When health practitioners and researchers look at underlying causes of poor health and well-being, they see a number of interconnected issues, from race to gender to socioeconomic status and more. For gender, the socially constructed norms and culturally defined roles, responsibilities, entitlements and rights of being female, male or other identities can shape an individual’s health outcomes.
For example, in sub-saharan Africa, three in five new HIV infections among 15-19-year-olds are girls and in 64 countries, only 54 percent of childbirths in the poorest households had a health professional present according to UN Women’s “Women’s Rights in Review” report from 2020. Health inequities like these are only exacerbated by other gender disparities such as nearly half a billion women and girls 15 years and older being illiterate.
Understanding gender differences and removing gender disparities that contribute to the underlying causes of poor health will require policies, programs, and cultural changes that promote gender equity.
But what does gender equity in health mean? One definition is fairly addressing the different health needs of people based on their gender – women, girls, men, boys, and other gender identities.
To get a first-hand perspective, we spoke with two Task Force partners G.S. Preetha, Professor and Dean of the International Institute of Health Management Research in Delhi; Sumitra Shrestha, Project Technical Team Lead for the non-governmental organization HEAL Group in Nepal; and staff member Eva Bazant, Senior Associate Director of Implementation Research for The Task Force’s Health Campaign Effectiveness (HCE) program.
Share some examples of how you’ve seen gender shape health.
Shrestha: In my experience, gender affects acceptance or utilization of health services even if they are free. While I was a district public health officer in a remote part of Nepal where medical services were only previously provided by a primary healthcare center, the first district hospital was opened to provide more health services. For one of the first births we had in the new hospital, the family members of the new mother and baby wanted them to be discharged the next day so that they could return to their home and continue household duties such as taking care of the animals. Unfortunately, the new mother really had no say in this decision even though it endangered hers and her baby’s health and the new hospital provided her the space and services to ensure a healthy recovery. This is just one example of ways I’ve seen gender norms limit people’s use of available health services or seek health care too late because of needing family permissions or duties or economic hardship.
Gender disparities in family planning is very common because reproduction or childbearing is mostly focused on women and not men. As of 2019, amongst current users of family planning in Nepal, female sterilization is the predominant method and being used three times more than male sterilization and condom use. During a family planning campaign, I helped conduct in a remote part of the country, it was made clear that even though male sterilization is easier and reversible, female sterilization is preferred. The reason mentioned was that the procedure will make men weak and sterilized men are not allowed to participate in religious ceremonies and rituals.
Preetha: Any public health professional has seen gender disparities firsthand no matter what sector of public health they are in. One way I’ve seen it is when I conducted a research project on understanding the social causes of newborn deaths in a state in India. The study revealed the discrimination that female babies faced, such as families choosing not to provide or spend on care for serious health conditions for female babies versus male babies, refusal of mothers to breast feed, transitioning two-three days-old newborn girls from breast milk to other forms of milk. The findings of another research project in two Indian cities which evaluated strategies of a family planning programme also spoke about the role of gender in decision making for contraception. Women shared experiences wherein they were denied the right to choose their preferred family planning method and forced to use the methods dictated by either their husbands or even their mothers in law.
Bazant: One global example is age at first marriage. It is universally lower for young women than young men, often due to lack of educational or economic opportunities and adherence to social and cultural traditions. Childbirth among adolescent girls is related to many adverse health issues and lower educational attainment, including a higher chance of adverse maternal and infant health outcomes, such as obstetric fistula and ensuing consequences of social stigma and exclusion.
Another example is exposure to HIV. In 2014, the prevalence of HIV among 15-24-year-old women in Lesotho was on average twice that of males in the same age group, with 23-24-year-old women having a prevalence rate nearly three times as high, according to the Ministry of Health and Social Welfare (MOHSW). However, despite efforts by the MOHSW, contextual gender power dynamics in the communities made it difficult for prevention and treatment interventions to be used by females and even males. In focus groups in two districts of Lesotho, 19-40-years-old men reported barriers to accessing HIV prevention and treatment services partly because of perceived stigma and negative reactions from others, expected experiences with health services that dissuaded some men from seeking care.
Using a gender lens to look at campaign-based delivery of health interventions may help maximize the receipt of health interventions as well. In Southern Africa, school-based campaigns of mass drug administrations may not reach all children and adolescents due to problems related to socioeconomic, cultural and gender issues such as child labor among boys and not allowing girls who are pregnant to continue with schooling. Recently, in a study on integration across vitamin A supplementation and deworming campaigns commissioned by the HCE program, key informants recommended doing a gender analysis. The results showed that gender biases occurred in households and campaign staff and workers had a lack of understanding of gender equality. To improve the campaigns, they started collecting sex-disaggregated data and gender was incorporated into the manuals used nationally and in messaging to communities, encouraging fathers and mothers to get involved in their children’s health. And those are just a few of many examples.
What are the consequences of not incorporating gender into the conversation on global health?
Preetha: Gender is a very important determinant of health; no area in the world perhaps is free from gender disparities. The inclusion of gender into the conversation on global health is key to solving many public health problems we face by initiating the understanding of the deep-rooted processes which cause gender discrimination. Basically, if we don’t look at global health through a gender lens then we are undertaking a blind journey that leaves the possibility of reaching our goals up to chance.
