Can gender budgeting lead to better health outcomes? – Indrani Gupta

Tiffany Nassiri-Ansari

In the fourteenth seminar of the Lancet Commission on Gender and Global Health series, Commissioner Indrani Gupta presented some emerging thoughts on gender budgeting and health outcomes based on her work at the Health Policy Research Unit at the Institute of Economic Growth (IEG), Delhi. Building on her diverse professional experience working at academic institutes, international organizations, and government bodies, Gupta established and continues to lead India’s very first centre for health economics and policy research at the IEG.  She was joined for this webinar by facilitator and Commission Co-Chair Pascale Allotey, fellow commissioners, and a YouTube live stream audience.

An introduction to gender budgeting

Gupta prefaced her presentation with a disclaimer that she is neither a gender expert nor a gender budget specialist, but rather an economist with many years of experience working in the health sector. For the Health Policy Research Unit team she leads, gender budgeting is a recent focus in their quest to better understand the relationship between health financing and outcomes, and the seminar represented some early thoughts on this work in progress.

The presentation began with a brief introduction to gender budgeting, which first gained traction in 1984 when Australian ministries and departments started analyzing the impact of annual budgets on women and girls. From there, Gupta traced the rise of the gender budgeting movement to the 1995 World Conference on Women in Beijing, where the concept aligned with the realization that there are tangible and significant social and economic costs associated with gender inequality, and “therefore human development objectives need to be incorporated into macroeconomic outcomes,” Gupta summarized.

Drawing from a variety of sources, Gupta presented a selection of definitions for gender budgeting which emphasize the need for a gender perspective in the allocation of resources to promote gender equality. She noted that although gender budgeting began with a narrow focus on reducing inequalities between men and women, “the needs of all people is now the emphasis, rather than men and women”. While this goal is more or less central to all applications of gender budgeting, however, Gupta’s team found that approaches vary significantly between countries, leading to heterogenous experiences of gender budgeting which are challenging to compile and compare.

Despite this diversity in application, some gender budgeting essentials can be clearly identified: gender-disaggregated data for a variety of indicators, multi-stakeholder consultations which incorporate civil society, and robust tracking, monitoring, and evaluating systems are all key to a successful gender-responsive budget. The tracking of resources should also encompass not just how funds are allocated but also how they are raised, in line with the original objective of gender budgeting to reorganize both revenue raising and spending. Closing out this brief introduction to gender budgeting with a laundry list of relevant tools, Gupta paraphrased Janet Stotsky to reassert the key takeaway from this section: “Gender budgeting is good budgeting”.

Assessing the impact of gender budgeting on health outcomes

Gupta’s team found a wealth of literature on the definition, implementation, and justification of gender budgeting, but far fewer resources on how exactly one might measure the performance and impact of gender budgeting on health outcomes. This was further complicated by the fact that while many countries have not formally adopted a nation-wide gender budgeting approach, informal and fragmented applications abound and frequently fly under the radar when it comes to documenting and assessing the real-world impacts of gender budgeting.

A small collection of quantitative papers measuring the impact of gender budgeting through labor force participation, school enrolment, and macro-aggregates like growth allowed researchers to conclude that gender budgeting has had an undeniable impact on increased representation of women in decision-making processes, better labor market conditions, education and employment for women, and financial independence for women as primary bank accountholders. While an analysis by Heymann et al. found that such gains in education and employment do have indirect impacts on health outcomes, Gupta cited a scoping review by Crespí-Lloréns et al. to note that very few policies “have been formulated, implemented, or evaluated to tackle the problem of gender inequality in health”.

This lack of clear indicators and relevant papers led Gupta and her team to look at more general indicators such as the maternal mortality ratio and all-cause mortality rates for all gender, the narrowing of the gender gap in mortality rates, improvements in treatment-seeking behavior, and an assortment of indicators on specific disease burden and health outcomes. Acknowledging the limitations of indices, Gupta nonetheless highlighted some relevant findings from an analysis of UNDP’s Gender Inequality Index based on health, empowerment, and labor market participation. Countries with lower human development levels ranked much worse on the index, leading Gupta to remark that “clearly, something hasn’t worked for the medium- and low-development countries yet”. Another helpful source of indicators came from the World Economic Forum’s Global Gender Gap Index; while countries ranked in the top ten varied in terms of the implementation of gender-responsive budgeting, Gupta noted with far more interest that most of the twenty countries in the bottom ranking do have gender-responsive budgeting, including India.

