Introduction: Gender, development, and health

The last decade, since the previous issue of Gender & Development on the theme of Gender and Health was published (Volume 9, Issue 2, 2001), has seen global and national trends of great importance. These include: increases in inequality and vulnerabilities amongst many populations in the global South and North; the acceleration of climate change, violent conflicts, and humanitarian crises; and the spreading of political systems and ideas based on nationalism and populism. We also witnessed a global reckoning on race, sparked by the high-profile killings by law enforcement of persons of African descent and marked by mass protests. More recently, COVID-19, the outbreak that began in Wuhan, China in December 2019, is now a global pandemic pushing million people into extreme poverty.

All of these events impact on gender and health at global, national, household, and individual levels – shaping the intimate lives, experiences, and well-being of people of all genders.

In 2018 it was estimated that at least half of the world's 7.3 billion people do not receive the essential health services they need, with substantial unmet need for a range of specific interventions (Mandahar et al. 2018). Health systems and the ways in which communities interact are not gender neutral and are too often rooted in gender inequality. Women and girls face greater risks of unintended pregnancies, sexually transmitted infections including HIV, cervical cancer, malnutrition, lower vision, respiratory infections, and elder abuse (World Health Organization (WHO) n.d.). WHO figures show that about one in three women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime (ibid.). These risks are shaped too by other axes of inequity, such as race. American Indian/Alaska Native and Black women are two to three times as likely to die from a pregnancy-related cause than white women (Centers for Disease Control n.d.). This disparity and injustice is also reflected in the UK, where between 2014 and 2016 the rate of maternal death in pregnancy was 8 in 100,000 white women, compared with 15 in 100,000 Asian women and 40 in 100,000 Black women (Anekwe 2020).

Harmful gender norms, such as constructions of masculinity, can also negatively affect men and boys, with wide-reaching implications, including for mental health. Specific notions of masculinity may encourage boys and men to smoke, take sexual and other health risks, misuse alcohol, and not seek help or health care (WHO n.d.). People with diverse gender identities can experience exacerbated violence, stigma, and discrimination within communities and in health-care settings, leading to an increased health risk and severe mental health challenges, including suicide (WHO n.d.).

The impacts of the COVID-19 pandemic on gender, health, and well-being are widespread and still unfolding. The loss of life, challenges to accessing quality care, including the emerging vaccines, the consequences of the measures taken to limit the spread of the pandemic (such as lockdowns, quarantines, closure of transportation and borders, etc.) on economic and people's livelihoods as well as mental health, sexual and gender-based violence, and educational opportunities, show that we are not ‘all in the same boat’. COVID-19 starkly unmasked inequalities, their gendered nature, and how they affect women, men, and people of all genders. COVID-19 both replicates and exacerbates the inequalities that shape different people's well-being, and access to the means and services necessary to safeguard their health.

Intersectionality and its application are gaining traction in global health and this concept serves as a framework in this introduction and many of the articles in this collection. The words of Audre Lorde, a black female activist, highlight the importance of this concept: ‘There is no such thing as a single-issue struggle, because we do not live single-issue lives’ (Lorde 1984, 138). Intersectionality has its roots in black feminist politics and scholarship and the work of Kimberlé Crenshaw (Timothy 2019), legal scholar and critical race theorist. Intersectional gender analysis is the process of analysing how gender power relations intersect with other social aspects to affect people's lives and create differences in needs and experiences. It allows us to see how such things are experienced differently by different groups of men/boys, women/girls, and people in all their diversity, including people with non-binary identities (WHO 2020). Socioeconomic identities such as gender, location, disability, wealth, education, age, caste/ethnicity, race, sexuality, spatial (urban and rural), and existing culture and norms all combine to determine privilege, or vulnerability, marginalisation, discrimination, and ability to access rights and protections, including those bestowed by health systems. Intersectionality – usefully depicted in Joanna Simpson's (2009) intersectionality wheel – enables a multi-faceted exploration of how factors of privilege and penalty may alternate between contexts or occur simultaneously. Intersectional gender analysis can support an analysis of how policies, services, and programmes can promote gender equity and social justice, and strategies to ensure ‘no one is left behind’ in the attainment of the Sustainable Development Goals (WHO 2020).

