Masculinities and health: Relational and intersectional perspectives

Tiffany Nassiri-Ansari

Poster for webinar hosted by Gary Barker.

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a fifth episode on July 27th. In Masculinities and health: Relational and intersectional perspectives, Commissioner Gary Barker emphasised the need for relational and intersectional perspectives to move the masculinities and health discourse beyond its current impasse. Barker, President and CEO of Equimundo: Center for Masculinities and Social Justice (formerly Promundo-US), was joined by three colleagues: 

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Barker and speakers were joined by fellow Commissioners and livestream audiences on Twitter, YouTube, and Zoom. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel. 

Setting the scene

Barker opened by situating this discussion as one that considers “the broad social determinants that drive health outcomes for women, men, and non-binary individuals” through the lens of masculinities and strives to move beyond the scarcity lens that frequently pits men’s health against women’s health without due consideration for the ways in which both intersect and impact upon each other. 

Gary Barker: "We often fail to look as well at how men's health - their premature death and chronic health needs - affect the lives of women and girls, and vice versa".

Critiquing the lack of relational approaches to men’s health, Barker noted that “it’s often women who pick up the pieces when sons or male partners or other men in the household either face chronic health conditions or premature death”. This lack of a “bigger picture” understanding also extends to the limited and superficial ways in which intersectionality has been applied to masculinities and health, with some analyses paying nominal attention to poverty as a key element but little else. Overall, this creates a “frozen picture of risk, vulnerability, and harm” that does not sufficiently interrogate the structural, systemic, and social forces at play, and fails to acknowledge the resilience and care shown, for example, by individual men or groups of men who act as activists and allies for their own health, and that of their households and communities. 

With those limitations in mind, Barker invited his colleagues to a panel discussion that specifically sought to address the broader structural, systemic, and contextual factors that shape men’s health. 

Panel discussion: Intersectional approaches, systemic reforms, and narrative shifts 

The three panellists drew from their rich and varied experiences within the broad area of masculinities and health to speak on the importance of intersectionality in the US context, the possibility of systemic change as illustrated by the Brazilian men’s health programme, and the value of narrative-based interventions that resonate with men and boys as applied by Movember in the UK. 

Derek Griffith: "We tend to prioritise masculinities and gender over other social determinants of health that may have equal, or potentially even more, implications for and drive the poor health of men".

Drawing on his work with men of colour in both the US  context and other countries, Griffith highlighted how race, ethnicity, and sexual orientation can intersect with gender to shape health needs and outcomes through economic and political factors. This tied into a larger finding about men’s individual perspectives on health issues, and the fact that the deficit lens often associated with masculinities in health is not consistent with the ways that  many men think about their health. Instead, he found that men “tend to think about their age… and what it means to be an adult, in addition to what it means to be a man or presenting as male or living their lives as men” in relation to their health. 

This mindset highlights the distinction between manhood and masculinities, and leads to a more relational approach for men in thinking about the impact they have on their families and communities. Griffith noted that men with this mindset tend to focus on their ability to positively affect others in their lives more than on their own physical and mental health. He also drew on Kimberlé Crenshaw’s work on intersectionality to comment on the need to “disrupt the tendency to see gender and race as separate” at three levels: the structural, the political, and the representational. These considerations inform the strength-based approach Griffith applies to his work on masculinities and health, which looks at policies and practices through the life course to identify, understand, and build on existing strengths and positivity in this area. Finally, he acknowledged that many countries and actors are “starting to recognise the importance of men’s health… frankly because men’s health tends to be a drain on the economies and health resources of a lot of our countries”. 

Brazil was an example of this integration of and focus on men’s health within national health systems, launching its men’s health programme in 2009. Unfortunately, Nascimento noted that the programme has not been fully implemented in the thirteen years since, as Brazil is a geographically large and economically disparate country. However, he remains involved in ongoing efforts to improve and implement the programme, with a particular focus on fatherhood and care in his work. His work with colleagues has identified fatherhood “as a good entry point to bring men to the health services”, and the implementation of Brazil’s childbirth companion law and engagement of men throughout their partners’ pregnancies has greatly improved men’s access to rapid tests, SRHR services, and immunisation among others. 

Marcos Nascimento: "We still need to sensitise health professionals about men and masculinities in health".

Returning to his initial point about the socioeconomic diversity among Brazil’s 5570 municipalities, which are responsible for implementing primary healthcare, Nascimento noted that more work is required to implement the national program at a local level, especially in terms of training healthcare providers to work with men. In this aspect, community health workers often set an example by making the effort to engage men beyond health settings. However, those working in both health services and research are gravely challenged at the moment by Brazil’s political climate, which Nascimento described as living “in an anti-gender offensive”. It is in this “conservative moment” that the need for and value of intersectionality becomes most apparent, as social movements and civil society organisations are tasked with an increasing amount of responsibility and ability to push forward agendas surrounding health programmes for LGBTQ+, Black, and other marginalised populations. 

Representing one such organisation, Sternberg described Movember as a “positive disrupter” that has shaped change by leading creative and thoughtful discussions on men’s health. Initially established as a fundraising campaign some fifteen years ago in Australia, today Movember “has an array of programmatic activity [worldwide]… and is increasingly thinking about how to move into… health systems more broadly”. This growth has been enabled by Movember’s ability to “engage men in ways that feel fun” as part of a “human-centred design approach to centring men’s health”. A large component of this engagement hinges on Movember’s discovery that most men do not resonate with many of the contemporary framings around masculinities and health, and the consequent pivot to “trying to contextualise these things and… make them feel like they are part of life”. 

Sarah Sternberg: "Rather than trying to fit a square peg in a round hole, we're much better off finding concepts that do resonate with men".

Echoing Nascimento’s comment that fatherhood is a tried-and-tested entry point for men into healthcare systems, Sternberg shared that Movember has also identified sports as “a really fruitful entry point” to both work with and challenge masculine norms regarding mental health and resilience. This is one of many examples of how Movember has experimented with framing and setting to challenge the broader sociocultural determinants of health for men, such as gender norms. Ultimately, Sternberg identified the key to this work being Movember’s ability to “situate ourselves in the lived realities of our audiences”, linking her remarks to the discussion’s larger theme about the importance of context-appropriate interventions. 

Audience Q&A: Addressing marginalisation, mitigating risk factors, and preserving autonomy 

Moderated by Barker, the brief Q&A session was able to address four questions from the audience on marginalised groups, risk factors, and strategies to engage men without side-lining women. 

What recommendations would you offer around changing societal and cultural expectations around men of colour who are gay, pan, or trans in terms of their health needs? How to get the health system to respond, and what are the cultural shifts that need to happen? 

Griffith began by establishing that the challenges described above are not with the populations themselves, but with systems and societies that fail to accept them. “We need to put our energy into changing the system, not changing the men we’re talking about,” he added, and suggested that trustworthiness and efficiency are two key areas for improvement. Nascimento agreed that systemic change is crucial, but also suggested that it could be beneficial to bring together key non-health players such as those working in education and social development to better assess and understand the health needs of populations. 

What are the necessary approaches and strategies for external causes of death such as accidents, suicide, and violence? Are there any nuances beyond the numbers for men versus women? 

In the Brazilian context, Nascimento stated that such external causes “provoke death in the male population much more than any disease or other factors”. While social class is crucial to analyses of external causes, he also stressed the need to approach this from a perspective that interrogates the relationship between masculinities and violence as the default conflict-management strategy for men. 

Speaking on a more structural level, Griffith added that infrastructure can also be a significant contributing factor to these external causes of death. He stressed that while gender is an important part of the conversation on violence, failed economic opportunities and the resultant quality of life are also key factors to keep in mind. In terms of suicide as an external cause of death, Griffith suggested that a better understanding of gendered symptoms of depression is needed. 

Cancer follows heart disease as the second leading cause of death among men in the US among other countries. What do we need to do to address this? 

