WORLD BANK GENDER THEMATIC POLICY NOTES SERIES: EVIDENCE AND PRACTICE NOTE ACHIEVING GENDER EQUITY IN HEALTH: KEY AREAS OF FOCUS UNDER UNIVERSAL HEALTH COVERAGE Sameera Altuwaijri, Seemeen Saadat, Meriem Boudjadja, Charlotte Pram Nielsen, Amparo Elena Gordillo-Tobar, Mirai Maruo, and Priyadarshani Rakh OVERVIEW Gender and health are intrinsically connected. Gender influences an individual’s way of living, well-being, health, and patterns of seeking and receiving health care throughout their life. Reducing gender gaps in health can increase human capital while ensuring that all sexes have the best possible start to life, have their health care needs met, and have the opportunity to reach their full potential. Achieving gender equity in health requires a systematic approach across health systems. Universal health coverage (UHC) provides such a platform, especially through integrated primary health care (PHC) services. Drawing on World Bank operational knowledge and experience, this thematic note presents five priority areas where investments can help to solidify gains and further reduce gender gaps in health. • Providing comprehensive sexual, reproductive, adolescent, and maternal health services (including family planning) empowers women, girls, and other gender identities and supports their health. • Coverage of healthcare for older adults, especially women, under UHC supports healthy aging. Integrating with models of long-term and community-based care brings services closer to people. • Supporting gender equality in health leadership can have a cascading effect on laws, policies, and regulations, as well as on the environment in which women and other gender identities work and receive healthcare. This includes addressing gender biases in medical training, career advancement, leadership training, and mentorship, as well as supporting inclusion, intersectionality, and diversity in decision-making bodies. • Covering mental health under UHC (including better training for health care providers and social and behavior change communication) will facilitate reducing gender gaps in access to and use of services for women, men, and other gender identities. • Reducing gender disparities in pandemic preparedness and emergency response will support continuity of essential health services; better communication; diagnosis and treatment of (drug- resistant) infections; adequate training, pay, and equipment for frontline workers, particularly women; and inclusion in leadership and decision-making bodies. TABLE OF CONTENTS INTRODUCTION 1 Gender and the health systems framework 2 The role of the private sector in health systems 3 PRIORITY AREAS FOR HEALTH AND GENDER EQUITY UNDER UHC 4 Sexual and reproductive health and rights 4 Healthy aging and access to health for older women 6 Supporting women’s participation in health leadership for gender equality 9 Addressing gender differentials in mental health 12 Enhancing gender equity in pandemic preparedness and emergency response in health 15 PROPOSED ACTIONS TOWARD GENDER RESPONSIVE AND TRANSFORMATIVE POLICIES AND PROGRAMS 18 Strengthening sexual and reproductive health care and rights 18 Promoting gender equity in health for aging populations 19 Supporting gender equality in health care leadership 19 Improving access to mental health services 19 Ensuring gender-responsive pandemic preparedness 20 REFERENCES 21 This thematic policy note is part of a series that provides an analytical foundation for the World Bank Gender Strategy (FY24–30). This series seeks to give a broad overview of the latest research and findings on gender equality outcomes and summarizes key thematic issues, evidence on promising solutions, operational good practices, and key areas for future engagement on promoting gender equality and empowerment. The findings, interpretations, and conclusions expressed in this work are entirely those of the author(s). They do not necessarily reflect the views of the World Bank or its Board of Directors. This note was prepared by Sameera Altuwaijri, Seemeen Saadat, Meriem Boudjadja, Charlotte Pram Nielsen, Amparo Gordillo-Tobar, Mirai Maruo, and Priyadarshani Rakh. It was peer reviewed by Ian Forde, and Avril Dawn Kaplan and benefited from inputs and feedback by Tanima Ahmed, Diana Arango, Hana Brixi, Silven Chikengezha, Sanola Daley, Charles Dalton, Zeynep Kantur, Amy Luinstra, and Laura Rawlings. INTRODUCTION Gender and health are intrinsically connected. Addressing In lower-income countries, vulnerable populations, gender disparities in health care services has the potential especially women, girls, and other gender identities, face to increase human capital by 22 percent (Mousa et al. 2021). multiple barriers to accessing health services. Vulnerable As a social determinant, gender influences an individual’s groups encounter the broader, persistent challenges within way of living, well-being and health, and patterns of the health sector, such as low government spending on seeking and receiving health care (Heise et al. 2019; Weber health; an underdeveloped, inaccessible, or cost-prohibitive et al. 2019). Both the biological sex1 and social constructs private health sector; low quality of public health care; of gender (gender norms) influence health outcomes and limited human resources for health, especially in across the life cycle. Gender inequalities impact the health rural and remote areas (Booty 2020; Banerjee et al. 2021). of women, men, and other sexual and gender minorities These shortcomings contribute to inadequate availability within lesbian, gay, bisexual, transgender, and intersex of quality health services, especially at the primary level of (LGBTI) communities. These inequalities can take various care. Gender and social norms, especially in lower-income forms, affecting not only health outcomes but also access settings, can further impact women, girls, and other gender to and use of preventive and curative health services. identities by limiting their access to jobs and financial They influence how easily people can access services, opportunities, as well as their decision-making power their ability to make decisions about their own health regarding when, why, and how to access and use health care and bodies, their ability to pay for services, and the care. Such barriers can contribute to delays in seeking quality of services received. Differences in health needs health care, especially concerning women’s own health. and opportunities accompany people throughout their lives, from infancy to adolescence, adulthood, and old age The World Bank recognizes gender as a core social (Vlassoff 2007; World Bank 2016; Lancet Series on Gender determinant of health as it works to mitigate gaps in Equality, Health, and Norms 2019). Moreover, gender biases universal health care, strengthen primary health care access, in the health sector (e.g., in health research and limited and improve the quality of health care. It is committed to representation of women in health leadership) affect how achieving gender equality through its policies, strategies, the sector is managed and the quality of services and analytical work, and operational action on health. Targets treatments provided. set under IDA commitments since IDA18 support the flow of development funds to strengthen 1  he differences in the biological determinants of health and illness include differential genetic vulnerability to illness, reproductive and hormonal T factors, and differences in physiological characteristics that can contribute to gender gaps in health over the life cycle. 1 countries’ programs and enhance the Bank’s response to women who work in informal sectors or who may not gender in its health projects. High-priority areas include participate in the labor market due to social norms and/or maternal and reproductive health, as well as training and care giving responsibilities. deployment of women health care providers. The Global Financing Facility for Women, Children and Adolescents Despite this potential, UHC interventions are often designed (GFF) multi-donor trust fund also focuses on improving without gender issues in mind. This includes foundational reproductive, maternal, newborn, child, and adolescent elements of UHC, such as collection, analysis, and use health and nutrition through evidence-based interventions of data for decision making; measuring and improving and targeted strengthening of primary health care systems. quality of care, including patient-reported outcomes and Since its inception in 2015, the GFF has been pivotal in experiences; and design, access, and use of digital platforms bringing together stakeholders for focused, government- for UHC. Evidence from countries, such as India, Brazil, and lead, sustainable funding for women and children’s health Ghana, indicates that the lack of gender consideration in in 36 low and lower middle-income countries.2 UHC design can perpetuate gender-based gaps in health. For instance, women may face barriers to registering for GENDER AND THE HEALTH SYSTEMS UHC-supported programs due to financial or physical FRAMEWORK constraints or a lack of identity and civil registry papers. Addressing gender inequalities in health requires a Women may continue to pay high out-of-pocket costs systematic approach across health systems. Universal health for sexual and reproductive health services due to coverage (UHC), with a specific focus on primary health care misinformation, limited coverage, or other costs that are (PHC), provides a compatible platform for addressing gender either