Why global health continues to deny gender equity
Flavia Bustreo, Rajat Khosla, Awa Marie Coll-Seck and Marleen Temmerlan argue that need for a transformational shift on gender equity in global health is urgent.
It is an indictment of our humanity that according to a recent report from WHO, worldwide every two minutes a woman dies in childbirth, totalling 800 women every day or 287,000 women annually. The progress made at the end of Millennium Development Goals is now starting to reverse. The data not only shows, as WHO Director General Dr Tedros Adhanom Ghebreyesus said, that “we are way off track to achieve the SDG target on maternal mortality”, but also a deep seated pattern of discrimination against women, which starts with discrimination against girls and ends with them dying in childbirth.
But for many working in global health, this shouldn’t come as a surprise. Every year, an estimated 21 million girls aged 15–19 years in low-and-middle income countries become pregnant. Worldwide, more than 650 million women alive today were married as children. At least 12 million girls are married before they reach the age of 18 annually. South Asia continues to bear the greatest burden of child brides (45 per cent), followed by sub-Saharan Africa (20 per cent), East Asia and the Pacific (15 per cent) and Latin America and the Caribbean (9 per cent). According to estimates up to 10 million more girls will be at risk of becoming child brides in the next decade as a result of COVID-19.
The recent Human Rights council report on progress, gaps and challenges in addressing child, early and forced marriage highlighted that serious bottlenecks still exist in addressing this practice. In 2019, 190 million (10%) of married women are estimated to have an unmet need for family planning. Each year there are 35 million unsafe abortions, resulting in life-changing injuries for millions and the death of at least 23,000 women annually. Furthermore, as highlighted by UNAIDS, “discrimination against women and girls in all their diversity still exists everywhere, harming their health and well-being and exposing them to heightened risk of HIV infection.” These numbers show a catastrophe in the making. Surprisingly, there is little global outcry, emergency mechanisms, or urgent action to examine what is happening to gender equity in global health.
At the multilateral level, gender equity and sexual and reproductive health and rights (SRHR) have become new faultlines. The polarisation of debate around gender and SRHR risks not only undermining and weakening multilateralism but also diverts attention from addressing the catastrophic consequences of discrimination faced by women and girls and gender diverse groups in their everyday lives in countries around the world. It is devastating that discussions around Comprehensive Sexuality Education (CSE) were derailed at the Commission on Population and Development (CPD) in 2023 due to opposition on the need and imperative of CSE, despite clear evidence from UN Agencies and others on its value.
The discussions at CPD evoked a sense of déjà vu of resistance from previous attempts to address gender equality and SRHR. For instance, at the 75th World Health Assembly, the Member States of WHO ended the negotiations on Global Strategy on HIV, Hepatitis B and Sexually Transmitted Infection 2022-2030 without a consensus, as a result of the reluctance of some Member States to agree to any references to gender, sexuality and sexual health. Beyond global policy negotiations resistance is also reflected in health programming with gender equity often reduced to tokenism. From COVID19, to Ebola, to Zika, to NCDs and beyond, scholars have pointed to the “conspicuous invisibility” of gender in programmes and policies.
Why, after almost 30 years since ICPD and the Beijing Declaration and numerous other declarations, commitments, and reaffirmations, is global health failing on gender equity? What is holding back governments and institutions from realising their commitments? What is it about gender that threatens the orthodoxy of governments, institutions, and policymakers?
As “new” priorities are brought to fore and the global development agenda redefined, women and girls are being systematically left behind despite attempts by many groups to raise concern, for example about the lack of focus on women’s health and rights on Universal Health Coverage resolutions and debates. The rise in maternal mortality and the falling investments and commitment to women’s health is particularly startling given that women represent the majority of healthcare workers, nurses and midwives. As a recent report from Women in Global Health highlighted, although 70% of health workers are women, they occupy only 25% of leadership roles and those from marginalized communities are most excluded.
In recent years there have been numerous reviews, studies, expert panels and commissions that have elaborated on promising, effective interventions to advance gender equality in the context of global health. This commentary provides an initial foray into what underpins the avoidance of genuine engagement in strategies for gender equity in global health.
Denials of gender equity are grounded in “deep-rooted patriarchy,” misogyny, and sexism exposing the “gender bias of global health”.
