For our part, we will emphasise the important role that gender plays across all of the MDGs at a side event today: Engendering pro-poor change: Putting gender at the heart of the MDGs. As noted in a recent ODI briefing paper, ‘The fact is that experiences of poverty differ according to sex, age, ethnicity and location. However, gender is only explicit in MDGs 3 and 5’. And although the briefing paper lays out an integrated framework for considering gender and the MDGs, supported by a social protection approach, this blog focuses on gender and MDG 6: combating HIV/AIDS, malaria and other diseases. It is informed by recent work ODI has undertaken to support the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation), a public-private partnership investing hundreds of millions of dollars developing new vaccines and immunisation coverage in the developing world, to create, adopt and implement a new gender policy.
Gender-based relations of power are at the root of gender inequality and form one of the most influential social determinants of health. Across the health sector, it is critical to understand the myriad ways in which gender-based social inequalities intersect with economic factors (as well as racial/ethnic hierarchies, caste domination, differences based on sexual orientation and other social stratifiers, such as levels of education) and influence demand for, access to and uptake of health care services.
Yet, i mmunisation – one of the ‘best buys’ in health – is often assumed to be ‘gender-neutral’. While there are significant gaps in our knowledgebase due to limited sex-disaggregated data collection and reporting, analysis of recent health literature and available data reveals a nuanced and complex range of gender inequalities. Significant biases in immunisation coverage exist against girls in South and Southeast Asia and West and East Africa. The largest gap is found in India, where immunisation among boys is 13.4 percent higher than among girls, and is exacerbated in families with multiple daughters. In other regions, however, gender differences do not just negatively impact girls. Data from Madagascar suggest a 12 percentage point lower rate of complete immunisation among boys, and in Nigeria, there is a 7.9 percentage point difference, at least in part due to popular fears of links between immunisation and male sterility. In addition, existing evidence suggests that the lack of current data that takes sex and gender into account at the sub-national level is likely to conceal significant gender inequalities in areas which are economically marginalised and/or suffer from high levels of social exclusion.
There is a common assumption that because immunisation services target girls and boys, men and women equally, equality in access will automatically result. But, access to immunisation services is underpinned by the same broad structural determinants as other health services. Underlying gender dynamics and the ways in which they intersect with other socio-economic factors must be understood and addressed within programming, service provision and health systems strengthening efforts if the health needs of all boys and girls, women and men are to be met. A gender perspective in health services, including immunisation, must account for:
- asymmetrical intra-household access to resources and decision-making power ;
- t he problem of women’s time poverty in utilising services;
- gender-based power inequalities that limit women’s voice and empowerment in familial and community health decision-making;
- health clinics as sites of unequal gender and socioeconomic relations;
- gender dimensions of clinical trial participation and health research;
- differential exposure and vulnerability to disease across the lifecycle for women and men, boys and girls as a product of biological and social aspects of sex and gender;
- and the potential sex-specific impact of immunisation on morbidity and mortality.
This year the GAVI Alliance embarked upon developing a gender policy in conjunction with a research team from ODI. As a critical component of developing an evidence-based policy, the process included a knowledge stocktaking exercise to map the existing evidence base regarding gender and immunisation, and the ways and extent to which gender differences are (in)visible in policy dialogues, programme design and implementation of immunisation services and related health services . The report was informed by a consultation process with the GAVI Alliance’s country, bilateral donor, multilateral agency, civil society and industry partners, and forms the foundation of the gender policy recently approved by the GAVI Alliance Board.
We welcome this new policy as a critical step towards achieving the comprehensive integration of gender in the health sector that is necessary to achieve the health-related MDGs (Goals 4, 5 and 6) and broader MDGs. However, as past evaluations of gender mainstreaming efforts have highlighted, policy documents with rhetorical commitments to addressing gender differences abound. By contrast, successful change in gender relations is heavily reliant on the implementation process, where the devil lies in the detail.
Transformative, gender-sensitive policy change requires sufficient and sustained financial and human resources, political will from senior managers, sex-disaggregated data collection and reporting, monitoring and evaluation, technical capacity building among staff, as well as accountability to ensure that evidence-based policy becomes a reality in practice. The international health community should support and hold accountable the GAVI Alliance to its gender policy commitments, as a part of re-dedicating efforts across the health sector to delivering upon the goals of gender equality. Only then will its mission to ‘save children’s lives and protect people’s health by increasing access to immunisation in poor countries’ be fulfilled.