not covered under UHC or are hidden, such as the gaps. UHC aims to “ensure that all people have accessible, cost of transport and lost income earnings (Sen, Govender, affordable, and quality health provision, regardless and EL-Gamal 2020). Designing health projects and of their wealth, gender, or other circumstances” (WHO programs that are responsive to gender issues in PHC can and World Bank 2021a). It aims to ensure that everyone help reduce gender gaps and achieve UHC. receives the necessary high-quality health care without Simultaneously, gender norms, social and cultural beliefs, suffering from financial hardship. UHC is a key World Bank and other socio-economic determinants can influence commitment under the Sustainable Development Goals women’s, men’s, and other gender identities’ access to and (SDGs). Simultaneously, PHC services are the first point of use of health services, affecting their health outcomes over contact with the health system for most people and an their life course. Women’s limited voice and agency due important one for survivors of gender-based violence (GBV). to regressive gender norms reduce their ability to make Ensuring that affordable, quality, and appropriate health decisions about their own bodies. Their restricted mobility care is available at the PHC level supports better health in some parts of the world increases their dependency on by establishing regular care and facilitating access to more men to be able to reach health facilities, which can cause specialized health care when needed. delays in receiving appropriate health care. Gender norms Implementing UHC has the potential to address gender around masculinity can become barriers to men seeking gaps in health by facilitating access to affordable and quality health care for themselves, including for mental health. health care. For instance, including sexual and reproductive Discrimination against other gender identities can limit health services as part of the package of essential health care when, where, and how LGBTI people access health care, even services under UHC can support women, girls, and other when it is available.4 Ensuring that health care providers are vulnerable groups (including LGBTI) in accessing essential trained to recognize and provide services without bias, can reproductive care by making it affordable. Similarly, where improve access for other gender identities, who often face health insurance is available, such as employer-based high barriers to health care due to societal discrimination. health insurance, it needs to be accessible, affordable, and The World Bank’s Health Systems Flagship5 framework equitable for women as they age. Alternatives to traditional identifies three performance goals of a health system: health insurance and pensions3 can enable coverage for improvement in health status, citizen satisfaction/ 2 Information on GFF investments and results available at: https://data.gffportal.org/.  3  or example, non-contributory programs or mechanisms, such as allowances or cash transfers, are often used in lower income countries for F maternal and child health and in some cases, for the provision of social security to older people and those with disabilities, such as the Karama program in Egypt, universal pensions in Mexico and Georgia, and monthly allowances in Timor-Leste (DeMarco et al. 2024). UHC can also be funded through taxation (as in the United Kingdom or Canada); microfinance or micro-pensions; social security credits for family caregivers for time out of the labor market caring for young or elderly family members (as in France and Germany); and funded schemes based on family savings or investments rather than individual savings and investment (Cameron 2019). 4  or more on this topic, see the World Bank Gender Thematic Policy Note on Sexual Orientation and Gender Identity (SOGI) Inclusion and Gender Equality F 5  his framework updates the approach to modeling a health system and encompasses the linkages between social determinants of health T (including gender), health systems, health outcomes, and human capital. 2 responsiveness, and financial risk protection (see Figure they receive. All three goals of the health system can be met 1). Addressing gender inequality in health is important for by supporting the availability of primary health care in or near achieving these goals. For instance, barriers to timely access villages or neighborhoods where women live, implementing to health services rooted in gender norms (e.g., women’s universal health coverage that supports women’s capacity to limited mobility or provider bias against LGBTI) or capacity to afford health care, and ensuring that essential packages of afford these services contribute to gender gaps in women and care under UHC cover women’s health needs (e.g., sexual and men’s health status and their satisfaction with the health care reproductive health, including for menopause).6 Achieving gender equality in health requires addressing barriers the effectiveness and reach of a response. The private sector is within and outside the health system with a focus on improving active in the manufacture and distribution of lifesaving products health outcomes for women, men, and other gender identities. A with the capacity and agility to scale at times of high demand, holistic approach capitalizes on the Bank’s current engagement and in the provision of diagnostics and health care services on gender gaps in health and sharpens focus on other emerging complementary to the public sector. In some developing or priority areas, such as pandemic preparedness and women’s countries, the private sector constitutes up to 80 percent of leadership in health and more broadly. health service capacities. Moreover, the mobilization of private capital can enable large-scale expansions of capabilities THE ROLE OF THE PRIVATE SECTOR IN in response to an emergency. The health sector provides HEALTH SYSTEMS opportunities for entrepreneurs, including those in health tech, to close access gaps and advance innovation. Women The private sector plays a critical role across the health value entrepreneurs, although small in numbers, serve critical areas chain, including in areas, such as research and development for in health, including patient care, health care service delivery, and new products (such as vaccines) and innovation that can enhance facilitating access to medical equipment and clinical services. 6  he World Bank’s self-paced e-learning module on Gender and UHC details how gender interacts with different aspects of the health system. T The course is part of the Health Systems Flagship series. 3 PRIORITY AREAS FOR HEALTH AND GENDER EQUITY UNDER UHC The World Bank’s Gender Strategy 2024–2030 provides Goals (MDGs), sexual, reproductive, and maternal health an opportunity to review and build on progress toward has been a global priority and progress has been made. reducing gender gaps in health. An array of World Bank Between 2000 and 2015, maternal deaths worldwide interventions has shown that achieving UHC supports declined by 33 percent, from 451,000 to 303,000, and the achievement of gender equality. In alignment with continued to decrease with an estimated 295,000 the Bank’s focus on UHC and PHC, the following five maternal deaths in 2017 (WHO 2019a). priority areas can help solidify gains and reduce gender gaps in health. Yet, poor reproductive and maternal health remains a significant challenge in many countries, with uneven progress within and across countries. Persistent social and gender SEXUAL AND REPRODUCTIVE HEALTH norms act as barriers to seeking knowledge and health AND RIGHTS care, while policies and legal frameworks hinder women, Sexual and reproductive health and rights (SRHR) adolescents, and other gender identities from exercising encompass a comprehensive understanding of the right to their rights. On the other hand, multisectoral action such as well-being and choice over one’s own body and sexuality expanding girls’ secondary and higher education and labor accompanied by a package of comprehensive sexual and market opportunities can help improve SRHR outcomes reproductive, maternal, and adolescent health services by reducing early marriages and births and giving women (e.g., Starrs et al. 2018). Lack of access to SRHR, such as more autonomy over their own health.7 family planning, hinders girls and women from delaying childbearing, determining the size of their families, and Harmful practices and reproductive morbidity (e.g., sexually pursuing education, employment, or other activities. transmitted infections, obstetric fistulas, and female genital Improving SRHR is crucial for reducing gender gaps in cutting/mutilation, among others) still cause considerable health with reverberating impacts across other aspects of suffering. Attention to these issues in development people’s lives (Starrs et al. 2018). discourse is sporadic and action often encounters stigma. The majority of maternal deaths (86 percent) are in lower- Creating space for SRHR means supporting better income countries, mainly in Sub-Saharan Africa and South physical, mental, and social well-being, especially for Asia (Sahoo et al., 2021). Unsafe abortion represents one women and other gender identities, through enabling of the main preventable causes to maternal deaths. In their access to comprehensive, respectful, and inclusive developing countries, an estimated 220 maternal deaths health care and supporting their voice and agency. Since occur per 100,000 unsafe abortions (Ganatra et al. 2017). the establishment of the Millennium Development 7 Gender Thematic Notes on Education, Social Norms, and Labor Force Participation further discuss these areas. 