The effect of gender roles and norms on men’s health
Worldwide, men’s life expectancy remains lower than women’s. Key factors contributing to this include poor health seeking behaviors of men compared to women resulting from an interplay of factors of masculinity and workforce participation that drives men to ignore health issues. In Sri Lanka, this poor health seeking behavior has manifested in lower rates of utilization of non-communicable disease screening facilities provided through healthy lifestyle centers. Making services more inclusive by extending them to workplaces can make access easier for men. Men are also more at risk of dying due to alcohol and smoking related diseases. The prevalence of use of both substances remains significantly lower among women. In Sri Lanka, for example, according to the STEPS Survey of 2015, the prevalence of current smoking among males was 29.4% and only 0.1% among females. Regarding alcohol consumption, 34.8% of males were current drinkers and only 0.5% of the females were current drinkers. It is clear that the use of these substances negatively impact on the health of men; targeted programs are necessary to provide assistance to quit their addictive behaviors. Research has shown that the top ten causes of ill-health affect men more than women.

In many contexts, the social and economic roles performed by men and women are different, and therefore the health risks they are exposed to over their life course differ. The intersection between gender, economic power, and social roles, for example, are contributing to different health outcomes between men and women. What this means is that men’s health is often more affected by working conditions, violence, and smoking, while women’s health is often more influenced by the burdens of caregiving to different generations with paid work and housekeeping.

The role of discourse in men’s health
In addition to considering how gender roles and norms affect men’s health, it is also important to consider the role of the language and how men are perceived by different actors. Actions and discourse of health service providers, managers, policy makers, and researchers, for example, can negatively affect men. Because we often fall into the trap of talking about women as victims who are acted upon, and men as agents who act, we often fail to recognize that the social forces that expose women to health risks (patriarchal gender norms that limit the possibilities for women’s agency) act equally on men, and equally constrain their choices. Even when the effect on these forces on men is recognized, the discourse fails to reflect it.

This discourse is a result of a gendered worldview in which men are afforded power and agency, but also, therefore, considered as perpetrators and risk-takers, and inappropriate subjects for sympathy, care and support. In other words, men are subject to social and cultural forces which make it difficult for them to protect themselves from risk without jeopardizing their masculine identities, but are also disadvantaged by global and national (often patriarchal) discourse that fails to consider them as victims acted upon by cultural and systemic forces. In Ghana, for example, public discourse on domestic violence often highlights men as perpetrators rather than victims. Data from the Domestic Violence and Victims Support Unit (DOVVSU), however, shows that a significant number of men have been abused by their wives. 2,807 men reported domestic abuse cases against their wives in 2015, while 3,143 reported domestic abuse in 2014 (Domestic Violence and Victims Support Unit Report, 2015).

It is important that we consider discourse in relation to how health services are provided. In South Africa, despite substantial evidence of the poor treatment outcomes of men with HIV, men are still neglected as a key-population for HIV interventions, in local and global treatment guidelines and funding opportunities. Because maternal and child health (MCH) constitutes a window of opportunity to initiate HIV testing and care, many HIV and sexual and reproductive health (SRH) services are provided in MCH contexts – contexts in which men might feel unwelcome or uncomfortable. In addition, most health services are provided by women, further alienate men who feel uncomfortable discussing sex with women. In South Africa, this phenomenon is exacerbated by the politicization of the sexuality of men (particularly black men) who, in the context of the HIV pandemic and racist social structures that are the legacy of apartheid, are considered as spreaders of disease and perpetrators of sexual violence. The vulnerabilities that are a result of these intersecting forces is further exacerbated by the poverty and inequality that affect such a large proportion of the South African population.

Health policy makers need to start considering the challenges men face in accessing care, for example by making health facilities more male friendly – distinguishing men’s SRH services from MCH services, and keeping health facilities open later so that men who work can still access them – as well as by explicitly recognising the needs and vulnerabilities of men in the discourse used in policy documents. In addition, the discourse we use matters, because it can undermine or reinforce pervasive paradigms of understanding. As health researchers, we need to be careful in the language we use, and encourage policy makers to do the same.

Note:  This blog is based on an online discussion about gender in health systems with 14 members of the new cohort of the Emerging Voices. The blog presents reflections made during those discussion.

In Bangladesh, some mHealth activities have sought to recognise the roles of men as gatekeepers to women’s health. Instead of only sending SMS messages to pregnant women, they also send them to husbands or other significant men who have been identified by the women. This seems to play two roles: it encourages men to take women’s maternal health seriously and makes it harder for these men to block women from using maternal health services. But does it also play a role engaging men in maternal health?  Does it also give men maternal health information which they find interesting and useful?  Is it helpful at all, or potentially harmful (i.e. does it increase their power over women)?

This leads us to ask: is there an inherent tension in involving men in maternal health – are we in fact increasing male authority in a domain that was at least partly in women’s control? Brazilian feminists have argued for a long time against the ‘maternal infantilisation’ of women, i.e. that women should still have primary authority about what happens to their health and bodies, including when it comes to pregnancy and childbirth. When we seek to engage men in maternal health, we need to ask whether it is done in a way that would be considered unethical or would in fact inhibit women’s autonomy (e.g. encouraging forms of community surveillance that take away women’s right to privacy). Questions that need to be asked include: when is it acceptable to share health records of one person with another and what are the gender dimensions involved? Under what conditions should men be encouraged to actively participate in women’s maternal health?  Are there ways to involve men, to promote gender equality and sustain women’s autonomy? What kind of services and support mechanisms do we need to navigate this?

