WUNRN
The
Lancet, Volume 381, Issue 9879, Pages 1783 - 1787, 18 May 2013
GENDER & GLOBAL HEALTH:
EVIDENCE, POLICY, & INCONVENIENT TRUTHS
Gender
is missing from, misunderstood in, and only sometimes mainstreamed into global
health policies and programmes. In this Viewpoint, we survey the evidence for
the role of gender in health status, analyse responses to gender by key global
health actors, and propose strategies for mainstreaming gender-related evidence
into policies and programmes.
We
use the WHO definition of gender: “socially constructed roles, behaviours,
activities, and attributes that a given society considers appropriate for men
and women”.1
When gender identity does not correspond with assigned sex, people might
identify themselves as transgender.2 An
individual's experience of gender and gender relations can change according to
context and situation.3
The term sex, by contrast, refers to biological characteristics that define
human beings as female or male.
The
exact contributions that sex and gender make to health status are often hard to
disentangle and quantify, and “biological influences and social influences do
not operate independently”.4
Moreover, they often interact with other social determinants of health.
We
analysed the recent Global Burden of Disease (GBD) study5 from a gender
perspective. Data from this study are intended to help policy makers to set
priorities and allocate resources according to population health needs. GBD
methods have been critiqued, including from a gender perspective.6
Nonetheless, these datasets provide a standardised method to compare rates of
morbidity and mortality risk across time and place.
All
top ten contributors to global disability-adjusted life-years (DALY) have
greater burdens on men than on women.5 Conditions
common in childhood—lower respiratory infections, malaria, preterm birth—are
more burdensome in boys than in girls, although diarrhoea affects them equally (appendix).
DALYs
are recorded as absolute numbers rather than rates; thus, imbalances in
demographics and population structure affect the overall DALY distribution
between men and women, especially in some settings. India's most recent census,
in 2011, recorded 30 million more males than females aged more than 7 years;7
similarly, more males than females were recorded across all age groups in the
2010 Chinese census.8
Sen9
estimated that more than 100 million women are missing globally; however, women
comprise 49·6% of the global population10
and have 45% of the overall DALY burden. Parity in life expectancy—used for the
first time in the GBD 2010—might overestimate the burden on men, but is
justified on the grounds that “there is no reason that society should have
lower aspirations for health for males than females”.5
Higher DALY burdens in men were also recorded in earlier global DALY estimates
based on a higher life expectancy for women than men.
GBD
life expectancy tables for 1970—201011 show that, at
all timepoints, women have a longer life expectancy than men, and that
decreases in mortality were smaller in men than in females of all age groups.
The smallest decrease in mortality rates during 1970—2010 was in young men aged
25—39 years, possibly because of injuries11—globally,
road injuries kill three times more men than women.12
Drawing
on the work of Lim and colleagues, who analysed the effects of 67 risk factors
and clusters of risk factors for their disease burden and found the top 10 all
to be more common in men,13 we review two
high-burden risks (alcohol and unsafe sex) to show the role that gender norms
have.
Alcohol-related
health problems, including injuries, road traffic accidents, cirrhosis, and
other health issues, are third in the global risk rankings, and the highest
ranked risk in eastern Europe, Latin America, and southern sub-Saharan Africa,13 behind
tobacco and high blood pressure. Alcohol, like tobacco, has a substantially
higher burden in men than in women—7·4% and 3%, respectively.13 Some of the
disparity could be due to physiological differences in how women absorb and
metabolise alcohol. However, much of the difference is derived from
gender-determined patterns of exposure—men drink alcohol in greater quantities
and more frequently than women.14
Alcohol
consumption is affected by culturally driven gender norms of behaviour,
portrayed and perceived as a positive aspect of masculinity.15
The effect is that women could be subjected to greater social opprobrium if
they are seen to drink alcohol, particularly to excess. Patterns of alcohol
consumption could be on the cusp of change in some societies. Data from
European surveys show that boys report drinking alcohol more often and in
higher quantities than girls, but that the reported frequency of drunkenness by
girls and boys is about the same.16
These findings reflect complex social shifts that might be partly influenced by
“greater female social and economic empowerment...as well as marketing
practices”.17
Although
unsafe sex was excluded from the most recent GBD risk analysis,13
it is a major contributor to global morbidity and mortality through HIV and
other sexually transmitted infections (with sequelae that include AIDS,
cancers, infertility, stillbirths, and neonatal mortality), unplanned and
unwanted pregnancies, and maternal mortality. Much of this burden falls on
women, and is driven, among other things, by gender norms.