Drawing on Movember’s work, Sternberg stated that while early care is the key to preventing death and mitigating the impacts of cancer, masculine norms typically prevent men from admitting vulnerability and seeking help. The rise of telehealth, driven by COVID-19 restrictions, further exacerbated this by adding an element of distance between men and healthcare providers. 

Griffith suggested that rather than looking at cancer and heart disease as two distinct causes of illness and death, perhaps more insight can be gained by analysing the two together to understand “what it is over the life course that puts [men aged 45 and older] at risk for both”. 

Are there any strategies for engaging men in prenatal care that pay equal attention to supporting women’s decision-making over their own sexual and reproductive health and bodily autonomy? 

Wrapping up the Q&A session, Barker stressed that the key to this challenge is not pitting men’s needs over the needs of women and other individuals, and that health services for men cannot come at the expense of women. Referring to his work for the Brazilian men’s health programme, Nascimento added that while Brazil still has a long way to go in addressing this, next steps must be guided by an understanding of gender equality which brings together and values all perspectives involved. 

Final thoughts and moving forward: A relational and intersectional approach 

Clockwise from upper left: Gary Barker, Sarah Sternberg, Derek Griffith, and Marcos Nascimento.

In conclusion, Barker summed up the panellists’ remarks to call for a more nuanced application of intersectionality to masculinities and health, underscored the need for more consideration of gendered norms and lived experiences, and remarked on the challenging nature of this work particularly in the context of rising political backlash against merely speaking about gender in some contexts. 

Finally, he urged those working on masculinities and health to adopt “this relational, intersectional life-cycle approach” as the way forward, and thanked the panellists for their contributions to crucial work that will inform the Commission’s approach to this topic. 

 

About the Author

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

Gender Activism, Politics, and Intersectionality in the Era of COVID-19

Tiffany Nassiri-Ansari

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a fourth episode on June 22nd. In Gender activism, politics, and intersectionality in the era of COVID-19, Commissioner Fran Baum examined the intersectional inequities exacerbated by the pandemic and invited colleagues to share their insights from studying the structural violence experienced by many throughout the pandemic. Baum, Professor of Health Equity and NHMRC Investigator Fellow at University of Adelaide’s Stretton Institute, was joined by three colleagues: 

  • Connie Musolino, Research Fellow at Stretton Health Equity, Stretton Institute, University of Adelaide 
  • Jennie Popay, Distinguished Professor of Sociology and Public Health, Division of Health Research, Lancaster University
  • Priyanka Samy, Anti-caste activist, National Federation of Dalit Women (NFDW) 

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Baum and speakers were joined by fellow Commissioners and livestream audiences on Zoom and Twitter. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel. 

Setting the scene

Baum began the session with an overview of the many inequities that predated the pandemic but were undeniably worsened by COVID-19, with compounding factors such as gender, class, caste, race, disability, and sexuality. She identified structural violence as the overarching theme of pandemic response, evident in the “massive vaccine inequity” seen around the world. At the time of her comments, for instance, only 13% of Nigeria’s population had received a single dose of any vaccine, compared to the vaccination rates of high-income countries which tend to hover between 80-90%>. Even within those countries however, she noted that “the picture would be very different” if these rates were broken down to focus on people with disabilities, people of different sexualities, and other marginalised populations. 

Beyond vaccines, the pandemic has generated gendered impacts that have disproportionately affected women and girls. Baum touched on women’s involvement in front line occupations, increased risks of experiencing violence during lockdown, additional burden of navigating care and work duties at home, and findings which suggest that women have been more affected by pandemic-related job losses and employment insecurity. Trans and gender diverse individuals have also faced gendered impacts in their experiences of the pandemic, with “the normal structural systemic inequities… [becoming] more pronounced”. 

To shed light on these experiences of the pandemic, Baum swiftly moved into the panel discussion, which focused on better understanding some of the challenges that emerged during the pandemic through an intersectional lens. 

Panel discussion: The exacerbation of existing inequities 

Between the three of them, the panellists brought to the discussion insights from an examination of COVID-19 experiences in 17 case study countries, experiences of community engagement with Dalit and Adivasi women, and compelling arguments for the importance of narrative. 

Musolino began with a focus on gender divisions in the care economy which emerged as a consistent theme across the 17 case study countries she recently analysed with colleagues at Stretton Health Equity. With women making up approximately 70% of the global health and social care workforce, the burden of care during the pandemic fell primarily on women shouldering paid and unpaid care responsibilities. The intersection of gender with class, caste, race, and more exacerbated the impacts of this burden for many, such as women of colour in the United States who were disproportionately represented in jobs which were deemed essential and necessitated continued work outside of the home even during the worst waves of COVID-19. Women employed in low-paid and precarious roles as caregivers for the elderly faced “some of the most deadly outbreaks”, but the informal nature of their employment often “meant that workers did not have access to paid sick leave and other entitlements, further increasing the risk of illness and spread”. 

Utilising a political economy perspective, Musolino argued that “the COVID-19 pandemic is intrinsically linked to local and global economic and political histories”, with the legacies of colonisation, slavery, and patriarchy evident in the continued exploitation of care worker in countries “which often rely on and exploit groups in poorer neighbouring countries” as evidenced by the example of Peru’s treatment of Venezuelan migrants informally contracted to be maids and carers. Migrant and undocumented workers, both in the care economy and outside of it, often have little to no access to social security or rights, are more vulnerable to exploitation and abuse, and face harsher public health measures than the majority of other workers as seen in the case of long-term residential aged care workers in Singapore. However, in the latter example, Musolino also highlighted how swift measures were put in place by the Singaporean government to support care workers once the virus began to spread in aged care facilities. 

Civil society activism tends to play a role in such stories of good practices, with Musolino crediting civil society not just for playing a role in political decision-making but also engaging in public discourse to raise awareness, fact-check misinformation, combat fear and stigma, and amplify the voices of marginalised groups by “pushing back against the politicisation of such identities during the pandemic”. However, different actors within the wider umbrella of civil society also feature prominently in cases of bad practices, such as anti-vaccination movements which have “lobbied governments and industry bodies to influence such things as withdrawal of mask mandates”. 

Ultimately however, Musolino emphasised the importance of civil society activism as a force for good, highlighting the role South African and Indian civil society groups played in ensuring access to vaccinations and “engaging in broader issues around politics and power… to highlight intersections of oppression during COVID-19”. 

Samy drew on her experience working with the National Federation of Dalit Women to speak on the role of civil society in the Indian context, and emphasised the influence of India’s caste system – “the longest surviving social hierarchy” – in individual experiences of the pandemic. She identified Dalit and Adivasi (tribal) women as “being at the lowest rung of the caste and gender hierarchies”, thus bearing the brunt of the exacerbated inequalities brought forth by COVID-19. The country-wide lockdown announced by the government in the early days of the pandemic had immediate effects on these marginalised groups, with Samy estimating that 90% of the internal migrants who lost their livelihoods and shelter overnight as a result of the lockdown belonged to Dalit and Adivasi communities. With no assurance of food or transport from the government, Samy recalled how “thousands of families – women, children, babies – walked back [to their villages] with several people dying of starvation en route”.  

The impact of the pandemic on Indian women was immediate and devastating – while 73 million women were found to be living in conditions of extreme poverty in 2019, by 2020 it was estimated that the number had swelled to 110 million. In a call-back to Musolino’s earlier comments about women occupying low-paid and precarious roles, Samy commented that most workers in the unorganised and informal sector belong to Dalit and Adivasi communities and were disproportionately affected by the economic impacts of lockdown. With the pandemic threatening gainful employment and exacerbating unpaid care burdens, marginalised women, women with disabilities, and trans women found their labour market participation substantially affected. 

