The Health of Women and Girls: How Can We Address Gender Equality and Gender Equity? Sarah Payne, BSc, PhD1

Semin Reprod Med 2015;33:53–60



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gender equity gender equality women’s health girl’s health gender mainstreaming

Address for correspondence Sarah Payne, BSc, PhD, School for Policy Studies, University of Bristol, 8 Priory Road, Bristol, BS8 1TZ, England (e-mail: [email protected]).

This article focuses on the health of women and girls, and the role of addressing gender inequalities experienced by women and girls. The health of both males and females is influenced by sex, or biological factors, and gender, or socially constructed influences, including gender differences in the distribution and impact of social determinants of health, access to health promoting resources, health behaviors and gender discourse, and the ways in which health systems are organized and financed, and how they deliver care. Various strategies to address the health of women and girls have been developed at intergovernmental, regional, and national level, and by international nongovernmental organizations. These include vertical programs which aim to target specific health risks and deliver services to meet women and girl’s needs, and more cross-cutting approaches which aim at “gender” policy making. Much of this work has developed following the adoption of gender mainstreaming principles across different policy arenas and scales of policy making, and this article reviews some of these strategies and the evidence for their success, before concluding with a consideration of future directions in global policy.

This article focuses on the ways in which the health of women and girls is influenced by sex, or biological factors, and gender, or socially constructed influences, and the role of both formal health policy and other organizations in addressing gender equalities in health. The aim of this article is to outline some of the key issues affecting the health of women and girls, and consider how policy makers and health professionals might address these. In particular, the article will argue that the main issues affecting health opportunities for women and girls reflect gendered inequity in the distribution of resources, including gender relations of power, and in health system delivery. We begin with a brief discussion of sex and gender—what we mean by these terms and how they help us explain variations in health between women, men, girls, and boys— and an outline of the major health conditions experienced by females, before turning to consider how health and other organizations have addressed gender equalities in this sphere, and the success or limitations of such strategies.

Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG

Explaining Differences between Women and Men: Sex and Gender While health differences between women and men, and girls and boys, are relatively well known, the meanings of “sex” and “gender,” and the complex relationship between sex, gender, and health, are at times less well understood. This, in part, reflects the history of women’s health movement which emerged in the 1970s and which focused initially on the then male dominance of the medical profession, and male control of women’s bodies through, for example, the availability of contraception and abortion, the over-medicalization of women’s reproductive health, and the ways in which women’s mental health problems were identified and treated. Feminist activists and academics pointed out that women were conceptualized as “other” in clinics and in medical textbooks, while male bodies and men’s health were framed as the norm.1,2 Particular attention was given to the failure of medical research to include women in sufficient numbers,

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DOI http://dx.doi.org/ 10.1055/s-0034-1395280. ISSN 1526-8004.

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1 School for Policy Studies, University of Bristol, Bristol, England

Health of Women and Girls


or at all, in studies on health conditions that affected both women and men.3 In addition, diseases that affected only women were often under researched. The women’s health movement also drew attention to the various ways in which women’s health chances were influenced by gender—women’s risk of poverty, for example, or the impact of domestic labor or women’s experiences of genderbased violence.1 The combined effect of these arguments was to stress the importance of socially constructed gender differences on women’s health opportunities and risks, and in the delivery of health care, and to minimize women’s biological difference. These original arguments have been followed more recently by an increasing understanding of the significance of biology which has led to a greater appreciation that “sex does matter,”2 and that the health of women and of men is affected by both their biology and the world they inhabit. However, “sex” and “gender” are at times used interchangeably or inaccurately, and it is important to clarify the key differences between these. By sex we mean biological influences, that is, reproductive, hormonal, and genetic differences between women and men and their impact on health. This includes a range of factors, such as the role of sex hormones in cardiovascular disease, for example, or the part played by women’s more aggressive immune system in resistance to infection and in their risk of autoimmune diseases.2 Gender also impacts on health in a range of ways. First, there are significant gender variations in the distribution of social determinants known to impact on health including poverty, social exclusion, housing risks, environmental harms, and the effects of paid and unpaid employment.4 Gender discourses—constructions of masculinity and femininity, and what it means to be male or female in a given society—also play a part especially in relation to health behaviors including the use of tobacco, alcohol, and illicit substances, for example, and participation in risky behaviors such as driving too fast or under the influence of alcohol.5 Second, gender-based violence also impacts on the health of women in particular.6 Gender discourses are also associated with participation in health-promoting activities including physical exercise, diets high in vegetables or fruit, and health screening and use of health care. Third, gendered policy making is a factor shaping health opportunities. Broadly speaking, by this we mean how well and in what ways health systems and those working within health systems meet the needs of women and men, including the extent to which research evidence is based on both men and women.4

