Statement by Rebeca Grynspan on Women and Health
Speech by Rebeca Grynspan
Associate Administrator United Nations Development Programme
Women and Health: A Cause for Optimism
Harvard School of Public Health
Wednesday, March 12, 2014
It is a pleasure to join you here at the Harvard School of Public Health. I extend my gratitude to Professor Nancy Krieger for inviting me to discuss the links between women’s empowerment, health and development.
These are very exciting times. With the Millennium Development Goals set to expire in 2015, serious discussions around the post-2015 development agenda are gaining traction. Especially because it is recognized that the MDGs were able to galvanize international and national efforts around very clear and relevant goals, that were very easy to communicate and that with the help of a useful accountability framework were able to mobilize societies and actions around them.
This year we also celebrate the 20th anniversary of the 1994 Cairo Conference on Population and Development, which recognized reproductive health and rights, as well as women's empowerment and gender equality, as being essential to development progress.
And next year we will also commemorate the 20th anniversary of the Beijing Declaration and Platform for Action. Precisely this week we are having the annual meeting of the Commission on the Status of Women, focusing on: “Challenges and achievements in the implementation of the Millennium Development Goals for women and girls”.
So the next few months will be very intense and present us with a lot of challenges but also with a great opportunity to build on the progress made and agree on a post 2015 development agenda that will renew and strengthen our commitments to gender equality, and women's rights and empowerment.
The 8th of March we celebrated “International Women’s Day”. The theme this year, "Equality for women is progress for all", reminds us that equality for women has an intrinsic value for societies. Nowhere in the world do women and men have equal status in society – something that is clearly and inherently unjust and unacceptable. This hurts women in many different ways, but it also hurts societies. This rooted asymmetry of power is a serious constraint to build societies that seriously aim at being fully democratic and based on the respect to human rights. How can we be serious if at least 50% of the population (not exactly a minority) cannot enjoy equal rights and opportunities from birth!
But we also know by overwhelming evidence, that gender equality and investing in women and girls is not only the right and ethical thing to do but also the smart thing to do and that it has an instrumental value to development. The links between maternal education and improvements in child health, or the loss to GDP due to low participation and gender discrimination in the labour market, or the loss in productivity and in goods are well known. The FAO estimated that if women in agriculture had the same tools and resources as men, production in developing countries could increase between 2.5% to 4%, leading to between 100 and 150 million less hungry people.
Despite this, women do 66% of the work, produce 50% of the food and get only 10% of the revenue.
Having said that, the title of my lecture is “Women and Health: A Cause for Optimism”, and while challenges are huge, I for one, want to start celebrating progress. Because if we don’t believe things can change we will lose the short and unique window of opportunity we have to accelerate action on gender equality – and I see, in many parts of the political spectrum, conditions to do so, recognizing, that we also face an important push back in some key areas, including on women’s sexual and reproductive health and rights. And that progress has been uneven between and within countries.
Status of Women’s wellbeing globally. So where do we stand?
The Millennium Development Goals contained two gender-specific goals – Goal 3: promote gender equality and empower women and Goal 5: improve maternal and reproductive health. They also included two additional health specific goals – Goal 4: reduce child mortality and Goal 6: combat HIV/AIDS, malaria and TB. Other goals targets also affected women, like Goal 1 to reduce extreme poverty by half and Goal 7 which included a target to increase access to improved sources of water.
According to the World Bank Goal 1 has been achieved ahead of time (China being an important reason for that) and also the access to improve sources of water, with universal coverage of primary education for boys and girls pretty close to being reached. And important progress in the fight against HIV/AIDS, Malaria and TB has been made, including women receiving antiretroviral therapy at equal to or higher rates than men.
Over the last 20 years, the number of women dying in pregnancy or childbirth has dropped by almost half, even though MDG 5 (on maternal and reproductive health) is the MDG that lags furthest behind. Crucially, rates among low-income groups are declining more rapidly (at 21 percent between 2000 and 2010) than amongst upper-middle income groups (13 percent over the same period).
However, two important caveats:
a. there are important and staggering differences between countries, and within countries in their achievements. In developing countries there are 240 deaths per 100 000 live births compared to only 16 per 100 000 live births in the Developed countries. And in some countries, including Somalia, Chad, and South Sudan, more than 1,000 women die for every 100,000 live births.
