Hands up, who thinks of women when someone mentions gender? Be honest now. You do? Well, guess what, you’re not alone. According to a couple of researchers writing in the Lancet today, many of the leading global health institutions do too. Worse, some don’t have much of a clue about gender at all. Here’s how Hawkes and Buse summarise their findings: “Gender is missing from, misunderstood in, and only sometimes mainstreamed into global health policies and programmes”. Ouch!
That there’s a blind spot in global health policy when it comes to men and gender surprised me, and the authors’ analysis of the 2010 Global Burden of Disease dataset (which was published in the Lancet last year) is frankly shocking: for each of the top 10 contributors to DALYs (see the table below) and the top 10 risk factors for ill health men fare worse than women. When it comes to mortality, men get some respite – faring worse than women in just 8 of 10 causes of death globally.
So, which global health institutions are gender-savvy, and which ones couldn’t tell a ladyboy from a ladybird?
Searching the health strategies from each selected agency, the authors found that the World Bank, WHO, ILO and the People’s Health Movement were top of the class, understanding that gender concerned “both men and women, and the relationship between them” and were committed to gender mainstreaming. In the ‘could-do-better’ category they found that the Global Fund, USAID, the US Global Health Initiative, and UK DFID understood gender primarily as a way to empower women and girls.
But who needed to stay behind after class? Surprisingly, the Bill and Melinda Gates Foundation – which had no provision for gender in any of its strategy documents. And, finally, only two organisations – the Global Fund and USAID – had a clue about transgender health issues. All of this may be news to you but not to the authors:
“The absence of gender mainstreaming in these organisations is not unexpected, since the approach is not part of current discourse on development goals.”
You could argue that the reason why gender is sidelined within development discourse is precisely because it doesn’t feature in the collective consciousness of the leading global health institutions, and thus is not something that would ever feature heavily in the health and development debates to which they are privy. After all, we have an MDG (3) devoted to gender – but why is gender not mainstreamed across all the MDGs? After all, that is what the world signed up to back in the (seemingly) impetuous days of the late 1990s. But whichever direction you choose to travel along the causal pathway, it’s not a positive finding.
Why do gender norms matter?
So what? Who cares? Well, Hawkes and Buse have a few things to say about that. Firstly, it seems that culturally driven gender norms of behavior are driving men’s health just as they drive women’s health. Look at alcohol. Traditionally, men drink more alcohol than women (and suffer more for it as a result) in large part because of gender norms of behavior that link alcohol consumption and masculinity. But here’s the rub:
“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”
In other words, in some societies, women are catching up with men in terms of excessive alcohol consumption (and all the associated ill health outcomes).
Secondly, gender norms have implications for unsafe sex that impact disproportionately on women, men who have sex with other men, and transgender people; gender norms restricting a woman’s autonomy could mean she is less likely to seek treatment for illnesses than a man in the same household; and gender stereotypes can deter HIV-infected men from accessing ARVs.
And is there a rub? You bet: In societies that are more gender equitable, health care seeking patterns for men and women are often quite similar, but inpatient care for some conditions show “significant gender-based inequalities (favouring men) in the actual provision of care”.
What to do about it?
The authors recognize that women are disadvantaged in most spheres in life – socially, economically, politically. But when it comes to health outcomes, the story is more complex. Men take more risks with their health, suffer more burdens of ill health and die younger than women do, all over the world. What can be done about this? Hawkes and Buse see three categories of policy reform: straightforward, more difficult and most challenging.
- Starting with the easiest first the authors see global health research and evidence that disaggregates by gender and sex as a quick-win (no surprises there; it’s been said before many times).
- More difficult is the task of changing mindsets about gender – getting gender equitable policies into the mainstream – boys and men have a stake in that just as women and girls do. The way to do that is partly about promoting the evidence that gender matters for everyone.
- Most difficult is recognizing that gender has a political dimension, meaning that “specific interests perpetuate gender norms and, hence, that explicit strategies are needed to address these interests”. And then confront those ‘specific interests’ (i.e. the commercial interests of the food, tobacco and alcohol industries) head on
So, there you have it – the real gender gap in global health.