Paper 5 Lancet Series on Gender Equality, Norms and Health Gender Equality and Gender Norms: Framing the Opportunities for Health Abstract word count: 172 Body word count: 4,886 Reference count: 154 Number of Panels: 2 1 Paper 5 Lancet Series on Gender Equality, Norms and Health 1 Authors: 2 Geeta Rao Gupta, PhD1; Nandini Oomman, PhD2; Caren Grown, PhD3; Kathryn Conn, MPH1, 3 Professor Sarah Hawkes, PhD4; Yusra Ribhi Shawar, PhD5, Professor Jeremy Shiffman, PhD5; Kent 4 Buse, PhD6; Rekha Mehra, PhD7; Chernor A Bah, MA8, Professor Lori Heise, PhD9; Margaret E 5 Greene, PhD10, Ann M. Weber, PhD11, Professor Jody Heymann, PhD12; Katherine Hay, MA13; 6 Professor Anita Raj, PhD14; Sarah Henry, MPH11; Jeni Klugman, PhD15, Professor Gary L. Darmstadt, 7 MD11 8 9 1 United Nations Foundation 10 1750 Pennsylvania Avenue, Suite 300, Washington, D.C. 20006 USA 11 12 2 The Women’s Storytelling SalonTM 13 3924 Macomb Street NW Washington D.C. 20016 USA 14 15 3 World Bank Group 16 1818 H Street NW Washington, D.C. 20433 USA 17 18 4 University College London 19 Centre for Gender and Global Health and Global 20 Health 50/50 30 Guilford Street, London WC1N 21 1EH, U.K. 22 23 5 Johns Hopkins University 24 Bloomberg School of Public Health and Paul H. Nitze School of Advanced 25 International Studies 615 N Wolfe Street, Baltimore, MD 21205 USA 26 27 6 UNAIDS 28 20, Avenue Appia, 1211 Geneva 27, Switzerland 29 30 7 Independent Consultant, Economist and Gender Specialist 31 1329 E. Capitol St. SE 32 Washington, D.C. 20003 USA 33 34 8 Purposeful 35 C/0Purposeful 2 Lewis Drive, Hill Station, Freetown, Sierra Leone 36 37 9 Johns Hopkins University 38 Department of Population, Family and Reproductive Health 39 Bloomberg School of Public Health and School of Nursing 40 615 Wolfe Street, Baltimore, MD 21205 41 42 10 GreeneWorks, LLC 43 3733 Warren Street, NW 44 Washington, DC 20016 USA 45 46 11 Stanford University 47 Department of Paediatrics, and the Center for Population Health Sciences 48 Stanford University School of Medicine 49 Stanford, CA 94305 USA 50 51 2 Paper 5 Lancet Series on Gender Equality, Norms and Health 52 12 University of California Los Angeles 53 Fielding School of Public Health 54 621 Charles E. Young Drive South 55 Los Angeles, CA 90095 56 57 13 Bill and Melinda Gates Foundation 58 1432 Elliott Avenue West 59 Seattle, WA 98119 USA 60 61 14 University of California San Diego 62 Department of Medicine, Center on Gender Equity and 63 Health (GEH) 9500 Gilman Drive 64 La Jolla, CA 92093 USA 65 66 15 Women and Public Policy Program 67 Harvard Kennedy School 68 79 JFK Street 69 Cambridge, MA 02138 USA 70 71 72 Corresponding Author: Geeta Rao Gupta, PhD1 73 Email address: [email protected] 74 75 Disclaimer: The views and opinions expressed in this paper are those of the authors and do 76 not reflect the official position of any of the organisations for which the authors work. 77 78 Funding: 79 This Series was funded by the Gender Equality, Integrated Delivery, HIV, Nutrition, Family 80 Planning, and Water, Sanitation and Hygiene Program Strategy Teams at the Bill & Melinda Gates 81 Foundation, and the United Arab Emirates Ministry of Foreign Affairs and International Cooperation, 82 through grants to Stanford University. The funders of the study had no role in study design, data 83 collection, data analysis, data interpretation, or writing of the report. The corresponding author had full 84 access to all the data and had final responsibility to submit the paper for publication. 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 3 Paper 5 Lancet Series on Gender Equality, Norms and Health 104 105 Abstract 106 107 The Sustainable Development Goals offer the global health community a strategic opportunity to 108 promote human rights, advance gender equality, and achieve health for all. The inability of the 109 health sector to accelerate progress on a range of health outcomes brings into sharp focus the 110 significant impact of gender inequalities and restrictive gender norms on health risks and behaviours. 111 In this paper we draw on evidence from the Series on Gender Equality, Norms and Health to dispel 112 three myths on gender and health and describe persistent barriers to progress. We propose an agenda 113 for action to reduce gender inequality and shift gender norms for improved health outcomes, calling 114 on leaders in national governments, global health institutions, civil society organisations, academia, 115 and the corporate sector to 1) focus on health outcomes and engage actors across sectors to achieve 116 them; 2) reform the workplace and workforce to be more gender equitable; 3) fill gaps in data and 117 eliminate gender bias in research; 4) fund civil society actors and social movements; and 5) 118 strengthen accountability mechanisms. 119 120 121 122 123 124 125 126 127 128 129 130 131 4 Paper 5 Lancet Series on Gender Equality, Norms and Health 132 Key Messages of the Series 133 • Gender norms and inequalities affect health outcomes for girls and women, boys and men, 134 and gender minorities. 