In secondary education, the gender parity index was only 0.83 for sub-Saharan Africa, while 1.07 in Latin America and the Caribbean. And in South Asia, children in the wealthiest quartile are two times more likely to complete primary school than those in the lowest.
b. We know that access is not the whole story be it education or health. Sometimes we forget the original goal: gender equality!! As the Secretary-General’s 2014 report for the Committee on the Status of Women indicates, while the MDGs “capture some important aspects of gender equality, the targets are narrow and misaligned from the full spectrum of women’s and girls’ rights”. Inadequate investments and uneven implementation of commitments perpetuate discrimination, inequality and exclusion.
So, for example, the remarkable gains in education have not translated to equivalent gains for women in the economic and political sphere. Despite progress in Latin America, for example, women still earn almost 20 percent less than men despite the fact that females have outperformed men in educational achievements. Not only that, wage differential are wider the more education women have compared to equally educated men. And women continue, to be significantly under-represented in politics –and unable to maintain any progress made unless positive discrimination laws are established. Women represent around 20 per cent of parliamentarians and, as of February 2014, there are only 19 female presidents and prime ministers (20 now considering Michelle Bachelet assumed the Presidency of Chile just yesterday).
With regards to HIV/AIDS, in 2012, 60 % of national governments reported the existence of discriminatory laws, regulations, or policies, which impede access to effective HIV prevention, treatment, and support services. We also know the pandemic often has a female face. In sub-Saharan Africa, women make up nearly 60% of people living with HIV. Globally, young women (aged 15 to 24) have infection rates twice as high as young men of the same age. Power differentials between men and women in relationships, as well as in society more broadly, are an important part of the explanation. For example, women who have experienced intimate partner violence are 50 percent more likely to be living with HIV than other women and where women lack property rights, they are also at higher risk of HIV. And finally, let us not forget, that women and girls often bear a disproportionate care-giving burden. Evidence from a recent UNDP study in Asia, for example, suggests that children, especially girls, living in households affected by HIV were less likely to attend school than children in households not affected by HIV.
And with respect to reducing maternal mortality we know that this is as much about women's status and empowerment as it is about improving access to quality health care. In many countries, for example, legal systems offer women and girls little support in protecting their reproductive rights. In some cases, legislation deliberately denies such rights, such as laws that prohibit adolescents from accessing contraception, or that do not ban child marriage knowing that early marriage puts girls at great risk for premature childbearing, disability and death or do not ban FGM. WHO estimates that more than 125 million girls and women alive today have experienced Female Genital Mutilation (FGM) which is not only a human rights violation, but also has been linked to significant complications in childbirth, including increased risk of newborn deaths.
Moreover, it is also important to explicitly talk about the differences among women and recognize that we are not a homogeneous group. Although women everywhere, for example, are exposed to gender-based violence and sexual harassment, with a WHO study noting that about one out of three women in the world will be or has been a victim of violence, the specific challenges and discrimination faced by certain women, such as women with disabilities, women from indigenous groups, women living in poverty, and women of diverse sexual orientation, must be examined.
So… as I’m sure many of you agree, the possibility to improve health outcomes for women and reduce inequalities in general cannot be tackled solely through actions of the health sector. UNDP’s work is precisely focused on action at this intersection – where discrimination and inequality leads to marginalization and vulnerability. In this way, our work complements other specialized health agencies since we work on the social, economic, environmental and cultural factors which contribute to disparities in health. At the same time we strive to understand and act on the linkages between health and development since our core mandate of helping countries reduce poverty, achieve gender equality and promote sustainable development is highly relevant to and indeed dependent on the improvement of health outcomes.
Now, before going to what is that the post 2015 agenda can consider let me just add to the picture, that while we are still struggling to address communicable diseases like HIV, we also see a long-term shift in the global disease burden towards non-communicable diseases. Already the developing world – home to more than 80% of NCD incidence – is suffering from the double burden of increasing rates of NCDs while not having yet conquered the scourge of infectious diseases.
In this case too, UNDP believes, that tackling NCDs will be impossible without addressing gender inequality and human rights more broadly. NCDs already account for 65% of deaths among women. Just a few examples of how gender roles and norms, have a heavy impact on the distribution of poor NCD health outcomes. For example, the WHO estimates that nearly 2 million people die prematurely, mainly women and girls, from illness attributable to indoor air pollution from household solid fuel use.
And although female tobacco use rates are lower than for men in almost all countries if we don’t act, through increased implementation of the Framework Convention on Tobacco Control, which will also help lower male rates, female tobacco use rates are expected to go from 12 percent in 2010 to 20 percent by 2025.