Key Issues in the Health of Women and Girls One of the most important features of gendered analyses of health is the different experiences of women and men in terms of life expectancy, causes of death, and morbidity. Women live longer than men in virtually every country in the world, although the extent of women’s longevity advantage ranges from 1 year, particularly in less economically developed countries, to 13 years in countries where the gap is most marked, especially those in Eastern Europe.7 This Seminars in Reproductive Medicine

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difference reflects both biological advantages enjoyed by women2,8 and gender-related health influences, especially male health behaviors which contribute to their premature mortality.5 In countries where women have very low life expectancy, we might therefore presume their biological advantage has been lost, and that their mortality reflects gender-based discrimination which impacts on their access to health-promoting resources and other social determinants of health. There are also complex patterns of difference between women and men in morbidity, which vary between settings and locations, over the life course and in relation to specific health conditions. In short, women in most—but not all— countries are more likely to report themselves as having poor health and are more likely to use services.4 However, measures of ill health such as disability-adjusted life years (DALYs), which are based on calculations of the value of years of disability-free life which are lost as a result of either premature death or the onset of disability,9 suggest quite a narrow gap between women and men in their experience of morbidity: men make up 55% of total DALYs lost per annum while women make up 45%. Within this picture, DALYs due to accidental and nonaccidental injury, heart disease, alcohol and drug use disorders, and cancer are higher for men. Healthy years lost by women are especially likely to result from cardiovascular disease; cancer; mental health problems, particularly depression and anxiety; and injuries. DALYs related to reproductive health—including, for women, maternal disorders, disability arising from pregnancy and childbirth, sexually transmitted infections, gynecological disorders, and cancers of the reproductive organs—account for around 5% of the female burden of ill health compared with only 1% of the male burden of ill health made up of reproductive disorders.9 While the health gap between women and men and men’s health disadvantage are important, the health of women and girls has been a particular focus of intergovernmental, regional, and national policy making across different policy scales. Patterns of female health across the life course varies between countries, as well as within countries, reflecting socioeconomic status, paid work, domestic responsibilities, ethnicity, sexuality, disability, the way health care is provided, and cultural factors. While there is no single picture of “women’s health,” we can outline some of the main features of health experiences of women and girls in different locations and spheres, beginning with the most common causes of mortality and ill health worldwide.

Cardiovascular Diseases Cardiovascular diseases affect women, in countries at all level of development, and in 2011 accounted for a third of all female deaths worldwide, mostly in older women.10 Around 40% of these deaths were due to ischemic heart disease, and 40% due to stroke. Cardiovascular diseases made up 11.2% of DALYs among women, with a similar split between ischemic heart disease and cerebrovascular disease, and again most of this burden of disease was experienced by older women.9 Regional figures reveal that the great majority of deaths, and

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the burden of cardiovascular morbidity among women, is found in low- and middle-income countries.11