The writers in this issue represent a diverse group of feminists, researchers, and practitioners working in health, academia, policy research and practice, in a wide range of different contexts and on a variety of health issues. Together the articles illustrate how intersecting inequities (gender, age, race, caste, citizenship, income) shape the social determinants of health, vulnerabilities, access to health services, and how health systems operate. They also show how these experiences are shaped by broader systems of oppression such as ageism, racism, and patriarchy, and class and caste structures that persist at different levels and sometimes over time and across generations. The articles also indicate the role played by social and historical forces, e.g. conflict, capitalism, and pandemics (such as COVID-19), often in extremely detailed ways that can reveal the complexities of such mechanisms and offer ways forward for gender transformative change.

In the next section (Part 2) of this Introduction, we synthesise the arguments and findings from the articles. In Part 3, we discuss lessons for change, specifically to create environments and momentum that promote well-being, and more just and gender-equitable health systems at multiple levels from the global to the personal.

Part 1: Gender, intersecting inequities, and broader forces of oppression

Many of the articles show how COVID-19 has amplified pre-existing gender-based structural inequities for diverse groups of women, challenging already weak health and social protection systems. Three in particular have clear common themes of the linkages between COVID-19, patriarchy, gender inequity, extreme poverty, and precarity, as well as short- and long-term health challenges across a range of different contexts. The same articles also highlight how policy responses to the pandemic have frequently ignored such inequities.

The regional account of the effects of the disease among domestic workers in Latin America by Louisa Acciari, Juana del Carmen Britez and Andrea del Carmen Morales takes as its starting point the informal and precarious status of domestic workers, the large majority of whom are black and indigenous women. Due to the nature of their work, the pandemic has created impossible alternatives. They risk either immediate contagion and exposure to violence and increased work burdens, on the one hand, or extreme poverty and diminished ability to survive, on the other.

An intersectional gender lens allows a focus on experiences of individual, social, and gender inequities that are context specific. The article by Ravikant Kisana and Nioshi Shah uses it to analyse the interplay of gender and caste amongst sanitation workers in Pune, India, the bulk of whom are women and belong to the lowest castes, considered as ‘impure’ by others. The women are aware that class and casteist attitudes create extreme risks in terms of exposure to COVID-19, destitution, and mental anguish. However, prevailing patriarchal norms and precarity lead them to dismiss that they are being exposed to ‘health risks’, and to prioritise the needs of children and men over their own safety and good health.

Increases in sexual and gender-based violence (GBV) are often linked to emergencies, conflicts, and epidemics (such as Ebola). In their article, Neetu John, Charlotte Roy, Mary Mwangi, Neha Raval and Terry McGovern show how in Kenya, government-imposed restrictions in response to COVID-19, such as quarantines and school closures, have exacerbated gender-based inequalities and increased exposure of women and girls to GBV. When government action did come, it was too late and, in some cases, led to further exclusions. For example, women lacking digital literacy skills and/or access to internet services were not able to participate in virtual court systems. Sector-specific guidelines to ensure availability of comprehensive GBV services and programmes were lacking, leading to confusion and large-scale disruption in the availability of GBV services and programmes on the ground.

Other articles review the challenges for gender, equity, and social justice in neglected and changing contexts. While definitions and figures vary, the World Bank estimates that some 2 billion people live in Fragile and Conflict-affected settings and the share of extreme poor living in these contexts is increasing (World Bank n.d.). Migrant populations, displaced people, and refugees frequently face barriers in accessing the health care they need. Two articles on fragility tackle these topics (that from Bharathi Radhakrishan, Jane Parpart, Dhanya Ratnavale and Courtenay Sprague, and from Sarine Karajerjian). Abu Conteh, Annie Wilkinson and Joseph Macarthy's article on urban informal settlements (sometimes known as slums) presents a different, fast-growing, and changing context where further dialogue and action to meet the health needs and rights of women and girls is needed.

Bharathi Radhakrishnan et al. use a case study in post-war Sri Lanka to understand the obstacles resettled women in the district of Jaffna face when accessing health services. An intersectional approach is explicit in the article, and while the research participants’ identity, specifically their ethnicity and religion, is part of the analysis, the findings highlight the ways in which it is particularly income and gender that affected women's health care-seeking behaviours across different ethnic groups. The article concludes that in post-armed conflict settings, it is essential to invest in health along with effective reconstruction, reconciliation, and human development.

Sarine Karajerjian's article is an account from research with Syrian women living in Beirut, Lebanon. Sarine Karajerjian follows the trajectory or journey of Syrian women and the accompanying fear and anxiety that has wide-reaching mental health implications. The trajectory started with the trauma of the war and of leaving their homes, social networks, and possessions to move to Beirut. It was followed by the challenges they encounter in Lebanon: lack of employment, changes in gender roles and family dynamics, complexities of getting support from an unfair bureaucratic system, and the efforts of finding opportunities for a better and safer future for their children. These all contribute to their current mental health status, yet again under attack from both the Beirut explosion of 4 August 2020, and by the wide-reaching impacts of COVID-19.