135 o Gender norms and gender-related inequalities are powerful determinants of health and 136 well-being, distinct from those caused by biological differences based on sex. 137 o Due to the historical legacy of gender-based injustice, the health consequences of gender 138 inequality fall most heavily on women, especially poor women; but restrictive gender 139 norms undermine the health and well-being of women and men, and gender minorities. 140 • Gender bias and inequalities are deeply embedded in research and in the health sector. 141 o Health research is biased and even discriminatory in how studies and instruments are 142 designed and data are collected, limiting analysis and use, and perpetuating gender 143 inequalities. 144 o Health systems reflect and reinforce gender inequalities and restrictive gender norms in 145 health care delivery and the division of labour in the health workforce, compromising the 146 health and well-being of patients, providers, and communities. 147 • Research, health systems, policies, and programmes can reduce gender inequalities and shift 148 gender norms and improve health. 149 o Despite challenges, the impacts of gender norms can be evaluated by applying innovative 150 research methods to existing survey data, thereby illustrating sex differences and gender 151 inequalities in health, and informing policy and programme planning. 152 o Gender bias in health systems can be disrupted by reducing gender inequality in the 153 health care workforce, valuing community care providers, and mobilising civil society to 154 hold systems accountable to the communities they serve. 155 o Programmes can change gender norms and improve health outcomes by engaging 156 multiple stakeholders from different sectors, including a diverse set of activities that 157 reinforce each other, and fostering the active participation of affected community 158 members. 5 Paper 5 Lancet Series on Gender Equality, Norms and Health 159 o Laws and social and economic policies, such as tuition free education and paid parental 160 leave, can change gender norms and improve health outcomes by markedly increasing 161 gender equality in key domains, including education, work, and family. 162 • The time to act is now. 163 o Despite challenges, the compelling evidence linking gender inequalities and 164 restrictive gender norms to poor health, combined with energised and 165 expanding social movements for gender equality, and the pressure to meet the 166 SDGs by 2030 provides leverage for political will to promote equality and shift 167 gender norms, not only to achieve health outcomes, but also protect human 168 rights of all. 169 o An agenda for action to promote gender equality and shift gender norms for improved 170 health outcomes requires 1) a focus on health outcomes and engagement of actors 171 across sectors to achieve them; 2) reforming the workplace and workforce to be more 172 gender equitable; 3) filling gaps in data and eliminating gender bias in research; 4) 173 funding civil society actors and social movements; and 5) strengthening 174 accountability mechanisms. 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 6 Paper 5 Lancet Series on Gender Equality, Norms and Health 194 Introduction 195 196 We live in a complex world. The progressive agenda that demands gender equality for girls and 197 women and gender norms that promote health and well-being for all, including gender minorities, is 198 highly visible today. Grassroots movements, fuelled and democratised by social media, have 199 heightened the prominence of these issues globally. Examples include ending sexual harassment in 200 the workplace (#MeToo, #TimesUp); shining a spotlight on violence against women (#Nirbhaya in 201 India and #NiUnaMenos in South America) and gender-related pay gaps (#EqualPay); advocating 202 against toxic masculinities that underlie male violence (@MenEngage); and promoting lesbian, gay, 203 bisexual, and transgender (LGBT) justice (#hrc, #WhereLoveIsIllegal).1—8 204 205 Simultaneously, a backlash is growing against the progressive agenda. Conservative voices continue 206 to use arguments, often couched in cultural, economic, or religious terms, to justify discrimination 207 against women and gender minorities, while upholding the traditional foundations of male 208 privilege.9,10 Co-opting the term “gender,” powerful forces are pushing against hard-fought gains in 209 human rights and health by rallying against the so-called threat of “gender ideology,” a term created 210 to indict a range of progressive views, such as LGBT rights, access to comprehensive sexuality 211 education, and accommodation of diverse family forms.9,11—15 212 213 In the struggle for gender equality, this tension between progressive and conservative forces, with a 214 two-step forward, one-step back pattern, is well known.