Cancers Cancers globally account for around a 14% of all female deaths, and 7% of the global burden of disease.9 Within this, reproductive cancers are particularly significant for women, accounting for 40% of female cancer cases worldwide.12 Breast cancer is the most common among women in higher income regions, accounting for between 25 and 28% of all female cancers.12 However, while incidence is higher in more economically developed countries compared with less developed countries, mortality rates are similar across all regions due to better survival rates in more developed countries. Female reproductive cancers also include cervical cancer (which accounts for just less than 10% of female cancers worldwide), uterine cancer (4.8%), and ovarian cancer (3.7%).12 Again there are differences between regions and countries in both incidence and mortality—cervical cancer in particular has higher incidence and mortality in less developed countries particularly those in sub-Saharan Africa, where cervical cancer is the leading cause of cancer death. Age-standardized incidence rates in the World Health Organization (WHO) Eastern African region, for example, are over 30 per 100,000 compared with rates of less than 6 in Australia and New Zealand. Among nonreproductive cancers, lung cancer is a significant contributor to cancer deaths for women worldwide, with a similar age-standardized mortality rate to breast cancer (14 per 100,000 and 15 per 100,000, respectively10). Lung cancer is more common among women in higher income countries, reflecting smoking behavior among women in previous decades. For example, in the Western Pacific region, 18.5% of all cancer deaths were due to lung cancer compared with 7.2% due to breast cancer; in Europe, 11.2% of female cancer deaths were due to lung cancer compared with 17% due to breast cancer; and in Africa, the proportion of deaths due to lung cancer is only 1.8% compared with 16.4% due to breast cancer.

Mental Health Around 75,000 female deaths each year are associated with mental and behavioral disorders, with a further 290,000 deaths among women as a result of self-harm or suicide. Most mental health problems do not result in death, however, and mental illness is a more significant contributor to morbidity, accounting for more than 8% of DALYs among women worldwide, including nearly 60,000 DALYs each year related to depression or anxiety.9 A further 12,700 females DALYs worldwide are attributed to self-harm. Women are exposed to various risk factors for mental health problems including poverty, the stress of combining paid and unpaid labor and domestic responsibilities, marginalization in the labor market and social and civic life, and gender-based violence.13

Sexual and Reproductive Health Health during reproductive years, from onset of puberty and menarche through to the menopause, is an important


contributor to women’s well-being, which varies between countries and between groups of women within countries. Reproductive health issues, including sexual health, fertility, pregnancy and childbirth, and health during the perimenopause and the menopause, span a significant period of the life course of girls and women. Sexual health is defined by WHO in relation to sexual rights; positive, pleasurable, and safe sexual experiences; and being free from coercion, discrimination, and violence. This includes having control over one’s sexuality, having access to information and sexual health care, as well as reproductive freedom.14 Such a holistic definition is, of course, valuable and important, but also difficult to measure. Instead, figures for women’s sexual and reproductive health focus on the absence of health or sexual rights. Sexually transmitted diseases are a major factor in the health of women and girls, causing a range of problems including acute illness and long-term disability, infertility, problems in pregnancy and premature death. Syphilis increases the risk of HIV transmission, and also risks of stillbirth and neonatal death. Nearly 500 million people aged between 15 and 49 each year are infected with chlamydia, gonorrhea, syphilis, or trichomoniasis, including 234 million girls and women.15 Sexually transmitted diseases, excluding HIV, also account for more than 5,300 DALYs among women annually, including 4,600 related to syphilis.9 Incidence rates are particularly high in the African region, although data are likely to be an underestimate in this area. Gaps in reproductive health care have been a major focus for efforts to address gender inequalities and women’s health needs. Despite a long-standing and widespread commitment to universal access to reproductive services following the 1994 International Conference on Population and Development,16 many women still do not have access to such services. More than 30% of women globally experience childbirth without skilled health personnel, including 52% of women in the African region, compared with 2% of women in Europe. In Somalia and Ethiopia, for example, only one in ten births are attended by skilled health professionals, while in Niger it is one in eighteen.7 Similarly, only 55% of women worldwide received four or more antenatal visits, while 46% receive postnatal care visits within 2 days of childbirth. Women in low-income countries are particularly unlikely to have this kind of care in pregnancy and childbirth. One of the most significant means of addressing maternal health, alongside policies to address women’s poverty, is through measures to enable women to control their fertility and prevent unwanted pregnancies. However, family planning is also far from universal: 11% of women worldwide who wanted to prevent conception did not have access to family planning, this rising to more than a third of such women in Haiti, Uganda, and Rwanda, for example.7 An associated health risk for women and girls is access to safe termination of pregnancy: one in ten pregnancies worldwide ends in an unsafe abortion, while unsafe abortions represent nearly half of all terminations each year.17 In 2008, 47,000 women died as a result of abortion,18 and abortion is associated with more than 2,000 DALYs per Seminars in Reproductive Medicine

