Do global health actors really understand why sex and gender matter to health? 

This International Women’s Day, Global Health 50/50 launches a new report which, together with a year of tracking sex-disaggregated data on covid-19, has forced us to return to a basic question and a very real concern. 

Do global health actors actually understand why sex, gender, and gender equality matter to health? 

The 2021 Report, Gender equality: Flying blind in a time of crisis, reviews the gender-related policies and programmes of the 201 most influential organisations active in global health. The report, produced annually, builds on four years of evidence to reveal progress and stagnation on gender equality in institutions, leadership, policies, and programmes. 

Perhaps the most concerning of its findings this year is that of a systemic failure to address the role sex and gender have played in health during the pandemic.

In a highly gendered pandemic, the 2021 Report found that 80% of 350 activities to address the health impacts of covid-19 had no consideration of gender. Just 1 in 10 activities considered gender in relation to vaccine research, development, and delivery; or the protection of healthcare workers. Among the few references to gender-responsive action, nearly 90% were focused on women and girls, despite a year of evidence on men’s higher risk of severe disease and death due to covid-19. Across these 350 activities, the health of transgender or non-binary populations was mentioned just twice.

In March 2020, Global Health 50/50 began tracking sex-disaggregated data on covid-19. As a small organisation, we were surprised this was a gap we needed to fill—an early indication that sex and gender would not be a priority in understanding and tackling the pandemic. 

A year on, however, the available data has been consistent in what it shows—sex and gender matter to health outcomes. Men are being admitted to ICU at twice the rate of women globally. Once infected, 50% more men are dying than women. The extent to which these disparities in the data are capturing true differences in health outcomes, or are the result of women’s lack of access to services or vital registration systems remains to be seen—but across all levels, gender matters. 

Covid-19, of course, is not an exception. Our 2020 Report highlighted that men and women experience different outcomes across almost all areas of health—this is no secret. Yet instead of using these data and insights to ensure gender was central to pandemic responses, when covid-19 hit, global health institutions and actors largely looked away. 

Perhaps unsurprisingly, the same neglect of gender has been seen in the reporting of sex-disaggregated data across other health issues. The 2021 Report finds that only 4 in 10 organisations sex-disaggregate their core programmatic data—a figure that hasn’t shifted over four years.

These findings point to a system that, despite decades of data and evidence, still does not seem to grasp the fundamental necessity of both sex-disaggregated data and gender-responsive health programmes that respond to this evidence. In times of crisis, these insights should be embedded in responses—so central to systems that their integration does not need to be considered. Yet instead we find that they are the exception. 

Part of our work involves trying to engage broader stakeholders—the press, civil society, the general public—and involve them as stakeholders in recognising how gender is embedded in marketing, institutions, and policies, with profound implications for our health. But this year we have been reminded that the global health sector may need persuading first. 

It is not too late to change this—the data and evidence can be used in covid-19 recoveries to consider gender and the ways in which experiences of the pandemic vary across individuals and communities. Whether that is in reducing exposure, countering mis-information, or tackling restrictive gender norms that keep people from health services: there is an opportunity to use these insights to promote better health outcomes for all people.

But beyond covid-19, these findings should act as a wake up call for the sector. Our gender is so intimately intertwined with our health and wellbeing; if it were considered, it could help us understand and address how our social and cultural environments impact the health of each and every one of us. 

And this cannot just mean for women. If covid-19, where men are dying at a 50% higher rate than women once infected, doesn’t prove that gender matters to the health of everyone, what will? Challenging patriarchal gender norms, policies, and health systems offers the opportunity to improve the health of all people—everyone has something to gain from this.  

Perhaps the neglect of sex and gender can be, in part, explained by the leaders of this global health system—70% of whom are male, and 84% of whom are from high-income countries. A new cohort of almost 100 leaders this year reflect a similar make-up. 

In a male-default world, how many of these men in leadership see themselves as “gendered?” If gender continues to be seen as an issue relevant to only those who deviate from the cisgender male norm, we may continue to struggle to get buy in from the current cohort of leaders. But as pressure for leadership to diversify grows, this may change—and perhaps, as we broaden our definitions of what “gender” means in global health and who gendered responses benefit, we may start to see more buy-in from men at the top, too. 

The 2021 Global Health 50/50 Report, Gender Equality: Flying blind in a time of crisis launches on March 8th 2021 and can be found here

Anna Purdie, Programme Manager, Global Health 50/50 / University College London Twitter: @anna_purdie

Unsia Hussain, Researcher, Global Health 50/50

David Zezai, Researcher, Global Health 50/50 and Data Explorer Consultancy, Harare, Zimbabwe Twitter: @DZezai

Sonja Tanaka, Coordinator, Global Health 5050 Twitter: @SonjaVTanaka 

Twitter: @Globalhlth5050  

Competing interests: none declared.