Beyond the economic impacts, Samy identified a “shadow pandemic” in which guidelines to social distance coincided with “the highest ever” incidence rate of violence and sexual harassments against marginalised women, who were “further distanced, discriminated, and distressed with no access to essential services and rights whatsoever”. Many girls and women were also forced to drop out of school due to lack of access to online learning platforms and economic burdens; the National Federation of Dalit Women partnered with these young women and girls to strengthen collective agency and leadership skills during the pandemic, providing opportunities for them to advocate for pandemic relief such as dry rations and free shelter. These young women and girls swiftly started engaging with the heads of village councils, advocating with local authorities, and building social capital in communities where people “who were earlier dismissive of our very being now respect and look up to us as leaders”. In the context of increasing depoliticisation and government crackdowns on civil society, Samy’s final message was a reminder that “inequality is political and therefore our efforts to overcome inequity and inequality also have to be political”, as demonstrated by the young women and girls who were able to organise and challenge political forces to advocate for change. 

The intersection between lived experiences and policy change is one Popay also explores through the COVID-19 Other Front Line Global Alliance, an online platform which highlights the stories of “groups bearing the brunt of social injustice… and [brings] the storytellers into conversations about the impact of the pandemic”. The platform was established based on the observation that insufficient attention was being given to “lived experience narratives that are not generated through research” in conversations surrounding COVID-19. Inspired by Maya Angelou, Popay stressed that “all our stories help us to understand the nature of social problems and begin to think about appropriate solutions”, with stories featured on The Other Front Line supporting the narratives shared by the other two panellists, particularly on the “intensification of [women’s] roles as carers” as well as unsafe living and working conditions. Other stories, however, showed “what equity might look like” and detailed “deepening social relationships in families and communities”; while Popay acknowledged that positive stories do not negate any of the negative experiences shared to the platform, she pointed out the value in understanding that these different perspectives can coexist, showcasing strength and resistance in different ways. 

While these stories hold potential for informing recovery plans, Popay noted that narratives are primarily used by civil society and rarely given value by policymakers and academics alike, who tend to view them as “simply anecdotal”. In closing, Popay acknowledged challenges such as digital inequalities and language barriers which might limit the stories shared on The Other Front Line and other such platforms, but called for a democratisation of these spaces to enable the identification of common interests “in as many ways as we can” so that storytellers do not merely experience social injustice, but are given a way to become part of the solution as well. 

Audience Q&A: Models of collective care 

A range of audience questions were acknowledged, touching on gendered environmental risks, men’s COVID-19 health risks, and collective practice of care. Due to time constraints, the panel was only able to address the latter in detail. 

Can collective practice of care and activisms demonstrate change by challenging the dominance of neoliberal concepts of self-care and individual responsibility? 

Drawing on her years of experience and learnings from The Other Front Line, Popay agreed that such practices hold promise but cautioned against the risk of “narratives of community care and powerful reciprocity” leading to a shift in responsibility from the public sector to communities. Models of community-driven collective care are insufficiently resourced, and Popay warned that “the risk is that the next iteration of the welfare state post-pandemic in countries that did have good welfare provision will be this DIY model”. Moving forward, she emphasised the need for sufficient financial and material support from the public sector to continue resourcing these community-delivered models. 

Final thoughts and moving forward 

In closing, Baum thanked the panel for raising these important issues about intersection, not just for public debate but also for Commissioners to keep in mind as they work to produce a final report that is sensitive and inclusive for all. 

About the Author

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

Gender Violence in Health Institutions as a Global Health Issue

Tiffany Nassiri-Ansari

Poster for "Gender violence in health institutions as a global health issue", hosted by Commissioner Simone Diniz with guest speakers Ana Flavia d'Oliveira and Daphne Rattner.

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a third episode on May 25th. In Gender violence in health institutions as a global health issue, Commissioner Simone Diniz revisited a topic she first explored twenty years ago in 2002’s “Violence against women in health-care institutions: An emerging problem”. Diniz, Professor of the Department of Health and Life Cycles as well as Deputy Director of School of Public Health at the University of São Paulo, was joined by two colleagues:

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Diniz and speakers were joined by facilitator and Commission Co-Chair Prof. Sarah Hawkes, fellow Commissioners, and livestream audiences on Zoom, Twitter, and YouTube. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel.

Setting the scene

Diniz began by noting that this webinar happened to fall on the twentieth anniversary of the abovementioned article, which was published by The Lancet in May 2002. Since then, there has been a notable increase in initiatives, responses, and particularly new terms surrounding the issue, such as the simultaneous existence of “too little too late” and “too much too soon” care often found in low- and middle-income countries.

Slide on "Essentialism, public health, and the correctional approach industry".

“This is a very intersectional form of violence,” Diniz commented on institutional gender violence, which operates upon the idea that women’s bodies are inherently defective and in need of routine correction. Experiences of obstetric violence are differentiated and exacerbated by a “hierarchy of motherhood” shaped by race, class, age, (dis)ability, gender, health history, marital status, and more.

She situated this issue within the broader movement for cognitive and epistemic justice, and highlighted activism and knowledge production within Latin America and the Caribbean since the 1990s as a key component of change. Chief among these actions has been the movement to humanise childbirth, which builds on two frameworks: human rights in health and evidence-based healthcare. Progress has been limited, however, by the idea that alliances and humanised care are “a luxury in poor settings”.

It is within this context that Latin American and global grassroots movements have been operating for decades, creating new terms, indicators, and evidence bases to identify and confront the challenge of obstetric violence. New initiatives to classify forms of violence and work across countries to conduct comparative studies are especially promising, and Diniz highlighted global progress on this front through the abundance of obstetric policies being formulated in Africa and Asia alongside Latin America.

Ultimately, the hope is to communicate the view that “women are understood not as victims of their own violent bodies, but submitted to gendered institutional violence in maternity care”, and promote respectful care through gender equity. Moving towards suggestions and solutions, Diniz identified midwives as a central figure in this fight, and stressed the need to invest power, money, and resources in women as they “fight for the rights of women, children, and communities”.

She transitioned into the panel discussion by raising a number of questions for consideration by both speakers and viewers alike, touching on the role of social movements in both the global South and the global North, the potential of educational institutions and governments to either help or hinder change, and the possibility for a ‘reverse-learning’ opportunity in which the South takes the lead on contextualising this issue within the lenses of intersectionality, coloniality, racism, and more.

Panel discussion: Naming and confronting obstetric violence

Moving into the panel discussion, Diniz introduced her colleagues and guest speakers as not just academics, but long-time activists. She invited both speakers to reflect on how knowledge itself has changed in the three decades since they first started working on this issue, how research and teaching can better harness the production of knowledge, and how international and collaborative activism can change reality.

Naming violence as violence

d’Oliveira began by noting that reflection is an important theme in healthcare, and this webinar allowed her to return to a topic she first started working on a long time ago. In 2002, when she and Diniz first published their paper with colleague Lilia Blima Schraiber, obstetric and institutional violence were just starting to be named around the world. At the University of São Paulo, colleagues felt that “it was not right that we had the space to write at such a prestigious journal as The Lancet and had chosen to expose such a bad image of Brazil”. Negative reactions to this work continued, with d’Oliveira and her fellow researchers dubbed “the violent women” for working on a WHO multi-country study on domestic violence.

Quote by Ana Flavia: "Violence is not easy to recognise, and its perpetuation is based also in this trivialisation and naturalisation".

This pushback and silencing would continue for more than a decade, as d’Oliveira and colleagues later discovered when they created the Don’t Stay Silent movement in 2014 to denounce sexual violence and abuse perpetuated by colleagues and professors within the university. Speaking out was crucial, d’Oliveira stated, as “naming violence as violence is a way to challenge its presence, its trivialisation, its naturalisation, but it may also be very threatening for those who want the issue to remain invisible”. The movement continued to speak out despite instructions not to, insisting that “a violent institution is no shelter and cannot support women experiencing domestic or sexual violence, and this is a precondition to support survivors – for the service not to be violent itself”.

