When men choose

When men choose

The political determinants of health that exclude women from equal decision-making power are more deadly for their health than any pandemic, with women and girls suffering from decisions that place low value on their health, safety and lives

The director general of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, has stressed that “universal health coverage is a political choice”. That particular political choice is a life and death decision for half the world’s population who lack full coverage for essential health services. Universal health coverage has the potential to change the health and lives of millions of people, the majority of them women. Many lack the opportunity to be heard by the political decision makers who will decide whether to adopt universal health coverage and who and what it will cover. Women and girls, in particular, suffer ill health and preventable death caused by political decisions that consistently place a low value on their health, safety and lives.

The COVID-19 pandemic has exposed serious gender inequities and deficiencies in health that decades of United Nations conferences for women, Millennium Development Goals, Sustainable Development Goals and other global political commitments have failed to resolve. Once again, in this pandemic the health of women and girls (half the world’s population) is suffering because they lack political voice.

Women are 70% of the health workforce, 90% of the world’s nurses and, in most countries, the vast majority of front-line health workers. That makes women indispensable to global health and to the prevention and response to COVID-19. Yet they hold only 25% of senior decision-making roles in health. Women from the Global South are particularly underrepresented. Despite so much female talent and expertise in the sector, most global and national COVID-19 task forces have only a small minority of women members. A study of 87 countries found 85% of COVID-19 national task forces had a majority of male members and 81% were headed by men. Only 5 of the 21 members of the WHO Emergency Committee on COVID-19 are women and 2 out of 22 members of the US coronavirus task force are. Women’s expertise in the health sector has not earned them an equal place at the pandemic decision-making table.

The representation deficit

The gender imbalance in health leadership and decision-making is a democratic deficit that goes beyond representation. Political decisions made in the COVID-19 pandemic risk ignoring lessons from previous pandemics that directly affect the lives of women and adolescent girls. For one thing, it is critical during COVID-19 lockdowns that essential maternal and reproductive health services for women are maintained. Pregnancy and childbirth do not stop in an emergency. One study of the Ebola epidemic in Sierra Leone found that cuts to antenatal care, family planning, safe delivery facilities and postnatal care services during the epidemic resulted in 3,600 additional maternal, neonatal and stillbirth deaths in 2014–2015. The stakes are high. One estimate of the potential impact of COVID-19 on sexual and reproductive health in low- and middle-income countries projects that a 10% cut in essential pregnancy-related and newborn care could result in 1,745,000 additional women experiencing major obstetric complications, 28,000 additional maternal deaths, 2,591,000 additional newborns experiencing major complications and 168,000 additional newborn deaths. Despite tragic lessons being documented from previous disease outbreaks, reports have already been received of lives lost as pregnant women struggle to access essential maternity services during COVID-19.

Would equal numbers of women in political decision-making change the outcomes for women’s health and lives? Currently, only 6% of heads of state and government are women and only 24% of parliamentarians are. Women are far from having equal representation with men. Only Rwanda, Cuba, Bolivia and the United Arab Emirates – four countries with very different political systems, cultures and income levels – have 50% or more female parliamentarians. There is, however, a growing body of evidence that women parliamentarians, when present in sufficient numbers, change the political agenda and prioritise health, particularly women’s health. Research from 139 countries found that between 1995 and 2012 a large increase in women’s parliamentary representation via quotas was followed by increased government expenditure on public health. Research on the impact of an influx of women in parliaments in 22 countries, following the introduction of quotas for women, found a 9–12% decline in maternal mortality in low-income countries, with the biggest falls coming where gender quotas had been in place the longest. These results are consistent with evidence suggesting that female parliamentarians are effective in agenda setting and coalition building, leading to greater parliamentary focus on health and women’s health issues.

The political determinants of health that exclude women from equal decision-making power are more deadly for their health than any pandemic. Men have been making political choices on women’s health for too long. Equal representation of women – diverse women – in health decision-making from community level to global is the smart route to universal health coverage and global health security.