There’s More to the Story: Overcoming Tenacious Gender Inequity for Greater Health Impact

There’s More to the Story: Overcoming Tenacious Gender Inequity for Greater Health Impact

Lucia Afiki and Esther Goodson are living positively with HIV. They are counselors for family planning and HIV & AIDS at Salima District Hospital in Malawi, where they openly tell their clients that they are HIV-positive. “When we are open with them about our status,” says Afiki, “people say, ‘Come closer, we want to learn from you.’” Goodson adds: “They say, ‘What should I do to look as good as you?’” The counselors tell them to visit a doctor and join a support group. This is an approach that saves lives. It also transforms social norms about health and gender.

Gender inequalities undermine the health of women and girls

Afiki and Goodson are among the disproportionately high number of young women living with HIV in Africa. Three-quarters of the 6.2 million young people in Africa with HIV are women.  Why?  Like many social dynamics of today, the story of gender inequity is captured thru HIV & AIDS with painful precision. The most tenacious form of discrimination worldwide today is not racial, ethnic, or religious. It’s gender discrimination. The stunning skewing of AIDS prevalence toward young women is a result of gender—inequality in education, personal and political power, economic power, and violence.

  • After national income fairly distributed, female education is the single most powerful determinant of a nation’s health. Yet two-thirds of children not in school are girls. In most low-income countries young women have 10 to 50 percent less AIDS knowledge than young men.
  • Women’s lack of personal and political power makes it difficult for them to negotiate safe sex and share their HIV status. Half of married women in Africa have no say in decisions regarding their health care. Women are out-numbered 4 to 1 in parliaments and legislatures worldwide.
  • Economic vulnerability increases the likelihood of women and girls turning to commercial sex or the “sugar daddy” relationship to survive. In Africa, 8 out of 10 women are in financially vulnerable self-employment or family work with little or no pay. The majority of women worldwide cannot get a bank loan or legally own property.
  • Partner violence and rape are significant contributors to the spread of AIDS. Globally, 35-70 percent of women are victims of violence in their lifetime. There are five categories of violence exclusively or predominantly experienced by women, including sexual violence, domestic violence, and crimes against women in armed conflict.

There’s more to the story – a gender-sensitive approach multiplies health impact

The global health community has looked at its work mostly through a health lens, but there is more to the story. Here are three examples of efforts in which MSH has had the privilege to be involved.

Bringing Health Care to Women in Ethiopia: The MSH-USAID HIV/AIDS Care and Support Program (HCSP) in Ethiopia tested six million people for HIV in three years, and supported those who tested positive, by focusing on families and linking all levels of the health system. But there’s more to the story. HCSP’s success was based on its gender sensitivity. In Ethiopia as elsewhere in Africa, nearly two thirds of HIV-positive adults are women and three quarters of HIV-positive 15 to 25-year-olds are women. In partnership with the Ethiopian ministry of health, HCSP employed community health workers to reach women at home, capitalized on existing networks and traditions to connect women to care, and employed women at all levels of service delivery. It also engaged men through couples counseling and worked with the government and private sector to institutionalize gender equity. As a result, 55 percent of those HCSP tested for HIV were women. Additionally, HCSP increased HIV testing among pregnant women seen at its health centers from 71 to 93 percent in two years.

Turning Women into Leaders in Egypt: The MSH-USAID Leadership Development Program (LDP) has partnered with numerous ministries of health in low-income countries to increase the impact of their health programs. In Egypt, it supported nurses in improving practices such as documenting patients’ vital signs and preventing surgical infection rates. But there’s more to the story. The nurses, who are mostly women, traditionally are not encouraged to make improvements in care. The LDP taught them to address a wide range of health care challenges, including the discrimination they face. The LDP also has been applied more broadly in Egypt, leading to a reduction in maternal mortality from 87 to 35 per 100,000 live births in the project region.

Supporting Women as Entrepreneurs in Tanzania: Private drug shops, which are the first point of care for most people in rural Tanzania, often dispense medicines of inadequate quality and quantity. But they are ubiquitous and financially sustainable. MSH worked with the Tanzanian government, the Gates Foundation, and others to create a public-private partnership to brand the shops. Now, trained drug dispensers provide proper medicines, advice, and referrals for a wide range of basic health needs. But there’s more to the story. The shops not only bring care closer to women in their homes, they are also operated mostly by women. Of the more than 3,000 drug dispensers we’ve trained in Tanzania, 90 percent are women.

We can and must overcome gender inequality—for the good of all

In these examples and others from around the world we can see that strengthening health systems and building the capacity of women as leaders can promote women’s and girls’ right to health. Viewed through the lens of gender equity, virtually every health program can become a force for both gender equity and greater health impact.

But this effort requires action from all of us. Gender inequality not only affects women and girls, it affects the well-being of entire communities and nations. The world will not move forward if only women push back against inequity. Men must pull back from the practices that create the inequity. We can see that efforts to sensitize and involve men are hugely effective.

Lucia Afiki, Esther Goodson, and their colleagues and clients in Malawi, male and female, are leading the way. They are breaking the cycle of oppression and reaping the rewards. They are living positively. They are proof that the staggering injustice of gender discrimination can be overcome and that we are all better off if we invest in the movement to eradicate it.

Jonathan D. Quick, MD, MPH, is President and Chief Executive Officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.

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