Moving on to maternal mortality rates (MMR), Gupta pointed out a consistent trend across nearly every country analyzed: most countries recorded a noticeable fall in MMR before implementing gender-responsive budgeting, with numbers holding steady in the years after despite continued use of gender budgeting. All-cause mortality rates for countries with low spending on health as a share of GDP presented even more of a conundrum, as the adoption of gender-responsive budgeting neither lowered overall mortality rates nor narrowed the gender gap in many countries. Overall, Gupta’s team found that while gender-responsive budgeting has not led to significant improvement in MMR or a narrowing of the gender gap in mortality rates, some countries that have not adopted gender-responsive budgeting have, in fact, seen improved gender equality in health outcomes along with indicators of overall improvement of outcomes for whole populations. This supports Gupta’s assertion that in the absence of gender-disaggregated data, proper evaluation of needs, and other key essentials, gender budgeting “becomes a mechanical exercise and can be counter-productive because it gives the illusion that you’re actually undertaking gender-sensitive budgeting when you’re basically not doing so”. She especially emphasized the need for nuanced gender-disaggregated data which captures between- and within-country variations that are key to context-specific programming and policy, pointing out that “these are the kinds of things you need to know before you can allocate well and allocate in a gender-sensitive way”.

Gender budgeting in India: A case study in percentages

While gender-responsive budgeting is a useful tool, no tool can overcome the limitations of an overstretched budget. Citing increased expenditures as the key to improved health outcomes in China and Rwanda, Gupta contrasted these case studies with India, where health financing has long remained static at approximately 1% of GDP while the share of gender budgeting amounts to less than 1% of GDP, with the Ministry of Health and Family Welfare receiving only a fifth of that 1%. “The amount we spend on gender-sensitive items is miniscule,” Gupta commented, perhaps explaining why India has slipped in global rankings for overall gender inequality despite sixteen years of gender budgeting. This challenge is further exacerbated by key findings from the 2020 Global Report on Public Financial Management which states that on average, countries perform better in preparing their budgets than executing them, and that “gender considerations in the design, implementation, and evaluation of budget policies are not yet mainstreamed in most countries” (Public Expenditure and Financial Accountability, 2021).

Further analysis of India’s gender-responsive health sector budget revealed the inclusions of items such as health systems strengthening, routine immunizations and similar programmes, and the new health assurance/insurance scheme recently launched by the prime minister. Gupta pointed out that misclassifications are unfortunately all too common in gender budgets all around the world, and things that should not be included are often found in the budget while things that should be included are left out. “For India,” she added, “the items that are there didn’t leap out as gender-sensitive”. While there are certainly sectors which India’s gender budgeting has benefitted, such as education and the labor market under the national rural employment scheme, gender budgeting in the health sector has become little more than “a routine exercise of fulfilling a reporting obligation rather than a well-thought-out planning exercise,” Gupta lamented.

Moving forward: Addressing the real problem in health financing

In closing, Gupta reiterated key findings relevant to the commission’s work. She particularly emphasized the fact that countries with good progress on health outcomes and inequalities are mainly countries that have been able to increase their health spending and expand universal health coverage (UHC), independent of their application or lack thereof of gender-responsive budgeting. For those that continue to implement gender-responsive budgeting, issues vary according to resource settings as developed countries are able to focus on broader causes of inequalities while developing countries are confined to more health-specific challenges such as burden of disease and health systems strengthening. This reflects their positionality within what Gupta termed “the low development-low health financing space” that is rife with adverse health outcomes, and ultimately serves to demonstrate that the budget itself matters more than budgeting tools in the health sector.

Gupta ended with a final call for those working within the space of health financing, including the commission, to focus on raising resources for UHC as it would ensure gender equality in access and outcomes as well as address other vulnerabilities aside from gender. For resource-constrained settings in particular, gender budgeting can often be a costly undertaking with unguaranteed returns – especially with the extremely limited resources allocated to it. Advocating a big picture approach, Gupta left fellow commissioners and audience members alike with this alternative proposal: “If you instead invest in UHC rather than redistributing the meager budget to this gender and that gender, I think that would be a very, very productive exercise”.

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

“As long as it still comes off as a cigarette ad, not a civil rights message”

Tiffany Nassiri-Ansari

This blog accompanies the Lancet Commission on Gender and Global Health seminar series. The series accompanies the development of the Commission, inviting Commissioners and Co-Chairs to discuss a key topic, question, or challenge that the Commission hopes to tackle. The series aims to involve a range of stakeholders and voices in its work and to promote discussion and debate on gender and health.

In the thirteenth seminar of the Lancet Commission on Gender and Global Health series, Commissioners Sarah Hill and Sharon Friel collaborated on a presentation based on their 2020 publication regarding alcohol and tobacco as commercial determinants of health. Hill currently serves as senior lecturer and Director of the Global Health Policy Unit at the University of Edinburgh, while Friel is a professor of health equity and Director of the Menzies Centre for Health Governance at the Australian National University’s School of Regulation and Global Governance (RegNet). The commissioners were joined by session facilitator and Co-Chair Sarah Hawkes, fellow commissioners, and a YouTube live stream audience.

Gender and the commercial determinants of health

Friel opened with a brief definition of the commercial determinants of health (CDoH), which focuses on “understanding the commercial forces, policies, practices, and products of the commercial sector, and how that affects health and health inequities”. She added that while much of the field revolves around the obvious and visible aspects of commercial forces, her work with Hill unpacks “some of the more indirect ways in which commercial actors and their ways of being” shape society, working conditions, expectations and norms, and policy as well as regulatory environments. She then handed over the presentation to Hill, who proceeded to draw connections between commercial determinants and gender through an analysis of how alcohol and tobacco companies target women.