The global health space continues to be male dominated, from leadership roles in institutions, to boards and the delegation’s representing governments at decision making forums. Several global health funds, such as the Global Fund, Gavi and Health Nutrition and Population (HNP) at the World Bank, have never been led by a woman. Largely male dominated and male led policy making and programming seeks to legitimise the curtailment of access to contraception for adolescent girls, safe abortions, to impose complete bans, or invoke criminal law sanctions on LGBTI persons. State policies legitimize sterilization of women marginalised by poverty, disability, or ethnic minority or migration status. Ideologies makes women’s care work as unpaid labour invisible and are used to “justify child marriage on grounds of custom and faith rather than denounced for the child abuse that it is.”
This reality creates and sustains unconscious biases, deeply embedded behaviours, values and processes across global health and intersects with inequalities across class, geography, race, income and other factors. This bleeds into political processes that generate backlashes towards gender equality. Macro-level politics and increasingly hostile ruling ideologies continue to evade gender equity and deny countless women their ability to express their voices and claim their rights, with direct bearing on the capacity and willingness of duty bearers to meet their legal and political obligations.
What would it take for us to turn the tide and to truly realise gender equity in global health? To begin with we need to acknowledge that these are not aberrations but part of a deliberate pattern. Activists responding to the anti-gender movement illustrate the coordinated and strategic nature of what often appears to be separate and uncoordinated backlashes. In doing so we need a deeper analysis of interplay of patriarchy, misogyny and sexism and its working in global health and at different levels. There are no silver bullets, however, some starting points would require:
Integrated approach to gender equity: Gender inequity in health cannot be separated from gender inequities in societies overall. Gender inequity in health is both a sub-set of and influenced by wider societal notions on equality, hierarchies, and privilege. Therefore, policies in other sectors can affect the implementation of innovative transformative gender policies in health. Policy inconsistencies beyond health can work to undermine any progression or advances in gender inequality in health. This would require a whole of government approach and working with partners across different sectors to build allyship for promoting positive gender norms.
Gendering global health space: The global health space continues to be largely male dominated. While there has been some development in terms of the representation of women in senior leadership roles, male domination continues to be the norm. Gendering the global health space would need to go beyond reaching a binary proportionality and requires reconstructing these spaces to facilitate the meaningful participation of diverse genders. From access to the languages we use to the format of global health discussions, they are meant to favour one gender to the disadvantage of others. In 2022, how can it be that gender and other inequalities continue to be grossly side-lined in global health spaces? It is incumbent on both governments and institutions to take effective steps to ensure gender equality in the global health space.
De-colonise structures, systems and processes and ensure diversity of voices: Global health as it exists today is not equal, diverse, or inclusive, nor does it have the tools to address the challenges of our lived realities. The multiple and intersecting inequities which we need to address do not conform to the disease model that continues to dominate the global health space. Global health as some have stated, “is yet to shed its colonial origins and structures”. The supremacies which these structures represent are not symmetrical but complex intersecting webs which continuously exclude the diversity of voices, of women and other genders, to maintain hegemonic control which leads to an unjust and unequal global health agenda. The change needed is substantial, structural and system wide. A decolonization approach requires addressing the injustices of colonization and neo-colonization, which in the context of global heath continue to be very ripe. Moving forward it would require not only rethinking the tools we use in global health, but also what constitutes the global health space. It would require the meaningful and equitable representation of low- and middle-income voices in global health structures, systems and processes for global health to have any legitimacy.
The need for a transformational shift on gender equity in global health is urgent. For it to happen, we need to start by understanding the supremacies, hierarchies and powers that create and enable the dominant structures in global health and to unearth the dynamics these structures operate within. This key is building allyship across different movements working on ensuring diversity and inclusion in global health. Only by dismantling the structures of power and privilege that continue to undercut global health can we aspire to realise health justice for all.
Flavia Bustreo, Chair, Governance and Ethics Committee, Partnership for Maternal, Newborn and Child Health, Geneva, Switzerland.
Rajat Khosla, Director, United Nations University-International Institute for Global Health, Kuala Lumpur, Malaysia. Corresponding Author: rajat.khosla@unu.edu
Awa Marie Coll Seck, Minister of state - Senegal and President Galien Africa Association.
Marleen Temmerman, Director Centre of Excellence Women Child Health, Aga Khan University EA, Senior Health Advisor SDG Partnership Platform, Kenya.
Photo by RF._.
