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Unequal,
unfair, ineffective and inefficient: Gender inequity in health
Why it exists and how we can change it: Final Report to the WHO
Commission on Social Determinants of Health
Gita
Sen, Piroska Östlin, and Asha George, Women and Gender Equity
Knowledge Network (WGEKN)
September 2007
http://www.siyanda.org/search/summary.cfm?nn=3163&ST=SS&Keywords=Unequal%2C%20Unfair%2C%20
Ineffective%20%26%20Inefficient&SUBJECT=0&Donor=&StartRow=1&Ref=Sim
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Executive Summary
Background
Gender inequality
damages the health of millions of girls and women across the globe.
It can also be harmful to men's health despite the many tangible
benefits it gives men through resources, power, authority and control.
These benefits to men do not come without a cost to their own emotional
and psychological health, often translated into risky and unhealthy
behaviours, and reduced longevity. Taking action to improve gender
equity in health and to address women's rights to health is
one of the most direct and potent ways to reduce health inequities
overall and ensure effective use of health resources. Deepening
and consistently implementing human rights instruments can be a
powerful mechanism to motivate and mobilize governments, people
and especially women themselves.
Gender relations
of power constitute the root causes of gender inequality and are
among the most influential of the social determinants of health.
They determine whether people's health needs are acknowledged,
whether they have voice or a modicum of control over their lives
and health, whether they can realize their rights. This report shows
that addressing the problem of gender inequality requires actions
both outside and within the health sector because gender power relations
operate across such a wide spectrum of human life and in such inter-related
ways. Taking such actions is good for the health of all people -
girls and boys, women and men. In particular, inter-sectoral action
to address gender inequality is critical to the realization of the
Millennium Development Goals (MDGs).
Like other social
relations, gender relations as experienced in daily life, and in
the everyday business of feeling well or ill, are based on core
structures that govern how power is embedded in social hierarchy.
The structures that govern gender systems have basic commonalities
and similarities across different societies, although how they manifest
through beliefs, norms, organisations, behaviours and practices
can vary. The report shows that gender inequality and equity in
health are socially governed and therefore actionable. Sex and society
interact to determine who is well or ill, who is treated or not,
who is exposed or vulnerable to ill-health and how, whose behaviour
is riskprone or risk-averse, and whose health needs are acknowledged
or dismissed.
However gender
intersects with economic inequality, racial or ethnic hierarchy,
caste domination, differences based on sexual orientation, and a
number of other social markers. Only focusing on economic inequalities
across households can seriously distort our understanding of how
inequality works and who actually bears much of its burdens. Health
gradients can be significantly different for men and women; medical
poverty may not trap women and men to the same extent or in the
same way. The standard work on gradients and gaps tells us easily
enough that the poor are worse off in terms of both health access
and health outcomes than those who are economically better off.
But it does
not tell us whether the burden of this inequity is borne equally
by different caste or racial groups among the poor. Nor does it
tell us how the burden of health inequity is shared among different
members of poor households. Are women and men, widows and income-earning
youths equally trapped by medical poverty? Are they treated alike
in the event of catastrophic illness or injury? When health costs
go up significantly, as they have in many countries in recent years,
do households tighten the belt equally for women and men? And are
these patterns similar across different income quintiles? This poses
a challenge for policy to ensure not only equity across but also
and simultaneously within households.
The right to
health is affirmed in the Universal Declaration of Human Rights
and is part of the WHO's core principles. This report is grounded
in the affirmation of equal and universal rights to health for all
people, irrespective of economic class, gender, race, ethnicity,
caste, sexual orientation, disability, age or location.
Gendered
Structural Determinants of Health
Gender systems
have a variety of different features, not all of which are the same
across different societies. Women may have less land, wealth and
property in almost all societies; yet have higher burdens of work
in the economy of 'care' - ensuring the survival, reproduction
and security of people, including young and old. Girls in some contexts
are fed less, educated less, and more physically restricted; and
women are typically employed and segregated in lowerpaid, less secure,
and 'informal' occupations. Gender hierarchy governs
how people live and what they believe and claim to know about what
it means to be a girl or a boy, a woman or a man. Girls and women
are often viewed as less capable or able, and in some regions seen
as repositories of male or family honour and the self-respect of
communities.