The article by Abu Conteh et al. applies an intersectional lens to health in informal urban settlements in Freetown, Sierra Leone. The context is one of hazardous environmental conditions, poor waste disposal, and waste burning leading to health problems, on the one hand, and limited state support, on the other. People's strategies and opportunities to access health care are mediated by their social status, with women disadvantaged by the social expectation to perform caring roles, while being less likely to be cared for. There is diversity within Freetown settlements and localised and spatial inequalities. In particular, the differences in service provision between formal and informal parts of the city stand out. For all, support links with social networks appear crucial to securing health in urban Sierra Leone. The authors argue that an intersectional analysis facilitates an understanding of the holistic nature of health in marginalised and growing urban settings. This is important for addressing complex health inequities as described in their article.

Other articles look at gendered needs and experiences across the life cycle. This includes young women and girls in a range of different Indian contexts (Margaret A. McLaren and Monalisa Padhee), youth and adolescents in Gujarat, India (Sangeeta Mecwan, Manushi Sheth and Renu Khanna), and older women in the Indian Sundarbans (Debjani Barman and Manasee Mishra).

Margaret A. McLaren and Monalisa Padhee's study is concerned with sexual and reproductive health and rights of young women. The article is a critique of some of the Water, Sanitation, and Hygiene (WASH)-based approaches to menstruation. It stresses that while hygiene promotion and access to products for menstrual protection and services (such as latrines) are important for the health, dignity, and privacy of women and girls, addressing issues of social stigma and structural inequality need to be prioritised, as part of a holistic approach to menstrual health.

Debjani Barman and Manasee Mishra's contribution examines the challenges to accessing vision care services at a late stage in life. As part of these considerations, the study looks specifically at older women's vulnerabilities. Gendered disadvantages such as women's restricted mobility and economic dependency are compounded by increasing age and visual impairment. Physical dependency worsens with time, as does increasing visual impairment. Women's gendered roles also undergo changes. Such dynamism bears on women's eye care-seeking behaviour. The article includes (rare) cases of women with favourable eye care-seeking behaviour, as examples of how women's compounded vulnerabilities could be mitigated through familial support and responsive eye care services.

Sangeeta Mecwan et al. discuss a case study on enhancing Social Accountability through Adolescent and Youth Leadership with interventions on sexual and reproductive health in Gujarat, India. In addition to rural, tribal, Dalit, and urban poor young people, the project engages with adolescents and young people living with disabilities and young people in sexual minorities groups. Adolescents and youth are a heterogenous group and depending on the context, their intersecting multiple identities can render them more vulnerable or privileged. Adolescents and youth require strong family and social support, as well as quality education, health, and other services for their comprehensive development.

Part 2: What have we learnt on the way forward for gender and health justice?

This section summarises the many lessons emerging from the articles, and surfaces additional elements of a more comprehensive account of factors that must be considered to create avenues toward fairer, more inclusive, and gender-responsive health systems. We have three key ways forward which interlink and complement each other as follows: (1) going beyond the biomedical model, by using diverse methods and analytical approaches to understand lived, gendered experiences and to drive change; (2) co-production, inclusivity, and collective organising support gender transformation of health systems; and (3) building stronger and more gender-equitable health and social systems for all.

Going beyond the biomedical model

Most global health leaders are trained in the biomedical model of health, and quantitative epidemiological and clinical research methods remain the norm in the measurements and indicators underpinning health policy and practice. Yet the articles in this issue use a diverse range of methods, which are mainly qualitative, including innovative approaches. For example, Abu Conteh et al. use narrative/life histories and governance diaries, and Sarine Karajerjian relies, among other things, on informal conversations with social workers supporting Syrian women refugees.

As in the Gender & Development issue on feminist research methods (Volume 27, Issue 3, 2019), here too there is an emphasis on the importance of research methods that reveal complexity and the nuances of the health and well-being experiences of diverse individuals. This includes a focus on valuing individuals and ensuring that both the researcher and the research participants retain their human faces and voices. Many articles also had participatory action research at their heart, ensuring diverse voices and perspectives are not only heard but also acted upon, with strong links to our second promising lesson: co-production and inclusivity.

There is also power and potential in the analytical lenses we can bring to research and activism. Here we outline the potential of feminist and decolonisation lenses, both of which complement and strengthen intersectionality theory and practice with its focus on understanding and challenging how power and privilege play out in the experiences of individuals and the structures that shape them.