4 Progress on adolescent SRHR is also uneven across regions, than 187 million unintended pregnancies averted (Global with adolescents in Sub-Saharan Africa and low-income Financing Facility 2022). Some recent examples of work in countries still experiencing high adolescent fertility and this area include the following: pregnancy-related mortality (Liang et al. 2019). An estimated 19 percent of adolescent births are in Sub-Saharan Africa The Sierra Leone Health Service Delivery & System Support (Kassa et al. 2019). As of 2013, an estimated 10 percent of Project aimed to improve the quality and use of essential adolescent girls in lower and middle-income countries maternal and child health services in Sierra Leone and gave birth, compared to less than 2 percent in high-income to support the country in responding to health crises. countries (Salam et al. 2016). Limited improvement in this Investments helped strengthen the delivery of maternal pattern means more disadvantaged adolescents are more and child health services, including ante-natal care, likely to become pregnant, give birth, and have higher skilled attendance at birth, and childhood immunizations, fertility (Huda et al., 2020; UNFP 2022). While the proportion especially for hard-to-reach and remote populations. of adolescents using modern contraception has increased These investments contributed to a 15-percentage point globally, especially among unmarried adolescents (at 51 increase in skilled attendance at birth, from 72 to 87 percent) over the past two decades, only 21 percent of percent between 2013 and 2020. During the same period, married adolescents report using modern contraception, the percentage of hard-to-reach communities with at least and unmet need remains high at 41 percent and 23 percent, one dedicated community health worker increased from respectively (Liang et al. 2019). At the same time, maternal 37 to 93 percent. mortality among adolescents is as high as 570 deaths per The Uganda Reproductive, Maternal, and Child Health 100,000 in Africa (Liang et al. 2019). Services Improvement Project sought to improve the These challenges and negative outcomes are rooted in utilization of essential reproductive, maternal, and child women and adolescent girls’ limited access to sexual and health services along with scaling up birth and death reproductive health services (especially family planning), registration services critical for ensuring accurate reporting dependence on others, and a lack of financial control on maternal and child survival and mortality. Under and decision-making power over their own bodies. The this project, skilled attendance at birth increased by 21 COVID-19 pandemic further increased the vulnerability of percentage points between 2015 and 2022, from 50 to 71 reproductive-age and pregnant women due to disruptions percent, and maternal death audits increased significantly in essential reproductive and maternal health care. At from 33 to 89 percent. the height of the pandemic, 94 percent of 112 countries The Investing in Maternal, Child, and Adolescent Health surveyed by the WHO reported disruption in at least project in Senegal also aims to improve the utilization one essential health service, and 35 percent of countries of essential RMNCAH and nutrition services meeting reported disruptions across reproductive, maternal, quality standards. Investments have contributed to a rise newborn, child, and adolescent health (RMNCAH) and in the utilization rate of modern contraceptive methods nutrition services (WHO 2021b). by adolescent girls in a relationship (ages 15-19) from a The World Bank has a long history of working on baseline of 8 percent to 16 percent between 2018 and 2023. sexual and reproductive health, especially supporting The First Laying the Foundation for Inclusive Development interventions that improve maternal health outcomes, Policy Financing supports Niger’s Ministerial Order in facilitate women and girls’ access to family planning, enabling married adolescent girls to access family planning and enhance the enabling environment. This is built on without parents’ or husbands’ mandatory accompaniment. strong analytics and evidence-based policy dialogue, first It also supports the establishment of Child Protection captured in the Bank’s reproductive health action plan Committees at the national, regional, communal, and (2010–2015), which defined priority areas for investing village levels as part of efforts to cease child marriage. in sexual, reproductive, and maternal health (including These are important steps toward women’s empowerment for adolescents). During the five years that followed, and reducing the risk of intimate partner violence and investment increased with approximately $2 billion sexual exploitation of young girls. invested in reproductive and maternal health projects.8 In 2015, the Bank along with partners launched the Global The Sahel Women’s Empowerment and Demographic Dividend Financing Facility (GFF) to further support countries in (SWEDD) flagship program works to enhance the status of advancing the RMNCAH agenda. Since partnering with the adolescent girls, empower women, and increase their access to GFF, countries’ investments have reached over 96 million quality education and reproductive, child, and maternal health pregnant women with four or more antenatal visits, over care services in Benin, Burkina Faso, Chad, Côte d’Ivoire, Mali, 103 million women with safe delivery care, 111 million Mauritania, and Niger. Each country has its own country-level newborns with early initiation of breastfeeding, and over project under the SWEDD umbrella. The initiative mobilizes the 500 million users of modern contraceptives, with more 8 Based on an analysis of the IBRD/IDA portfolio. 5 entire community—from religious leaders, politicians, and health • Communicating via multiple delivery channels and professionals to mothers and husbands—to harness recognition in local languages helps to deliver family planning of women’s enormous economic potential. It invests in health information and products, including both facility and service delivery, social and behavior change, and girls’ education community-based efforts, to the most vulnerable and employment. SWEDD has helped over 9,000 midwives women and girls complete basic training and receive short-term continuing • SBCC is pivotal for encouraging the uptake of timely education, contributed to an increase in contraceptive use with sexual, reproductive, and maternal health care. This over 300,000 new users in target areas, and reached 4 million includes interventions that engage men and boys to people with social and behavior change communication (SBCC). improve their knowledge and promote better health- In addition, SWEDD has supported 300,000 girls with financial seeking behaviors for both women and men. and in-kind support to stay in school and helped 120,000 out- of-schoolgirls learn life skills between 2015 and 2021. • Coupling SRHR with nutrition interventions supports better reproductive and maternal outcomes along with Lessons learned on improving reproductive and improved newborn and child health outcomes. maternal health outcomes for women and girls • Coverage of the continuum of care under UHC enables The World Bank’s experience and lessons from the affordability and reduces financial constraints. global development community’s support for sexual • Conditional and in-kind transfers can support equity and reproductive health suggest the following key in access to maternal and child health care, as well as elements of successful interventions to improve better performance among providers, but this needs to women’s health outcomes. be applied with caution to avoid coercion. • It is important to provide comprehensive sexual, reproductive, and maternal health services (including HEALTHY AGING AND ACCESS TO HEALTH ante-and post-natal care, skilled birth attendance, and FOR OLDER WOMEN family planning information and services) to ensure a continuum of care. Women make up nearly half (49.5 percent) of the world’s total population of 7.8 billion people.9 Due to a combination • Family planning is a best buy because it empowers of biological and behavioral risk factors, women tend to live girls and women to make decisions about childbearing longer than men. While the proportion of women ages 0 to (when and how many) and facilitates their potential for 59 years is 42 percent of the total population at the global higher education and labor market participation. level (a deficit of 8 percent), the proportion shifts as the 9 Health, Nutrition, and Population Statistical Database, World Bank. 6 population ages, with women ages 60 and above making Moreover, women may not seek or receive care in a timely up over 55 percent of older age groups (see Figure 2). As manner. For example, across Sub-Saharan Africa, women the world population continues to age, the cohort of older come to health care facilities with stage 3 or 4 breast and/ women will also increase. These women may be living or cervical cancers because they do not access diagnostic with multi-morbidities and may be financially constrained, services early on due to barriers in access and affordability, especially in low and middle-income countries with limited cultural norms, and stigma (Gebremariam et al., 2023; Ngwa or no coverage under health insurance or social protection et al., 2022). This not only compromises their survival but programs (where they exist), since women constitute a makes treatment even more unaffordable or inaccessible. smaller proportion of the labor market and often drop However, innovations in digital technology can address out after childbirth or due to other care responsibilities or such issues (see Box 1). are more often engaged in informal markets. This is the feminization of aging and old-age poverty. Women’s quality of life as they age can deteriorate into or further into relative poverty because of out-of- considerably due to illness and lack of resources. Control pocket health expenditures (WHO and World Bank 2021b). over financial resources and access to care are two Women, particularly older women who are dependent on important dimensions of healthy aging where women are others, are vulnerable to delayed or foregone health care often constrained (McMaughan, Oloruntoba, and Smith due to the high and prolonged cost of services for age- 2020; Read, Grundy and Foverskov 2015; Miszkurka et al. related health conditions. 