Moving on to speak about the different forms of violence, d’Oliveira also touched on different experiences of violence and levels of vulnerability for different women, emphasising that “we are not just one woman. We are women in our diversity, and violence affects us all but in different ways”. She identified the medical system as a key player in the reproduction of gender, class, and race inequalities alongside perpetuating institutional violence, and called for changes in health systems, knowledge, and practice to centre women and recognise them as subjects rather than objects.

Ultimately, d’Oliveira noted that by 2002, researchers already had more than ten years of evidence that violence could occur within the health system. Twenty years later, “it is difficult to believe and it is very upsetting that in the very place of care where people are suffering and need treatment and cure, violence [remains] present”. She called for change in how health and medicine are taught and practiced, challenged the Brazilian government’s attempts to prohibit the term “obstetric violence”, and advocated for collaborative and cognitive justice to transform care “into a more pleasant, healthy, and meaningful experience for all involved”.

Motors of change

Picking up on d’Oliveira’s call for change, Rattner identified “two big motors of change” in her reflections on the past two decades of activism and progress in the movement for humanised care: international organisations and grassroots movements. She noted that the World Health Organization first started writing about appropriate technologies for birth and women’s right to proper prenatal care in 1985, and yet this remains an issue to this very day.

Quote from Daphne Rattner: "Every women has the right to proper prenatal care, and has a central role in all aspects of this care".

However, more actors have since joined the call for change, such as the International MotherBaby Childbirth Organization, the International Federation of Gynecology and Obstetrics, and the White Ribbon Alliance. Working together as a movement, these international organisations emphasise that “woman-centred care, childbirth care, pregnancy care, and postnatal care should become a positive experience for women”, and play a key role in bringing knowledge and guidelines to this space.

Their work unfolds in parallel with the activism of grassroots organisations such as the Brazilian Network for the Humanization of Childbirth (ReHuNa), which Rattner has been involved with since its establishment in 1993. ReHuNa organised the first International Conference on the Humanization of Childbirth in 2000, and has been working ever since to “give visibility to this violence” through policy influencing, advocacy, international convenings, diffusion of information, and more. The three speakers and other colleagues published a paper based on this work in 2018, titled “Disrespect and abuse in childbirth in Brazil: Social activism, public policies and providers’ training”.

Rattner ended with an assessment of the current situation in Brazil and contemporary challenges. In 2011, the Stork Network proposed the establishment to 250 new birth centres to change the childbirth care paradigm in Brazil; as of today, only 50 of those centres have been created, making it “very difficult to change the environment of childbirth care”. ReHuNa has identified an additional 50 birth centres not included in the network’s list, and is calling for “more training, more schools of midwifery,” and more investment in prenatal care.

However, the situation is complicated by government pushback as mentioned by d’Oliveira. Rattner pointed out that medical councils are also “one of the centres of resistance”, with some going so far as to issue resolutions against humanised care and women’s bodily autonomy. The COVID-19 pandemic has further exacerbated this situation by reversing the clock on maternal mortality, with Brazil now reporting numbers comparable to those from the 1990s, due in part to the government’s failure to produce timely guidelines for vaccinating pregnant women. Ending her grim assessment of the current situation, Rattner branded these failures to prevent avoidable deaths as “a kind of institutional violence”.

Audience Q&A: Defining and classifying forms of violence

Hawkes returned to thank the speakers for sharing a “rich set of ideas, experiences, and solutions” before segueing into the audience Q&A session, which covered two questions on definitions and classification.

“You mentioned the different terms relating to obstetric violence – how do you think that the use of different terms and the multitude of terms affects the reporting and understanding of the issue?”

Diniz reflected on both the advantages and disadvantages of working with multiple terms. She stated that the multiplicity of terms allows for many approaches and different perspectives, and that this captures the richness and diversity of the issue and allows for the customisation of the problem to local cultures and languages.

“There is an advantage in the openness,” she said, but at the same time there is a disadvantage as “we need something that’s relatively comparable for us to create indicators that could be used in different settings”. Common indicators for comparative analyses are crucial, and Diniz pondered on the ways in which the Commission might play a role in “trying to figure out what would be the commonalities for international, global collaborative research and action”.

Slide on obstetric violence as a frontier object with many terms.

“To what extent can we classify the omission of services as obstetric violence? Is it obstetric violence when countries remove the right to legal and safe abortions?”

This question on classification elicited a small debate among speakers. Diniz felt strongly that the denial of abortion services is in fact a form of obstetric violence, and Rattner added that there are different levels of violence to be considered, from the individual to the systemic. At the societal level, she opined that the “absence of laws to guarantee women’s rights can be called some form of violence too”. Crucially, Rattner reminded everyone that “things at the social level can seep into the interpersonal level, as they interact and intersect”.

However, d’Oliveira raised a question about definitional limits, and asked whether there is a line between gender-based violence and gender inequalities and discrimination. She pointed to the existence of terms such as reproductive justice and reproductive coercion which might be more relevant to the issue of abortion rights and laws, and recommended that the term ‘obstetric violence’ be reserved for instances of humiliation and abuse. d’Oliveira highlighted a WHO multi-country study on intimate partner violence as a relevant example in terms of how ‘violence’ was defined as a fixed set of actions, and suggested that “we need a set of acts that we call violence, and a set of unfair distributions of healthcare that we call gender-based inequalities”. In summary, she acknowledged that the lack of safe abortion is a cause of maternal mortality around the world, but urged audiences to think strategically and consider: “How much do we gain or lose by putting everything under the umbrella of obstetric violence?”

Final thoughts and moving forward: From the individual to the structural

Clockwise: Daphne Rattner, Ana Flavia d'Oliveira, Simone Diniz, and Sarah Hawkes.

Due to time constraints, a number of audience questions were unfortunately left unaddressed. Hawkes identified key themes from these questions, which touched on individual experiences of violence, systemic and structural determinants, and the complex overlaps between obstetric violence and reproductive justice.

She linked these themes to a topic that the Commission as a whole is grappling with: “Situating inequalities not just as an individual experience, but also as something that is embedded within the systems and structures that we all operate within”. In closing, Hawkes stressed that in order for progress to take place, systems and structures will have to change just as much as individuals and practices.

 

About the Author

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

Radically Sensible: Feminist Philanthropy in Global Health

Tiffany Nassiri-Ansari

Poster for Radically sensible: Feminist philanthropy in global health, highlighting host Jessica Horn and speaker Latanya Mapp-Frett.

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a second episode on May 12th. In Radically sensible: Feminist philanthropy in global health, Commissioner Jessica Horn discussed the importance of feminist philanthropy within global health funding with featured speaker Latanya Mapp-Frett, President and CEO of Global Fund for Women. The session was moderated by Tiffany Nassiri-Ansari, a member of the Commission’s Secretariat.

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Horn and speakers were joined by facilitator and Commission Co-Chair Prof. Pascale Allotey, fellow Commissioners, and livestream audiences on Zoom, Twitter, and YouTube. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel.

Setting the scene

Allotey opened the session with some reflections on the impact of COVID-19, which has simultaneously highlighted inequities and created opportunities for change. However, she warned that the nature of this change is “politically charged, with significant risk of further exacerbating injustice in the interest of particular types of responses to the pandemic”. The ramifications on funding have been significant, with major funding pulled out from developed programs and poverty reduction. With the pandemic shaping a preference for technological fixes, low- and middle-income countries have been left stranded due to a reluctance to share technological know-how or acknowledge contributions and expertise from “less powerful spaces of influence”. Ultimately, Allotey noted that “financial resources remain a powerful driver and hamper our efforts to flip this narrative”.

The attitudes and values driving the dearth of technological transfer and LMIC engagement are familiar to those working within the Commission, and these realities have shaped the Secretariat’s decolonial feminist approach to public engagement. Drawing upon the decolonial scholarship of Maria Lugones, Boaventura de Sousa Santos, and more, the Secretariat acknowledges that normative ideas of gender, health, and gender and health are undeniably colonial, both in their historical origins and contemporary operationalisations, and seeks to challenge this status quo by seeking out the voices, stories, and successes that are crucial to a better future for gender and health yet continue to be marginalised by the mechanisms of coloniality.

