2. Causal pathways that determine gender inequities in health

In 2007, a ground-breaking paper by the Women and Gender Equity Knowledge Network of the WHO Commission on Social Determinants of Health synthesised knowledge about the health outcomes of unequal gender relations. The framework developed by the authors Sen, Östlin and George included three main causal pathways that shape gender inequities in health:

1. discriminatory values, norms, practices and behaviours
2. differential exposures and vulnerabilities to disease, disability and injuries
3. biases in health systems.

Pathway 1: discriminatory values, norms, practices and behaviours

Gender norms influence the perceived value of the individual and their power to make decisions about their own health, as well as individual health-related attitudes, behaviours and practices.

Above all, access to health services is linked to the relative ‘value’ of girls and women versus boys and men, and to unequal access to household resources, authority and decision-making. Evidence across LMICs shows that gender inequality privileges the health and wellbeing of boys and men, especially in settings characterised by a strong preference for sons. One extreme expression of this gender bias is the excess mortality of girls as a result of prenatal sex selection and postnatal discrimination in some countries, especially in South and East Asia.

Women and girls who lack resources and decision-making power often depend on male members of their household to access health services, with adolescent girls, in particular, needing the consent of their parents or spouse for such access. Studies have found, however, that men often lack the necessary health knowledge and are unwilling to spend money on the health of women and girls, rather than their own health needs or those of their sons. The end result is that women and girls delay accessing the care they need, struggle to complete treatment, or are forced to use informal healers and their therapies.

In many societies, norms associate masculinity with strength, toughness, independence, self-reliance and risk-taking. Older adolescent boys and young men tend to engage in excessive alcohol consumption, unprotected sex, dangerous driving or violent practices and have higher rates of substance abuse, injuries from traffic accidents and homicides.

Girls and young women, however, are often seen as more vulnerable and risk-averse and are expected to show modesty, submission and dependence while their movements are restricted and monitored and their sexuality is controlled. As a result, adolescent girls and young women are less physically active and more likely to experience violence or suffer depression.

Gender norms also influence health-seeking practices. Because they feel pressure to appear strong, men may dismiss their own health care needs, and avoid seeking health care. Women are more likely to seek help for physical and mental health problems, yet they are also expected to be self-sacrificing and put the needs of other family members before their own health.

Such prevalent norms can have harmful consequences for those who do not adhere to them. Adolescent girls who become pregnant outside marriage, for example, might not seek reproductive health services because of perceived stigma. Where restrictive norms emphasise female modesty and purity, ‘good’ girls and women can only move in public spaces if accompanied by a male guardian and cannot be examined by male health providers. Similarly, men who do not conform to the masculine heterosexual ideal may avoid seeking health care for a sexually transmitted infection (STI) to avoid discrimination and humiliation.  

Pathway 2: differential exposures and vulnerabilities to disease, disability and injuries

Gender norms and roles shape disparities in exposure and vulnerability to health risk and disease. While biological sex differences interact with gender and other social determinants to increase vulnerability to disease (e.g. HIV infection for women), gender roles also expose men and women, boys and girls to health risks in different ways.

At work, men and women tend to dominate tasks and occupations that are seen as suitable for their bodies and their gender roles. Men, therefore, undertake more physically intensive work and account for most workers in construction, transportation, fishing and fire-fighting, while women are concentrated in caring and service professions or light assembly work.

This gender segregation in the labour market exposes men and women to different physical and psychosocial risks and hazards. Men have more occupational accidents than women and are more exposed to noise, vibration, extreme temperatures, chemicals or the impact of heavy lifting and carrying. Women, however, are more exposed to highly repetitive and monotonous work, poor postures, stress and sexual harassment and violence. Those working in cash crop production, in particular, are exposed to pesticides and toxic chemicals. More women than men report musculoskeletal problems, repetitive strain injury, work-related fatigue, adverse reproductive health outcomes, infections and mental health problems.

At home, women and girls are expected to shoulder most domestic and care work, leaving them little or no time for other activities. Indeed, data from 83 countries show that women spend 18% of their day on unpaid domestic and care work, compared to 7% for men, and that they do 2.6 times more unpaid domestic and care work than men. Women aged 25-44 with young children spend more time on their care than any other female age group. Similarly, data from 33 countries indicate that girls aged 7-14 do more household work than their male peers while caring for younger siblings.

In 2013, a report by the UN Special Rapporteur on extreme poverty and human rights to the UN General Assembly acknowledged unpaid care work as a major issue for human rights, including the right to health. Globally, when unpaid work is included, women work longer hours than men, and their burden increases with poverty and social exclusion: women and girls in poor households in all countries spend more time on unpaid care. The report points out that there are limits to how much care one person can provide without harming their own health.

Women and girls are also responsible for collecting water and fuel for domestic use: tasks that eat into their time for education, income-generation and rest. National survey data show that they are responsible for water collection in 80% of households without access to clean water on the premises, with women and girls in the poorest rural households travelling longer distances and spending more time to reach water sources. Similarly, they are more likely to gather fuel wood, with girls in households that rely on it for cooking spending 18 hours each week on its collection.

This work is physically demanding: women and girls may walk miles with loads of wood, dung or other fuels that weigh 40 kg or more on their backs or heads. Such tasks expose them to a range of risks such as spinal conditions and chronic headaches, injuries, animal attacks and violence.  

Gender roles can contribute to gender morbidity and mortality in natural disasters. An analysis of data from 141 countries found that women and girls are more exposed to disaster risks and are more likely to suffer higher rates of morbidity and mortality than men and boys when disasters strike because of constraints on their mobility and limited skills and abilities to save themselves. The study revealed that the higher women’s socioeconomic status, the weaker the impact of disasters on the life expectancy gender gap; disasters cause the same number of deaths for men and women where they enjoy equal rights.

Pathway 3: biases in health systems

Sen et al. (2007) stressed that health systems do not only produce health care, but also reflect, convey and reinforce societal norms and values. Health systems are not gender or power neutral: their main components are affected by entrenched gender norms that often compromise their effectiveness.

Health providers, for example, may reproduce gender stereotypes and provide different care for men and women who are suffering from the same health problem. They may discriminate against, or even abuse, those who do not adhere to gender norms or refuse male involvement in health programmes for women. Female health providers are also more likely to find it difficult to advance their careers.

Many health systems continue to neglect gender and the way in which gender relations shape access to resources, roles and responsibilities and decision making. They fail to acknowledge the different health needs and problems of both women and men and, therefore, fail to provide the health services they require.