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Health of Women and Girls

Health of Women and Girls


year, two-thirds of these among women aged between 20 and 35 years.9 Despite WHO and UN strategies to address this including recommendations about safe practices and their work within countries to increase access to safe abortion, in 68 countries, abortion is either illegal or permitted only to save a woman’s life, and nearly two-fifths of the world’s population live in countries with highly restrictive abortion laws.19

Female Genital Mutilation Female genital mutilation (FGM) or female genital cutting (FGC) as it is sometimes known, refers to the practice of partial or total removal of, or injury to, external female genital organs, and represents an important health risk for girls and women in some parts of the world. Figures for FGM are difficult to collect and estimates are likely to understate the size of the problem worldwide. However, WHO estimates suggest that 100 to 140 million girls and women have been subjected to FGM, mostly at a young age. There are particularly high rates of FGM among girls and women living in African countries, notably Somalia, Djibouti, Northern Sudan, Guinea, and Mali.20 FGM is associated with both immediate health consequences including intense pain, shock and trauma, blood loss, infection, retention of urine, and long-term effects which include infertility and complications in labor, problems with sexual intercourse, retention of menstrual blood, together with recurrent urinary and bladder infections.

HIV and AIDS The populations most affected by HIV and AIDS vary between countries and regions, and there are important differences between women and men both in their risks of HIV transmission, and AIDS, and also the impact on their lives.21 For women and girls, both sex and gender play risk of HIV transmission. Biological risk factors lead to greater vulnerability for women as a result of unprotected heterosexual intercourse, through the viral load of semen and the permeability of the vaginal walls, and younger women are particularly affected by these risks.21,22 However, these biological risks combine with gender differences in power, which impacts on women’s ability to negotiate safe sex or resist sexual intercourse, both within relationships and outside, including sex work, their economic reliance on men, and their risks of poverty.23 Gender-based violence also significantly increases the risk of HIV transmission for women particularly among sex workers, female drug users, and transgender women.23 Globally, around 50% of adults living with HIV are women, but this proportion increases to 59% in the African region compared with 32% in Europe and 31% in the Americas.24 Young women in sub-Saharan Africa are disproportionately at risk as a result of gender norms and pressures.24

Childhood Health and Girls While many of the health risks discussed earlier also affect young women and girls, there are other diseases with particular risks for this group. Although malaria has decreased Seminars in Reproductive Medicine

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significantly in the last decade,25 it is associated with more than 288,000 deaths and 37,000 DALYs among women and girls each year, predominantly in less developed countries, and especially in sub-Saharan Africa, India, and Pakistan. Young girls are particularly at risk, with 70% of the female global burden of malaria among girls younger than 5 years.9 Another important risk to the well-being of young girls is the phenomenon known as “missing girls,” the result of the “female disadvantage in natality” due to sex-specific abortions of female children, and the neglect and infanticide of new born girls.26 Estimates of how many girls are lost this way are difficult, but the totals are high. Allahbadia, for example, suggests that 50 million girls are missing in total from the Indian population in 2002 as a result of sex-selective abortion and infanticide, with up to 5 million terminations of girl children each year.27 These practices are found in several countries, including parts of India, China, South Korea, Taiwan, and some parts of sub-Saharan Africa, and are associated with a culture in which girls are less valued than boys.

How Do We Address Gender Equality in Health Several strategies to address gender variations in health have been developed at international and intergovernmental level, at national level in several countries, and by a range of international nongovernmental organizations. The adoption of gender mainstreaming principles, following a series of global conferences on women in development, has been central to this. Gender mainstreaming was defined in 1997 by the United Nation as: “The process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in all areas and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated. The ultimate aim is to achieve gender equality.”28 The WHO is among other major intergovernmental organizations in committing itself to gender mainstreaming. In 2001, WHO identified two goals of gender mainstreaming: gender equality and gender equity. Gender equality refers to “the absence of discrimination on the basis of a person’s sex in opportunities, allocation of resources or benefits, and access to services,” while gender equity is more clearly focused on questions of power: “Gender equity means fairness and justice in the distribution of benefits, power, resources and responsibilities between women and men. The concept recognizes that women and men have different needs, power and access to resources, and that these differences should be identified and addressed in a manner that rectifies the imbalance between the sexes.”29