Restrictions
on their physical mobility, sexuality, and reproductive capacity
are perceived to be natural; and in many instances, accepted codes
of social conduct and legal systems condone and even reward violence
against them.
Women are thus
seen as objects rather than subjects (or agents) in their own homes
and communities, and this is reflected in norms of behaviour, codes
of conduct, and laws that perpetuate their status as lower beings
and second class citizens. Even in places where extreme gender inequality
may not exist, women often have less access to political power and
lower participation in political institutions from the local municipal
council or village to the national parliament and the international
arena. While the above is true for women as a whole vis a vis men,
there can be significant differences among women themselves based
on age or lifecycle status, as well as on the basis of economic
class, caste, ethnicity etc.
Much of the
above also holds for transgender and intersex people who are often
forced to live on the margins of mainstream society with few material
assets, who face extreme labour market exclusion leaving them little
other than sex-work as a means of survival, and who are often ostracised,
discriminated against, and brutalised.
The other side
of the coin of women's subordinate position is that men typically
have greater wealth, better jobs, more education, greater political
clout, and fewer restrictions on behaviour. Moreover men in many
parts of the world exercise power over women, making decisions on
their behalf, regulating and constraining their access to resources
and personal agency, and sanctioning and policing their behaviour
through socially condoned violence or the threat of violence. Again,
not all men exercise power over all women; gender power relations
are intersected by age and lifecycle as well as the other social
stratifiers such as economic class, race or caste. The impact of
gender power for physical and mental health - of girls, women
and transgender /intersex people, and also of boys and men -
can be profound.
Furthermore,
the extent to which the needs of young populations as well as older
populations have to be met through the unpaid 'care'
work of women is exacerbated by crumbling health services and vanishing
paid health staff. Women become the shock-absorbers in the system,
expected to act as such in both normal economic and health times,
and during the bumps caused by health crises and emergencies.
Together, gender
systems, structural processes and their interplay constitute the
gendered structural determinants of health. What determines the
pace or pattern of change in gender systems and how they affect
people's health? The interplay between gender systems and
structural processes such as rising literacy and education, demographic
transitions in birth and death rates and in family structures, globalisation
(including its effects on labour forces, policy space, health systems,
and violence), and the strengthening of human rights discourse,
work to weaken or strengthen gender hierarchies and their effects
on people's health.
In some instances,
however, these changes also set off backlashes as those who wield
gender power in families, communities and religious structures attempt
to control and discipline (especially) young women. Trying to hold
on to such power has led to attempts to roll back internationally
agreed norms on gender equality and sexual and reproductive health
and rights in particular. Such attempts have had serious implications
for the health and human rights of women and men and of young people.
Three implications
of globalisation are of particular significance for our focus on
gender relations.
The first is
how it has transformed the composition of workforces, and the implications
for women's health. Feminisation of work-forces has gone hand
in hand with increased casualisation, and continuing unequal burdens
for unpaid work in the household, with serious implications for
women's health, both their occupational health and the consequences
of insufficient rest and leisure.
A second gendered
consequence of globalization is through its narrowing of national
policy space that has resulted in reducing funds for health and
education with negative impacts on girls' and women's
access.
A third aspect
of globalisation of importance for health is the rise in violence
linked to the changing political economy of nation states in the
international order. Importantly, gendered violence does not only
affect girls and women but includes violence against boys and men,
as well as transgender and intersex persons and all those who do
not meet heterosexual norms.
Some of the
negative consequences of globalisation contrast with the deepening
during recent decades of the normative framework of human rights.