Building on Friel’s introduction, Hill explained that a CDoH perspective allows for an exploration of the ways in which commercial actors influence the determinants of health at multiple levels, moving beyond individual consumption and exposure to consider their impact on structural determinants of ill-health and inequity. While the field has traditionally focused on industries whose products are directly harmful to health, such as tobacco and alcohol,  Hill noted that emerging work expands the idea of commercial determinants to consider a broader range of commercial actors and industries whose products might not always have a direct physical effect on health, but whose activities shape both physical and mental health in harmful ways nonetheless. While social and commercial determinants exert cross-cutting influence and are inextricably linked, the latter is distinguished by its focus on how commercial actors influence public and global policy “in ways that are often  hidden from view”.

With the basics established, Hill proceeded to bring in the gender aspect of this presentation by defining gender for the purposes of this session as “socially constructed differences between different groups”. Pausing to acknowledge that sex does play an important role in health, she positioned gender as the key analytical lens in this presentation as it permeates across different layers of social determinants, from intimate relationships to communal ties to social structures. Hill also emphasised the importance of an intersectional approach, stressing that “gender is just one aspect of social location and identity… that’s going to be shaped and modified by other aspects of social location” such as age, class, and race. Scaling up from micro- and meso-levels to the macro or structural further reveals how determinants of health are differently gendered to impact all gender groups – not just women and girls – in a variety of ways. This particular presentation, however, focused on “gender norms shaping women’s and girls’ exposure and vulnerability to adverse health experiences,” as illustrated by the case studies presented by Hill in the next section.

Evolutions in tobacco and alcohol advertisements

Drawing upon tobacco and alcohol advertisements targeted at women, Hill offered a historical account of how the traditionally male-centric tobacco industry identified women as a significant untapped market in the early 20th century, and subsequently “started putting a lot of effort into trying to recruit women as smokers,” with the alcohol industry following closely on its heels. These efforts included advertising campaigns which actively engaged with gender and gendered norms at the time, but a key finding of Hill and Friel’s work is that “the approaches used by those industries have changed over time… There’s a sense in which as gendered norms changed, particularly in high-income countries such as the United States, industries also changed their marketing strategies so that they were interacting with the fluid nature of those gendered norms”. This evolution in engagement has led to advertising campaigns such as Budweiser’s new take on an old concept, which allowed the company to perform progressiveness while still utilizing gender norms to their advantage.

This marketing pivot was particularly evident in the 1980s, when “there was a move towards engaging with ideas of women’s empowerment and liberation in advertising,” a highly visible way for companies to present themselves as progressive actors solely for the purpose of financial gain, not social change. Following a legal case in the late 1990s, internal tobacco industry documents were made publicly available and offered indisputable evidence which made it “very, very clear that they were playing on these changing norms in order to market their products”. A particularly damning example presented by Hill highlighted a Virginia Slims advertisement placed in Ebony magazine, which caters primarily to an African-American audience. Internal documents reveal the motivations and considerations behind this campaign, summarised in a flippant line that would go on to serve as the title of Hill and Friel’s paper: “As long as it still comes off as a cigarette ad, not a civil rights message”.

This perfectly encapsulates the “corporate cynicism” that hides beneath the veneer of these companies’ progressive advertisements and activities even today, as they continue to “launch campaigns that are not presented as advertising but are clearly intended to associate their brands with ideas of progress”. These marketing efforts have been largely successful, with women in high-income countries smoking nearly as much as their male counterparts, but Hill cautioned that women in emerging economies are now vulnerable to the pressures of these industries constantly on the lookout for their next potential market. Flashy partnerships forged in the name of empowering women are merely a means to an end, promoting corporate brands while advocating women’s transition into economically independent customers who then “become consumers in their own right”.

From the visible to the invisible

Digging deeper, Hill moved from the visible activities of these industries in advertising and corporate social responsibility (CSR) campaigns to their hidden impacts on the structural determinants of health, arguing that their pervasive influence in public and private policy works to reinforce gender inequities embedded within the global free market system. Hill observed that “a market society tends to operate in ways that systematically disadvantage women,” and it is precisely this “market privilege” which alcohol and tobacco companies work to reinforce by preventing market regulation and actively expanding their activities in emerging markets. This allows them to wield significant influence over not just market economies, but also labor markets where women are over-represented in low-paid and casual employment and under-represented in positions of political and economic influence. At the same time, reduced state capacity in market-oriented societies undermines provision of essential services such as education, health and social care in ways that leave girls and women particularly vulnerable.

