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9. Health systems and gender normsShow sections
9. Health systems and gender norms
As part of the wider context in which they operate, health systems are not gender neutral. They reflect and reproduce established gender norms and contribute to gender inequities. There are two main pathways through which they shape health outcomes for young women and men: service delivery and provider-patient interactions; and the involvement of men and women in health care provision.
Norms and health service delivery
Health systems that overlook gendered power relations that shape gender differentials in health needs and outcomes, fail to plan and provide appropriate services. Gender norms often influence whether a health system and its providers recognise a health problem and provide the appropriate treatment. For example, chronic pain or depression among women is often normalised, and domestic violence is not always seen as an issue that demands a health response.
Health providers and systems may also discourage the active involvement of men in maternal and child care. An analysis of demographic and health survey (DHS) data from 36 countries found that men’s presence at prenatal care visits reached or exceeded 60% in only six of them. Even when men want to be with their partners, they may be discouraged as childbirth is considered ‘women’s business’ in some contexts.
Health systems and their providers may also pay insufficient attention to gender gaps in access to services and fail to make appropriate provisions. They may not recognise, for example, that the poorest women may struggle to access health care. They may also overlook the way in which gender norms shape women’s mobility and social interactions. In settings characterised by gender segregation, lack of female health providers can be a major barrier for girls and women’s access to health services.
The gendered attitudes and behaviours of health providers also shape patients’ access to, and use of, health care. Where female sexuality is only acceptable within marriage, studies find that adolescents, in particular, fear providers’ attitudes towards premarital sexual activity, while health workers find it difficult to provide the information and services they need.
Fear of (or actual) mistreatment during childbirth makes women reluctant to access professional care. A systematic review found that physical and verbal abuse of women by health providers was reported across all regions, together with stigma, lack of privacy and confidentiality, with women from different ethnic backgrounds, unmarried girls and women and poor women often reporting greater discrimination. Single mothers seeking maternal services in public health facilities, in particular, can face abusive treatment.
Disrespectful comments, discriminatory attitudes and even denial of treatment are accentuated in the case of groups who transgress gender norms and face increased vulnerability, such as sexual minorities. In Argentina, 67% of young transgender women reported having faced discrimination from health workers and 32% by other patients, with those affected three times more likely to avoid using health services than others.
Norms and the health workforce
Gender norms also shape the structure and hierarchies of the health workforce and compromise the development of effective and equitable health systems. Gender norms and stereotypes influence the participation of women and men in the workforce and shape unequal chances of entering or succeeding in the health profession.
Women account for the majority of the global health workforce, yet this is characterised by occupational segregation. In many settings, they comprise the majority of nurses, community health workers and midwives, while men dominate jobs seen as requiring ‘higher’ skills in health delivery and management positions. Nursing, for example, has been linked traditionally to the maternal instinct of caring and has been seen as less of a specialised profession and more of a ‘natural’ feminine characteristic. Analysis of data from Kenya has found that nursing, nutrition and community health work are seen as ‘women’s work’.
The number of men studying nursing is, however, increasing, challenging the norms that label those doing ‘women’s work’ as less masculine. In addition, women’s participation in medical schools is increasing, although they are often less likely than men to practise medicine once they are trained. In Rwanda, 47% of male junior medical students reported surgery as their first preference, compared to just 20% of their female counterparts.
As well as affecting education and employment patterns, gender norms also influence the work experiences and opportunities of health workers. Evidence from health facility surveys in six LMICs shows that women nurses and midwives are far less likely than their male counterparts to have had training. Women often receive lower wages, as shown by a global review of data from 20 countries, with women’s skills and occupations de-valued as ‘female’. Women health workers are also more vulnerable to workplace violence and abuse: in Rwanda they accounted for three quarters of the health workers who reported being sexually harassed at work.
Women also account for the vast majority of unpaid care workers for family members with chronic medical conditions or disabilities. Their caregiving work is demanding but largely undervalued, even though it fills a major gap left by formal health care. Estimates indicate that the average annual value of such unpaid contributions accounts for between 2.27% and 2.43% of global GDP.