Unbiased health systems are necessary for effective and efficient health care delivery. Their strength is fundamental to achieving universal health coverage, a target of the SDGs shared by 193 nations.
Unfortunately, a new Lancet Series on Gender Equality, Health, and Norms finds that health systems reflect and reinforce the gender biases and restrictive gender norms in society, and these biases and norms undermine the work of health systems and compromise the safety and well-being of providers – and the overall health of people and communities.
Restrictive gender norms – defined as social roles that are considered appropriate for people based on their actual or perceived sex – are reinforced in the system when health services prioritise care in ways consistent with traditional norms. This results in poor care for women, men and gender minorities, in ways that include valuing women based on their reproductive capacity and care provision for children; viewing men as strong, and thus, not in need of care; and defining both men and women strictly as heterosexual and cisgender. Men are often excluded from maternal and child health care, despite evidence of the importance of their inclusion – and research shows clinical resistance to men's engagement in maternal and paediatric care, which reinforces restrictive, factually incorrect norms that men are not needed for maternal and child health.
Gender inequalities also manifest in the health care workforce, where men hold greater authority as health professionals, relative to women. The paradigm "men cure, women care" highlights the overwork, devaluation and abuse of women health care providers. Globally, women remain least represented at the top of the medical hierarchy among ministers and physicians, and are most represented at the bottom as nurses, nurse midwives and community health workers (CHWs). While CHWs play an integral role in supporting the health system's reach and impact for socially marginalised groups, typically in their own communities, these positions continue to range from low-paid, to incentivised, to unpaid. Challenges of overwork and abuse manifest in work stress, job dissatisfaction, and burnout, resulting in poorer quality of care and even abuse of patients and poorer patient outcomes.
Yet the Series also finds that health systems can change. Health systems can be disrupted using gender transformative approaches operating outside health systems, through social and economic policies supportive of gender equality; within health systems, via support, value and safety for workers; and with health systems, through social and community accountability – to alter restrictive gender norms and reduce gender inequalities. Gender transformative approaches can help address gender inequalities within health systems by including increasing representation of women physicians to improve better health outcomes; acknowledging that gender parity alone does not mean equal treatment, pay or opportunity; increasing community respect and support of frontline workers to improve productivity and impact; and improving institutional support and respect for nurses to improve quality of care.
Finally, those working to change health systems should align and ally with social movements, community activism and collective efforts for change and accountability. Women's movements and social movements that target gender roles have gained traction, bringing gendered health policy improvements, as with the expansion of reproductive rights in Ireland and the strengthening of the criminal justice system's response to rape in India. Community organising and self-help groups can increase health care access and improve health provider responsiveness as evidenced by the transformative work in the National Rural Livelihood Mission as well as work with self-help groups in Bihar, India.
This evidence suggests that we need to go beyond seeing gender equality as an 'add on' – and instead see it as a fundamental factor that predetermines and shapes health systems and outcomes. We need to rethink our models, which at their core reflect our collective aspirations of what health systems are meant to deliver. We need to make our aspirations around gender equality explicit – from policy, to administration, to service provision – and evaluate and assess progress against these values. Drawing from research in this Series, and building on prior work, we put forward a set of aspirations for gender equitable health systems, that:
1. Reflect and reinforce a gender equitable society;
2. Address gender norms and root causes of inequalities, across the life course;
3. Provide equal opportunity for healthcare professionals of all genders to enter, thrive, and advance within health systems;
4. Ensure equal access and usage of high-quality health services by people of all genders, unimpeded by financial, social and geographic barriers; and
5. Commit to being held accountable to address gender inequalities at all levels.
We must take steps immediately — at the societal and political level — to transform the way gender is reflected in our health systems. Health systems must be held accountable to address gender inequalities and restrictive gender norms. Given the persistence of restrictive gender norms within systems – even with progressive policies and programs – innovative approaches are needed. The global health community needs to see themselves as an integral part of this broader social reform.
Dr. Fortunate Sindisiwe Shabalala is a Senior Lecturer & Head of Department, Faculty of Health Sciences, University of Eswatini.