Slide with quotes on decoloniality and decolonial feminism from Boaventura de Sousa Santos and Maria Lugones, respectively.

Nassiri-Ansari presented the Secretariat’s latest engagement initiative, the Changemakers workshop series, which works with youth-led grassroots feminist organisations in sub-Saharan Africa to understand past successes and envision future agendas. The programme’s primary intent is to learn with and from, as well as to co-create meaningful outcomes through equal partnerships. The Secretariat’s decolonial feminist approach included pre-workshop conversations with each partner organisation to better understand their needs and expectations, and it was through these initial conversations that the limits of current funding models became clear.

Despite increasing acknowledgement that ‘universal’ solutions, more often than not designed in the global North, are not an effective route to change and that grassroots actors are best positioned to understand and solve the challenges faced by their communities, this crucial body of work continues to be overlooked and underfunded within the broader landscape of global health funding. This circles back to ideas of (de)coloniality, as current funding mechanisms continue to operate based on colonial notions of what counts as ‘good’ evidence, what expertise looks like, and where success stories can be found.

Given the clear limitations of current funding mechanisms, this session introduced feminist philanthropy as not just an alternative, but a new model for funders. For the Secretariat, both feminist philanthropy and decolonial feminism are an extension of feminist standpoint epistemology/ies, the conviction that every person has valuable knowledge because, not despite of, the fact that their knowledge is uniquely situation to their own contexts and communities. Applied to a funding model, this mindset compels funders to treat valuable knowledge as such and challenges conventional ideas of what and who is worth funding.

Initial reflections on feminist philanthropy

“What does feminist philanthropy mean to you?”

Moving onto the panel discussion, Nassiri-Ansari posed the above question to both speakers to probe their personal understandings and operationalisations of feminist philanthropy. Mapp-Frett drew a connection between the historical and the contemporary, reflecting on childhood memories of watching her grandmothers and other women in her Philadelphia community coming together to raise funds for legal fees, healthcare, education, and entrepreneurship. “This is what women do with money,” she stressed, going on to point out that “the real tragedy is that we are still convincing people that [feminist philanthropy] is the right thing to do”.

Horn added to the historical origins of feminist philanthropy by tracing its roots back to women’s funds such as Mama Cash and Global Fund for Women, which took “a model that has existed in communities for a long time” to a global level, with particular support for work happening in the global South. She framed feminist philanthropy as an exercise in learning from community practices and scaling up “this idea that feminist vision and feminist transformation has always been for the benefit of everybody”.

Quote from Latanya Mapp-Frett: "Feminist funding means shifting power to historically marginalised communities, including women, girls, and gender nonconforming people".

In times of crises, Mapp-Frett and Global Fund for Women believe that it is even more important to support women who have proven themselves to be the most effective agents for change, working on the frontlines and responding to their community’s immediate needs. Despite this track record, however, Mapp-Frett shared that “less than 1% of gender equality funding reaches the grassroots”. Horn pointed out similar findings from “Where is the money for women’s rights?”, a research project started by the Association for Women’s Rights in Development (AWID) in 2005 which “created an evidence base for understanding the patterns of funding globally for women’s rights… and the deficit in funding”.

Both speakers emphasised the feminist philanthropic model of flexible and core funding that “centres the leadership of women, gender nonconforming people, and people facing additional marginalisations”, and in so doing supports work that is by and for those most affected by the issues at hand. The gradual adoption of these models and values by larger foundations is particularly heartening for Horn, who spoke on the need for gender equality advocacy and initiatives at all levels, from the local to the global.

Feminist philanthropy as a trust-based model not only provides flexibility in how it funds, but also creates resilience through long-term support and accords respect to community organisations with experience and expertise, something that Horn said “could do with more engagement in the mainstream philanthropy sector”.

Panel discussion: Feminist philanthropy as the way forward

“What are the challenges and shortcomings within current models of funding, and why is the status quo so resistant to change?”

Picking up on Horn’s earlier comments about respect, Mapp-Frett identified silo funding as not only a shortcoming in the current landscape, but “a form of disrespect” in how it reduces women and women’s lives to oversimplified components such as reproductive rights or education. Citing Kimberlé Crenshaw’s work on intersectionality, Mapp-Frett advocated for an approach which acknowledges that women “experience multiple and overlapping sources of oppression” simultaneously and constantly, and shifts priority-setting power from funders to women. In so doing, Global Fund for Women has been able to collaborate with and support partners who demand “that gender justice movements reflect an anti-patriarchal, anti-racial, and decolonial principle all together”.

Approaching the question from a different angle, Horn pointed out that grant-makers are sometimes stuck “between a rock and a hard place” which limits their ability to be part of the change they want to see. Within spaces of bilateral funding in particular, the use of taxpayer money can leave funders beholden and accountable to the scrutiny of the electorate, leading to “very tightly designed and accounted for funding arrangements”. Private philanthropy has a role to play here as they do not face the same constraints, and can lead the charge for a change in this dynamic that gives grassroots organisations more breathing space.

Quote from Jessica Horn: "It's really difficult to solve complex long-term problems with short-term money".

Both speakers identified current grant cycles as a significant challenge to the work of grassroots organisations, which often deal with very complex challenges that cannot be solved within two or three short years. Horn drew on evidence-based prevention of intimate partner violence through norm change as an example of projects which achieve change within a short timeframe, but are not sufficiently resourced to protect these gains against backlash in the long run. The lack of long-term funding is further compounded by the lack of core funding, which together form resource constraints that significantly hamper organisations’ ability to build leadership and resilience. Mapp-Frett underscored the importance of adequate and sustained support, stating that “we really have to invest in this work because it is the only thing that is going to mean lasting social change”.

“How do we mainstream learnings and successes from the grassroots as evidence that the shift to feminist philanthropy is necessary, possible, and needs to be scaled up?”

Mapp-Frett suggested that the onus is on funders to look for actors and successes, rather than waiting for organisations to bring solutions to them. She suggested that the same technology employed for search and advertising algorithms could be put to good use in this regard, by making it easier for funders to identify and connect with emerging gender justice movements around the world. In terms of scaling up, a mindset shift is required to understand that scaling up does not mean taking programs from one context and imposing them upon another; rather, it is about scaling up discourses to create more space for conversation, representation and participation in terms of diverse leadership, and sharing of solutions.

Quote from Latanya Mapp-Frett: "The solutions are out there. They're local, brilliant, and exciting - how do we find and support them?"

Horn identified a range of actors working on feminist transformation alongside grassroots organisations, and crucially pointed out that “the whole ecosystem is generally starved”. If funders rely on knowledge products to identify key actors and learnings, they must acknowledge that these structures, particularly African feminist knowledge production, are more often than not un(der)-resourced. She echoed Prof. Sylvia Tamale’s call to decolonise knowledge production, and pushed funders to rethink their requirements and resources for documentation. Knowledge production happens on the ground despite constraints, but to fund into this “would help create a really fascinating evidence base that could be more widely used”.

Financial support would have to go hand-in-hand with broader reforms of the colonial power dynamics within knowledge production as well, challenging ideas of who is deserving of lead authorship, what counts as expertise worth sharing, and how knowledge products should be formatted. Accessibility to knowledge and affordability of publication are also in need of rethinking, as current knowledge production processes are so restrictive and expensive “that it means very little ends up being part of the global repository of what we consider to be evidence”.

Quote from Jessica Horn: "There's so many layers to this work, but it has to begin with acknowledging that there is knowledge and expertise in the context that we're talking about."

The continued failure to acknowledge and document learnings from the grassroots feeds into what Horn called “naïve activism”, a misguided idea that activism simply happens without intentional, iterative, and systematic strategising. This dismissal of grassroots expertise could not be further from the reality of successful grassroots organising, and the onus is on the rest of the feminist transformation ecosystem to recognise the expertise that goes into this work by supporting documentation, analysis, and conversation to inform “broader ways of thinking about how change happens and what to do”.