Claire Somerville and Khatia Munguambe's article contextualises the Mozambican example within the relationships, knowledge, and power structures of the global development systems. It illustrates the necessity of analytical lenses which ‘de-stabilise the entrenched relations of power and assumptions derived from colonialisms of the global North’ (this issue, 202) and decolonise the epistemologies of gender and global health. They build on African feminist scholars’ critical work, to explore how biomedical and western norms in global health both hide and undermine local epistemologies and explanatory systems of understanding hypertension and related stroke in Mozambique. New critical approaches and decolonised, feminist approaches demand listening and responding to lived local realities and aetiologies of illness. They also mean working in partnerships with communities to co-produce appropriate and responsive health services as discussed below.

Louisa Acciari et al. also call for a comprehensive paradigm shift with recovery from the COVID-19 pandemic being driven by feminist analysis that takes into account the centrality of care, and reorganises reproductive work on a fairer and more sustainable basis. This, they argue, will need to be holistic and comprehensive, with action in the health sector and beyond in new partnerships. This will need to include adequate and equitable financing that addresses underlying economic inequalities, guarantees decent work, sustainable development and gender equality, and supports a better distribution of care and domestic work across society.

Co-production, inclusivity, and collective organising

Several of the articles in this issue include recommendations of best practice, from organisations embedded in and working to promote health and well-being in a gender transformative approach. Co-production, collective action, and inclusive and holistic approaches that promote accountability are key.

Collective action brings change. In Kenya, Neetu John et al. describe how the government only started taking action on increases in GBV triggered by the COVID-19 pandemic after a group of seven grassroots women's rights NGOs wrote a public letter in April, urging the government to tackle rising GBV and ensure availability of critical GBV services.

The focus of the article by Louisa Acciari et al. is to highlight the importance of care work and the impact that COVID-19 has had on the (mostly women) domestic workers who mostly perform it in countries in Latin America. Its true heart lies particularly in the roles played by their collective struggles, as members of trade unions and specifically IDWF's (International Domestic Workers’ Federation) and CONLACTRAHO's (Confederation of Domestic Workers of Latin America and the Caribbean). The unions and their members have been fighting for equal rights and decent work for decades. In 2011 they finally obtained a dedicated International Labour Organization (ILO) Convention (189) and in 2013 they created the first women-led global federation (the IDWF). During the pandemic, domestic workers’ unions responded by sharing crucial information, by legal mobilisations, and by distributing humanitarian aid to the most vulnerable among the workers. The research on which the article is based was carried out in collaboration with the trade unions, the survey was disseminated through IDWF's and CONLACTRAHO's affiliate organisations, and union leaders conducted phone interviews with members who could not be reached in other ways.

Inclusive approaches and co-production can also enhance social accountability for health and well-being. Sangeeta Mecwan et al. show how the notion of intersectionality and co-production are core to the strategies employed by SAHAJ, a local NGO working with adolescents and youth in India. Their intersecting identities – as tribal, Dalit, rural poor youth, and youth living with disabilities and belonging to sexual minorities – determine whether they are more vulnerable or privileged. The article offers lessons on what works: having a common understanding of the conceptual framework, values and principles of the project, and of key concepts related to gender, Sexual and Reproductive Health Rights (SRHR) and Social Accountability. Shared understanding helps build close partnerships with stakeholders at all levels: NGOs, local authorities, informal local organisations, schools, and parents. SAHAJ has also consciously created regular opportunities and spaces for collective reflection and learning among partners. The article provides valuable lessons that can contribute to programming and research for adolescents and young people and to operationalise what we understand as an ‘inclusive approach’.

Margaret A. McLaren and Monalisa Padhee also document change, brought about by the holistic strategies used to promote the menstrual health but also the reproductive rights of younger women, and freedom from stigma. Ensuing recommendations include: respect the autonomy of individual women; recognise the importance of local contexts; develop inclusive curriculums and educational resources; ensure the engagement of community health workers and teachers; and above all, acknowledge that menstrual health must be addressed within the larger context of gender, stigma, and structural inequality.

The article by Bharathi Radhakrishnan et al. warns us of the fact that fundamental change in gender relations and inequalities takes time, due to the strong patriarchal culture in Jaffna and throughout Sri Lanka. However, it concludes that local development actors can form partnerships and take steps to better educate communities about these gender dynamics and their influence on access to health care, particularly for women. Such initiatives – which should include men – could highlight the influence of caretaking responsibilities and gender norms on women's access to health care, and potential redistribution of such responsibilities when health services are needed.

