing the effects of gender based inequality to women and children's health in Kosovo

Building up Health Competence

Von Fried Didden & Aferdita Ademi / Schweizerisches Rotes Kreuz SRK

This article is focused on women's position in Kosovo society, addressing the obstacles that women and girls in Kosova face towards achieving equal fulfilment and enjoyment of their rights and the impact on their health and the health of their children. One example is described to point out the efforts of the Swiss Red Cross to influence women's health and indirectly their position in Kosovo's society.

Kosovo is a small and landlocked territory in the centre of the Balkan Peninsula. Kosovo borders Macedonia, Albania, Serbia and Montenegro. Its area covers 10 877 km2 and is at present divided into 30 municipalities. The capital city is Prishtinë / Priština. At the end of the Second World War, Kosovo was predominantly a rural society and 80 percent of the total population lived outside the cities. In 2000, it was estimated in a Living Standard Measurement Survey that still over 60 percent of the population lives in rural areas. Kosovo has still particularly large households. Most of the households have a single family but there are "multiple households" with 2 or 3 families living in one household.

The resident population in Kosovo is approximately 1.9 million inhabitants. In an ageing Europe, the population of Kosovo is an exception. The population is very young, with 33 percent of people being under 15 years of age. The level of the "active" population (between 15 and 64 years of age) is about 62 percent. The dependency ratio is high, largely because of the large proportion of people under 15.

According to the Living Standard Measurement Survey, 12 percent of the population is extremely poor and another almost 40 percent is poor. According to the World Bank, 12 percent of the population lives without any income, in a very difficult situation, poorly fed and dressed, living in an environment of poor public health services and low levels of education.

A major problem in Kosovo is the high unemployment rate, which has major social and economic consequences. The average monthly salary in Kosovo in a social-owned enterprise is approximately 60 - 120 Euro. Various sources estimate the current unemployment rate at about 55 percent, representing thus more than half of the working population.

Women: little autonomy, low literacy, high fertility...

Women share the burden of these harsh socio-economic conditions. The changing and difficult economic conditions have affected differently various groups of women. The proportion of men integrated into the labour force is double (60 percent) to that of women (30 percent). The picture is very clear that the women have no equal access to economic opportunities. In various municipalities, women claim that there is discrimination against them in applying for new jobs. Conversely men are much more closely identified with the public world, with the activities of waged work and the rights and duties of citizenship, women are more identified with working at home and taking care of household which brings them into the unequal economical and social situation.

This lack of these economic power opportunities heavily affects women's autonomy in the private and public sphere and curtails their ability to claim and enjoy their rights. Women and girls who depend entirely on male members of the family cannot attend schools against the will of the family, and have little saying in family or community matters. The most important duty of the women is the responsibility for household and domestic labour - for the care of children and the elderly.

In Kosovo, illiteracy is a gender issue. Women have a lower educational attainment than men in all age groups. This problem persists particularly in rural areas. There is no major difference between the inclusion of girls and boys in primary school. However, this changes in secondary and higher education, where 54 percent of the girls and 65 percent of the boys attend secondary schools, and 18 percent of the boys and 16 percent of the girls higher schools.

The fertility rate in Kosovo remains high, compared to the rest of Europe. Kosovo women have, on average, 2.7 children. Women give birth at brief interval. The mean interval between successive births is two years. According to statements from the UNDP (2002), Kosovo women deliver too many babies in a very short time interval and have wrong eating habits during pregnancy. Based on a survey carried out by UNFPA in 1999, it was estimated that 5.4 percent of mothers were malnourished (insufficient calorie intake, lack of proteins). At the same time, maternal obesity was also high with 10.7 percent. Both aspects are affecting the health mother and children. According to the survey done by UNFPA, the perinatal mortality rate (fetal and neonatal losses in relation to all infants born) was 33/1000. Maternal mortality ratio per 100.000 live births was 23 in the year according to a UNICEF Evaluation report.

