Moving beyond the rhetorical: Investing in gender equality to achieve the right to health

After decades of work to tackle gender disparities in healthcare, gender remains a significant factor in the poor health of millions around the globe.

Women account for the majority of the world’s poor, and being a poor woman carries serious health risks, including a higher prevalence of HIV and AIDS and an increased risk of sexual and family violence. Maternal mortality remains alarmingly high in many developing countries, especially in sub-Saharan Africa where more than 900 women die for every 100,000 live births. This rises to a high of 2,100 per 100,000 in Sierra Leone, where a woman has a 1 in 8 chance of dying during pregnancy or childbirth. In the industrialised world, just 8 women die per 100,000 live births and the risk of maternal death is 1 in 8,000.

While some progress has been made in reducing child deaths, which have fallen below 10 million per year, UNICEF’s State of the World’s Children Report 2008 warns that failing to improve maternal health threatens the chances of reaching MDG4 – a two-thirds reduction in child mortality between 1990 and 2015.

The resources needed to translate ambitious global commitments into practice are lacking at every level, from local NGOs to multilateral organisations. This year the UN theme of International Women’s Day is ‘investing in women’. If we are to achieve health for all, it is vital to address the impact of gender inequality on the underlying social determinants of health through evidence-based policy commitments backed by the necessary financial and human resources.

Since the 1995 UN Beijing Conference on Women, a growing body of research has emerged to illustrate the business case for investing in women, and the ways in which gender inequality undermines both development and poverty reduction. E vidence suggests that when men and women are relatively equal in status, economies grow faster and the health and well-being of everyone – men, women and children – improves. This is because:

• Healthy, educated, empowered women are better able to contribute to the economic productivity of their own generation, and to foster the socio-economic development of the next.
• Gains in child survival and nutrition as a result of household income growth are more significant when that income is in the hands of women. They tend to be the primary care-givers and are often the first to spot children’s illnesses. However, they often lack power when it comes to critical household spending decisions, including spending on healthcare.
• There is also a strong link between lost economic productivity and women’s poor health. USAID has estimated over US$15 billion in global costs through diminished productivity due to the death of women and newborns.
• Benefits from improvements in women’s health and status have also been shown by UNICEF and others to have a positive spillover impact on child well-being, helping to break the effects of lifecycle and inter-generational poverty.

Four key steps are needed to turn business cases into actual practice:

• investing in better data collection to measure progress;
• enhancing the capacities of health policy-makers and implementers to use the data;
• mainstreaming gender, particularly in donor reporting; and
• ensuring greater and more strategic resources.

First, on data collection, there is an urgent need for greater consistency and broader collection of sex-disaggregated data to improve our understanding of trends in health gender gaps over time, across and within countries. For example, it is typically assumed that immunisation services reach boys and girls equally. A careful examination of data, however, shows that in India, 13% more girls than boys are unvaccinated, and that this disparity increases the more girls there are in the family. Armed with this kind of data, health programmers can begin to investigate the gender barriers that underlie this difference, and take appropriate action.

However, there is often a reluctance to invest in the necessary institutional changes to undertake such data collection, followed by political reluctance to report on the findings.

Second, on enhancing capacity to use the data, it is critical that we invest in the gender analysis skills of health policy-makers. They need to be aware not only of the gendered balance of power within households and how this affects decisions on health, but also the range of infrastructural and socio-cultural factors that may hinder the uptake of health services by men and women. We also need to be careful that arguments that focus on the efficiency of involving women in community healthcare delivery do not mask the role of their unpaid work and the risks of exacerbating their time poverty.

Third, on mainstreaming gender, concerted efforts are now required to incorporate gender-sensitive health indicators and analysis into harmonised donor reporting guidelines. Wide-spread commitments to gender in Poverty Reduction Strategy Papers and the near universal ratification of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), suggest support for gender-sensitive data reporting. In this vein, the Global Fund and the GAVI Alliance, two major international public–private partnerships, are developing gender policies specific to their roles as major players in the international health arena. Although somewhat belated, these efforts represent exciting steps towards the mainstreaming of a gender-sensitive approach into the policies and practices of two major health funders. The GAVI Alliance, for example, aims to integrate gender holistically into its country support and vaccine investment mechanisms, and to play a catalytic role in spotlighting knowledge and resource gaps.

Finally, tackling gender inequalities in health demands significant financial resources. The 2008 Commission on the Status of Women has found that $25­–28 billion is needed annually to achieve MDG3 – promote gender equality and empower women. Meeting this challenge will require a commitment to gender responsive budgeting (GRB), which provides a tool for recognising the gender-sensitive needs of marginalised populations, as well as gender-sensitive monitoring of aid. The 2007 OECD-DAC report Aid in Support of Gender Equality and Women's Empowerment, for example, tracks the percentage of aid with a primary or significant focus on enhancing gender equality. It found that the percentage of DFID's aid commitments with a gender focus fell from 47% in 2004 to 35% in 2006 of all aid available in the sector – significantly lower than the percentage from donors such as Canada and Sweden.

In conclusion, achieving consistent progress towards gender equality in health and in other spheres of development hinges on sufficient investment in measures to tackle gender inequality. New data, indicators and tools give us unprecedented ability to monitor progress and hold governments and agencies accountable. There is now the potential to move beyond verbal promises and towards a substantive investment in the right to health for all.