Gender and Health
Gender is a crucial element in health inequities as it influences the control men and women have over the determinants of their health, including their economic position and social status, access to resources and treatment in society.
Decades of active lobbying by non-governmental organizations and women’s rights advocates have had a major influence in ‘gendering’ health policies, such as the shift in focus from family planning to reproductive health paradigms and the global acknowledgement that violence against women is as much a health issues as a social issue. The Nobel Laureate Amartya Sen, in his seminal book ‘Development as Freedom’, emphatically stressed the relationship between women's education, social status and overall child and maternal health when he made education and health as the two basic capabilities that makes life meaningful and the enjoyment of freedom possible. Analysis of economic and socio-cultural context is an important component of health policy analysis because contextual factors significantly influence the health policy process and the overall health of population directly and indirectly. Paying attention to contextual factors helps in understanding the role of the state, society and market forces influencing health agenda, health planning and implementation, and even more important health outcomes. Health as a sector best typifies the fallacy of the trickledown theory – that despite periods of high economic growth and activity, significant changes in social indicators have not happened.
Gender inequality damages the health of millions of girls and women across the globe. It can also be harmful to men’s health despite the many tangible benefits it gives men through resources, power, authority and control. These benefits to men do not come without a cost to their own emotional and psychological health, often translated into risky and unhealthy behaviors, and reduced longevity. Taking action to improve gender equity in health and to address women’s rights to health is one of the most direct and potent ways to reduce health inequities overall and ensure effective use of health resources. Deepening and consistently implementing human rights instruments can be a powerful mechanism to motivate and mobilize governments, people and especially women themselves.
Gender practices in Pakistan
The United Nations Millennium Development Goals report 2011 has prioritized the goal for promoting gender equality and women empowerment but targets are far from its reach, especially in South Asia. Pakistan challenged with gender inequalities, and despite efforts there is a wide gap between males and females in terms of employment opportunities, paid work, access to health services and health outcomes in Pakistan. The gender inequality has deep roots in Pakistani society. Culturally, women are at a disadvantage from birth and are subject to discrimination during their entire lifecourse in Pakistan, while men are perceived economic and social utility. This gender preference can be assessed by unbalanced gender ratio (91 women for every 100 men) in Pakistan, when compared with industrialized countries.2 Male infants enjoy more family resources and care in terms of better nutrition and healthcare access than females of the same age. Female children are, therefore, susceptible to face more neglect and live in poor health compared to male children. This neglect of girls continues in their childhood and adolescence, with only 25% of women able to complete their primary education as compared to 49% of men in Pakistan. Female literacy is only two thirds that for men in urban Punjab, and is beyond doubt much worst in rural areas of Pakistan. These early life experiences may simply reinforce the intergenerational continuity of female vulnerability in the society. Marriage may further deepen the inequality problem as females are often considered economic liability to a family because of dowry-endowment tradition in the country. When the dowry expectations of husband's family are not met, husbands and in-laws may threat the bride to kill, or they may torture the bride mentally and physically in an effort to encourage her family to fulfill their dowry obligations. The older the girl, the higher the dowry that is likely to be demanded, women are therefore, likely to get married at much younger ages as compared to their men counterparts, as a result of which females become economically and socially dependent. These factors clearly compromise their productivity by limiting their role in family decision-making even in matters related to their well-being Early marriage predisposes these girls to early pregnancy and child birth with an estimated 42% getting pregnant prior to the age of 20 years.5 Women married as children appear to be at forefront for domestic violence from their husbands and their in-laws. Frequent burns among married women due to stove bursting more often by husbands and in-laws point towards most extreme forms of domestic violence in Pakistan. This nexus of early marriage and pregnancy is an accepted risk factor for poor health outcomes such as anemia, hypertension, premature and low-birth weight infants, but has not been thoroughly studied in Pakistan. Similarly, one study documented that poor nutritional status and gender inequality issues, might have been contributing significantly to observed high rate of osteoporosis in a sample of Pakistani women. Another study indicated that tuberculosis case notifications were 20 to 30% higher in Pakistani females as compared to men of the same age but did not explain its putative mechanisms.
Despite deep-rooted gender inequality in the country and its adverse health consequences among women, the implementation of specific interventions to reduce these gender differences are still not sufficient. One of the general measures is education which is pivotal in the country's development; investing in education is helpful for human development and improving the quality of life. Overall, education is a tool to provide ideas, develop, learn and adjust to changing social and cultural environment within a country and around the world. Furthermore, education helps to increase income, reduce poverty and improve health. It has been shown that doubling the proportion of girls educated at the secondary level, could reduce the fertility rate by 1.4 children per women (from 5.3 to 3.9) after accounting for access to family planning and healthcare.10 Further, infant mortality rate has reduced by 5-10% with each additional year of a mother's schooling.10 Undoubtedly, increasing the secondary and higher level of schooling has shown a substantial beneficial effect on women's own health outcomes, and for risks of disease; same holds true for use of prenatal and delivery services and postnatal care among women. Similarly, enrollment of girls in secondary school may reduce early marriage and related problems such as early child birth and high fertility, as depicted by earlier study showing its inverse relation with early marriages (before the age of 18 years). Therefore, interventions such as reducing the cost of study in schools, scholarship program, building schools close to girls' residence and making them safe and girl-friendly are bound to reduce gender inequality, if correctly implemented in Pakistan. Nevertheless, such measures to empower women and reduce gender inequalities effectively in the country should be supplemented by specific interventions such as promotion of civil, sexual and reproductive health rights for women, creating equal opportunities for employment, reducing income gaps and occupational segregation among both sexes, focusing on prosecution of men who inflict violence, empowering women to oppose violence, making strict laws against child marriage, and providing equal opportunities for making strategic choices and decision. Complex pathways of gender inequalities leading to poor health outcomes such as maternal and child morbidities and mortalities, nutritional deficiencies,8 and intentional injuries have not been clearly understood, and making this a health research priority may facilitate effective policy-making and implementation of local prevention programs and better healthcare delivery in the country.