At
the level of sexual relationships,18
through community norms and national and international structural and policy
drivers,19
gender norms reinforce the vulnerability of girls, women, and transgender
people to adverse sexual and reproductive health outcomes. For example, gender
norms in southern and eastern Africa mean that people in sexual relationships
often differ substantially in age, and contribute to higher HIV prevalence in
young women than in young men.20
However, gender norms can also promote and perpetuate risk-taking sexual
behaviours among men—particularly younger men.21
Generally, however, gender inequalities ensure that the consequences and health
implications of unsafe sex are borne mainly by women, men who have sex with
men, and transgender people.2
Gender
is an important influence on health knowledge and health behaviours. Globally
comparable data sets are scarce, and tend to be limited to a few specific
conditions that indicate progress towards Millennium Development Goals (MDGs).
For example, data on MDG 6 show that in 21 out of 24 sub-Saharan African countries
a higher percentage of men aged 15—24 years than women know that correct condom
use can prevent HIV transmission.22
Few
cross-national datasets compare health-care seeking (rather than intervention
coverage) for women and men, particularly for the same condition. Evidence from
cross-sectional surveys is somewhat contradictory. That women might use health
services more frequently than men in many settings is often biased by women's
use of health services during their reproductive years. Women's access to care
might be limited by gender norms that restrict their autonomy over whether and
when to seek care,23
and these norms could mean women are less likely to seek treatment for
short-term and long-term illnesses than men in the same household.24
Moreover, in some settings health reform has resulted in gender-inequitable
access to care. Out-of-pocket expenditure on health resulted in a higher risk
of catastrophic health expenditure25
in women-led households in some countries.26
Health-care-seeking
patterns are, however, complex and not always fully explained by the notion
that only women have restricted access to care. For example, a large,
multicountry review of access to antiretroviral therapy concluded that more
attention needs to be paid to HIV-infected men to ensure that gender
stereotypes do not prevent them from protecting their health.27
What
happens in societies that are more gender-equitable and where health care is
universally accessible? In the UK, investigators have examined the experiences
of men and women who report the same underlying symptoms, or conditions, or
both. Perceptions of need or urgency to consult,28
or reports of consultation for symptoms of minor illness within the past month,29
show few differences between the health-care consultation behaviours of men and
women. However, reviews of British patients on pathways that require inpatient
care have shown significant gender-based inequalities (favouring men) in the
actual provision of care.30
Gender,
either alone or with other key determinants of health, is an important driver
of health outcomes for both men and women. How do global health institutions
address gender?
In
1997, the UN Economic and Social Council defined gender mainstreaming as
“assessing the implications for women and men of any planned action, including
legislation, policies, or programmes…so that women and men benefit equally, and
inequality is not perpetuated”.31
We used this definition to review the approaches of selected major global
health institutions.
We
selected the institutions on the basis of their involvement in global health in
significant resource commitment,32
mandate to provide normative guidance, stated interest, stated goal to
represent those most affected, or funding of relevant scientific research. We
recognise that the organisations selected are not fully representative of all
global health actors.
Using
publicly available documents from organisations' websites we searched the
health strategy of each agency using the terms “gender”, “sex”, “woman/women”,
and “man/men”. We examined whether gender was addressed in the overall health
strategies of each organisation, and reviewed specific gender strategies where
these existed. We did not review strategies that only focused on the health of
one sex (appendix).
Although
the survey was not exhaustive and the strategy documents might not fully
reflect the work or resource allocation of these organisations on the gender
determinants of ill health, three distinct patterns emerge. First, gender is
understood to mean “concern for both men and women, and the relationships
between them” (UN Development Programme), gender issues are to be mainstreamed
throughout the activities of the organisation (World Bank, WHO, International
Labour Organization), and everyone should have access to gender-sensitive
primary health care (People's Health Movement).
Second,
gender means “addressing gender inequalities and strengthening the response for
women and girls” (Global Fund to Fight AIDS, TB, and Malaria), focusing on
women and girls (United States Agency for International Development [USAID],
United States Global Health Initiative, UNDP, UK Department for International
Development [DFID]), or normalising existing health and survival
inequalities—the World Economic Forum calculates a global gender gap index on
the basis that women live 5 years longer than men. Third, concern with gender
is absent from strategic plans and core aims (Bill & Melinda Gates
Foundation).
Only
two of the institutions, the Global Fund and USAID, specifically mention
transgender health issues in their strategy documents.