Physical inactivity – one of the main risk factors for NCDs, is also higher among women than men in all regions and in nearly every country. Laws, gender norms or concerns about safety may prevent girls and women from playing outside, walking to and from school and engaging in sports. We can change these. In fact, investing in the education of girls, can have multiplier effects. Between 1995 and 2008 in seven sub-Saharan African cities, obesity nearly doubled among less educated women. Meanwhile, among women with secondary or higher education, overweight and obesity declined by 10 percent. And we know that investing in girls’ education has many other positive impacts such as delaying the age of marriage.
Post-2015 – A cause for Optimism
Moving ahead to post-2015, widespread mobilization, including by women’s organizations, offers an opportunity to redress the shortcomings of our current development approaches and focus more explicitly on inequality.
The Open Working Group on Sustainable Development Goals has been meeting to formulate proposals for the post-2015 development agenda. In its 8th meeting the co-chairs’ concluding remarks noted the “…very broad support for a two-pronged approach to reflecting gender equality and women’s empowerment in the Sustainable Development Goals: through a stand-alone goal and mainstreaming gender equality in other goals.”
They also noted that the new framework should reflect key areas omitted from the MDGs, including violence against women and women’s unpaid care work, access and control of resource as well as greater voice, participation and decision-making.
This indication of gender equality as a central pillar of the next development agenda, and a broader set of indicators, is a very encouraging sign.
At UNDP, we firmly believe that the empowerment of women and girls, gender equality, and the respect, protection and fulfillment of women’s human rights, including their sexual and reproductive health and rights are fundamental priorities for any rights-based, people-centred and planet-sensitive agenda. No decisions have yet been made, but we would expect nothing less than the promotion of gender equality as part of the new agenda’s DNA. Not properly addressing gender inequality would be a regrettable and inexcusable step backwards.
Universal Health Coverage and Women’s Health
In the health arena current discussions about universal health coverage provide another important opportunity for raising the stakes for gender equality. The potential for the inclusion of universal health coverage within the post 2015 development agenda should mean nothing less than a commitment to preventative and curative health services for all girls and women, everywhere.
In developing regions, only half of all women receive the recommended amount of health care that they need and again there is nothing inevitable about this. In fact it is entirely avoidable.
An extensive WHO analysis of women and health found that roughly 80 percent of cervical cancers occur in countries where prevention, screening and treatment are limited or non-existent. In Mexico, the Seguro Popular introduced in 2003, focused on expanding coverage for 90 percent of common health conditions, and within the first two years it was associated with increases in skilled birth attendance, antenatal care, cervical cancer screening, and mammography. Analyses concluded that the programme was “improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor” and generating a wide range of impacts on women’s health. Because of programmes like this, Mexico is projected to reach MDG 4 on reducing child mortality prior to the 2015 target.
Of course, even with UHC, if women do not have full control over their bodies and future, women’s health will suffer. In a six country study in the western Pacific, for example, over 80 percent of adolescent girls aged 15-19 had one or more problems in accessing health care, many not related to affordability, including: not getting permission, not being willing to go alone, and a general concern that a female health care worker would not be available.
So how can public health research support policy-making to tackle gender inequities and other emerging development challenges with health implications?
Firstly please keep engaged. You have networks, and influence, critical for bringing about change.
Second, there is a pressing need for new indicators on gender inequality, many targets are selected in part due to the availability of data, rather than an assessment of what dimensions are most important to monitor. In terms of health, the focus on gender statistics remains heavily concentrated on mortality – which is not enough.
Ways to capture impacts on women’s health and development, including gender-based violence, women’s time burdens, unpaid work and decision-making are key to improve the framework and with it the results. Boosting investment in their monitoring will be critical to the post 2015 development agenda.
Third, we said that we should be careful not to see women as an homogenous group – research needs to take into account that different groups of women and girls are exposed to different forms of discrimination and different types of barriers throughout their life course.
Fourth, we need more research on the links between health outcomes and policies outside of the health sector. The methodological tools to understand the structural factors - social, environmental, legal, financial and political - which impact health are constantly being refined to allow for more credible causal inference, including through multi-level modelling.
So the challenge is to put research into action at the scale needed to see a real impact on population health.
I called these comments ‘a call for optimism’ even though I have reflected on the persistence of gender inequality. Recently, the landmark report from the Lancet argued that a ‘grand convergence’ in global health is possible within our lifetimes.
Redressing the fault-lines of the MDGs in the post 2015 development agenda, combined with the reaffirmation of Cairo and Beijing commitments is a unique opportunity that we can seize to make this prediction reality. The Health Sector together with the Development community and the academic world can embody the much needed comprehensive approach to health, development and human rights that so many around the world are demanding and waiting for.