2012). For example, in India, widowhood is associated with women’s use of public health services in older ages but Although data on LGBTI is limited, and often from higher- not so for men or married women, who are more likely income countries, it points to worse experienced health to use private health care, which may offer higher quality outcomes. In Canada, a recent large-scale study found that of services (Hossain et al. 2021). In 2017, it was estimated a significantly higher share of LGB persons reported poorer that about half a billion people were pushed or further functional health than their heterosexual counterparts with pushed into extreme poverty, and 2.2 times as many went bisexual females faring the worst: 20 percent reported fair or poor health compared to 11.2 percent of heterosexual 7 BOX 1: DIGITAL TECHNOLOGY INNOVATIONS BRING SERVICES CLOSER TO PEOPLE Beyond availability and affordability of services, two key barriers to women’s access to health care are limited information and mobility. This is exhibited in the delays in seeking care, especially for noncommunicable diseases, such as diabetes or cancers, which can often be overlooked without knowledge, regular screenings, and preventative care. Investing in health education through social messaging and targeted campaigns, coupled with innovative digital technologies, can help to address these barriers. In 2022, the World Bank partnered with the Consumer Technology Association for the Global Women’s HealthTech Awards. NIRAMAI and UE LifeSciences were two of four winners for private sector innovation. NIRAMAI has developed a novel software-based medical device for detection of early-stage breast cancer in a simple and private way. Their solution is a low cost, accurate, automated, portable cancer screening tool that works for women of all age groups and breast densities, addressing a key unmet need in cancer screening. UE LifeSciences has developed iBreastExam, a radiation-free device that enables earlier stage detection of breast cancer at low-cost and minimal training compared to other options. To date, the company has reached over 500,000 women in countries such as Egypt, India, and Botswana, helping to detect over 200 cases of breast cancer. Source: Global Women’s HealthTech Awards, 2022 winners females (Rauh 2023). Work by Fredriksen-Goldsen and live with the long-term side effects of COVID-19 as well as colleagues in the United States highlights that older lesbian other noncommunicable diseases as they age (Lindhal et and bisexual females faced similar physical health issues al. 2022). Health systems must take action to reduce this as their heterosexual counterparts but reported more burden of male mortality and ensure people, especially disability and poorer mental health. They were also less older women, receive appropriate and affordable care. likely to have health insurance and more likely to face financial constraints (Fredriksen-Goldsen 2013). The World Bank has done analytical work to address cross- cutting issues, such as social protection and long-term care, Traditionalism, negative attitudes toward aging, and for aging populations in middle-income countries. In some stigma can also contribute to a lower quality of life and cases, particularly in Eastern European economies, data do health, whether perceived or experienced, for women not reveal significant gender gaps in access to social services, and men (Sun et al. 2022; Nair et al., 2021), including but data are also not geared to examine other issues, such within the LGBTI community. Women’s limited voice and as the feminization of old age and old age poverty. Gender agency, financial dependence on others, and living longer gaps are most often examined in the context of women’s with multi-morbidity contribute to their lower levels of employment and care responsibilities. There is a need and self-rated health (Carmel 2019). Similarly, experiences of opportunity for dedicated data collection and analysis on discrimination contribute to poor health among LGBTI gender gaps among aging populations regarding access to people. A recent Finnish study, for example, found that health services and health outcomes (beyond mortality), in the aftermath of COVID-19, women reported more especially for countries with greater gender inequalities. symptoms and a lower quality of life than men (Lindahl et al. 2022). Earlier studies in Brazil and the United States With a significant proportion of the global population expected found that older women will experience higher levels to be over the age of 60 by 2050, including in Sub-Saharan of physical disability compared to men due to socio- Africa, women will constitute a larger proportion of the elderly. economic inequalities across the life course (Guerra, They need interventions that will empower them across their Alvarado and Zunzunegui, 2008; Thorpe et al., 2008). As life course with access to resources, such as income, social populations continue to age, the prevalence and severity protection, and health insurance, and more control over of disabilities are expected to increase (UN Women, 2012). decision making about their health and well-being. Moreover, with COVID-19 becoming endemic, there is likely Interventions to reduce gender disparities in to be increased levels of illness and mortality due to the healthy aging disease, impacting women and men differently. Current As governments establish UHC systems, these systems patterns from a handful of higher and middle-income must address gender disparities in access and affordability countries indicate a higher rate of male hospitalization and of care for older cohorts. This should come with other cross- mortality due to the disease compared to women (Global cutting interventions that support women’s empowerment Health 50/50). On the other hand, a larger proportion of across the life course. The following interventions can help survivors of COVID-19 are likely to be women, who may to improve gender equity in healthy aging: 8 • Provide coverage for women under UHC or other payment senior leadership roles are held by women (Mousa et al. arrangements for health services beyond reproductive 2021) and of these, only 5 percent are women from low and maternal health (i.e., coverage across the life cycle). and middle-income countries (WGH 2023). Fewer than 9 percent of health tech startups are founded by women • Provide PHC services that address the health care entrepreneurs, and women comprise only 11 percent of needs of older populations, such as management of noncommunicable diseases, psychosocial support, partners in health tech companies (Raphael 2019). Similarly, menopause care, and osteoporosis, and ensure on average, women hold only 30 percent of executive these are integrated with models of long-term and positions and 18 percent of board seats in the biotech community-based care for older populations. industry (Pagliarulo 2020). In 2023, less than 10 percent of investor funding went to health tech companies founded • Support better access to information on health and by women entrepreneurs (Tecco 2017). Yet, women make social services, their availability, coverage eligibility, up 70 percent of frontline health care workers globally, and how to access these, with dedicated campaigns often as lower-paid, junior-level staff, or unpaid volunteers. targeted at women and in local languages. The vast majority of registered nurses, 80 percent, are • It is essential that UHC systems respond to the gender women (see Figure 3). gaps in access and affordability for older and elderly cohorts. Better coverage for older and elderly women These gaps are the result of barriers created by social and can help reduce financial constraints on households gender norms that impact women’s lives and by decisions that often lack this knowledge. that influence their health, education, employment opportunities, and career advancement. For example, • Introduce SBCC to promote healthy habits and normalize unconscious (or visible) bias in school systems that the use of psychosocial services, especially among men. discourage girls in science, technology, engineering, and • Enable cross-cutting solutions that empower women mathematic (STEM) education (McDaniels 2016; Liu 2018; and other gender identities and increase their capacity Raabe, Boda and Stadtfeld 2019; Sansone 2019) or in the to have financial coverage, such as pensions. workplace create glass ceilings for women. In addition, women’s double burden of care for children, elderly, or disabled family members can limit their interest, capacity, SUPPORTING WOMEN’S PARTICIPATION and/or opportunity to access employment, equal pay, IN HEALTH LEADERSHIP FOR GENDER or leadership opportunities (Pérez-Sánchez, Madueño, EQUALITY and Montaner 2021; McDonagh et al. 2014; Albertini 2016; The gender gap in health leadership is glaring. Although Mahtad et al. 2019; Ahmed et al. 2023). In Cambodia, for women account for 71 percent of all global workforce example, women represent 20 percent of the senior roles in professionals and 59 percent of all graduates in the medical, the Ministry of Health. When offered leadership positions, biomedical, and health sciences fields, only 25 percent of women, by necessity, have to take a consensual approach 9 to acceptance, seeking approval from families first (Dhatt et 2018). In Spain, an analysis of regional hospitals found al. 2017). Similar experiences of discrimination can also limit that, while 74 percent of professionals were women, only the participation of LGBTI people in leadership positions. 