Audience Q&A: In search of good practices

Despite time constraints, the session was able to address two audience questions:

“As a local small-scale NGO catering to a small population, what would be our responsibilities to show the commitment that would get us the attention of the global funders? In short, what are the responsibilities at the recipient’s end?”

Both Horn and Mapp-Frett preached the importance of collaboration and coalitions in response to this question. For Horn, staying on task is the key to finding a good funder match, and aligning funder priorities with existing projects will also help prevent mission drift, which becomes a real risk when organisations are forced to redefine their work to fit funder requirements. In practical terms, she advised presenting a clear understanding of not just the problems, but also the potential solutions.

Mapp-Frett advocated for alliances amongst organisations, and suggested building coalitions to maximise shared resources and pooled funding. Collective strategising through the sharing of ideas and capacity building through the sharing of skills can also aid the resource mobilisation process. In the long run, Mapp-Frett also pointed out that coalitions can create a sense of community to combat the depression and burnout that frequently accompany the endless work of social justice activism.

“Are there any funders who do this particularly well now, who are helping to set the pace and provide a model for donors who may want to do better at this but aren’t quite sure where to start?”

Mapp-Frett noted that Global Fund for Women is in fact part of an international network of women’s funds known as Prospera, which works across six regions through a number of similarly minded partners. She also suggested looking to regional funds in Africa, Asia, and Latin America, in addition to the increasing number of national funds with a feminist approach. Larger NGOs such as Oxfam are also joining the movement, with specialised feminist funds that offer unrestricted core support for women’s organisations. In the mainstream philanthropy arena, even funders such as the Gates Foundation “are starting to see that the voices of these organisations are going to be hugely important in advocacy” and shifting their support accordingly.

Horn highlighted the movement around participatory grantmaking, pioneered by the Central American Women’s Fund, which puts applicants in charge of deciding on the allocation of funds. She named a number of other funders inspired by this model, such as FRIDA and UHAI, and also pointed those interested in more participatory grant-making to the hashtag movement #ShiftThePower. Ultimately, Horn offered a positive outlook: “There’s a lot of spaces in philanthropy that really are looking at these models and looking at how to do it better”.

Final thoughts and moving forward: Why feminist philanthropy?

For her final question, Nassiri-Ansari requested a one-minute elevator pitch for why feminist philanthropy needs to be the next step in global health funding.

Mapp-Frett emphasised that “funding bold, ambitious, and expansive movements… is what’s going to create the change that we really hope for in our lifetimes and beyond”. Ground-up funding that is responsive to the needs of movements is key in these uncertain times we live in, and Global Fund for Women is committed to providing continued and flexible support to their partners in order to build and strengthen the kinds of grassroots leadership that will be essential to driving long-term change.

Horn reiterated the importance of supporting grassroots organisations, pointing out that “activism is going to lead the change because it has led the change”. History shows that active women’s involvement has been key to progressive movements and democratic wins that benefit all of society, and we cannot forget past lessons in our present if we want to “keep building towards equitable futures”.

Screenshot of (in clockwise order) moderator Tiffany Nassiri-Ansari, host Jessica Horn, and guest speaker Latanya Mapp-Frett.

In closing out the session, Horn stressed the need for ecosystemic approaches to gender and health, and pointed out that the nature of public health makes it well positioned to carry out the ‘whole picture’ interventions that will be necessary for effective change. This approach will ensure that funders are resourcing “the full ecosystem of transformation, and that includes feminist activism” – which Horn called essential to solving the challenges that lie at the intersection between gender and health. Feminist philanthropy, through its provision of long-term, flexible, and core funding, is well-suited to supporting this ecosystemic model.

Finally, it is critical to ensure that any and all partnerships with grassroots organisations involve learning with and from, as this conversation has highlighted the historical importance and expertise of women’s movements that mobilise communities to acknowledge and confront the intersectional challenges presented by reality. Moving forward, those working in the space of feminist transformation, be they academics or funders, must acknowledge feminist civil society “as a domain of expertise, and not just of practice”.

About the Author

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

Vaccines to Vaccinations: Gender in Promoting Immunisation

Tiffany Nassiri-Ansari

The Lancet Commission on Gender and Global Health’s seminar series returned with a new season, In Conversation With, on April 29th. In the first episode, Commissioner Nina Schwalbe hosted a panel discussion on the importance of gender in promoting immunisation to mark World Immunisation Week 2022. Schwalbe, Principal Visiting Fellow at the United Nations University – International Institute for Global Health (UNU-IIGH) and Adjunct Assistant Professor at Columbia University’s Mailman School of Public Health, was joined by a panel of five speakers:

  • Phionah Atuhebwe, New Vaccines Introduction Officer, World Health Organization – Regional Office for Africa (WHO-AFRO)
  • Akosua Sika Ayisi, Deputy Director for Public Health, Greater Accra Regional Health Directorate, Ghana Health Service
  • Jamille Bigio, Senior Coordinator for Gender Equality and Women’s Empowerment; Acting Deputy Assistant Administrator for Gender Equality; and Director of the Gender, Equality and Women’s Empowerment Hub, United States Agency for International Development (USAID)
  • Sarah Goulding, Assistant Secretary and Principal Specialist on Gender Equality, Australian Department of Foreign Affairs and Trade (DFAT)
  • Mira Johri, Professor, Department of Health Management, University of Montreal; and Principal Scientist, University of Montreal Hospital Research Centre (CRCHUM)

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Schwalbe and guest speakers were joined by facilitator and Commission Co-Chair Prof. Pascale Allotey, fellow Commissioners, and livestream audiences on Zoom, LinkedIn, Twitter, and YouTube. A recording of the ninety-minute webinar is publicly available on the Commission’s YouTube channel.

Setting the scene

Allotey opened with an introduction to the In Conversation With seminar series, which allows Commissioners to deep dive into “a critical area of global health… that is bereft of gender considerations” in search of challenges, possible solutions, and good practices. Beyond facilitating dialogue with experts on the subject, each webinar also aims to leave audiences “stimulated and inspired to push harder and further in [their] work towards achieving equity and social justice with the goal of health for all”. Right off the bat, she also addressed the elephant in the room: the all-women panel for this session had been assembled in response to the fact that “several male colleagues noted that sex and gender are not priorities in this space,” a claim challenged by each and every speaker based on their experiences and expertise.

With the scene thusly set, Schwalbe began the session with a brief presentation that highlighted evidence on gender and vaccination, with data based on an analysis she had been involved with while serving as the United States Agency for International Development’s (USAID) director of vaccine access and delivery. During her tenure, Schwalbe oversaw the Biden administration’s donation of a billion vaccines to COVAX, and witnessed first-hand how “gender affects the entire vaccine value chain, starting with production and design” all the way through to delivery.

Data collected from the early days of vaccine delivery revealed that supply constraints and prioritisation determined whether more men or women were vaccinated; more men received early access to COVID-19 vaccines in countries where the military was prioritised, whereas the inverse was true for women in countries where healthcare workers received priority. However, as supply constraints eased, Schwalbe and team were curious to track the gender distribution of vaccine recipients based on the hypothesis that adequate supply would lead to “numbers more reflective of a country’s population structure”.

Turning to the WHO’s COVID-19 Dashboard “more than a year after vaccines were made available in most countries,” they found that some of the sex-disaggregated data in the database were more than a year out of date. The data that Schwalbe and team found were “flawed, inadequate, and outdated,” with only 56 out of a total of 157 countries providing data to WHO reporting sex-disaggregated data in January or February 2022.