Bazant: A consequence of not incorporating gender into global health programming is that some serious problems continue or worsen, affecting women and men’s ongoing health and well-being. Focusing on gender in public health also means opening our eyes to some serious problems, which are sometimes hidden, but can be addressed in the health system. One example is gender-based violence, highlighted on International Women’s Day by the Director General of the World Health Organization (WHO) – any form of violence against a person based on that person’s biological sex, gender identity or expression, or perception of adherence to expectations of what it means to be a man or woman, boy or girl. It is a public health problem, a human rights violation and it impedes countries’ sustainable development.
Focusing on gender and other areas of equity in health programs means having a more holistic view that beyond biology or genetics, people operate in a social and cultural environment that affect and may constrain their choices and opportunities and affect their health.
Shrestha: We understand that gender is more than a physical or biological structure. It is more of a power relationship that is socially created. That’s why not incorporating gender in public health leads to lower acceptance of health interventions, meaning that it is harder to meet the United Nations’ Sustainable Development Goals. I see it as blaming the victim and not supporting or facilitating them to address the challenges they face because of their gender, and it will only let the vicious cycle of disparity continue.
How have you seen gender incorporated in public health?
Preetha: Gender is deeply embedded in the concept of public health – in the problems, determinants and solutions. Gender disparities which are widely prevalent in our societies have become key determinants of health and the wellbeing of people through variables like health practices/risky behaviors, feeding/dietary practices, access to health, health seeking behaviors, and health care utilization. We have dismal social, economic and health indicators for girls and women in most societies. Some examples are the vicious cycle of womb-to-tomb malnutrition, early marriage, multiple births barely spaced apart, challenges of timely health care, maternal deaths, low birth weight and continuing intergenerational malnutrition leading to poor health outcomes based on gender.
These issues often bring in a connotation of discrimination suffered by women. However, boys and men also are not free from gender-based discrimination. Men are continuously under pressure in terms of meeting societal expectations of being super humans with no feelings or emotions. As an example, I put forth two caricatures of adolescent boys – one of a boy who develops anxiety and stress disorders on account of the physical and mental changes that occur during puberty, and the other, a boy who succumbs to peer pressure to engage in risky behaviors. Both situations may be resulting from a lack of attention to the concerns of adolescent boys because of the perceived ‘men have to be tough’ notion by societies.
Shrestha: Early in my career, gender was linked mainly to women as child-bearers or mothers. Now, I see a trend of making gender one of the indicators of health. For example, in the latest Nepalese Department of Health report (2018/2019), disaggregated data by sex is presented for just two interventions: school health and nutrition programs and beneficiaries for emergency response to flood-affected areas. The sex-disaggregation of data is helping public health programs be more mindful of how well they’re reaching each gender in many areas of health.
Bazant: Gender affects everything we do, in the way that social and cultural norms and roles may shape our expectations and behaviors. Gender may affect people’s exposure, susceptibility or vulnerability to viruses, bacteria or pathogens in the environment. Gender may affect behaviors that result in poor or better health. Gender may affect health-seeking behavior for prevention or treatment services offered by the health system, or how the services are provided.
Many resources exist to help in understanding how gender influences our lives, including our health. One resource is the Bill & Melinda Gates Foundation’s Gender Equality Toolbox, which offers a primer on gender integration, empowerment and equality.
What does gender equity in health mean to you?
Bazant: Gender equity is part of broader discussions happening around equity in health programs. Intersectionality is an area of emerging research that looks at how different forms of discrimination – such as those based on race, class and gender – interact to shape vulnerability and/or privilege and social position or status that influence people’s health behaviors, practices, service access and use, and outcomes at a point in time.
Shrestha: For me, gender equity means that all people (male, female and third gender) are able to access and benefit from the health services and programs provided.
Preetha: Gender equity to me is about preventing or eliminating any social, cultural, economic disadvantage that emerges due to someone being male, female, or alternate sex in attainment of the highest possible level of health on account of one’s gender.
How do you think the global and public health sectors need to change to improve gender equity in health?
Shrestha: In my opinion, it can be improved by developing and implementing health programs in collaboration with all of the people in the community. This way we will have better insights on their needs and create more inclusive global public health programs by activities and evaluations that break social barriers.
Preetha: Gender influence on health is not a standalone phenomenon but a reflection of a deep-rooted social value system. Addressing gender inequities in global health and public health rests on an intersectoral, whole-of-society approach. Admittedly, if we look at the example of increased malnutrition in girls versus boys, it can’t be solved by the health sector alone. The issues associated will involve son-preference in societies, practices of infant and child feeding, food security, female literacy, socioeconomic parameters and many more factors. Hence, it has to be stressed that the causes of malnutrition in girls and the solutions lie in multiple sectors in addition to public health. Multidisciplinary, intersectoral action, also including the participation of the community, is key to adopting an effective global public health action plan to address gender equity in health.
Bazant: In the global public health sector, each organization, including The Task Force, can address gender in the ways that draw on their assets and strengths to contribute to the larger pathways towards better health. At The Task Force:
- We can gather a group of interested staff, advisors, or volunteers who can focus on gender within a broader agenda on equity to help develop even more effective programs;
- For those who want to learn more, we can take a virtual course;
- We can address gender through a gender analysis and using a gender framework. This will include utilizing the sex-disaggregated data that many Task Force programs are already collecting and collecting data on gender-sensitive, empowerment and equality indicators;
- We can seek to understand how our programs fall along a continuum of being gender aware, gender sensitive, and gender transformative, as the WHO defines these terms, and suggest appropriate actions along with communities, partners and sponsors.
Header photo: Women participate in a public health awareness campaign for lymphatic filariasis elimination in the Indian state of Uttar Pradesh. Photo courtesy of Anu Laxmi for the Neglected Tropical Diseases Support Center.