24 percent were service chiefs (Pérez-Sánchez, Madueño, and Montaner 2021). Evidence from the European Society Even in countries where women form a significant for Medical Oncology shows that although women and proportion of the formal labor market, their numbers men doctors have similar career trajectories in their early dwindle at the upper levels of leadership where decisions years, women are five times more likely to experience are made. This can have a cascading effect on laws, policies, career interruptions due to family needs, which can be a and regulations, as well as the environment in which significant barrier to their career advancement (Bergoff et women work and the care they receive. In the United States, al. 2021). In other instances, women decline leadership roles for example, women make up about 40 percent of all due to family obligations and concerns over harassment physicians and surgeons, but only 16 percent of permanent (Mathad et al. 2019). medical school deans (Warner, Ellmann, and Boesch Gender gaps in leadership are a considerable barrier to For example, women made up the majority of frontline health reducing gender gaps in policy and programs across economic, care providers during the COVID-19 pandemic, but in most political, and social dimensions, including in health care (Mousa cases, the personal protective equipment (PPE) provided to et al. 2021). Such gaps in leadership contribute to a lack of them was too big as it was sized for men (Women in Global understanding of the barriers women and LGBTI people may Health 2021). Even when efforts were made to have more face in accessing and paying for health care, and how policies balanced gender representation on COVID-19 task forces, only and legal frameworks perpetuate the problem. Gender-biased 4 percent of the 334 COVID-19 task forces in 137 countries had understanding of the constraints that women health care gender parity, and 18 countries had no women at all (UNDP/ providers may face in the workplace can lead to poor planning UN Women/University of Pittsburgh 2021). Similarly, limited and structural weaknesses, as well as supply chain inadequacies. representation of women as team leads of clinical trials or in other bodies that contribute to policy and decision making 10 means that medical research, protocols, diagnoses, and In response to the growing recognition of the business case for treatments can overlook gender-specific issues and concerns, gender diversity in private health care leadership, IFC published not only for women and girls but also for LGBTI populations. the Women’s Leadership in Private Health Care Report in 2019 and launched the Women’s Leadership in Private Health Care Global Reducing and eliminating gender gaps in health leadership has Working Group in 2020. The initiative brought together CEOs the potential to reduce gender gaps in service delivery. Advancing and human resource directors from 17 health care companies in women as leaders in health requires intentionality and the a community of practice dedicated to identifying and addressing commitment of institutional and discipline leaders (Hobgood the barriers to women’s leadership in the health sector. IFC hosted 2022). It requires addressing barriers within the health system four peer-to-peer knowledge sharing and networking events to and on cross-cutting issues, such as social norms, education, and guide working group members in identifying actions to move the labor market challenges. The World Bank increasingly supports needle on gender equity in their organization. It also delivered countries in promoting women’s leadership. nine learning webinars on key gender themes, which engaged 376 participants representing 169 organizations from across the For example, the GFF piloted the Greater Leaders Program globe, with a satisfaction rating of over 85 percent. Participating as part of the broader Country Leadership Program to train companies implemented initiatives on gender equality and current and upcoming women leaders in the health sector. inclusion in their operations to better foster women’s leadership. Group and one-on-one advisory sessions enabled participants Specifically, health care companies conducted gender workforce to tap into their individual leadership capacities to better serve diagnostics; created gender strategies; appointed internal gender the sector, overcome obstacles, and use personal networks equality committees; implemented respectful workplace and experience to create positive, meaningful results. The and GBV prevention policies; and revised their recruitment participating leaders gained greater self-awareness and and human resources practices through a gender lens. The confidence in their management style and were able to put IFC’s Women’s Employment Program also supports women’s their learning into practice at work and inspire others. leadership in health care provision (Box 2). BOX 2: WOMEN’S EMPLOYMENT PROGRAM In Mexico, IFC investment client Grupo Neolpharma partnered with IFC to conduct a Corporate Gender & Inclusion Assessment in 2022 under the Women’s Employment Program. The company is implementing an action plan to increase women’s representation in leadership positions, set a talent development framework, and create a policy and practices framework for promoting an inclusive and respectful workplace. By June 2023, the company had hired three women in C-suite positions, increasing the number of women leaders from five to eight. The number of promotions granted to women employees more than doubled, going from 65 to 147 women promoted (53 percent of the total promotions granted) and the retention rate of women 12 months after returning from maternity leave increased from 60 to 90 percent. By March 2024, the company had implemented leadership training for women, and the number of employees trained in Respectful Workplaces increased by 60 percent (from 1,200 in 2022 to 2,000 employees in 2024). In addition, grievance channels have been implemented across all locations. In Ethiopia, four women physicians founded the Hemen Maternal and Children’s Specialty Medical Center (in 2008 to offer high-quality women’s reproductive and children’s health care services. As a Women’s Leadership in Private Health Care Global Working Group member, the company conducted a Corporate Gender & Inclusion Assessment in 2021and found that, while the company was founded and led by women and women represented 80 percent of its employees, men were more likely to be promoted and there was a gender pay gap. By 2022, the company introduced a new gender policy, established a gender diversity policy committee, reviewed their employee promotion tool to ensure equal representation in leadership positions, addressed their gender pay gap, and implemented flexible work arrangements and other policies to ensure employee retention. Ways to Encourage Women’s Leadership in Health Concerted effort is needed to address policy, institutional, and structural biases that hinder women’s advancement within The benefits of gender parity in leadership are emerging and there leadership roles (Harrison et al., 2022; Moyer et al.2018). Training is increasing evidence that women leaders positively impact programs in science and medicine and other interventions maternal and health care policies, strengthen health facilities, should include awareness and education around gender and reduce inequalities (Downs et al. 2014). Within health, it is stereotypes, intersectionality, and the value of diversity in necessary to facilitate women’s opportunities to advance their improving outcomes in science and medicine (Coe et al. 2019). careers through interventions to support skills development and At a structural level, it also means acknowledging and creating mentoring. However, this alone is not sufficient. space for different leadership styles and tackling labor market 11 challenges, such as gender-based pay gaps and placement available for most countries, and international standards opportunities. Other proactive interventions to help do not exist to measure this (Bonfert et al. 2023). increase women’s representation in health leadership • Engage in cross-cutting dialogue and interventions, include the following: such as social and behavior change communication that • Encourage leadership that cements gender engages both women and men on a range of topics to transformative approaches into institutional