Knowledge Brief Health, Nutrition and Population Global Practice GENDER GAPS IN HEALTHY LONGEVITY: OUTCOMES, BARRIERS, & IMPLICATIONS Seemeen Saadat, Meriem Boudjadja, and Sameera Altuwaijri July 2024 KEY MESSAGES: • Gender gaps in access to, and use of health and long-term care services affect both women and men, albeit differently. • While male mortality due to key non-communicable diseases (NCDs), particularly in the middle-ages is high, women live longer with these diseases. This has implications for universal health coverage (UHC) and social protection systems. • Social and financial barriers that accumulate across the life course impede women’s access to care and solutions need to be cross-cutting. • Health and long-term care systems need to be gender-responsive, ensuring that services are available and accessible, with adequate quality of care. • Investment in sex disaggregated data and gender specific indicators to monitor key indicators for healthy longevity (e.g., on NCD prevalence, UHC) is needed for policy and planning. Introduction income countries points to higher male mortality due to Women and men experience aging differently. Along with heart disease and diabetes, for example. On the other physical and physiological differences, social and gender hand, women in these countries are likely to have similar norms contribute to different experiences for women and prevalence levels as men of these diseases but will likely men that manifest across the life cycle. These differences, live longer with a lower quality of life. Women’s longer life such as in education, age at marriage, employment expectancy1 implies a greater concentration of NCDs opportunities, caregiving responsibilities, and living among women in older age groups and more years lived arrangements contribute to gender-based differences in with disability. Women also go through menopause as socio-economic status as well as health outcomes for they age, which takes a physical and mental toll, and is women and men as they age (Carmel 2019; Hosseinpoor linked to an increased risk of contracting non- et al. 2012; Weber et al. 2019). communicable diseases (Hess et al, 2012). These differences are also reflected in the onset and At the same time, older women, especially in lower experience of non-communicable diseases (NCDs) for income countries, are less likely than men to receive both women and men. Evidence from high- and middle- proper healthcare due to their greater financial Page 1 HNPGP Knowledge Brief • vulnerability – a direct consequence of gender gaps over and female levels of CVD prevalence are similar for ages the life cycle that affect women’s patterns of labor force 45-59 years old, especially in lower income countries, but participation, income generation opportunities, and decision-making capacities (Quick, Jay, and Langer 2014; Figure 1. Ratio of female to male NCD deaths, Cotlear 2011). Similarly, gender roles and expectations by sex and income group, ages 45+ (2019) about behavior create inequities in health and access to Low health services before birth and continue through the Income entire life course of a person. Women’s limited voice and Lower agency, for example, in some countries makes it harder Middle for them to access reproductive, maternal and child health Upper services for themselves and their children freely. Similarly, Middle men may deliberately ignore illness or avoid seeking High medical help, to avoid being perceived as weak by their Income peers. These patterns influence the health outcomes of 0 0.2 0.4 0.6 0.8 1 1.2 women and men and persist over their life course. CVD Diabetes Cancers (all) This brief summarizes key findings of a study that aims to examine the challenges related to healthy longevity and healthcare from a gendered perspective, especially for begin to diverge for the 60-79 years old cohort in older women in low- and middle-income countries. countries with higher GNI, with a higher burden among men. Yet, for those aged 80 years and above, prevalence is considerably higher for women than men (Figure 2). Study Methods Figure 2. Cardiovascular disease prevalence (%, 2019) The study is based on a literature review and data by GNI per capita and sex analysis using the Global Burden of Disease for data on prevalence and mortality for key NCDs (heart disease, Ages 60-79 years Ages 80+ years 40% 25% cancers, and diabetes) and mental health; and the World Development Indicators for data on income for the year 35% 20% 30% 2019. We examine the proportion of deaths attributable to 25% 15% a disease and disease prevalence by sex and income by 20% three age groups: 45-59 years, 60-79 years, and 80 years 15% 10% and above. The literature review provides supporting 10% 5% insights into the of demand and supply challenges 5% affecting access to care and health outcomes of older 0% 0% adults. 0 50000 100000 0 50000 100000 GNI per capita Female Male Disease Burden by Sex Figure 3 presents a similar pattern for CVD mortality at the country level. CARDIOVASCULAR DISEASE Figure 3. Cardiovascular deaths (%, 2019) Cardiovascular diseases (CVD) are the leading cause of by GNI per capita and sex mortality, responsible for roughly 18 million deaths each Ages 60-79 years Ages 80+ years year (WHO 2021). Older adults, both women and men 40% 60% bear the largest burden of CVD: in 2019, CVD accounted 35% for 41.6 percent and 38.2 percent of all female and male 50% 30% deaths respectively for those aged 45 years and above 25% 40% globally (IHME 2020). At the aggregate level, the ratio of 20% 30% female to male CVD deaths is higher, while for middle 15% 20% income countries, male mortality is higher than that of 10% 5% 10% women (Figure 1, yellow bars). 