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Health of Women and Girls

Addressing Gender Variations in the Social Determinants of Health The 2008 WHO Commission on the Social Determinants of Health report identified the importance of a range of social determinants of health, including paid employment, living and working conditions, access to education, and the distribution of power. The report also identified gender equity as a significant influence on the health of women and girls and highlighted gender relations of power which shape differences in access to health-promoting resources, together with, for example, access to and control over resources and entitlements, paid and unpaid work, and leisure.31 While the final report was criticized for equating gender justice with women’s health rather than both women and men, and for not engaging with the limitations of gender mainstreaming approaches,32 the inclusion of gender inequity as a key social determinant in this major report continues to highlight the importance of gender differences in power and resources in shaping women and girl’s health opportunities.


Strategies to address these influences go beyond health policy, and include, for example, programs run by the World Bank and UN Women around education enrolment, women’s agricultural work, and women’s economic empowerment.

Addressing Gender Behaviors and Health Strategies to address the health of women and girls also need to address gendered behaviors which impact female health. This includes the ways in which gender roles are proscribed, and the ways in which men and women incorporate ideas about masculinity or femininity, often described as “doing gender.”33 A clear example of gendered behaviors which impact on health is gender-based violence, and strategies to address this include interventions to challenge male behavior,34 and those which aim to empower women and provide safe places of refuge.35 Several organizations have also developed initiatives to address gender-based violence in relation to the transmission of HIV, due to the increased risk of transmission associated with such violence.35 Such strategies aim to address male behaviors as well as supporting women, and challenge cultural acceptance of gender violence. Other health behaviors, including those which promote health and those which impact negatively on health, are also associated with ways in which both women and men “do gender.” However, many of the health behaviors with adverse health costs are more common among men—tobacco, alcohol, and substance use; risk taking; diets that are high in saturated fats and low in fruit and vegetables, for example.5 One behavior which adversely affects the health of women and girls is their reduced likelihood of participation in leisurebased physical activity, which reflects access to leisure time and the resources needed for many forms of exercise, combined with cultural limitations on women’s activities outside the home. Some of these patterns in health behavior are changing. Smoking, while more common among men globally, is increasing among some groups of women and, as smoking rates in less developed countries rise, more women are adopting this behavior.36,37 As a result, the gap between women and men in tobacco use has narrowed in many countries, and in some the number of women smokers now equals or is greater than the number of men.36 Many of the programs to address tobacco use at country level are shaped by the WHO’s Framework Convention for Tobacco Control which introduces several different approaches to help women and men stop smoking and prevent smoking initiation. Girl and women’s lower participation in leisure-based physical activity in comparison with men has also been addressed by some programs. The WHO Global Strategy on Diet, Physical Activity and Health, for example, includes some recommendations on gender inclusion and differences in activity levels, and identifies some of the factors limiting women and girl’s participation in physical activity including cultural factors, and problems faced by school-based programs to address girl’s activity levels due to their lower levels of school enrolment. However, gender is not mainstreamed in the program. National level public health strategies in some Seminars in Reproductive Medicine

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Together these goals recognize the ways in which gender variations in health reflect not only gender discrimination—in health systems and in wider society, including employment, legal, and citizenship rights, for example—but also gender differences in power and access to resources, and that gender justice requires policies which address both of these dimensions of difference. This means that many of the factors influencing the health of women and girls will be outside the remit of health systems, and that progress in other policy arenas is important, as are partnerships between organizations at both international and national level. The following sections explore some of the ways gender equality and gender equity have been addressed at international and national levels, both through specific interventions and vertical programs, such as those to address maternal health, and through gender mainstreaming approaches to policy and decision making. In doing this, we should recognize that policies to address gender will need to consider the health problems faced by both men and women, because it is only through a direct examination of gender and how it affects health for both women and men that we are able to explore gender relations of power and the damage caused by gender. In addition, policies to address gender variations and the health of women and girls need to be based on a birth to adulthood perspective: the health of women is affected by their experiences early in life, and it is important to address gender variations in health and problems faced by girls early on.30 The next sections explore some examples of these approaches to gendering health policy and addressing women and girl’s health, focusing on gender variations in the social determinants of health, gender behaviors and gender discourse, and gender in health systems, followed by a consideration of the role of global health governance in relation to gender mainstreaming, and of the future for strategies to address women and girl’s health.