Building stronger and gender-equitable health and social systems for all

The articles in this issue reiterate how gender and other intersecting axes of inequity shape experiences of health and well-being for all, across the life cycle, across a range of health issues and contexts. COVID-19 has amplified these inequities in complex and varied ways and requires new methods, approaches, and coalitions to enable advocacy and accountability for stronger and more gender-equitable health and social systems. The structural and gendered drivers of ill health are many and require proactive concerted action and strategic partnerships within and beyond the health sector.

Within the health systems we need programmes that recognise and respond to intersectional gendered experiences, as argued by Debjani Barman and Manasee Mishra in their analysis of the provision of eye care services, so that the needs of older women are met in an appropriate manner as they age. We also need health programmes that are accessible to all. This may require strategic partnerships between formal and informal providers in response to contexts such as the informal settlements in Freetown. Here, as demonstrated by Abu Conteh et al., high levels of poverty affect affordability and cause different health-seeking preferences, with socially vulnerable groups often forced to pursue riskier options and strategies.

Many health issues require some form of multi-sectoral action. For example, Neetu John et al. stress how holistic responses to GBV require analysis and action in the justice sector (police courts); health and social services (clinical and post-rape care, counselling, and shelter); and prevention (community-based, prevention and awareness raising, contraception). Beyond the health sector, multisectoral partnerships and alliances which support action on gendered structural determinants have much potential for impact. Louisa Acciari et al., for example, highlight promising examples from Argentina where protecting the rights of domestic workers has had positive impacts on their health.

Conclusion

As editors, we agree with the implicit and explicit position of most articles in this collection, that intersectional analysis of health is necessary to understand its complex and holistic nature. We also embrace many of the feminist approaches to the right to health for women, girls, and people of all genders suggested by the authors.

For research, this includes using a range of methods to understand the lived experiences of different individuals, and building data systems that can identify differences and track change by gender and other intersecting axes such as poverty, sexuality, disability, etc. We support the importance of using processes of co-production to address the structural drivers of inequities that limit health and restrict the inclusivity and equity of health systems, especially when responding to new and complex challenges (as exemplified by COVID-19).

At the level of policies and programmes, we support the articles’ findings that achieving lasting changes in gender and health requires politically nuanced, contextually specific, and gender transformative strategies that include promoting collective action, inclusive organising, rights-based processes, strategic and collaborative partnerships, and social accountability.

Above all, we hear and echo the more radical call that comes from some of the articles, and more specifically that by Claire Somerville and Khatia Munguambe, on the necessity to engage in personal and professional practices that have as their purpose the de-colonisation of both global health and feminisms, and actively allow space, autonomy, and leadership to alternative views, voices, and identities.

Finally, we wish to subscribe to the strong consensus that emerges from the articles in this collection, that, after COVID-19, in the words of Louisa Acciari et al., ‘We do not want to go back to “normal”, we need a fairer, more inclusive and gender-responsive alternative’ (this issue, 29) to global health.

Additional information

Notes on contributors

Janice Cooper

Janice Cooper is the Senior Project Advisor on Global Mental Health in Liberia for the Carter Center, with over 25 years of experience managing mental health research, policy, and implementation projects in Liberia and the USA. She consults with the Liverpool School of Tropical Medicine's REDRESS project on mental health and neglected tropical diseases. A native Liberian, she co-led the Mental Health & Psychosocial (MHPSS) pillar during Liberia's Ebola outbreak. Email: [email protected]

Renu Khanna

Renu Khanna is a researcher and activist and founder trustee of SAHAJ-Society for Health Alternatives based in Vadodara (Gujarat), a community-based action research and advocacy organisation working on social accountability issues in the areas of Maternal Health, Child Rights, Adolescents’ Development. She has also mentored several grass-roots women's and community health organisations in India over four decades. Email: [email protected]

Ines Smyth

Ines Smyth is a feminist, a co-editor of Gender & Development, and an Independent Consultant working with different institutions on women's rights in the global South. Email: [email protected]

Sally Theobald

Sally Theobald is Professor in Social Science and International Health at the Liverpool School of Tropical Medicine in the UK. She is currently working on a number of global health research projects which include a focus on gender and health, including: ARISE – Accountability in Urban Health; Reducing the Burden of Severe Stigmatising Skin Diseases (REDRESS); ReBUILD for Resilience; and COUNTDOWN: Calling Time on Neglected Tropical Diseases. Email: [email protected]