Drawing her presentation to a close, Hill stressed the need to keep in mind that while these “sophisticated advertising and CSR campaigns” are the most visible activities of commercial actors, “at the same time there’s a whole lot of activities happening behind the scenes that are less visible but that are also very pervasive and important in terms of their impacts”. For industries, the visible and the hidden work in tandem “in ways that reinforce market privilege, that undermine regulation of their activities, and that… [contribute] to structural inequities that are really important in understanding women, women’s health, and the health of other gender identities,” ultimately increasing gender inequities across the social determinants of health. It is absolutely vital that those within the realm of public health continue monitoring the activities of these industries and raise awareness of the extent to which these industry practices negatively influence both health and gender equity, but Hill also urged researchers to consider what kinds of evidence are needed “to better inform efforts to resist the adverse impacts of these commercial determinants on gender equity and health,” pointing out that such industries engage with and manipulate ideas of masculinity just as much as they do ideas of femininity, “in ways that are also problematic and harmful to men and boys”.

Moving forward: Untapped potential for the commission

To conclude, both commissioners offered some reflections and suggestions for the commission. Harkening back to her earlier call for an intersectional approach, Hill underscored the need for “more evidence about the kind of structural impacts” these industries have on various gender groups, labor markets, and economic resources, particularly as multinational companies move into low-and-middle-income settings in search of new markets. She also emphasised the need for a better understanding of how policy makers, advocates, and communities can “look to find alternative ways of engaging with gender in ways that don’t reinforce a very neoliberal economic paradigm, but that shift our understanding of gender and gender norms away from one of individual identity to a more collective understanding”.

Speaking more broadly about commercial determinants, Friel commended Hill for “a compelling argument for why we have to pay attention to these commercial forces” when it comes to understanding differential health outcomes across gender, and noted that the commission has the potential to significantly advance the field of commercial determinants by focusing not just on products, but “how commercial forces structure society and what that means for health”, paying due attention to the institutional, instrumental, discursive, and ideational power these industries wield to not just shape policy and regulatory environments, but structure society as a whole. In closing, she expressed her hope that the Lancet commission will “shine a very important light on these commercial forces as a major, major driver of the differential health outcomes that we’re seeing globally”.

You can watch the full online seminar here.

The views expressed in this post are those of the presenters and author and may not reflect those of UNU-IIGH or the UCL Centre for Gender and Global Health.

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Masculinities and Health: Experiments in (attempted) systems change – Gary Barker

Tiffany Nassiri-Ansari

This blog accompanies the Lancet Commission on Gender and Global Health seminar series. The series accompanies the development of the Commission, inviting Commissioners and Co-Chairs to discuss a key topic, question, or challenge that the Commission hopes to tackle. The series aims to involve a range of stakeholders and voices in its work and to promote discussion and debate on gender and health.

In the twelfth seminar of the Lancet Commission on Gender and Global Health series, Commissioner Gary Barker drew on his experiences within the intersection of masculinities and gender to offer insights and interventions gleaned from his work with Promundo. A developmental psychologist by training, Barker serves as the CEO of Promundo-US, a network of six independent NGOs utilizing research, program implementation, and advocacy to encourage healthy masculinities and male allyship in gender equality in large-scale social institutions such as schools, workplaces, and beyond. The webinar was facilitated by Commission Co-Chair Sarah Hawkes, and attended by fellow commissioners as well as a YouTube live stream audience.

Situating men’s health within gender and health

On the one-year anniversary of the commission’s launch, Barker shared his reflections on not just individual men’s health, but also the structures, systems, and norms that work together to shape masculinities. His presentation drew from Promundo’s experience to better understand how systems work (especially health systems), how services are delivered, and how program outcomes impact the lives of individuals. This perspective is indicative of Promundo’s approach to men’s health as a whole, as its efforts seek to go beyond the program level to consider the intersections between gender and masculinities on a larger scale. Barker’s personal background as a developmental psychologist complements this organizational approach, as he works to better understand how gender and masculinities shape who we are in the world.

Barker started his presentation with a brief snapshot of men’s health in both the global and local contexts, highlighting contestations within the arena of gender and global health where men’s health struggles to carve out a space for itself without being framed as a competitor to women’s health. A common misconception of men’s health – and indeed, gender equality as a whole – holds that our patriarchal structures privilege all men over all women, but an intersectional understanding facilitates a more nuanced consideration of socioeconomic stratification among men and women alike, and the complex power differentials that result. Men’s health services cater to some men and some health issues, such as sports medicine and cardiovascular health, while other fields more closely linked to non-hegemonic masculinities remain underfunded and understudied.

While drawing connections between health and social norms, especially those related to masculinities, Barker also urged researchers and practitioners to look beyond gender when considering the social determinants of health. He illustrated how corporate interests, for example, can have both helpful and harmful influences on men’s health; positive interventions include corporate funding for those fields overlooked by public health budgets, while negative outcomes are shaped by targeted marketing of tobacco and alcohol. Beyond that, Barker also encouraged a more relational understanding of men’s health, illustrating how chronic illness and premature death can negatively impact partners and families. Other limitations that need to be confronted when working within the space of men’s health include the centrality of heteronormative approaches, and the “project logic” prevalent within health interventions that falls short of the systems change needed in health.