This is not to say that engaging men is necessarily counterproductive. In India, our experience shows that the framework which guides such engagement is what matters – it should not be instrumental, i.e. we should not engage with men because they are “decision makers”/”gatekeepers” and can affect service uptake, but as partners who have a responsibility to share the burden of contraception, childbearing and rearing, and who have a responsibility and interest in advancing gender equality. Rather, that the basis of engagement aims to foster a recognition of, and discussion around, men as fathers and male privilege. As feminists have long known, men must be involved in the dismantling of structures and harmful social norms that jeopardize women’s well-being – norms such as early marriage, early childbearing, violence, restriction of mobility and so on. Even then, there is a temptation to persuade men to support women’s health and empowerment through an easier route by making utilitarian appeals like “if your daughter is well educated, she will be a good mother”. While this may help to convince the community to not force their girls to drop out of school, will it not further essentialize women’s roles as mothers?

Men and maternal health (UNFPA /Omar Gharzeddine)

What is the role of health systems researchers in addressing this issue? Health system researchers are in a unique position to support policy champions and bridge the gap between research and policy by linking appropriate policy audiences in developing research, disseminating research findings effectively to different stakeholders, and supporting a policy community to work on issues informed by research. A recent review, critically examining the emerging evidence base on interventions that engage men in maternal and newborn health, has found important gaps in how male involvement is conceptualized, and recommends more research to document the gender transformative potential of these interventions.

Building on this, we call on health systems researchers to investigate the context specific gendered determinants of maternal health, and be aware of how interventions interact with these contexts. Such informed investigations would ensure that evidence based approaches to engage men keep gender equality, women’s autonomy and rights at the center, rather than focusing instrumentally on health outcomes alone. We need efforts that engage policy makers and implementers in supporting long lasting change, rather than superficial measures that further involve men in maternal health in ways that may not be helpful and indeed in some instances be harmful.

Note: This blog is based on an online discussion about gender in health systems with 14 members of the new cohort of the Emerging Voices. The blog presents reflections made during those discussion.

The majority of health workers in lower tiered positions, such as within primary health care provision, are women. Despite women making up a significant proportion of health care workers, they are grossly underrepresented in leadership positions across the world. This is not unique to the health sector. In the corporate world, for example, the report on The State of Women in Healthcare: 2015 indicates that only 4% of CEOs are women.

Greater participation of women at the leadership level has been shown to result in policies which enhance the position and rights of women. For instance, Rwanda which has the highest level of women parliamentarians of any country, has also over the years invested in policies on ending violence and discrimination, investing more in health services, and investing more in improving women’s participation in the workforce. In the case of Rwanda, the participation of women at the political level went way beyond the 30% quota instilled in 2003. Contrast this to the Kurdistan Region of Iraq, where despite a similar quota women constitute only 3% of leadership positions. This raises the question of the need for, and role of, quotas for women at the leadership level.

Encouraging women’s representation through quotas?

Deliberate efforts like putting quotas, reservations, and affirmative action to ensure participation of people from marginalized, vulnerable or less vocal sections of the populations could encourage more women’s participation at multiple levels of policymaking and the workforce. But do they really work? Are quotas a legitimate way to reach equilibrium and ensure at best some form of equal representation at the top? While quotas might ensure that more women have a seat, do they actually increase women’s meaningful and effective participation? If not, what is needed alongside quotas to ensure women’s meaningful and effective participation?

While a quota system may provide a way to encourage women’s representation at the leadership level, it is only a short-term solution. If women’s participation at the top is going to be meaningful and effective, longer-term strategies are needed to transform the unequal gender norms, roles, relations which perpetuate and reinforce gender inequities within the health system and inhibit women’s participation at the leadership level.

Increasing women’s value within the health system

Community health workers –the cornerstone of early primary health service programs, and for many people their only contact with the health system – are largely women. Women who take on this position often do so for little or no pay. Even as one acknowledges the role of the female community worker, we wonder if they would be better paid and organized if the majority of the workforce were men. Studies have found, however, that even within the same occupation (including those that are female dominated) not only are women promoted less frequently than men, but they also earn less. Gender inequities within the health system are a reflection of gender inequity within society. Gender pay inequity can therefore been seen as a reflection of the value placed on women’s work and their overall status within society. Women’s work is often seen as less important or worthwhile, and their role has health workers is no exception. As we usher in the Sustainable Development Goals, we should strive to progressively change the value placed on women’s work and role within the health system, and offer equal opportunities and compensation to reflect this.

Minimizing gender bias within the health system

The issue of women’s role within the health system is becoming increasingly important, especially as we start to see a feminization of the medical workforce. In many countries, for example, the number of medical graduates are increasingly female. It will be interesting to see if the feminization of the health workforce translates to the top – as more women enter the health workforce will this be reflected at the leadership level? This is unlikely if we do not first minimize gender bias within the health system (and society more generally), which devalues women’s work, leads to lower compensation, and means that less women are given the opportunity to advance within their career.

Minimizing gender bias within the health system “requires systematic approaches to building awareness and transforming values among service providers,” along with developing policies and strategies to remove barriers to women’s career advancement and ability to engage in leadership roles. Women make up a large majority of the health care profession – it is time that they are recognized for their contribution and adequately represented at the top.

Note:  This blog is based on an online discussion with 14 members of the new cohort of the Emerging Voices. Over the past few weeks we engaged in a discussion on gender in health systems (one of three parallel discussions) with these 14 EVs. One of the most visible themes to have emerged from the discussions, and also perhaps an instinctive reaction of health system practitioners was that of gender (here mostly in the context of women) within the context of human resources for health and human resources in general.  The blog presents reflections on the issue of leadership and HRH from our discussions.