New Delhi: In October 2023, gender and public health experts from the UN agencies and academia, as well as government representatives from the Philippines and Sri Lanka, among other countries gathered at the conference room at the India Habitat Center in New Delhi. At the panel discussion titled “Advancing Equity: Improving Population Health through Gender Mainstreaming in Policy,” organised by Vital Strategies they unanimously agreed that a lot more needed to be done to create gender-responsive public health systems.
“To say that something is not affected by gender in some way is ignoring the reality of our daily lives,” said Michelle Kaufman, Director of the Gender Equity Unit at the Johns Hopkins Bloomberg School of Public Health. “Gender underlies everything we do in our daily lives and our work, how we interact with others,” she said.
Kaufman’s observations raise the question of how–if at all– policymakers and healthcare providers account for gender. To include a gender perspective in healthcare, policymakers need data and evidence that can indicate gendered impacts. For healthcare providers to be gender-inclusive, they need policies, funding and guidelines.
However, governments often lack accurate and inclusive data on gender determinants of health. Gender is a social construct–roles, behaviours, expressions and identities–that can impact health outcomes. Sex is a biological category assigned at birth. As such, both terms cannot be used interchangeably.
Gender mainstreaming is a process that addresses the unique health needs and experiences of both men and women while recognizing the biological, social, economic and cultural factors that also contribute to health disparities.
Let’s consider how we include gender perspectives within health systems.
Gender is not just a ‘women’s issue’
First, we have to broaden the definition of gender to look beyond the binary, while also taking into consideration intersectionality.
Ravi Verma from the International Center for Research on Women, was also speaking at the panel, noted there is a practice of conflating gender with ‘female’, as well as viewing it as women’s issues.
“It's so easy to put the blame or put the onus onto the women for any decision that is reinforcing patriarchy in some way,” he said.
Verma points to how Indian grassroots healthcare providers in charge of family planning often report that women express a desire to get a tubectomy, a surgical procedure to clip the fallopian tubes, whilst simultaneously stating they do not want their husbands to undergo vasectomies. This ignores the gender dynamics and social conditions on the ground, Verma pointed out. In India, female sterilisation is almost 10 times higher than male sterilisation. The burden of family planning is on women.
However, Verma warned against making assumptions about why this is the case. Male sterilisation rates remain low because of a variety of reasons ranging from patriarchy to misconceptions about the surgical procedures, experts have noted.
Kaufman told Missing Perspectives how men sometimes lose out and their needs are neglected because of a narrow understanding of gender in health systems. She said that gender-based violence is seen as primarily affecting women and girls, however, there is also interpersonal violence that men engage in and fall victim to that is linked to gender roles and norms.
For instance, a majority of the perpetrators of mass shootings in the US are male. Of 172 mass shooters between 1966 and 2000 studied by the Voice of America, only four were women. Other reports have noted how a majority are cis-gendered men.
“This is a gender issue too,” Kaufman noted.
In conflict zones, surveys and reports show that men suffer high levels of gender abuse. For instance, more than one in three Congolese male refugees have experienced sexual violence in their lifetime, according to the Overseas Development Institute. Sexual violence against men and boys has been reported in 25 conflict zones.
Engaging men in the conversations is important for better public health outcomes, Verma noted.
Sex and gender disaggregated data
Civil registrations and personal public data, such as birth and death, also highlight gender inequity. Birth registration establishes a child’s identity and ensures their right to be recognised as a person before the law. However, birth registrations do not occur smoothly across the world and 1 in 4 children under age 5 have not had their birth registered, according to the UN.
Chloe Harvey of the UN Economic and Social Commission for Asia and the Pacific (UNESCAP) at the discussion noted that women and girls often face critical barriers and structural impediments from birth and throughout the life cycle in registering their vital events. She explained that this also has intergenerational impacts. For example, for women who don’t have their birth or marriage registered or they are unmarried, may be unable to register the birth of their child without providing this documentation. This potentially makes it impossible to register the birth of their child and thus, the cycle continues.
Research has found that individuals without birth certificates are more susceptible to violence, abuse and exploitation. Young women without them, for example, face an increased risk of child marriage and trafficking.
By analysing routine health data with a gender lens, public health advocates and policymakers can identify the many gender inequity and gender-related health issues often camouflaged in large data sets.
These disparities extend to death registrations too. More than 8 million deaths in Asia-Pacific are never registered each year, the Economic and Social Commission for Asia Pacific noted in early 2023.
“[Throughout Asia and the Pacific], there are distinct inequalities in death registration, whereby women are less likely to have their deaths registered,” said Harvey. “This is usually due to a lack of incentives, as women usually have fewer assets than men.” Studies show there is an incentive to register a death only when there are claims of pensions, inheritances, or other social benefits.