Schwalbe summed up the situation thusly: “Despite binding commitments by the UN and requirements by COVAX, sex-disaggregated data on vaccines are simply not being reported by countries regularly, consistently, or in real time”. This lack of sex-disaggregated data is only one of the many gender barriers to immunisation, which the aforementioned USAID analysis concluded “were well-documented prior to COVID-19″. Challenges such as literacy and education gaps, work and domestic care obligations, limited mobility, and lack of decision-making power in the household were found to be relevant across all settings, ranging from low- to high-income countries, and these issues “strongly map to the current delivery challenges for COVID-19 vaccines”.

The fact that insufficient measures were taken to preempt these well-known gender barriers to immunisation is discouraging for the social determinants of health, Schwalbe cautioned, noting that “the outlook for measuring other determinants is bleak” if we cannot get something as simple as sex-disaggregated data reported regularly. Relevant mechanisms are in place, with countries using electronic reporting forms such as DHIS2 and fulfilling mandatory WHO reporting requirements through the monthly eJRF system, but “we need to bang the gender drum loudly and repeatedly so that every public health strategy is underpinned by a consideration of gender and other social determinants”.

Wrapping up her presentation, Schwalbe had one final message for the global health community which walked the line between grim and optimistic: “Given the billions of dollars spent in response to COVID, if we don’t come out of this pandemic with a better data system that allows real-time reporting of sex-disaggregated data at a minimum, we have failed. That said, we can use the evidence we have to double down on gender programming as a cornerstone of an equitable response”.

Initial reflections on data

Allotey opened the floor for initial reflections from Schwalbe and fellow speakers following the presentation, posing a question on the problems with data collection: “Is it an issue of quality, access, or negligence?”

Schwalbe opined that the problem is all of the above, necessitating a push-and-pull strategy. She noted a push to invest in country-level data systems, but suggested that we need to go one step further and add a pull incentive by making gender- and sex-disaggregated data a matter of policy – “it should be a mandatory requirement for countries, full stop”.

The question of mandating sex-disaggregated data was one which Schwalbe and team explored in depth during her tenure at USAID, pondering the extent to which they or other mechanisms such as COVAX could make this requirement a condition of aid. Ultimately, Schwalbe felt that reporting requirements must be complemented by advance notice and sufficient support. “If you’re going to make it conditional, you have to set a deadline in the future that allows countries to get up to that point whereby they can meet the deadline,” she recommended, and noted that there is a broader discussion about accountability and where the responsibility to set requirements and monitor compliance lies. Closing out this section of the webinar, she posed a question to both the WHO and WHA: Why, despite repeated calls over decades, is sex-disaggregated data still not a hard and fast requirement?

Panel discussion: Data, barriers and enablers, and solutions moving forward

“Tell us a little bit about how you use data to inform your work in Ghana.”

Moving onto the main event, Schwalbe introduced the three sections of the panel discussion: data, barriers and enablers, and solutions forward, with a Q&A session slated halfway through. Dr. Akosua Sika Ayisi (Ghana Health Service) began the data section with a case study of how Ghana successfully used data to inform and adapt the country’s vaccine rollout, particularly for women and healthcare workers.

Ayisi stressed that “data is the starting point of the gender discussion” in her introduction to Ghana’s electronic health database system, an investment which has paid dividends in real-time gender-disaggregated data. Beyond mere collection, Ghana actively uses data in a dynamic approach that allows for swift identification of and action on new issues as they arise. The country’s database is complemented by routine research, such as a study carried out by   to assess the willingness of healthcare workers to participate in clinical trials for or accept the COVID-19 vaccines. Such studies among healthcare workers serve as fertile grounds for gender analyses given the increasing feminisation of health workforces around the world; Ayisi noted that in Ghana alone, women make up roughly 60% of the health workforce. The pre-rollout study carried out by Alhassan et al. revealed that women in the health workforce were up to 11 times less likely to accept a COVID-19 vaccine as compared to their male counterparts, and Ayisi credits findings such as these for Ghana’s preemptive development of “a very aggressive risk communication campaign aimed at health workers” which has now led to 90% of the country’s healthcare workers having received at least one dose of the vaccine, with the majority being women.

Data also reveals valuable information and crucial differences within, not just between, populations. Initial data showed that Ghana’s overall vaccine campaign had achieved comparable coverage between men and women, but the figures between urban and rural recipients were skewed, with those in urban areas making up roughly 62% of vaccine recipients while those in rural areas accounted for only 38% . Data analysis also revealed that of the women who had received vaccines, the majority of them were urban women working in the formal sector. This intersectional analysis led to concerted efforts to better understand the barriers to immunisation faced by rural women, informed by rural women themselves who revealed in focus group discussions and key informant interviews that static vaccine centres which necessitated travel and consumed time due to their fixed locations and long queues were the primary barriers for rural women who could not step away from their day-to-day responsibilities of informal work and caregiving. Ultimately, this combination of real-time data and stakeholder engagement allows Ghana to develop flexible, dynamic, and responsive rollout strategies which are continuously reviewed to ensure that no one is left behind in the nation’s vaccination campaign.

“What do you think it will take to make gender-disaggregated data a norm in practice and policy as we’ve just seen in that example from Ghana?”

This is “certainly the kind of model that we want to see,” Ms. Jamille Bigio (USAID) said in her remarks following Ayisi’s intervention, going on to outline how USAID is taking steps to support a “standard of practice” in which data is not only collected, but analysed and used. At the global level, Bigio stressed the need for WHO, UNICEF, and other UN agencies to not only set international standards for gender indicators, but to ensure and support the integration of these indicators into health information systems. Echoing Schwalbe’s call to provide the necessary support for countries to meet such standards and requirements, Bigio shared some known challenges countries have faced in reporting sex-disaggregated data in a timely manner; chief among these challenges were data backlogs in the move from analog to digital, lack of technical familiarity and assistance, and training for research clerks in this shift towards digital. These are all issues USAID is actively providing support on, but Bigio urged donors to collectively step up in this arena and identify possible ways to support digital solutions as well. The goal, ultimately, should be a global system of data collection which allows for widespread and long-term analysis of both quantitative and qualitative data.

While numbers matter, Bigio emphasised the utility of a qualitative tool such as Johns Hopkins’ COVID-19 Behaviours Dashboard which surveys knowledge, attitudes, and practices around COVID-19. In so doing, the dashboard has revealed gender differences in vaccine confidence and uptake in many countries, with the data enabling more tailored interventions to promote vaccine demand. A mixed-methods approach allows for not only the identification of inequity but also an understanding of why it exists and how best to reduce it, with Ayisi’s case study of Ghana serving as the perfect example.

Schwalbe invited reflections from fellow panellists at this point, all of whom touched on the demonstrated importance of gender-disaggregated data. Ms. Sarah Goulding (DFAT) in particular pointed out that the identified challenges are indicative of the broader struggles faced by those attempting to collect sex-disaggregated data at large, and offered her thoughts on why so many peers believe that gender is not a barrier to immunisation. Given that most immunisation research and implementation in recent decades has focused on early childhood immunisation, Goulding conceded that surface-level analyses of the data indeed suggests that there is no significant difference in vaccine uptake between boys and girls. “There’s been this myth that gender doesn’t matter to routine immunisation,” she acknowledged, but closer intersectional analyses reveals that challenges faced in the COVID-19 vaccination rollout are not unique, with women, girls, and disabled children in hard-to-reach populations bearing the brunt of immunisation inequity.

Offering some final thoughts on data, Ayisi stressed the importance of making sex- and gender-disaggregated data a priority right from the start, in policy-making and agenda-setting spaces, to ensure that enough resources are made available to not only implement the collection of such data but integrate it into routine health systems.

“With the benefit of hindsight, what would you have predicted as the barriers and enablers, and what are your key takeaways?”

Prof. Mira Johri (University of Montreal) was invited to start the discussion on barriers and enablers, and drew from her research on routine immunisation, particularly in the Indian context, to point out that many of the challenges faced in the COVID-19 vaccination rollout are neither unknown nor unexpected. “Over a 25-year period, we’ve come to realise that social norms, values, and beliefs that shape gender and other forms of access imply restricted agency” through a number of determinants, yet this knowledge was not applied at the policy-making level. Johri stated that this raises the question of who sits at the table in decision-making spaces, a group which is “often very male, often very privileged”.

