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Review
. 2019 Jun 22;393(10190):2535-2549.
doi: 10.1016/S0140-6736(19)30648-8. Epub 2019 May 30.

Disrupting gender norms in health systems: making the case for change

Katherine Hay  1 , Lotus McDougal  2 , Valerie Percival  3 , Sarah Henry  4 , Jeni Klugman  5 , Haja Wurie  6 , Joanna Raven  7 , Fortunate Shabalala  8 , Rebecca Fielding-Miller  2 , Arnab Dey  9 , Nabamallika Dehingia  9 , Rosemary Morgan  10 , Yamini Atmavilas  1 , Niranjan Saggurti  11 , Jennifer Yore  2 , Elena Blokhina  12 , Rumana Huque  13 , Edwine Barasa  14 , Nandita Bhan  2 , Chandani Kharel  15 , Jay G Silverman  2 , Anita Raj  16 ; Gender Equality, Norms, and Health Steering Committee
Collaborators, Affiliations
Review

Disrupting gender norms in health systems: making the case for change

Katherine Hay et al. Lancet. .

Abstract

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

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Conflict of interest statement

Declaration of interests

The work of the Series was funded by the Gender Equality, Integrated Delivery, HIV, Nutrition, Family Planning, and Water, Sanitation, and Hygiene programme strategy teams at the Gates Foundation and the United Arab Emirates Ministry of Foreign Affairs and International Cooperation through grants to Stanford University. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data and had final responsibility to submit the paper for publication. The views expressed are those of the authors and are not necessarily those of the Gates Foundation and the United Arab Emirates. As corresponding author, AR had full access to all data and final responsibility to submit for publication. KH and YA are employed by the Bill & Melinda Gates Foundation. The other authors declare no competing interests.

Figures

Figure 1:
Figure 1:. Global analysis of female physician share and wage gap
(A) Distribution of female physician share and physicians per capita across categories in 91 countries. (B) Female:male wage gap across categories in 91 countries. Bars show group means and error bars indicate minimum and maximum values. Parity is defined as 45%−55% female.
Figure 2:
Figure 2:. Global analysis of female physician share and gender equality indicators
Association of female physician share (A) with Social Institutions and Gender Index and subindices and (B) with Global Gender Gap index and subindices. Each line represents the coefficient and 95% CI for separate fractional logit generalised linear model regressions, adjusting for gross domestic product (as a natural log) and year.
Figure 3:
Figure 3:. Global analysis of female physician share and health outcomes
Global analysis of the association of maternal and infant mortality (A), life expectancy outcomes (B), and universal health coverage index (C) with female physician share. Each line represents the coefficient and 95% CI for separate generalised linear models with a Poisson family and log link (A), linear (B), or fractional logit (C) regressions, adjusting for gross domestic product (as a natural log) and year.
Figure 4:
Figure 4:. Associations of family and community support and respect with accredited social health activists productivity and health impact
(A) Number of households visited. (B) Number of women accompanied to facility. (C) Percentage of women receiving minimum antenatal care. All three models were adjusted for sociodemographic covariates. *Statistically significant at p<0·O5. †Statistically significant at p<0·O1.
Figure 5:
Figure 5:
Effects of self-help group-based health intervention on interactions between clients and accredited social health activists in Bihar, India
Figure 6:
Figure 6:
How can we disrupt gender inequalities in health systems?
See this image and copyright information in PMC

References

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