This deepening has been important in altering values, beliefs and
knowledge about gender systems and their implications for health
and human rights. The first action priority is therefore to protect
and promote women's human rights that are key parts of the
normative framework for health. But this in turn requires strengthening
women's hands and empowering them so that they can actually
claim and realize their human rights. This points to the next two
action priorities: cushioning women who act as the 'shock
absorbers' through key structural reforms including gender-sensitive
infrastructure, and expanding women's opportunities and capabilities.
Norms,
Values and Practices
Gendered norms
in health manifest in households and communities on the basis of
values and attitudes about the relative worth or importance of girls
versus boys and men versus women; about who has responsibility for
different household / community needs and roles; about masculinity
and femininity; who has the right to make different decisions; who
ensures that household /community order is maintained and deviance
is appropriately sanctioned or punished; and who has final authority
in relation to the inner world of the family /community and its
outer relations with society. Norms around masculinity not only
affect the health of girls and women but also of boys and men themselves.
Challenging
gender norms, especially in the areas of sexuality and reproduction
touch the most intimate personal relationships as well as one's
sense of self and identity. No single or simple action or policy
intervention can be expected therefore to provide a panacea for
the problem. Multi-level interventions are needed.
We identify
three sets of actions:
(A) creating
formal agreements, codes and laws to change norms that violate
women's human rights, and then implementing them;
(B) adopting multi-level strategies to change norms including
supporting women's organisations;
(C) working with boys and men to transform masculinist values
and behaviour that harm women's health and their own.
Differences
in Exposure and Vulnerability
Male-female
differences in health vary in magnitude across different health
conditions. Some health conditions are determined primarily by biological
sex differences. Others are the result of how societies socialize
women and men into gender roles supported by norms about masculinity
and femininity, and power relations that accord privileges to men,
but which adversely affect the health of both women and men. However,
many health conditions reflect a combination of biological sex differences
and gendered social determinants. Understanding the roles that biological
difference and social bias play is important to understanding differential
exposure and vulnerability.
Where biological
sex differences interact with social determinants to define different
needs for women and men in health, policy efforts must address these
different needs. Significant advocacy is required to raise attention
and sustain support for other services that address the specific
health needs of poor women, and those in low income countries, thereby
reducing their exposure and vulnerability to unfavourable health
outcomes. Not only must neglected sex-specific health conditions
be addressed, but sex-specific needs in health conditions that affect
both women and men must be considered, so that treatment can be
accessed by both women and men without bias. Two intertwined strategies
to address social bias are: tackling the social context of individual
behaviour, and empowering individuals and communities for positive
change.
Strategies that
aim at changing high risk life-styles would be more effective if
combined with measures that could tackle the negative social and
economic circumstances (e.g. unemployment, sudden income lost) in
which the health damaging life-styles are embedded. Individual empowerment
linked to community level dynamics is also critical in fostering
transformation of gendered vulnerabilities. For strategies to succeed
they must provide positive alternatives that support individuals
and communities to take action against the status quo.
The
Gendered Politics of Health Care Systems
While the traditional
approach to health care systems tends to be management oriented
with focus on issues such as infrastructure, technology, logistics
and financing, the WGEKN looked at the human component of health
care systems and the social relationships that characterize service
delivery. Evidence shows the different ways in which the health
care system may fail gender equity from the perspective of women
as both consumers (users) and producers (carers) of health care
services.
Action priorities
include supporting improvements in (especially poor) women's
access to services, recognition of women's role as health
care providers, and building accountability for gender equality
and equity into health systems, and especially in ongoing health
reform programmes and mechanisms.
Lack of awareness
(knowledge of women, their families and health care providers about
the existence of a health problem) and acknowledgement (recognition
that something should and can be done about the health problem)
are important barriers to women's access to and use of health
services. Access depends therefore both on factors affecting the
demand side (how families treat women who may be potential users
and how women see themselves) and the supply side (including different
aspects on the side of providers). Health systems also tend to ignore
women's crucial role as health providers, both within the
formal health system (at its lower levels) and as informal providers
and unpaid carers in the home.