In terms of what could have been predicted and what could have been done differently, Johri pointed out that solutions which were touted as progressive were more often than not also blatantly exclusive. Citing India’s “digital-first approach” to vaccine rollout as an example, Johri pointed out not only the well-known digital divide and tech illiteracy that often plagues already-marginalised groups, but also the fact that these very groups are also known to be more susceptible to misinformation and distrust due to their limited access to trustworthy sources of information. Adding the fact that women tend to deprioritise their own health to the mix, this confluence of known factors adds up to a discouraging picture of a situation that could have been avoided had the right voices been consulted at the decision-making table to begin with.

Given the same question, Dr. Phionah Atuhebwe (WHO-AFRO) underscored her fellow panellists’ point that all of the challenges identified in this session predate COVID-19, and should have been preemptively accounted for. The continued exclusion of pregnant and lactating women from vaccine designs and trials, for instance, only fueled the fires of uncertainty, misinformation, and distrust throughout the COVID-19 vaccine rollout. The African continent in particular houses a young population with a significant number of young women of child-bearing age, and questions about side effects for pregnant women and potential complications with fertility in the future quickly morphed into deterrents. This was exacerbated by sociocultural norms which award decision-making power to men in most households; Atuhebwe noted that men were in fact comfortable with receiving vaccinations themselves but frequently barred the women of their households, particularly their wives, from getting vaccinated due to a fear of “lineage discontinuity” in the event that the vaccine resulted in infertility for women.

Echoing Ayisi’s example of Ghana, Atuhebwe noted that healthcare workers elsewhere in the world had expressed similar reservations to the initial vaccine rollout, and the gendered nature of the health workforce necessitated the use of a gender lens to understand these barriers to immunisation. The deprioritisation of women’s health by both women themselves and society at large, similar to Johri’s findings in India, further exacerbated the situation. Atuhebwe’s team found that many women did not travel to vaccine centres not only due to logistical difficulties, but also due to fear of contracting COVID-19 at these centres and bringing it back to their children. Notably, in situations where their children required medical care, these women took necessary precautions such as masking and brought their children to seek treatment.

“Can you point us in the direction of gender-related learnings from COVID vaccines that can inform either further COVID vaccine rollouts or routine childhood vaccinations?”

As the panel discussion drew to a close, Schwalbe steered the conversation towards actionable suggestions and potential solutions by addressing the above question to Goulding, who offered three final points. To begin with, Goulding stressed the need to keep in mind the importance of social factors in the midst of exciting scientific innovations. “When you’re focusing very much on trying to understand a new disease, it’s all about the science and sometimes you forget about the social contexts,” she pointed out with a reminder of the gendered inequalities that have created a silent pandemic in tandem with COVID-19 such as the increase of gender-based violence, early child/forced marriage, and school dropouts for girls.

Secondly, Goulding reminded policymakers and campaign designers of the critical need to engage with community organisations, especially women’s organisations which prioritise the kind of gender analyis that is needed to support program design and implementation. She cited Fiji as an example, noting that women’s organisations were able to weather three cyclones in addition to the COVID-19 pandemic to carry out gender analyses which supported the campaign to reach out to women and explore issues surrounding access to services, travel costs, and understanding the benefits of the vaccine. This community engagement has had tremendous success, with over 71% of the island’s population now double-vaccinated.

Finally, Goulding reminded everyone of the bigger picture beyond COVID-19, and the need to continuously support immunisation innovations for gender and health. She noted with pride Australia’s contribution to the development of the HPV vaccine to prevent cervical cancer, and the recent WHO announcement that a single dose of the vaccine is now enough to provide full protection. Amidst all the challenges faced by those working on the COVID-19 vaccine rollout, this served as a timely reminder that such work does make a significant difference to the lives of women and girls.

Audience Q&A: Data requirements and community engagement

With an abundance of audience questions streaming in, Schwalbe presented the topics of making sex- and gender-disaggregated data mandatory and reaching the unreached to the panellists for further exploration.

“Why isn’t the WHA doing anything to make gender/sex-disaggregated data a requirement? Why is the WHO finding this a challenge and why can’t it be a priority from the start of a policy framework?”

Schwalbe posed the above question to Goulding and Bigio as speakers affiliated with member-states. Goulding noted that despite the vast majority of her peers acknowledging the importance of sex- and gender-disaggregated data, many are conscious that COVID-19 has strained health systems beyond capacity and are wary of enforcing additional requirements. Bigio called for a continual “demand signal” in the form of consistent and sustained calls for disaggregated data to show that there is interest and utility in the exercise.

“How can we build an engagement of women’s groups and girl-led/centered organisations into this process as we think about gendering programming?”

Johri and Atuhebwe provided examples of good practices on this question, with Johri sharing an emergency response service she and colleagues were involved with in India’s early stages of the COVID-19 pandemic. Harking back to her earlier comments on known barriers to digital access and tech illiteracy amongst key populations, Johri emphasised that this intervention was designed with these challenges in mind and mobilised 29 civil society organisations to design a service that reached over a million people within the space of 100 days and illustrated that the best solution is not always the “highest” tech or “fanciest” app. Atuhebwe drew on her experience with the HPV vaccine rollout in a number of African countries such as Rwanda, Malawi, Liberia, and Ethiopia, where campaigns proved effective with women’s and girl’s groups as opinion leaders in the effort to engage the target audience through peer-to-peer education.

“Are any of you aware of efforts or can describe some best practice about reaching the trans community?”

This question noted the significance of what might very well be the first universal adult vaccine rollout in modern history, and the conspicuous absence of gender-disaggregated data beyond the traditional male/female indicator. Schwalbe noted that the lack of replies to this question served as an answer in and of itself, and acknowledged that “we do have to start walking the talk on thinking about gender as a little bit more diverse than sex”.

Final thoughts and moving forward: Stop/Start/Continue

For her final question, Schwalbe asked panellists what one thing they would stop, start, and continue with regard to gender and immunisation. Three key themes emerged from the rich and varied answers given by the speakers: 

  • Expanding ideas of robust data: On the country level, both Bigio and Goulding urged for a rejection of non-disaggregated data, while Ayisi called for a move beyond superficially disaggregated data (limited collection of male/female field) at the country level in favor of more robust international data requirements that would allow for analyses at the global level. On a similar note, Johri advocated for an end to the dominance of biomedical approaches in innovations and interventions, urging those in global health to make use of the wealth of data and evidence gathered from community knowledge and other sources. 
  • Challenging limited ideas about gender: Atuhebwe urged policymakers and practitioners alike to stop seeing women as merely mothers and wives rather than human beings with full and equal rights to health and wellbeing. Bigio likewise challenged limited notions about gender to point out the rich diversity of experiences among and between women, men, and individuals of diverse gender identities, and stressed the need to acknowledge and account for these differences when thinking about experiences of and access to health services. 
  • Empowering women at all levels: Finally, panellists strongly emphasised the need for women and girls to be represented and included at all levels, from the collection of individual person-level data to the co-creation of vaccine campaigns with women’s rights organisations to the inclusion of women in decision-making spaces. Ayisi paraphrased a saying about youth activism to stress the importance of representation in decision-making, noting those affected by the challenges are the very same who can best advocate for the solutions. 

Returning to close out the session, Allotey shared some reflections for panellists and participants alike to carry with them moving forward, stressing the need for both sex- and gender-disaggregated data to better analyse and understand the power dynamics behind the challenges identified in this webinar. She called on those present to “keep interrogating and pushing those who hold accountability to be accountable” in the process of ensuring sex- and gender-disaggregated data collection. Finally, Allotey urged audiences to keep in mind the power of community organisation and the importance of sharing best practices in the quest to move our work forward as a collective. 

About the Author

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