The high rate of child and maternal death, the low use of contraceptives (around 20 percent of the women) and the high rate of abortions (officially 4.8 abortions in 100 live births) are the consequences of the lack of knowledge and access to healthcare services especially on reproductive and child health. Low use of contraceptives is obvious; there is a difference of use of contraceptives between women who live in the town and in the villages. Urban women use around 21 percent contraceptives.

Empowerment - the key to health

The inequality in education and socio-economic conditions and the still dominant patriarchal culture affects the health of the women and their children. Investing in education of women is an important condition to their future position, and health status.

Since 1999 the Swiss Red Cross is active in Kosovo. After the conflict the first goal of their presence was to relief the most urgent needs of the population through emergency aid. In the first one and a half years much effort was put in reconstruction activities and giving aid to the suffering population.

After this phase the Swiss Red Cross continued with development programs. In 2000 the first steps were made in this new direction. The choice was made to concentrate the Swiss Red Cross activities on the low health status of the population and the reform of the healthcare system.

A project, through a partnership between the Red Cross of Kosovo and the Swiss Red Cross, in close collaboration with the Institute of Public Health, started in 2001 with the development of the project of Family Health Education Courses, being implemented throughout Kosovo. The aim of this project was to improve the public and professional capacities in promoting health, increasing health awareness, as well as change of behaviour in the community towards health. The project was completed at the end of 2003: more than 6'000 women and men were trained all over Kosovo, more than 100 trainers educated. The project will be continued by the Red Cross of Kosovo as one of its new strategies.

One of the important lessons learnt in the Family Health Education Courses project was to start new projects on a smaller scale (doing pilots) instead of implementing them on a national level and involving communities on a much broader scale. The capacity building and organisational development processes of partners should not be underestimated and are one important part of all projects and programs. These and other findings lead to the conclusion to put family medicine and family health into the centre of the future activities of the Swiss Red Cross in Kosovo in line with the National Health Strategy and strongly addressing the needs of the population for preventive reproductive health: family planning, contraception, antenatal, delivery and postnatal care, mother (parents) and childcare and abuse of women and children in the family.

In September 2003, the Swiss Red Cross made the decision to establish a new project, which was granted by January 2004 through the Swiss Solidarity Chain. Swiss Red Cross was officially invited to join meetings and to contribute to the discussions about the healthcare reforms and to implement a pilot project in the action plan of the Ministry of Health regarding the health goals of a healthy start in life; protection of young people; and increase of capacity of human resources in primary healthcare. A local Steering Committee was organised in September 2003. It decided for the project-implementation in two municipalities: Viti and Kacanik.

Within the planned project, empowerment of people, particularly women, improvement of their self-esteem and helping them to develop and use their physical, mental and emotional capabilities are the major objectives. The project intends to influence the attitude, knowledge and opportunities of Kosovo's population within preventive reproductive health. The project aims at building up health competence among the population. And, in the long-term, the project will contribute to the reduction of levels of discrimination against women and the increase of their opportunities.

The lessons learnt within these two pilot areas will be replicated in other areas and regions of Kosovo. The Ministry of Health, in cooperation with the municipalities and departments involved, will be in the position to draw clear conclusions from the pilot projects and replicate them in other parts of Kosovo.

Women in Kosovo's society are still vulnerable; gender-based inequality and discrimination exists on prominent level. As they have major negative effects on the health of the women and their children, they the need attention of the Government, local and International NGOs. The contribution of the Swiss Red Cross will hopefully improve the reproductive health status and position of women in Kosovo.

* Afërdita Ademi, a medical doctor specialised in family medicine, heads the SRC Health programme in Kosovo. A portrait of her, "Sensibilisiert für die Minderheiten", can be found in the SRC Magazine on www.redcross.ch. Fried Didden, Nurse and Social Scientist, is a Dutch working since two years in the SRC Health Programme in Kosovo. Contact: iz@redcross.ch