address social and cultural barriers, like encouraging frameworks and human resource policies. Health girls’ participation in STEM education, reducing sexual institutions in both the public and private sectors can harassment and violence, and sharing household and conduct gender assessments to quantifiably measure care responsibilities equitably. gender dynamics and gaps, including recruitment and promotion, and identify policies and actions to reduce ADDRESSING GENDER DIFFERENTIALS IN gender pay gaps, provide maternity and paternity leave, enable women to have shared caregiving MENTAL HEALTH responsibilities and reduced disruptions to their careers, Emotional and mental well-being is an important part and enforce strong frameworks to address sexual of overall health. Both women and men suffer from the harassment and workplace violence negative consequences of poor mental health, but their health outcomes vary. A significantly larger proportion of • Support enabling environments for women’s leadership, such as fostering mentorship and networking for women live with major depressive disorders compared women health care workers (Chung et al. 2023) and to men (see Figure 4). There are some exceptions, such as providing opportunities to participate in decision- the United Arab Emirates, Qatar, and Lao PDR, where the making bodies, such as hospital committees, and in highest levels of depressive disorders are among men, leading clinical trials. even in comparison to other countries. In other countries, such as Vietnam, Ukraine, and Pakistan, the prevalence of • Ensure that research and data are disaggregated and depressive disorders among women is double that of men. reflexive in terms of sex and gender, especially since (IHME 2020). data on leadership in private sector institutions are not For women, post-partum depression (PPD) takes a significant can affect women of all backgrounds, data suggest poverty toll on mental health, but it is often not recognized, and is a major risk factor, with 25 percent of new mothers living women receive limited, if any, support. The global prevalence in poverty (and lacking access to quality health care and of PPD is estimated at 17 percent, with Southern Africa education) experiencing PPD (Wang et al. 2021). having the highest prevalence rate at 40 percent. While PPD 12 Another major factor contributing to women’s poor mental substance abuse, feelings of guilt and shame, and suicidal health outcomes is post-traumatic disorders (PTSD) after ideation (Covers et al. 2021). Approximately 70 percent of rape10 or other incidents of gender-based violence (GBV) rape or sexual assault victims experience moderate to and abuse (see Box 3). Exposure to rape often leads to severe distress—a larger percentage than for any other psychological problems, including depression, dissociation, violent crime (RAINN 2020). BOX 3: THE HEALTH SECTOR RESPONSE TO GENDER-BASED VIOLENCE GBV is a global development challenge and a public health issue. It affects survivors across cultures and economies. One third of women worldwide—736 million women—have experienced intimate partner violence or sexual violence from a non-partner in their lifetime (WHO 2021b). Nearly 12 million girls are married each year before reaching the age 18 (UNICEF 2022) and at least 200 million girls and women have undergone female genital mutilation in 31 countries with representative data on prevalence (UNICEF 2023). GBV also takes other forms, such as emotional and financial abuse, which are more widespread but less discussed. The risk of violence can be even higher in emergencies, conflict, and natural crises. Two forms of GBV, reproductive coercion and obstetric violence, are based in denying women their right to health care. Reproductive coercion takes the form of contraceptive sabotage, impregnation of a female partner against her will, and control of pregnancy outcomes (Grace and Anderson 2016). It is often directed at women experiencing intimate partner violence. These women are less likely to report using condoms with their male partners (Grace and Anderson 2016; Maxwell et al. 2015). Obstetric violence is an act of mistreatment, abuse, negligence, or disrespect during childbirth, perpetrated often by health professionals (Jardim and Modena 2018). Not only does it go against the health sector’s fundamental role in preventing and responding to GBV, but it can also disincentivize women to seek maternal and reproductive health care. Respectful maternal care is an essential component of quality care (WHO 2014). The consequences of GBV are significant. GBV impacts physical and mental health of survivors with far reaching impacts, such as injuries, mental health problems, a higher rate of substance abuse, and poorer sexual and reproductive health outcomes, including unwanted pregnancies. It can lead to adverse impacts on children (Ellsberg et al. 2008; WHO 2021c; Grose et al. 2020; Acharya et al. 2019). Violence against women is estimated to cost countries up to 3.7 percent of their GDP—more than double what most governments spend on education (WHO 2021b). The health sector provides opportunities to identify survivors of violence, provide care, and prevent future harm (Arango et al 2015). Health care providers are well positioned to provide screening and clinical interventions to improve health outcomes during obstetric care and annual examinations (The American College of Obstetricians and Gynecologists 2013). Quality medical services, including mental and psychological care, emergency contraception, and prevention and treatment of sexually transmitted disease and HIV are vital to meet the needs of survivors (WHO 2020). The COVID-19 pandemic further contributed to worsening persisting even after one year (Etheridge and Spantig 2022). mental health outcomes and expanding gender gaps. Contributing factors include anxiety, stress, the burden of Evidence from the United Kingdom shows large declines care often borne by women, and the associated loss of in mental health for both men and women, with women income (UN Women). faring significantly worse (see Figure 5) and the pattern 10 P  ost-traumatic stress disorder (PTSD) is a mental health condition characterized by symptoms of intrusions, avoidance, negative cognitions and mood, and hyperarousal related to exposure to the traumatic event. 13 Despite the higher burden of mental health disorders women and men inflicting self-harm at the global level, among women and evidence of comparable or higher albeit with variation by country. Figure 6b shows that, levels of attempted suicides, men are more likely to die compared to women, men are more likely to die due by suicide (El Halabi et al. 2020; Roh, Jung, and Hong 2018; to self-harm (IHME 2019). Men tend to use more violent Tucker 2020; Värnik 2012). Figure 6a shows the prevalence methods to harm themselves than women (El Halabi et al. of self-harm by sex, with roughly similar numbers of 2020; Mergl et al. 2020). 14 Gender differences, societal pressures, inequalities, and In the Cox’s Bazar district of Bangladesh, GBV remains stereotypes widen gaps in how mental health impacts highly pervasive within the Rohingya Displaced Population women and men, how it is managed, and the outcomes. and host communities. Despite the urgency, there is a Norms surrounding masculinity can act as barriers to men critical gap in service delivery for GBV survivors due to skills seeking help or treatment for mental health issues. Women, gaps and scarcity of resources. The Health and Gender on the other hand, may be more willing to seek help, but Support Project for Cox’s Bazar District Project supports other factors, such as limited financial capacity, lack of the strengthening of GBV services at different tiers of information, care responsibilities, or distance from health health facilities. It helps reduce gaps in service provision care providers, can hinder access to professional care. by expanding mental health and psychosocial support for survivors of violence, including age-appropriate GBV Although data on LGBTI is limited, evidence from response services for adolescents. higher-income countries with generally more favorable environments for LGBTI, points to continued stigma and Interventions to Improve Access to Mental discrimination against LGBTI populations and, consequently, Health Care an increased burden of poor mental health among this Prevention and promotion of mental health are required population. For example, a survey of 7,126 young LGBTI to reduce the growing magnitude of mental illnesses. The people ages 16–25 in England found that 52 percent of the following interventions can help to improve mental health surveyed participants experienced depression; while one services and outcomes. in eight people (13 percent) reported attempting suicide, often driven by the discrimination they face. Fourteen • Develop mental health promotion programs and percent reported avoiding seeking health care due to fear policies that take a gendered, life course approach of discrimination, and roughly the same proportion had and are holistic, community-based, client-driven, and experienced discrimination personally (Stonewall 2018). supported by advocacy services. Across the world, such challenges point to the need for • Since the health sector is often the first point of contact for survivors of violence, establish an integrated health interventions to destigmatize mental health disorders, system with health care providers across specialties. address norms that prevent people, especially