Delving into the quantitative evidence on men’s health, Barker shared that 50% of premature male mortality and 70% of male morbidity is attributable to five health risk factors: diet, smoking, alcohol, drug use, and occupational risk. Returning briefly to the question of social norms, Barker shared that representative data validates a connection between masculinist views and health outcomes, an association that holds up “in robust ways” across multivariate and bivariate analyses, but these social norms “are never, never the only issues”. Susceptibility to these factors is shaped by norms, behaviors, and structural factors that operate far beyond surface-level understandings of gender and masculinities, with income level, educational attainment, geographic context, marketing pressure, family dynamics, and more coming together to form the complex terrain of men’s health. Using norms as a point of entry, gender-transformative approaches which actively engage with men ultimately yield better results in terms of changing men’s individual outcomes and behaviors, with evidence of a positive ripple effect on households and family members as well. Barker then transitioned into the next section of his presentation, which highlighted two Promundo projects as examples of gender-transformative approaches.

Brazil: Prenatal visits as the point of least resistance

National men’s health programs are not easily found, with Barker noting that there are only approximately six countries in the world with such programs. This absence is especially noticeable in the Global South, making Brazil’s implementation of a National Men’s Health Program in 2009 particularly noteworthy. The program was born out of activism and created in dialogue with women’s rights and women’s health, taking special care not to divert attention and resources from “the fragile gains made in terms of women’s health”. After a rough start which included a sparse budget and narrow focus on urology, the program developed a more holistic approach that sought to locate men within the public health system and meet them where they are. Accompanying a partner to a prenatal visit was identified as the primary point of contact, and a prenatal health protocol flow was developed to transform the point of contact into a point of entry.

The program targeted patients and providers alike, with the prenatal health protocol complemented by an online training course on men’s health. While Barker noted that impact data is scarce, a 2017 survey showed that 75% of women reported having their male partner present at one or more prenatal visits, while two-thirds reported having their male partner present at birth – a marked improvement from 16% in 2012. As for health professionals, 82,000 individuals registered for the aforementioned online course, although there is insufficient data to determine how many continued beyond the initial registration and first session. Nonetheless, prenatal visits now serve as the single largest path to Brazilian men’s participation in primary health care.

Despite this significant achievement, Barker took care to note the challenges and limitations of this program. The overwhelming focus on men’s presence at prenatal visits leaves room for many men to fall through the cracks, including boys and younger men, elderly men, and gay and non-binary men. Other health issues also suffer from limited attention in the Brazilian health system, such as suicide, traffic accidents, mental health, and violence, a key contributing factor to men’s health which was also mentioned by fellow commissioner Morna Cornell. Finally, Barker noted with no small amount of concern that right-wing political efforts to undermine and defund Brazil’s public health system abound, and men’s health stands to be caught in the cross hairs.

Rwanda: Parenting as the site of gender-transformative interventions

While Promundo’s work in Brazil focuses on prenatal visits, a partnership with the Rwanda Men’s Resource Center (RWAMREC) has resulted in a father-inclusive parent training module that serves as a gender-transformative couples’ intervention. Building on an existing Rwandan norm where men believe they should be involved in the lives of their children, the Bandebereho program identified fatherhood as the point of entry to engage men in discussions about reproductive health, maternal and child health, preventing violence against women and children, proactive caregiving, and healthier couple relations. Informed by the understanding that parenting and health-seeking behaviors are deeply influenced by both gender norms and service provision, Bandebereho is a 17-session participatory curriculum designed to: encourage reflection on and questioning of gender roles and inequitable norms; equip parents with parenting, health, and relationship skills and information; encourage couples’ communication; and facilitate the practice of new behaviors in a safe and supportive group environment. The program as a whole sits within the framework of gender equality and women’s rights, and ensures that local stakeholders such as the Ministry of Health and community leaders are recruited as co-owners of the process.

A randomized control trial of 1199 couples demonstrated a positive impact on multiple health and gender outcomes, including violence prevention, maternal health, gender equality, and caregiving. Remarkably, these results held up two years later, even as the rest of the country experienced a spike in men’s violence against women in the midst of the COVID-19 pandemic. The next step is for Bandebereho to not only scale up but scale in, a necessary step that Barker explained is key to increasing the availability, reach, and sustainability of the program nationwide. The process involves handing ownership over from NGOs to the community health workers system, and integrating Bandebereho into the routine work of community health workers. The transition to scaling in continues, with 27 district and health authorities trained to support and monitor Bandebereho implementation thus far.

The task ahead: Addressing blind-spots in men’s health

In the final moments of the presentation, Barker reflected on the remaining blind-spots within men’s health that gender and global health will need to address moving forward. As the commission continues to grapple with questions about access and equity, Barker called for a new approach that addresses these challenges at the beginning of interventions rather than the end. He also reiterated the need for a relational perspective on men’s health, and an expansion from short-term project-focused approaches to long-term system-wide changes. Successful interventions such as those highlighted in this presentation are time- and cost-consuming, and funding mechanisms must be transformed to better support programs that seek to improve system capacities over the 10-year or more period that such change often entails.