The
absence of gender mainstreaming in these organisations is not unexpected, since
the approach is not part of current discourse on development goals. For
example, the MDGs have been criticised for treating gender in an excessively
narrow manner and thereby failing to address how gender influences progress in
poverty reduction and sustainable development, service access, care and care
giving, voice, and agency.33
We
believe that the absence of any reflection on gender in key strategic documents
of some actors, or its misappropriation to mean the health of women and girls,
could unwittingly reinforce inequalities in health. For example, as the world's
largest private grant-making foundation, the Gates Foundation has been
described as a superpower of Global Health.34
The Foundation's apparent failure to seek to address a major inequity between
the burden of disease experienced in women and men is difficult to reconcile
with its ostensible goal of ending inequity in health, although we recognise
that some of its major grants address the burden of disease of both sexes—eg,
tobacco control.35
Similar
criticisms can be made of other leading global health players that fail to
consider gender as a key determinant of health improvements.
The
rationale for global health institutions to focus on health of women and girls
is understandable since gender inequalities have an enormous effect on the
lives of women and girls throughout the world. Girls and women are almost
universally less powerful, less privileged, and have fewer opportunities than
men. The idea of working to redress these imbalances is probably a very
powerful one for the global health community. Moreover, good evidence exists
that maternal health influences the health and survival of children.36
However, focusing on the health of women is complementary to, but not
synonymous with, the promotion of gender equity in health.
Global
health policies and programmes focused on prevention of and care for the health
needs of men are notably absent.37
How can we change this? Experience suggests that to overcome entrenched ideas
within global health is difficult, and a concerted effort will be necessary to
ensure that programmes address the health needs of both women and men.
Galvanising gender into global health necessitates that thoughts and actions
are more political to influence interactions among the prevailing ideas,
relevant interests, and institutions which determine health policies.
As
the international community engages in discussions about the post-MDG
sustainable development framework, now is the time to promote the evidence that
gender affects the health outcomes of everyone. Gender equitable policies need
to be mainstreamed into all development activities, whether the policies are
addressing the structural drivers of women's disempowerment or tackling more
negative aspects of masculinity.
Achievement
of gender equity in health outcomes will need concerted efforts to confront the
underlying interests that drive poor health for all, including efforts to
better understand and control the effects of commercial interests that exploit
and perpetuate gender stereotypes, norms, and behaviours.38
For example, addressing of the underlying drivers of gender inequitable burdens
associated with, among others, tobacco and alcohol, means, in the words of
WHO's Director General, tackling of “corporations that are so big, rich, and
powerful, driven by commercial interests, and far less friendly to health”.39
A
shift in global burden of ill health towards the non-communicable diseases,
coupled with changing social norms towards greater gender equality in some
societies, could result in the present health outcomes of men increasingly
reflected in poor health outcomes of women. In the same way that it makes sense
for the health-care sector to join forces with other sectors to address social
determinants of health, it would arguably serve the long-term interests of
women to join such coalitions too, so as to address a common and growing burden
of ill health.
Achievement
of equitable health outcomes for women and men should not involve diversion of
resources from existing women-focused programmes—eg, reduction of maternal
mortality, or addressing of violence against women. Instead, the global health
community should advocate additional investments in other burdens of ill health
which are equally damaging to the health of individuals and societies.
Evidence
shows that gender—a social construct—has a substantial effect on health
behaviours, access to health care, and health system responses. Gender norms,
whether perpetuated by individuals, communities, commercial interests, or
underpinned by legislation and policy, contribute to disparities in the burden
of ill health on men and women. In some settings and for some conditions, women
suffer more ill health, but globally males have a higher burden of disease and
lower life expectancy than females. Some of this difference is due to
gender-influenced patterns of behaviour—particularly alcohol and tobacco
consumption (men) and risks associated with unsafe sexual behaviour (women).
The tendency to underplay or misunderstand the role of gender, or to equate the
gender dimensions of health solely with the specific health needs of women, has
led to a failure to address the evidence of gendered determinants that affect
and drive the burden of ill health of both men and women.
Progress
of mainstreaming of gender into global health will entail three steps. The
first, which is straightforward and has been repeatedly called for, is
disaggregation by gender or sex in global health research, interventions,
monitoring, and evaluation. More difficult than this first step will be to shift
mindsets to appreciate that gender norms affect everyone's health. Most
challenging, however, will be an acknowledgment that gender in global health is
a political issue in that specific interests perpetuate gender norms and,
hence, that explicit strategies are needed to address these interests.
Now
is the time to take the call from Alma Ata in its literal sense—“Health is for
All” not only for some. Embedding of gender in global health provides one
promising route to attainment of the longstanding, but long-languishing, human
right—the right to health.
Contributors
SH
and KB contributed equally to the conceptualisation of ideas, analysis of
evidence, and drafting and redrafting of the paper.
Conflict
of interest
We
declare that we have no conflicts of interest.
Acknowledgments
We
thank Nicola Low, Jamie Uhrig, and Mike Rowson for their helpful comments on
drafts of this paper. The views expressed by Kent Buse are his own and do not
reflect an official position of UNAIDS.
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