Janet Fleischman. "Making Gender a Primary Focus of Global Health Security." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, March 19, 2021. Accessed April 21, 2021. https://healthsecurity.csis.org/articles/making-gender-a-primary-focus-of-global-health-security/
“The pandemic appears to be reversing the global gains that we’ve made in HIV/AIDS, tuberculosis, malaria, malnutrition and maternal and child mortality . . . Here’s the truth, when women face obstacles to obtaining quality healthcare, when women face food insecurity, when women are more likely to live in poverty and therefore disproportionately impacted by climate change, more vulnerable to gender-based violence, therefore disproportionately impacted by conflict, it’s harder for women to fully participate in decision-making, which of course, in turn, makes it that much harder for democracies to thrive.”
Vice President Kamala Harris, Remarks at the United Nation’s 65th Session of the Commission on the Status of Women, March 16, 2021
The Covid-19 pandemic has glaringly illuminated and exacerbated gender inequalities in health and development around the world. These mutually reinforcing crises, further compounded in countries with high HIV burdens, demonstrate that strengthening global health security requires a concerted focus on the health, development, and leadership of women and girls. Given the Biden-Harris administration’s new commitments to global health and gender, this is a propitious moment for the United States to catalyze programs, policies, and resources focused on women and girls to advance global health security strategy. “No country can recover from this pandemic,” President Biden said on March 8, International Women’s Day, “if it leaves half of its population behind.”
Requiring a gender lens for global health security is consistent with U.S. national interests in advancing women’s and girls’ access to healthcare, promoting social and economic development, providing humanitarian assistance, and increasing the odds of success for preparedness, response, and recovery activities. Such an approach calls for concerted action on four key fronts, and the administration will be judged on the progress it makes in these areas:
- prioritizing women and girls in the global response to Covid-19, including by addressing the secondary impacts such as gender-based violence (GBV), economic hardship, and loss of educational opportunities;
- strengthening access to sexual and reproductive health and maternal health as cornerstones of U.S. support for primary health care (PHC) globally and for building stronger health systems;
- elevating women’s and girls’ health and protection in humanitarian crises, especially addressing GBV and supporting the provision of reproductive and maternal health services; and
- engaging and elevating women at the family, community, national, and global levels as decisionmakers on health security, which includes female healthcare workers, who make up 70 percent of the global health workforce.
In its early days, the Biden administration has given promising signals about promoting action on women, girls, and global health security. In January 2021, the Biden-Harris administration announced its commitment to address the impact of Covid-19 on women and girls in its National Strategy for the Covid-19 Response and Pandemic Preparedness, which signaled the importance of mitigating the secondary impacts of Covid-19 on the health and development of women and girls. Recognizing the dire impact of the pandemic on vulnerable communities, the strategy specifically notes the disproportionate impact on women and girls and recognizes that the pandemic could reverse gains in global health and PHC, including childhood immunizations, maternal and child health, HIV/AIDS, and the related surge in GBV.
In sharp contrast to the Trump administration’s policies—which effectively banned use of the term “sexual and reproductive health,” inaccurately contending that it was code for abortion—the new strategy states that improving health outcomes for women and girls means recommitting to sexual and reproductive health and rights and to maternal and child health. It further commits to putting women and girls at the center of global recovery efforts from Covid-19, and supporting UN Secretary General António Guterres’s appeal, in which he stated that such a global recovery “starts with women as leaders, with equal representation and decision making power.”
Without any doubt, the impact of Covid-19 on women and girls has been dire, destabilizing communities around the world, with particularly devastating effects in lower- and middle-income countries. The toll on women and girls is reflected in both direct and indirect ways: rising levels of GBV, intensified by the Covid-19 lockdowns and accompanying economic stress; loss of educational opportunities, with some 11 million girls at risk of not returning to school due to Covid-related causes, including unintended pregnancy and early marriage; and economic hardships, related to loss of formal or informal employment and increased burdens of caregiving. In addition, women and girls have confronted disruptions that reduced access to sexual and reproductive health services, antenatal care and maternal health, and HIV prevention activities, thus increasing their risks of unintended pregnancies, unsafe abortion, and maternal mortality or morbidity. Taken together, these factors further elevate risks to global health security and global development.