Barker ended by drawing attention to the crucial intersection between gender, health, and politics. Speaking from his perspective as a researcher working in the United States and Brazil, he drew a link between the “combined, deliberate misinformation about COVID, much of that very masculinist in its focus” and “harmful and anti-gender equality agenda conversations”, leaving fellow commissioners and casual audiences alike with food for thought.

You can watch the full online seminar here.

The views expressed in this post are those of the presenter and author and may not reflect those of UNU-IIGH or the UCL Centre for Gender and Global Health.

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Men: the elephant in the (gender and global health) room – Morna Cornell

Tiffany Nassiri-Ansari

In the eleventh seminar of the Lancet Commission on Gender and Global Health series, Commissioner Morna Cornell confronted the elephant in the room head-on by presenting an evidence-based argument for including men in gender and health discourses, policies, and programs. As Senior Research Officer at the University of Cape Town’s School of Public Health and Family Medicine, Cornell draws on her expertise in human rights activism and public health research to call for the inclusion of men’s health in the global health agenda, an endeavour informed by her background in HIV/AIDS advocacy in South Africa. This session was facilitated by Commission Co-Chair Sarah Hawkes and enriched by the participation of fellow commissioners as well as a highly engaged YouTube live stream audience.

“The most unequal country in the world”

Cornell began the session by situating herself in the South African context, noting that the sub-Saharan country has been labelled the most unequal country in the world. Poverty and extreme inequality fuel what Cornell referred to as “overlapping epidemics” within the country, which is currently battling a resurgence of COVID-19 among its largely unvaccinated population whilst struggling with a health system challenged by recent political upheaval. Endemic rates of unnatural death and increasing incidences of NCDs further exacerbate the situation for everyday South Africans, creating highly gendered health exposures and outcomes that remain poorly understood.

Photo credit: TIME magazine

It is in this tumultuous milieu that one finds the world’s largest number of people living with HIV (PLHIV), a population of more than seven million people as of 2020. Reflecting on her experiences as the former Executive Director of the AIDS Consortium, Cornell recalled the bleak span of time throughout the 1990s when HIV “was literally a death sentence because we had no treatment”. Sustained activism pushed back against this write-off of PLHIV and would eventually contribute to South Africa having one of the most progressive constitutions globally, one which Cornell noted “entitles people living with HIV and their families to full and equal enjoyment of all rights and freedoms”.

The promise of rights, however, is not a self-fulfilling one. Realising these rights promised to South African PLHIV and their loved ones required advocacy, money, and most importantly, raised the underlying question: who deserves care? In the early years of treatment, as the profile of the global epidemic shifted and became increasingly heterosexually transmitted, women and children were described as “innocent victims”, i.e. deserving of care, and activists fought for treatment to prevent HIV transmission to infants and to keep mothers alive. In contrast, men were explicitly blamed for transmitting HIV and effectively relegated to the bottom of the list of those deserving of care.


Who deserves care – and who can afford it?

In 1996, Cornell attended the 11th World AIDS Conference in Vancouver, where a groundbreaking announcement offered the long-awaited glimmer of hope: triple-drug therapy to suppress virus replication. “Suddenly,” Cornell marvelled, “there was a possibility of life… if you could afford it”.

Within just two short years, however, the primary challenge facing HIV/AIDS activists shifted from the search for treatment to the distribution of treatment. 1998’s 12th World AIDS Conference, held in Geneva, aimed to bridge the treatment gap between richer and poorer nations, with the conference’s theme revolving around questions of equity and treatment access – a familiar struggle, Cornell pointed out, in the current COVID-19 pandemic. This inequity manifested in the stark contrast between stories coming from the Global North, where the term “Lazarus effect” had been coined to describe the near-miraculous experiences of those on treatment, and the Global South, where death tolls continued to rise while treatment remained out of reach for those who needed it most. Cornell recounted how this “massive and widening gap between the Global North and the Global South” sparked rage, suggesting that some lives matter more than others.

This rage gave rise to social justice movements and treatment activism, which saw “people living with HIV putting their bodies on the line in clinical trials without guaranteed post-trial access,” Cornell recalled. The courageous and tireless work of activists eventually led to the marketing of an affordable generic combination that drastically reduced triple-drug therapy costs. In 2004, the South African ART program began; today, it is the largest of its kind with over 5 million people on treatment by 2019 – “a remarkable achievement,” Cornell noted, “particularly in our context”.

Missing voices: Male mortality in the HIV/AIDS crisis

As is so often the case with complex challenges, the story did not end there. In 2002, while co-authoring the book Waiting to Happen: HIV/AIDS in South Africa, Cornell had identified a common thread running across all 90 papers: “What does it mean to be a man or a woman in South Africa? And how does this understanding impact on HIV risks?”