Absence of effective
accountability mechanisms for available, affordable, acceptable
and high quality health services and facilities may seriously hinder
women and their families in holding government and other actors
accountable for violations of their human rights to health. Health
sector reforms can have fundamental consequences for gender equality
and for people's life and well-being, as patients in both
formal and informal health care, paid and unpaid care providers,
health care administrators and decision makers.
However, health
sector reforms that have been implemented in many countries have
tended to focus on their implications for the poor, and their consequences
for gender equity in general and particularly in health care have
seldom been discussed or taken into consideration in planning. Health
sector reform strategies, policies and interventions introduced
during the last two decades have had limited success in achieving
improved gender equity in health. Minimizing gender bias in health
systems requires systematic approaches to building awareness and
transforming values among service providers, steps to improve access
to health services and developing mechanisms for accountability.
Health
Research
Gender discrimination
and bias not only affect differentials in health needs, health seeking
behaviour, treatment, and outcomes, but also permeate the content
and the process of health research. Gender imbalances in research
content include the following dimensions:
- slow recognition
of health problems that particularly affect women;
- misdirected
or - partial approaches to women's and men's
health needs in different fields of health research; and
- lack of recognition
- of the interaction between gender and other social factors.
Gender imbalances
in research process include:
- non-collection
- of sex-disaggregated data in individual research projects
or larger data systems;
- research
methodologies are not sensitive to the different dimensions of
disparity;
- methods
used in medical research and clinical trials for new - drugs
that lack a gender perspective and exclude female subjects from
study populations;
- gender imbalance
in - ethical committees, research funding and advisory bodies;
and
- differential
treatment of women scientists.
Mechanisms and
policies need to be developed to ensure that gender imbalances in
both the content and - processes of health research are avoided
and corrected.
The importance
of having good quality data and indicators for health status disaggregated
by sex and age from infancy through old age cannot be overstated.
Gender-sensitive and human-rights- sensitive country level indicators
are essential to guide policies, programs and service delivery;
without them, interventions to change behaviours or increase participation
rates, will operate in a vacuum.
Removing
Organisational Plaque
The WGEKN report
complements its work on the substantive content of gender equitable
approaches to health by looking into key organisational questions.
Working towards gender equality challenges long-standing male dominated
power structures, and patriarchal social capital (old boys'
networks) within organisations. It crosses the boundaries of people's
comfort zones by threatening to shake up existing lines of control
over material resources, authority, and prestige. It requires people
to learn new ways of doing things about which they may not be very
convinced and from which they see little benefit to themselves,
and to unlearn old habits and practices.
Resistance to
gender-equal policies may take the form of trivialisation, dilution,
subversion or outright resistance, and can lead to the evaporation
-- of gender equitable laws, policies or programmes.
Tackling this requires effective political leadership, well designed
organisational mandates, structures, incentives and accountability
mechanisms with teeth. It also requires actions to empower women
and women's organisations so that they can collectively press
for greater accountability for gender equality and equity.
The report provides
a number of good practice examples from different countries.
The
Way Forward
This report
has shown that gender relations of power exist both within and outside
the health sector, and exercise a pernicious influence on the health
of people. It has drawn together the rapidly growing body of evidence
that identifies and explains what gender inequality and inequity
mean in terms of differential exposures and vulnerabilities for
women versus men, and also how health care systems and health research
reproduce these inequalities and inequities instead of resolving
them. The consequences for people's health are not only unequal
and unjust, but also ineffective and inefficient.
It has also
documented the growing numbers of actions by non-governmental and
governmental actors and agencies to challenge these injustices and
to transform beliefs and practices within and outside the health
sector in order to generate sustained changes that can improve people's
health and lives. In particular, it calls for support for women's
organisations that are critical to ensuring that women have voice
and agency, that are often at the forefront of identifying problems
and experimenting with innovative solutions, that prioritise demands
for accountability from all actors, both public and private, and
whose access to resources has been declining in recent years.
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