Advancing global health security also relies heavily on strong PHC systems, which provide the foundation for communities to withstand health shocks, build resiliency, and maintain the trust and confidence of the population and access to healthcare throughout crises. This was abundantly clear in the 2018-19 Ebola crisis in the Democratic Republic of Congo, where disruptions in PHC led to massive declines in vaccinations and contributed to a severe measles outbreak that by late 2020 had killed twice as many Congolese as Ebola did. Writing in the British Journal of Medicine, a group of distinguished global health leaders concluded: “When primary healthcare is strong, these same systems also become a robust first line of defense against disease outbreaks and global health security threats.” They identified essential services in PHC to be reproductive, maternal, newborn, and child health, noncommunicable diseases (NCDs), malnutrition, and HIV/AIDS, TB, and malaria.
As most observers of PHC facilities in lower- and middle-income countries can attest, a core component of PHC involves sexual and reproductive health and maternal and child health, evidenced by the long queues of women and children waiting for hours for services. And since women and girls are disproportionately affected by global health security crises, PHC is critical to enable them to care for themselves and contribute to their families and their communities. Access to these essential services is often a prerequisite for women and girls to be able to meaningfully engage in decisionmaking and leadership in their communities, health systems, and governance structures. Accordingly, the consequences of disrupting these essential services are devastating to communities, measured in reduced antenatal visits, lack of access to modern contraception, failure to receive childhood immunizations, and loss of screening and treatment for sexually transmitted infections and for HIV, among other impacts.
The Biden-Harris national strategy also acknowledged what has been abundantly clear but consistently overlooked in humanitarian crises around the world; that engaging women is vital to strengthening the humanitarian response and building resiliency in communities to improve health security. As Roopa Dhatt of Women in Global Health has explained, pandemic response efforts are undermined by the gender inequities in the health workforce, where women make up 70 percent of the global health workforce but only 25 percent of leadership. “Responses to outbreaks are weakened where female talent, expertise, and diverse perspectives are excluded,” she wrote.
Crisis responses around the world continue to present glaring gaps in addressing the health and protection of women and girls and in involving them as decisionmakers at every level. This requires listening to, engaging with, and strengthening the capacity of healthcare providers, community outreach workers, women’s organizations, and legal assistance personnel to provide essential health and protection services for women and girls. These gaps are amplified for adolescent girls in crisis settings, especially when families are broken up and social services such as health care and education collapse. Adolescent girls are at high risk of GBV, including forced marriage, trafficking, transactional sex for survival, and sexual assault by armed forces, humanitarian actors, and others. Prioritizing women’s and girls’ health, safety, and participation and incorporating a meaningful gender and GBV analysis into all crisis responses should be a requirement and reflected in program designs and implementation.
These risks for adolescent girls and young women are strikingly evident in Yemen, one of the world’s largest humanitarian crises, where the collapse of the health system and the economy, combined with food insecurity and the violence of the ongoing conflict, have had a devastating impact on this population: according to the United Nations Population Fund (UNFPA), rates of child marriage rates have escalated, with some two-thirds of girls married before the age of 18, and girls under 18 representing over 20 percent of female-headed households. An estimated 3 million adolescent girls and young women are at risk of sexual violence and GBV in Yemen.
Addressing the gender dimension of global health security could build on the extensive U.S. capacities in the areas of maternal and child health, reproductive health and family planning, and GBV prevention and response. Given that 34 million women and girls of reproductive age are estimated to be in emergency situations, often targeted with sexual violence as a weapon of war, and that pregnancy and childbirth do not stop during crises, the disruption of sexual and reproductive health, maternal health services, and broader PHC systems undermine resiliency, stability, and global health security. To date, there has been no coherent U.S. strategy to effectively integrate the health and safety needs of women and girls into health security strategy. This will require determined, high-level U.S. leadership, coordinated action by U.S. government agencies, and additional flexible resources. In an October 2019 report for the CSIS Commission on Strengthening America’s Health Security, CSIS called for the U.S. government to catalyze action to improve the health, safety, and security of women and girls to advance global health security. Such a strengthened approach to health security relies on continued bipartisan congressional and multilateral support.
The devastation caused by the Covid-19 pandemic makes this agenda even more urgent today. The Biden-Harris administration has taken some important first steps, including President Biden’s Executive Order establishing the new White House Gender Policy Council and mandating it to develop a government-wide strategy on gender equity domestically and globally within 200 days. But this work will demand concerted, consistent, high-level U.S. leadership, combined with expansive strategies to engage diplomatically with national governments and multilateral organizations and to empower and engage women in the global healthcare workforce and in communities around the world. In the words of Julissa Reynoso, co-chair of the new White House Council on Gender Policy, the full participation of women and girls in society is “essential to the economic well-being, health, and security of our nation and the world.”
Janet Fleischman is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.
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