Harvey further noted that while women in the Asia Pacific region are less likely to have their deaths registered due to lack of incentives since they often have fewer assets than men, there are also distinct sex differentials in patterns of mortality and this information is needed for designing gender responsive health policies. This highlights the need to improve civil registration completeness for people of all genders, she said.
Data to drive gender-responsive health policies
A lack of data is a key challenge for the health sector and evidence-based policymaking. Without analyses of gendered impacts on health, it is difficult for governments to focus their policies on what is needed on the ground, Kanta Singh of UN Women India said at the event.
This issue also brings to the fore poor documentation, processes and data collection.
India’s health response to gender-based violence is an example of this. India lacks proper documentation of the health impacts of violence, even in obvious injuries, as per an assessment by the UNFPA.
Poor recording leads to inaccurate medical histories and inadequate or delayed treatment. It also hinders a survivor’s access to justice. Moreover, the lack of data on the burden of gender-based violence on the health system impacts funding, policy and interventions, the report noted.
An analysis by KGMC and Vital Strategies of 1,467 autopsies of women at a government hospital in Mumbai found that 12.3% of the deceased had previously suffered domestic violence.
Nidhi Chaudhary, Principal Technical Advisor of the Data Impact programme for the Asia Pacific region at Vital Strategies, noted that these deaths had to do with socio-cultural issues, and thus these don’t get captured as a cause anywhere.
Around 47% of the deaths were due to suicide, and another 47% were due to accidents, and around 6% were due to homicide. Partners were the perpetrators of domestic abuse in around 61% of deaths, while in 39% of deaths, family members were the perpetrators. An overwhelming 87% of deaths had a history of marital disputes and family issues.
Chaudhary points out that until recently there was a gap within the International Classification of Diseases (ICD) coding of causes of death, which did not include gender-based violence. Thus standardised guidelines to record deaths due to gender-based violence were missing; and these are being formulated in recent times, she said.
Despite staggering levels of violence against women, India currently doesn’t have a national policy for health system response to domestic violence, and whilst several states have their own specific policies, investigations by Missing Perspectives have shown they aren’t being implemented.
Ensuring gender perspectives within the system
If there’s one promising case to consider–it may be the Philippines, which has in recent years incorporated gender perspectives within its public health policy and decision making process.
At the event, Adriel Pizarra, a Medical Officer of the Department of Health in the Philippines, shared several key factors that have helped expedite this process.
First, he emphasised the importance of intersectoral collaboration. The health department worked with the Philippine Commission on Women, which has been tasked to ensure the gender responsiveness of the different sectors.
Second, a key enabling mechanism–which Pizarra called the “facilitator of success”--is the Philippines’ Magna Carta of Women (Republic Act No. 9710),modelled after the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW). However, unlike most countries, the Philippines has incorporated the CEDAW into their own laws, with legislation specifically stipulating its role as a “women’s human rights law that seeks to eliminate discrimination through the recognition, protection, fulfilment, and promotion of the rights of Filipino women…”
By doing so, the health department was provided legislative tools and mechanisms to ensure gender responsiveness in their healthcare strategies. This includes gender-sensitive planning and budgeting mechanisms, as well as those that enable assessment of the gender responsiveness of various initiatives of the department, he explained. Among other provisions, the Magna Carta also allows for technical working groups across different units of the health department. Yet challenges persist. There is a need for more capacity-building opportunities for all health cadres in policy-making and service delivery, as well as the need for sex-disaggregated data for important indicators.
“We know that to supercharge economies and development, we need to empower women, but for too long the unique needs and opportunities facing women remain invisible to policymakers,” said Ruxana Jina, Director of Data Impact, Vital Strategies. She advocated for the utilisation of smart data strategies that use a gender lens to look at existing data and collect new data to inform public health policies.w
Jina said, “We know that policies that uplift women drive benefits across families, communities and economies – everyone benefits from gender equity.”
The author attended the event at the invitation of Vital Strategies.
Full photo caption - Speakers at the Advancing Equity pane held in New Delhi in October 2023: (From Right) Ravi Verma, International Center for Research on Women; Vindya Kumarapeli, Ministry of Health, Sri Lanka; Adriel Pizarra, Department of Health, Philippines; Michelle Kaufman, Gender Equity Unit, Johns Hopkins Bloomberg School of Public Health; Kanta Singh, UN Women; Chloe Harvey, UN Economic and Social Commission for Asia and the Pacific; and Ruxana Jina, Director of Data Impact, Vital Strategies.