Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why it exists and how we can change it Final Report to the WHO Commission on Social Determinants of Health September 2007 Women and Gender Equity Knowledge Network Submitted by Gita Sen and Piroska Östlin Co-coordinators of the WGEKN1 Report writing team Gita Sen, Piroska Östlin, Asha George 1 We are very grateful to the members and corresponding members of the WGEKN, and the authors of background papers for their willingness to write, read, comment and send material. Special thanks are due to Linda Rydberg and Priya Patel for their cheerful and competent support at the different stages of this report. We would also like to thank Beena Varghese for her inputs to the report. Members Rebecca Cook Rosalind Petchesky Claudia Garcia Moreno Silvina Ramos Adrienne Germain Sundari Ravindran Veloshnee Govender Alex Scott-Samuel Caren Grown Gita Sen (Coordinator) Afua Hesse Hilary Standing Helen Keleher Debora Tajer Yunguo LIU Sally Theobald Piroska Östlin (Coordinator) Huda Zurayk Corresponding members Pat Armstrong Jennifer Klot Jill Astbury Gunilla Krantz Gary Barker Rally Macintyre Anjana Bhushan Peggy Maguire Mabel Bianco Mary Manandhar Mary Anne Burke Nomafrench Mbombo James Dwyer Geeta Rao Gupta Margrit Eichler Sunanda Ray Sahar El- Sheneity Marta Rondon Alessandra Fantini Hania Sholkamy Elsa Gómez Erna Surjadi Ana Cristina González Vélez Wilfreda Thurston Anne Hammarström Joanna Vogel Amparo Hernández-Bello Isabel Yordi Aguirre Nduku Kilonzo Authors of background papers Karina Batthyány Melissa Laurie Sonia Correa Ranjani Murthy Lucinda Franklin Piroska Östlin Asha George Loveday Penn-Kekana Veloshnee Govender Rosalind Petchesky Aditi Iyer Sundari Ravindran Helen Keleher Gita Sen Aarti Kelkar-Khambete Rachel Snow Reviewers of background papers Gary Barker Piroska Östlin Anjana Bhushan Martha Rondon Lesley Doyal Gabrielle Ross James Dwyer Gita Sen Sahar El-Sheneity Hania Sholkamy Alexandra Fantini Wilfreda Thurston Ana Cristina González Vélez Joanna Vogel Amparo Hernández Bello Huda Zurayk Peggy Maguire Mary Manandhar Other contributors Marion Stevens Tanja Houweling Göran Tomson Gabrielle Ross Susan Watts ii Acknowledgements We express our gratitude for the collective patience and expertise generously offered by Knowledge Network Members, Corresponding Members, Authors of background papers and case studies involved in this report, and their Reviewers. We are also indebted to Commissioners Hoda Rashad, Monique Begin, Mirai Chatterjee, Ndioro Ndiaye and Denny Vågerö for their guidance and support, and to Commissioner Rashad especially for hosting the Cairo meeting of the Knowledge Network. Our focal points, Gabrielle Ross from WHO and Tanja Houweling from University College London have been very supportive. Special thanks to Dorrit Alopaeus-Ståhl at the Ministry of Foreign Affairs in Sweden for her support and the external reviewers of the draft version of this report for their valuable comments. We thank also our colleagues in the Globalisation and Health Systems Knowledge Networks, who have been particularly helpful in sharing ideas and evidence. We thank also our institutions, the Indian Institute of Management Bangalore and the Karolinska Institutet in Sweden for giving home to the organizational hubs of the Knowledge Network. Disclaimer This work was made possible through funding provided by the World Health Organization (WHO), the Swedish National Institute of Public Health (SNIPH) and the Open Society Institute (OSI) and undertaken as work for the Women and Gender Equity Knowledge Network established as part of the WHO Commission on the Social Determinants of Health. The views presented in this work/publication/report are those of the authors and do not necessarily represent the decisions, policy or views of WHO or Commissioners. iii TABLE OF CONTENTS POLICY BRIEFING.....................................................................................................................................................VIII EXECUTIVE SUMMARY .............................................................................................................................................. XII I. INTRODUCTION........................................................................................................................................................... 1 I.1 BASIC UNDERPINNINGS .............................................................................................................................................. 1 I.2 BEYOND MOTHERHOOD AND APPLE PIE..........................................................................................................................3 II. THE EVIDENCE BASE OF THE REPORT ..................................................................................................................... 5 III. DIAGNOSIS: SO WHAT’S THE PROBLEM?................................................................................................................. 6 III.1 GENDER, WOMEN, EQUITY AND EQUALITY..................................................................................................................... 6 III.2 INTERSECTING SOCIAL HIERARCHIES ........................................................................................................................... 8 III.3 SOCIAL STRATIFIERS AND STRUCTURAL PROCESSES – HOW DO THEY INTERACT?................................................................. 9 III.4 CAUSAL PATHWAYS AND A FRAMEWORK..................................................................................................................... 10 IV. GENDERED STRUCTURAL DETERMINANTS ........................................................................................................... 11 IV.1 WHAT DO WE KNOW?............................................................................................................................................. 11 IV.1.1 Gender as a social stratifier.......................................................................................................................... 12 IV.1.2 Gendered structural processes..................................................................................................................... 14 IV.1.3 Women’s movements and human rights ........................................................................................................ 21 IV.2 PROMOTING HUMAN RIGHTS AND STRENGTHENING WOMEN’S HANDS............................................................................. 22 IV.2.1 Deepening the normative framework and realizing human rights...................................................................... 23 IV.2.2 Cushioning the ‘shock absorbers’ ................................................................................................................. 24 IV.2.3 Expanding women’s capabilities – focus on education .................................................................................... 25 V. NORMS, VALUES AND PRACTICES.......................................................................................................................... 28 V.1 WHAT DO WE KNOW?.............................................................................................................................................. 28 V.1.1 How do norms work?.................................................................................................................................... 28 V.1.2 Gendered norms affecting health................................................................................................................... 30 V.2 CHALLENGING GENDER STEREOTYPES AND HOW THEY AFFECT HEALTH ............................................................................ 33 V.2.1 Create formal agreements, codes and laws to change norms that violate women’s human rights, and implement/enforce them........................................................................................................................................ 34 V.2.2 Adopting multi-level strategies to changes norms including support for women’s organisations............................ 36 V.2.3 Working with boys and men for male transformation........................................................................................ 40 VI. DIFFERENCES IN EXPOSURE AND VULNERABILITY............................................................................................... 42 VI.1. WHAT DO WE KNOW?............................................................................................................................................ 42 VI.1.1. Mapping male-female differences in health ................................................................................................... 42 VI.1.2. Understanding male-female differences in health........................................................................................... 43 VI.1.3. Exposure and vulnerability due to both sex and gender.................................................................................. 45 VI.1.4. Exposure and vulnerability due primarily to gender ........................................................................................ 48 VI.2. REDUCING THE HEALTH RISKS OF BEING WOMEN AND MEN............................................................................................ 51 VI.2.1 Meeting differential health needs .................................................................................................................. 51 VI.2.2. Tackling social bias