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countries, however, do address this health behavior in terms of gender and the need to increase participation by girls and women.

Addressing Gender Inequality in Health Systems Health systems play a key role in addressing inequalities, including identifying and meeting the needs of women and girls. Critical aspects of health systems in relation to equality include how they are financed, the distribution of services and the allocation of resources, service delivery, and the training of health workers. Health finance is a major factor in barriers to health care for women and girls. While WHO promotes the goal of universal access to care, based on social insurance and free at the point of delivery, and while many countries have formally committed to universal access, few countries achieve this ideal. The lack of universal provision, with a reliance instead on a mixture of user fees, private insurance, donorsponsored facilities, and limited state care, is most marked in poorer countries. User fees constitute one of the most significant financial barriers to health care, and there is evidence that girls and women are disproportionately affected by such fees.38,39 Addressing gaps due to lack of finance can involve exemptions from fees for specific groups, including pregnant women and young girls, for example. However, such exemptions are of little value if services themselves are not available due to resource shortages. Other barriers can include lack of infrastructure, which makes travelling to health care problematic, and again gender plays a part in cultures where women may not travel alone, and where women and girls find it difficult to access resources needed to pay for travel, or time away from domestic and employment responsibilities. Solutions to problems regarding access to health care can take many forms. Programs designed to address specific health needs of women and girls are designed and delivered by a range of intergovernmental organizations including the United Nations, WHO, World Bank, and by international nongovernmental organizations such as the Bill and Melinda Gates Foundation, GAVI Alliance, and Pepfar. UN Women, for example, runs several programs on both gender-based violence and HIV and AIDS. Country-level support by UN Women has helped to develop safe houses and support for women subject to gender-based violence, together with strategies that address policing and legal rights. At the level of international nongovernmental organizations, the Bill and Melinda Gates Foundation has adopted a gender mainstreaming strategy across their work, and finances several health-based programs around HIV and AIDs and access to contraception.40 Engenderhealth is another global nongovernmental organization, based in the United States and funded by both private and government donations, which focuses on maternal health, family planning, and HIV and AIDS. It provides health resources to support safe contraception and childbirth, and also engages with policy makers around issues of gender equity. Engenderhealth has adopted a framework that addresses both men and women as Seminars in Reproductive Medicine

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partners in their programs, and sees men as critical in the success of reproductive health systems and support. Gender mainstreaming is also associated with specific tools of analysis, including gender budgeting, gender-disaggregated data, and gender impact analysis. Gender responsive budgeting has been defined as assessing the impact of budgets from a gender perspective, looking at both expenditure and revenue decisions.40 From a gender mainstreaming and human rights perspective, the underlying focus of gender budgeting is to ensure that fiscal decisions do not discriminate against women and budgets are used to promote gender equality and gender equity. Within a health framework, this approach might be applied in several ways. For example, gender budgeting in reproductive health might lead to increased allocations to contraceptive services, resources for care in childbirth, or might be used to remove user fees for such services,41 as well as making changes to how financial contributions are assessed. Gender-disaggregated data are also seen as essential in gender mainstreaming analysis, and the ability of health systems to respond effectively to the needs of women and girls is often limited by the failure of health-monitoring systems and other indicators to collate data which is gender disaggregated. WHO’s advocacy of gender-disaggregated data includes the development of 34 core gender health indicators as a minimum requirement for use at country level. These indicators are divided into three groups: health status, social health determinants, and health system performance.42 Finally, there is the question of resources needed to address gender, both across programs and externally (operational mainstreaming) and internally in an organization’s own work (institutional mainstreaming). One of the greatest problems facing all scales of policy making attempting to address gender is the funding required: the development of gender-disaggregated data, training and capacity building, and meeting gaps in provision which gender analysis identifies all require resources. In resource-poor settings, in particular, it is difficult to command such costs, especially when they can only be found as a result of a diversion of expenditure from other budget headings.