0% 0% 0 50000 100000 0 50000 100000 We also examine the distribution of disease burden at the country level by age and sex. With a few exceptions, male GNI per capita Female Male Page 2 HNPGP Knowledge Brief • DIABETES CANCERS Diabetes accounted for roughly 1.55 million deaths of Cancers present a complex picture. The overall burden of which 95 percent were among persons aged 45 years and mortality from all cancers is higher among men than above in 2019 (IHME 2020). At the aggregate level 3.6 women globally (Figure 1, grey bars), with gender gaps in percent women and 2.9 percent men die from to diabetes mortality being the greatest in middle income countries among older adults. The largest burden of deaths is in and for those aged 60-79 years. However, women aged LMICs: 4.7 percent for women and 3.9 percent for men; 45-60 years have higher levels of cancer prevalence than while the largest gender gap is in upper-middle income men globally, even though mortality rates remain similar countries with diabetes responsible for 3.4 percent female for this age cohort (graphs not shown). There are also and 2.4 percent male deaths (Figure 1, blue bars). As with differences in the types of cancers that are most CVD, diabetes mortality among women increases with prevalent, with 60 percent of the disease burden for age as figure 4 indicates. women stemming from breast and female reproductive cancers. Breast cancers are also the leading cause of Figure 4. Deaths due to Diabetes (%, 2019) female mortality from this disease. For men, prostate by GNI per capita and Sex cancers are the most prevalent, while respiratory cancers are the leading cause of mortality (IHME 2020). Age 60-79 years Age 80+ years MENTAL HEALTH 50% 60% 40% 50% One in five persons globally suffers from a mental health 40% illnesses, with depressive disorders constituting the 30% 30% largest share. Prevalence levels of depressive disorders 20% 20% are consistently higher for women compared to men. 10% However, there are variations: in countries such Pakistan, 10% Ukraine, and Viet Nam the female burden of depressive 0% 0% 0 50000 100000 0 50000 100000 disorders is up to twice that of men; and it is three times GNI per capita that of men for Japanese women 80 years and above Female Male (13.17% vs. 4.96%). On the other hand, in the United Arab Emirates and Qatar, prevalence of depression among men aged 45 to 59 years is three times higher Diabetes accounts for roughly 16 percent of all the than that of women in the same age group (IHME 2020). disease prevalence among older adults, with about 97 Relatedly, prevalence of self-harm among women and women for every 100 men living with diabetes. However, men exhibits similar rates, except for ages 80 years and when disaggregated by age, the data show growing older, when the burden is higher for women. However, gender gaps among older albeit smaller cohorts, with deaths due to self-harm are consistently higher among women bearing greater burdens (Figure 5): higher men for all three age groups. Evidence suggests that the disease prevalence among men in upper and higher methods used by men and women to commit self-harm income countries is especially evident among the 60-79 may be behind this difference (Altuwaijri et al. 2024). year old cohort, whereas among the very old, prevalence becomes higher for women. Key Barriers to Care Figure 5. Diabetes Prevalence (% 2019) by GNI per capita and Sex A key question is how the distributional effects of factors such as income, mobility, distance, and availability of services affect access to health services for aging Ages 60-79 years Ages 80+ years populations, and especially women. Some studies find 40% 15% evidence of higher utilization of health services, most 30% often in higher income countries among women (Bertakis 10% et al. 2000), others find just the opposite results (Song 20% and Bian 2014; Azad et al. 2020). However, common 10% 5% themes are women’s lower economic status and higher costs for healthcare. Delays in seeking healthcare due to 0% 0% 0 50000 100000 poor access to transport, limited mobility due to social or 0 50000 100000 cultural norms, women’s care responsibilities are often GNI per capita Female Male cited as significant barriers to women’s access to care Page 3 HNPGP Knowledge Brief • (Hamiduzzaman et al. 2017; Washington et al. 2011). HMIS and CRVS systems, should ensure wider coverage Financial dependence on others, especially in lower and collection of sex disaggregated data (especially for income countries is another barrier for older and widowed rural/remote populations). women, who often lack their own resources due to limited participation in formal labor markets, limited control over assets, and/or lack of coverage under social protection or References health insurance systems. This also affects their use of Altuwaijri, S., S. Saadat, M. Boudjadja, C.P. Neilsen, A.E. Gordillo- Tobar, M. Maruo, P. Rakh. 2024. Prioritizing Gender in Universal Health long-term care. Similarly social or gender norms can Coverage. Gender Thematic Policy Note Series: Evidence and Practice become barriers to better health. This is especially a Note. Washington, D.C.: World Bank. barrier for men in seeking mental healthcare. Azad, A.D., A.G. Charles, Q. Ding, A.W. Trickey, S.M. 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[Accessed: interventions that reduce social and other access barriers November 16, 2022] to healthcare (e.g., addressing stigma around mental health, reducing risky behaviors) can help reduce the This HNP Knowledge Brief presents key findings from a study on the “Gender Gaps in Health and Well-being of Older Adults: A Review of the burden of disease for women, and especially for men. Burden of Disease of Non-communicable Diseases and Barriers to (iv) Expanding use of sex-disaggregated data and Healthcare for Women and Men” by Seemeen Saadat, Meriem Boudjadja, gender specific indicators on NCDs and healthy longevity and Sameera Altuwaijri, conducted as part of the Healthy Longevity to improve understanding of gender based gaps in health Initiative – a World Bank initiative in collaboration with the University of Toronto, PAHO and others, and with financial support from the Access outcomes and access to care. Investments to strengthen Accelerated Trust Fund. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4