A deeper dive into these questions gave Cornell the first inkling that “our epidemic might be more about gender than biological differences” and steered her towards clinical research in search of answers. Cornell’s years spent working on clinical trials spurred her to pursue tertiary education for the very first time in her mid-forties. In her Master’s thesis, she found that men living with HIV had higher mortality rates on treatment than women. A literature review failed to generate much in the way of good evidence, and Cornell found that “the prevailing wisdom anecdotally blamed men for their own poorer outcomes,” with explanations like: men are reluctant to go to the doctor, only do so when they are older and sicker, and are unlikely to initiate treatment or remain in care. Reading these generalisations about men’s alleged health behaviours presented as fact did not sit well with Cornell and led her to test these claims in one of her PhD papers in a study of over 46,000 PLHIV with good – though routine – data.

Cornell found that men being older and sicker when they started treatment explained some, but not all, of the excess mortality and found no evidence to support claims about men being less likely to adhere to treatment regimens and more likely to die after being lost to care. Finally, a self-described “Aha!” moment led her to compare the gender difference in mortality on ART to the gender difference in mortality among the HIV-negative population. Against all expectations, Cornell found that HIV-negative men faced an even greater mortality risk than HIV-positive men on ART. In her own words, “being in HIV care seemed to protect men on treatment against some health risks, and over time on antiretrovirals the deaths were less and less likely to related to HIV or ART and more likely to reflect background risks”. In South Africa, she added, these background risks are predominantly from violence, road traffic accidents, and suicides.

Over the years, Cornell has found increasing evidence of gender inequity in HIV programs across sub-Saharan Africa. On the one hand, women have higher incidence rates and are thus prioritised – appropriately, as Cornell pointed out – for targeted funding and programming, resulting in better access to treatment and lower mortality. On the other hand, men are much less likely to be tested and start ART, are indeed sicker and older when they begin treatment, and thus have a higher risk of death – a hidden truth that only becomes evident when data are disaggregated.

Beyond women’s health: Understanding gender inequity in global health

Piecing together separate instances of gender inequity in health, Cornell painted a bigger picture in which men’s health is systematically underrepresented in global and national policies despite a growing body of evidence documenting their poorer access to and outcomes in health care. She asserted that this is not indicative of a conscious desire to exclude men. The early focus on women’s health was appropriate given the nature of patriarchal power dynamics but has had the unfortunate side effect of conflating gender with women. Today, this conflation of gender with women manifests itself in the language we use, the groups we target for interventions, and the funding priorities we set. In addition, the conflation of gender with women also reinforces the gender binary and runs the risk of excluding trans and non-binary people from discourses, policies, and programs on gender and health.

These patterns suggest a collectively-held implicit bias, which Cornell defines in accordance with Merriam-Webster as “present, but not consciously held or recognised”. While neither intentional nor malicious, this bias has significant and wide-ranging ramifications as it perpetuates “a sense, somehow, that men are less deserving of care than women and that men are individually responsible for their own poorer health outcomes”. Referring to a 2013 paper by Commission Co-Chair Pascale Allotey, Cornell echoed her assertion that “a female bias in gender research constrains debate and limits our opportunities to intervene effectively” and argued that such bias may even provide some explanation for the limited success to date in mainstreaming gender and health.

Bridging the past and present, Cornell acknowledged that historically, men as a group have held greater social power than women as a group – but men are neither homogenous nor all-powerful. She argued that we need to consider how men and women are born with biological sex and then immersed into a gendered system; and how their gendered pathways to health or ill health can be influenced by race, class, sex, age, and (dis)ability among many other factors. An intersectional approach to gender and health would also consider historical contexts such as the impact of colonialism and apartheid on marginalised men, whom Cornell pointed out “are not necessarily privileged in health and may face higher morbidity or mortality than women” based on recent disaggregation of COVID-19 data.

Towards a paradigm shift: Next steps for the Lancet Commission

Situating her presentation in the context of the work awaiting the commissioners, Cornell called for the Commission to take into account the issue of scale in global health, to confront “issues that impact on large numbers of people, particularly those who live in extremely unequal societies where making a difference can impact on many lives”. Cornell argued that the road to Universal Health Coverage (UHC) can only be realised through a paradigm shift away from the current view of men’s health as “an optional add-on”, a practice that undermines men’s right to health as well as the efficacy of public health responses. She urged the Commission to “highlight the historical neglect of men’s health, check for implicit bias not only in ourselves but also in the policies and websites of international health agencies, major donors, and national programs, use an intersectional lens that is context-specific, and ensure that we do not perpetuate outdated thinking about gender”.

In closing, Cornell acknowledged that such a paradigm shift will be a challenge. However, reflecting on her personal journey in public health, she said that “change is not easy – but it is possible,” a lesson learned from her years in HIV/AIDS activism and the hard-won victory of seeing millions of people once sentenced to death now living healthy lives on ART.