Gender Mainstreaming and Global Health Governance The WHO adopted gender mainstreaming as a strategy for addressing gender differences in health, on the basis of a human rights discourse and because integrating a gender perspective in health policy and planning was seen as a more efficient use of resources. WHO called for all member states to adopt gender mainstreaming and gender equity principles, and to develop gender-disaggregated data and gender tools of analysis, while recognizing for itself a leadership and research role, and WHO continues to play a part in governance in this area. WHO has, for example, developed several programs in relation to women’s health (and fewer on men’s health). However, a recent internal review of WHO’s implementation of a gender mainstreaming approach across its activities reported that less than a quarter of WHO publications used gender-disaggregated data, and less than one-third of public speeches by WHO senior management referred to gender.

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WHO concluded that “WHO has implemented a far-reaching gender mainstreaming program, but the impact on day-today work has been limited.”43 This brings us to the final question in relation to strategies to address the health of women and girls—what is the evidence for their success? A recent UN review of progress on gender achievements, following the 1995 Beijing Conference, suggested a mixed picture. Progress had been made in some countries in the identification of gender-specific needs in health, women’s access to health care, training on genderspecific conditions, and in women’s sexual and reproductive health, but challenges remained, including the lack of genderdisaggregated data, low levels of skills and training, and financial resources. Empirical studies also highlight the lack of resources, data, capacity, and skills, together with problems posed by a tendency for mainstreaming, once introduced, to focus on technocratic solutions which fit the status quo, rather than more long lasting or deeper change.44,45 Ravindran and Kelkar-Khambete’s review of reproductive health initiatives, for example, found that training in gender was more common than clinical interventions, and that many programs accommodated gender differences rather than tackling underlying inequalities or their causes.46 While gender mainstreaming approaches aim to make explicit gender inequalities and injustice, the need to reconfigure resource allocation and “ways of doing,” and to challenge existing gender relations of power, can mean that progress is limited and short-term.


gender mainstreaming might be extended to these targets. For example, maternal health and maternal mortality are significant indicators of women’s empowerment, as well as their risk of premature death. To these measures, we might add access to contraception and abortion, as further indicators of women’s sexual determination and sexual rights. Similarly, targets in relation to HIV and AIDS need to be gender specific as well as reflecting other aspects of diversity and disadvantage. There is also scope for extending the vision. The 2013 UN panel report on the post-2015 development agenda47 argues that all targets should be measured separately for women and men, girls and boys, alongside a strengthened gender equality goal which might target child marriage, gender-based violence, equality in capabilities and resources, and inclusion of women in civic life, for example—a position endorsed by UN Women.48 Whatever the outcome of these deliberations, it is vital to recognize the importance of the health of women and girls in both less developed and more developed countries, and the need for policy to address these issues explicitly. We also need to consider how this is best achieved—while global targets such as the MDGs create impetus and enable policy makers to stress the importance of globally endorsed goals, gender mainstreaming in health has perhaps achieved mixed success, and the persistence of barriers to change suggests that there is need for continued reflection and debate over how to best improve the health of women and girls.

Conclusion: What Is the Future for Policies to Address the Health of Women and Girls? The Millennium Development Goals (MDGs) have acted as a prompt and a stimulus for gender mainstreaming and the need to address the health of women and girls as part of global development policy, particularly through MDG3, to promote gender equality and empower women, and MDG5, to improve maternal health. Strategies to meet MDG3, for example, have focused, to a large extent, on development policy in relation to gender gaps on education, paid work, labor market participation, and income: all factors which are significant in shaping women and girl’s access to health-promoting resources, equality, and ability to delay childbearing. While some countries have made significant progress against the MDGs, there are also those which have not, where maternal mortality remains high or has even increased, and where gender inequalities continue. As we approach 2015, the year by which the MDGs were to be achieved, there is increasing debate over their replacement and the next steps, and acceptance that successor goals must be debated across all stakeholders. Health is seen by many as central to any new targets which are initiated, both because health is central to development and poverty reduction, and because health indicators are important measures of success or otherwise. However, updating the global goals calls for new ideas about development objectives and what, exactly, might be included as measurable targets, using which indicators. This includes consideration of the ways in which

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The health of women and girls: how can we address gender equality and gender equity?

This article focuses on the health of women and girls, and the role of addressing gender inequalities experienced by women and girls. The health of bo...
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