men, from Health care providers should be trained to recognize seeking help, and invest in mental health services for women, signs of GBV and engage strong referral systems to men, and other gender identities and sexual minorities. support greater awareness, early identification, and prompt intervention for at-risk individuals. The World Bank’s work on psychosocial and mental health is limited but growing in the wake of the COVID-19 • Use SBCC to engage communities and men to discourage pandemic, when several operations provided psychosocial violence, reduce stigma for survivors, and share information support, especially to health care workers. Prior to the about the availability of services, along with improving pandemic, the Bank invested in mental health as part of access to emergency health care and psychosocial support. its health response in countries experiencing some form of • Support cross-cutting solutions that can serve as fragility, such as the following examples. a protective factor, such as promoting educational attainment for girls. For example, the gender gap in Liberia is a post-conflict fragile state and one of the poorest depression in the United States closed by 39 percent countries in the world, with 63 percent of the population between 1955 and 1994 due to women’s attainment below the age of 25 years. The civil unrest and instability of college degrees (Platt et al. 2020). In Zimbabwe, due to two devastating civil wars between 1989–1997 evidence shows an extra year of education lowered the and 2001–2003, and the 2014 Ebola epidemic have had a likelihood of depression by 11 percent and anxiety by 10 strong impact on the mental health of its population. The percent (Kondiroll and Sunder 2022). 2010 Global Burden of Disease showed that mental health disorders accounted for more disability-adjusted life years (DALYs) than any other noncommunicable disease ENHANCING GENDER EQUITY IN PANDEMIC in the country. Between 2015 and 2018, the World Bank’s PREPAREDNESS AND EMERGENCY Supporting Psychosocial Health and Resilience in Liberia RESPONSE IN HEALTH Project responded to the intermediate psychosocial and The COVID-19 pandemic exposed weaknesses in health systems mental health impact of the Ebola crisis and helped build and exacerbated gender gaps. Health systems around the world long-term psychosocial health and resilience for people regardless of income level struggled to curb the rapid spread and communities. The project contributed to improved of COVID-19, but those in low and middle-income countries mental health for 66 percent of the project beneficiaries were particularly vulnerable. The stress of COVID-19 disrupted and increased the share of service providers trained to essential health services., including childhood immunizations, provide psychosocial and mental health services from 15 family planning, reproductive and maternal care, and to 68 percent. treatment and prevention of other communicable and non- communicable diseases, such as HIV, tuberculosis, and diabetes. 15 For example, a year into the COVID-19 pandemic, an estimated services, with 1.4 million unintended pregnancies (UNFPA, 2021). 12 million women across 115 low and middle-income countries Figure 7 captures the challenges to women and girls’ health and had experienced disruptions in access to timely family planning well-being due to the COVID-19 pandemic. Studies indicate that, to varying degrees, countries saw These challenges are indicative of gender gaps across increases in maternal, neonatal, and child mortality due different areas of health. Box 4 highlights the persistence of pandemic-related service disruptions (Marchand et al. gender gaps in health through the lens of addressing anti- 2022) and maternal exposure to COVID-19 (Stevenson 2022; microbial resistance. Michels, Marin and Iser 2022; Maza-Arnedo et al. 2022), with higher risks among unvaccinated women (Atak et al, 2022). Interventions to address gender disparities in the health response to pandemics and Women’s health and well-being were affected in other ways other emergencies during the pandemic. For example, women were more Strengthening health system resilience with a focus on PHC likely to experience domestic violence. Reported incidents is central to maintaining and strengthening essential health of violence increased by 5 percent in Australia to up to 35 services that are responsive to health emergencies and percent in some states of the United States (Mittal and Singh crises like the COVID-19 pandemic. This includes addressing 2020). One community case study in Lagos, Nigeria found that gender gaps in access to health care and taking appropriate half the women in the community had suffered domestic measures to support frontline workers, especially women. violence within the first three months of the lockdown (Wada Prior experiences with reaching populations in emergencies, et al. 2022). As frontline health workers, women were also at a such as the Ebola crisis in West Africa, or during fragility higher risk of exposure to disease. Women also stayed home or conflict situations across the globe underscore the to take care of children, the elderly, and the sick, which not unique challenges women face in accessing hygiene and only increased their burden of care but also contributed to health care. The following list of gender-responsive actions higher levels of stress and anxiety (Shahbaz et al. 2021; Awan recommended by the World Bank during COVID-19 draws et al. 2021; Mehta et al. 2021). on lessons learned and can be taken forward to continue building the resilience of health systems. 16 BOX 4: THE GENDER EFFECT ON THE GROWING THREAT POSED BY ANTI-MICROBIAL RESISTANCE In December 2023, the World Health Organization (WHO) convened a technical consultation around a people- centered approach for addressing Anti-Microbial Resistance (AMR) in health. Research shows the persistent gender gaps that exist in the health sector including its AMR response. Analysis of 178 National Action Plans (NAPs) for AMR across countries found little focus on equity in use and access to antimicrobials and limited recognition of the need to address cultural and gender drivers of health-seeking and health-providing behaviors (Charani et al., 2023; Patel et al., 2023). A further review of 145 publicly available NAPs for gender confirmed the lack of attention to gender considerations in most NAPs, with approximately 86 percent of NAPs not having any mention of sex or gender. Research indicates that prescribing patterns, participation in infection prevention behaviors, and access to health care can all differ by gender (Gautron et al., 2023; Jones et al., 2022; WHO, 2022). Gender also plays a role in who has the resources and decision-making power to access appropriate care and treatment for resistant infections that can contribute to differences in the quality of care (Jones et al., 2022; Batheja & Goel, 2022), and may impact people differently based on the risk of infection associated with their occupation (Gautron et al., 2023; WHO, 2022). The technical group recommended considering a more practical cross-sectoral approach at country level that supports costed Gender-Responsive National Action Plans on prevention and response to AMR. Source: WHO Informal Expert Group Meeting on Antimicrobial Resistance and Gender, 30 November – 1 December 2023,. Organization: violence (FCV) to ensure women have access to health and social services (e.g., relax ID card requirements or • Consider measures that bring services closer to women, issue other forms of ID) such as mobile services or home visits. • Include women in pandemic response committees and • Ensure continuity of essential health care services, management structures. including reproductive and maternal health services, at the community level; implement mobile services, • Consider developing and implementing gender- online, or telehealth visits where possible. responsive National Action Plans to address the growing threat posed by antimicrobial resistance. • Ensure health care workers are provided and use PPE for their own safety. Behavior Change: Financing: • Engage men and community leaders to ensure women’s access to health care. • Provide financial support, such as subsidized or free testing, treatment, or vaccination, to ease access barriers • Provide access to psychosocial services for at-home for women and other vulnerable populations. caregivers and health care workers. Public Health: • Provide hazard pay or incentives to frontline workers and death benefits for their families to encourage retention. • Ensure information on illness, symptoms, preventative measures, and management options (testing, treatment, • Take actions to reduce pay disparities and formalize vaccines) is communicated widely. informal workers and volunteers. • Communicate in local languages and through various • Set targets for women-owned firms in supply chains media, such as radio and TV, and use visual aids so where such firms and entrepreneurs are identified. (e.g., that illiterate women can also access and understand masks, hand sanitizers, cleaning supplies). information. Regulations: • Ensure public health messaging conveys where and how people can seek services. • Include actions and targets for reaching women and other vulnerable populations in pandemic response plans. • Train health care workers to provide health emergency and pandemic-related information and services; train • Take extra care in situations of fragility, conflict, and them on the proper use of PPE. 17 • Collect data disaggregated by sex and age to monitor who Cross-cutting actions: receives services, where, how, and for how much money. • Ensure women participate in clinical trials and treatment research so that research and findings are cognizant of and reflect any sex-based differences in trial outcomes. PROPOSED ACTIONS TOWARD GENDER RESPONSIVE AND TRANSFORMATIVE POLICIES AND PROGRAMS The following priorities and action areas support a their own bodies. The Bank will continue to use instruments continuation of the World Bank’s existing focus and work to that have had some measure of success in delivering results, reduce gender gaps in health and build on its engagement such as pay-for-performance and cash transfers. to further bolster the right to health. Given the cross-cutting nature of gender and rights, the Bank will explore opportunities to support multi-sectoral STRENGTHENING SEXUAL AND action that enhances women’s empowerment, voice, and REPRODUCTIVE HEALTH CARE AND RIGHTS agency. This will be especially important when working with The World Bank will continue to support sexual and client countries to support policy actions that strengthen reproductive, maternal, and adolescent health as part of peoples’ sexual and reproductive health and rights. Action the essential package of health services under UHC. This areas include the following: includes the provision of family planning information and • Improve access to, availability of, and quality of SRH services and coverage of adolescents through youth-friendly health care for women and adolescent girls through services for SRHR and RMNCAH. To encourage the uptake integrating SRH services and information under UHC, of service, the Bank will continue to support investments particularly at the PHC level. in SBCC to build community awareness and acceptance, enhance knowledge, and create positive attitudes and • Encourage the integration of GBV prevention and norms toward sexual and reproductive health and rights. management services with SRH at the PHC level Other areas of intervention include training health care (including information, medical, and psychosocial providers at all levels of the health system to improve the support for GBV). quality of services, facilitating women and adolescents’ • Support implementation of policies, protocols, and access to these services, and advancing legal and policy standards for improving access to, and quality of care frameworks that bolster women and girls’ right to control for LGBTI people. 18 • Support countries in strengthening SRHR and GBV in leadership positions in the health care sector, including awareness and acceptability of services (including for clinical research and medical decision-making bodies. It is adolescents) through policy and legal reforms, SBCC, evident in PPE that does not fit and pay that is not equal. comprehensive sexuality education, and other actions. While women make up a large proportion of the health care workforce, they are mainly frontline and lower-level • Support training for service providers—men and women at all levels, not just frontline—to enhance services free of workers. Few women are in decision-making positions to stigma and discrimination, especially for LGBTI people. influence financial coverage for health, research in health, or management and administration. • Support multi-sectoral action, such as secondary and higher education, to enhance women and girls’ voice and A growing body of evidence shows that women’s leadership agency and reduce discrimination against LGBTI people. in political decision-making processes improves women’s leadership overall (UN Women, 2022). It is critical that women’s potential for leadership is developed, and health systems PROMOTING GENDER EQUITY IN HEALTH are supported to promote women within their ranks and FOR AGING POPULATIONS encourage their voice and agency. Cross-cutting interventions As the world population continues to age, it is important can help close gender gaps by supporting greater participation to pay attention to gender gaps. Men are more likely to die of women in decision-making roles, building mentorship of noncommunicable diseases than women, but women programs, and requiring project committees and other are vulnerable to the feminization of aging characterized bodies to include women. Action areas for building women’s by prolonged morbidity, poverty, and a lack of health care. leadership in health include the following: Affordable access to health care and health information for middle-aged and elderly populations supports healthy • Support interventions to promote women’s leadership aging and reduces the burden of disease on populations development, such as mentorship programs, care support, and equal pay for equal work. as well as on health systems. More analytical work and learning from cross-sectoral operational experiences are • Enable SBCC to reduce gender biases and stereotypes needed to strengthen the gender analysis and response of in education and labor markets and to reduce sexual UHC operations. Action areas include the following: harassment in the workplace. • Invest in analytical work on the feminization of aging, • Encourage and establish guidelines for women’s including disaggregated data, to understand the inclusion in decision-making bodies. Similarly, ensure challenges that older women face and how to address inclusion of LGBTI representatives on decision- them, especially in low and middle-income countries. making bodies responsible for establishing health care protocols and standards for LGBTI populations. • Explore further and in-depth analytical work on aging and access to health care for other gender identities. • Include measurement indicators on women’s leadership to assess the proportion of women • Facilitate health systems investments within the in decision-making committees. UHC framework that address identified gender gaps in access to health care, especially for older women, such as limited coverage under social protection and IMPROVING ACCESS TO MENTAL insurance schemes. HEALTH SERVICES • Ensure UHC interventions cover health care for women The World Bank is focused on ensuring available and and other gender identities across the lifecycle, affordable mental and psychosocial health services are part including for GBV. of essential health services under UHC. This includes SBCC to encourage the uptake of services for those who need • Encourage governments to examine ways to support them without the fear of stigma. The Bank’s work in this area informal caregivers, particularly women. continues to expand, building on operational experiences in FCV contexts and COVID-19-related emergencies. A clear SUPPORTING GENDER EQUALITY IN HEALTH action plan is needed to encourage better inclusion and CARE LEADERSHIP monitoring of mental health interventions in UHC with data disaggregated by sex to address gender gaps. Action One of the main challenges to achieving gender equality areas include the following: and equity in health is the gender imbalance in health care decision making and leadership. The implications of • Cover mental health and psychosocial support, gender imbalance are reflected in the lack of understanding including for survivors of GBV, under UHC. of how disease symptoms may appear differently for women and men, treatments that are based on men’s • Include interventions to provide mental health support physiologies, and the limited representation of women to health care workers. 19 • Include SBCC and other interventions to normalize • Cover essential and emergency services within UHC, seeking mental health care for women, men, and LGBTI especially at the primary level, to support the availability people, which may require different types of messaging. and affordability of services. • Support the establishment of protocols and standards • Promote the safety of health service providers and that protect the right to health of LGBTI populations. protect them from GBV, especially in the event of health emergencies. • Support innovative community measures that promote the re-integration of patients with mental illness into a • Ensure information related to health emergencies is productive society as full members. available in local languages and through diverse media, such as radio, TV, and visual aids, to maximize reach to • Measure mental health coverage, disaggregated by sex women who speak local languages or may be illiterate. and age, and to the extent possible by gender identity. • Support the inclusion of women in decision-making bodies, especially within the health care system. ENSURING GENDER-RESPONSIVE PANDEMIC PREPAREDNESS • Provide appropriate training and support (including pay, PPE, psychosocial support) for women frontline workers. The COVID-19 pandemic and epidemics related to Ebola and Zika underscore the importance of reducing gender • Support the gender-friendly costing of national gaps in health systems’ response to health emergencies. As action plans to address the growing threat posed by countries focus on building the resilience of health systems, antimicrobial resistance. it is important to include gender-sensitive interventions in contingency plans, such as ensuring access to health • Ensure data monitoring is gender-sensitive and information, maintaining continuity of essential care, and includes key indicators that measure gaps specific to women, such as women receiving ante-natal care or the enabling affordability of care for women. 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