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Gender in global health: Can human rights play a useful role? – Sofia Gruskin

Mireille Evagora-Campbell

As part of the Lancet Commission on Gender and Global Health seminar series, Commissioner Sofia Gruskin brought her multi-disciplinary expertise to the question of whether human rights can play a useful role in strengthening attention to gender in global health. Gruskin argued that, with collective clarity on the strengths and challenges in applying a human rights framework, it can be a valuable tool in pushing for action within this sphere. Sofia Gruskin is Director of the USC Institute on Inequalities in Global Health, Professor of Preventive Medicine and Chief of the Disease Prevention, Policy and Global Health Division at the Keck School of Medicine, and Professor of Law at the Gould School of Law.

Gruskin began her seminar by addressing the notion that human rights is an inappropriate or ineffectual framework for addressing gender in global health. She situated this hesitancy within the context of perceived tensions between gender and human rights actors, spanning multilateral, member state and research communities, which at times position the two as opposing paradigms.

Interrogating this misconception, for Gruskin, is as urgent as ever: COVID-19 has highlighted that neither human rights nor health can be taken for granted – and also that solidarity at the global and community level is not as forthcoming as we might have hoped. At a time of increased appetite for government accountability in the wake of misuse of the law in the name of pandemic control, shrinking civil society space and dismantling of human rights and health funding, it is an important moment to probe the role that linking human rights and gender approaches may have for global health.

Gender and human rights: reinforcing frameworks to address global health challenges

Gruskin made a compelling case that gender and human rights can be mutually reinforcing frameworks for global health so long as we commit to honest examination of their objectives, purposes, strengths and weaknesses, beginning with common definitions of the two fields.

‘Operationalising the links between human rights and gender… may be one of the most opportune things we can do for the field of global health right now’ said Gruskin.

Fittingly, Gruskin made a point to define human rights and global health for the sake of the discussion – but not without critiquing the classical conceptualisations of the two fields: while she defined human rights as primarily concerned with the relationship between individual and State, this framing, for Gruskin, is too narrow to capture obligations so present in the current moment such as those of multilateral corporations and of current societies to the planet and future generations. Likewise, across many of the influential framings of global health (including as an area of study, an inspirational goal, an instrumental goal and a right) colonialist tendencies  exist which must be scrutinised and addressed.

Part of the value of bringing a human rights lens to global health, argues Gruskin, lies with its capacity to draw attention to process and to the legal accountability of governments for the many rights (from the right to equality and non-discrimination, to the right to food and the right to seek and enjoy asylum) relevant to health and wellbeing.

At the interface between human rights and global health are several applications of the former, including to signal a concern with justice (“rhetorical approach”), to call out violations (“violations approach”), to improve access to health services and interventions (“operational approach”) and to prevent, address and ensure accountability for human rights violations through legal engagement (“legal approach”). According to Gruskin, the effective application of human rights requires clarity on the intersection and divergence of these methods – and indeed a lack thereof is one reason for the confusion around the optimal uses of human rights in the context of heath.

Legal human rights engagement for gender equality in health

Gruskin chose to focus on the “legal approach” as the one, perhaps least linked to the work of many global health practitioners, with particular potential to contribute to the sphere of gender and global health.

To illustrate some of the challenges of, and need for, legal engagement, Gruskin took a deep dive into the international legal and political frameworks relevant to global health to examine some of their strengths and limitations in relation to gender. She highlighted striking ambiguities relating to gender visible in these frameworks. Inconsistencies, Gruskin demonstrated, are found in the use of the terms “sex” and “gender”, both within treaty bodies – for example in CEDAW data-collection reporting guidelines – and between treaty bodies, with some treaties subsuming gender into sex and others distinguishing the two. Likewise, throughout the Sustainable Development Goals, gender is treated as a male-female binary and in just one instance (Goal 5.6 on reproductive rights) is the link between health and rights recognised.

This legal obscurity is not simply a matter of language: it has tangible consequences for how governments treat their legal commitments in relation to gender and what this means for real people’s lives – especially, as Gruskin observed, if a country is bound by multiple treaties with competing definitions of gender.

Take guidance from those at the margins, not the mainstream

In closing, Gruskin emphasised the enduring value of applying a human rights lens in pushing for gender equality in health – and its demand that we look beyond health outcomes to who is benefitting and who is being left behind by health services and utilise accountability mechanisms in the promotion of health equity.

Gruskin concluded by stressing that “human rights still has much to offer, particularly if we take inspiration less from the mainstream of human rights than from its edges and particularly if we listen to the arguments, the strategic knowledge and the priorities of the communities whose health and rights are most impacted in the current moment.”

Positioning the commission

Gruskin underlined the role that the Commission can play in demonstrating the importance of attending to both human rights and gender in improving population health. She challenged the Commission to think radically in order to harness the strengths of its collective disciplines to move towards this goal.

The Commission can also catalyse action by working to identify tangible examples of what it means to apply a human rights lens to gender and global health in order to concretise this in practice.

Progress will require aligning all levels of the global health system – multilateral, regional, country, civil society and local levels – and the Commission is well-positioned to work with and across these actors in its engagement on gender and global health.