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A virus, an inanimate piece of floating genetic material doesn’t discriminate, that doesn’t mean that all parts of society are equally pained. In fact, pain is biased, and the virus has just exposed the health inequalities across the system to be addressed. Taking lessons from COVID-19 response and related health emergencies, this article is an effort to analyse and present the case on why a more fair, inclusive gendered lens is required for health system governance.
Since the beginning of the pandemic, there has been a lot of research coming upon how COVID-19 discriminates between genders. Similar trends were noticed in previous outbreaks of SARS and MERS, where it appears to affect men worse than women. It is reported that in most countries’ men are 50-60% more likely to die from the virus following the diagnosis than women, but this is not the only way that the disease impacts gender. The social, economic and long-term health consequences disproportionately impact the lives of women and girls. The health crisis is a catalyst worsening the divides and inequalities within the societies; impacting more severely the most disadvantaged, marginalised including women, migrants, differently-abled, HIV patients and sexual minorities.
Noted challenges in case of an outbreak, the similar pattern we experienced during COVID-19 pandemic:
1) Due to health system disruption, pregnant women are unable to attend health clinics during and after the outbreak, which results in increased maternal mortality and morbidity.
2) Access to reproductive health: with lockdown restrictions, supply chain disruption, reallocation of resources, the situation leads to difficulties in access to reproductive health services including contraception, antenatal and post natal care, menstrual hygiene products, access to safe abortion and post-abortion care etc.
During such health emergencies, a gender-focused response is needed, which can be achieved through multispectral response including targeted and protected funding for gender-focused governmental and non-governmental organisations, programs, gender and sex-disaggregated data collections for real-time gender analysis of the situation. During lockdown in India, supporting and funding active grass root women support groups who expanded the help lines via technology-based platforms like online and mobile platforms was helpful to mitigate immediate effects.
3) It is reported that school closures are predicted to have far reaching and long-term consequences including a spike in adolescent pregnancies and girls being less likely to return to education. For example, in the Ebola crisis there was a 65% increase in adolescent pregnancies and due to discriminatory policy in Sierra Leone, pregnant school girls were not allowed, and hence the country lost a generation of girls who did not return to school.
Furthermore COVID-19 could lead to an increase in cervical cancer which is already the leading cause of cancer death in females. Human papilloma virus (HPV) vaccine program for preventing cervical cancer which is implemented in the school has been disrupted globally.
4) Economic ramification: Women represent a massive proportion of the unprotected informal economy, livelihoods that include agriculture, markets and domestic workers. It’s reported that women globally perform 3 times as much as unpaid caregivers than men, and within families working from home during lockdown, a double burden falls on women as both full time homemaker and careers professional. Economic insecurity also underlies the increase in domestic violence.
5) Gender based violence: Women, children and the elderly are vulnerable and unable to access needed help and services.
6) Stigma and frontline female health care givers: Due to social and gender norms, women are family caregivers and frontline health care workers. Globally approx. 70% of the health workforce is made up of women and they lack a support system. During COVID-19, with high transmission rate, consequent fear and misinformation surrounding the virus when combined with gender inequalities, women front liners are more likely to be shunned by their households and communities.
Additionally, intersectional communities are heavily affected. There is a further population, who are at risk of discrimination and systemic stigmatisation inhibiting health care services, which makes them more vulnerable to health emergencies. The HIV affected people because of their weaker immune system run the, risk of decreased access to antiviral therapy medication, and the attached social stigma makes them more vulnerable. The differently-abled who require additional health support are likely to be disproportionately impacted and pained due to a disrupted/weakened/ and sometimes inaccessible health system. Migrants and displaced people; with limited or no access to health services, living in congested quarters with limited access to clean water, food and shelter are especially vulnerable. The multidimensional nature of a crisis requires a multi-dimensional solution and we need to recognise multiple voices; we need to make sure that diversity is part of that solution.
Summarily, Health system governance should be human centric and barrier free, inclusive, non-discriminatory with a tailored and targeted response. Health challenges will not be solved without greater diversity most notably involving women in the decision making. With just 25% female representation within global health leadership and only 5% coming from low and middle income countries, all women’s voices must be heard and centred by high level decision makers to address the needs.
At present, enormous disruption has been created by the pandemic, blind spots are exposed and we have realised the need to rethink health system governance, rethink engagement patterns, and rethink who should be at the decision table. Rethinking engagement patterns also involves decision makers consciously and deliberately leaning out to create space for more diverse voices to be listened to. It is time to note that increasing diversity and inclusiveness is critical to efficient and sustainable governance. We should eliminate the blind spots by rethinking how alliances should be made to include the inputs of those who are closer to certain less obvious realities and problems and therefore closer to the solution.