1. Importance of gender considerations for achieving health and nutrition outcomes for women and girls

Health is one of the key indicators of economic development of a family, community and nation. In addition to genetical conditions of individual or communities, economic status/poverty, availability and accessibility to quality health care services and resources, environment, and the social/community context are major determinants of health and nutrition outcomes (WHO). Gender disparity and gender inequality lies at the root of all these factors that causes differential/poorer health conditions of women, girls and children. There is ample evidence to inform the prevalent difference of health and nutrition outcomes between boys and girls or women and men. However, there is a major evidence gap to inform the impact of social/gender norms on the negative health status of women and girls. The role and influence of elements of her eco-system across her life cycle is also a critical gap area.

Despite India’s progress in reducing child mortality i, the benefits thereof have not been equally shared by the male and female child. According to the ‘Levels and Trends in Child Mortality’ report’ by the United Nations Inter-agency group for child mortality, fewer nations showed gender disparities in child mortality, & across the world, on average, boys have a higher probability of dying before reaching age-5 than girls. But this trend wasn’t reflected in India. India is among the few countries in the world where, the mortality under-5 years of girls, exceeded that of boys. This means that girls have a higher probability of dying before attaining the age of five years than boys. Through backward deduction, this means that effects of malnutrition are more pronounced for girls than boys ii . The root cause of such male-female differentials is the socio-cultural practices and mindset of the people which contribute to continued widespread prevalence of gender discrimination. Understandably, reducing the prevalence of malnutrition among girls holds the key to reducing the burden of female under-five deaths. Research shows that the girl child experiences mistreatment and neglect from the time of birth and thereafter during early childhood, facing a disadvantage in accessing nutrition and is thereby exposed to a higher risk of morbidity and mortality. Based on analysis of differential treatment of girls and boys in North India, Barbara Miller terms the prevailing anti-female bias as extended infanticide in her book ‘The Endangered Sex: Neglect of Female Children in Northwest India’.

Differential gendered treatment of boys and girls, impact their health (physical, emotional, social, spiritual and intellectual) and overall social upbringing negatively. Social norms of restricted and controlled environment of upbringing severely truncates their growth and development as a healthy holistic human resource. High degrees of morbidities start during adolescence. As per WHO, most of the adult life mental health disorders start at the age of 14, which go undetected and untreated. Iron deficiency anemia is one of the top causes of years lost by adolescents. Unhealthy food and nutrition availability and habits are foundation to sick adulthood for these adolescents. In all such situations, girls are further disadvantaged due to their weaker and lower social status.

Adult female members of the household also tend to be treated as inferior and receive a relatively lower share of nutrition and economic resources. In this context, maternal nutrition has significant carry-over costs as well. Undernourished girls grow up to become undernourished mothers and give birth to potentially undernourished, low-birth-weight children, who are more susceptible to death and disease. In fact, this potentially explains why India has the largest incidence of low-birth-weight children globally. If this inter- generational self-perpetuating cycle is not broken, the problem of malnutrition would continue to fester.

Multiple studies have also shown that the predicament of women is more pronounced for low-income households with strong ‘son’ preferences and a greater prevalence of gender-bias. Women in households continue the practice of eating last and leftovers iii , have little say in purchasing decisions of the households, limited access to mobility and therefore avail timely health services, and the list is long…. contributing to their poor health and nutrition status iv .

Gender norms, socialization, roles, differentials in power relations and access to and control over resources contribute to differences in vulnerabilities and susceptibilities to illness, how illness is experienced, health behaviours (including health-seeking), access to and uptake of health services, treatment responses and health outcomes.

2. Socio-cultural / Socio-ecological and other frameworks supporting gender issues

Gender roles and barriers owing to gender norms and other stereotypes have been put into certain frameworks by many agencies that guide program design and are used for various gender analysis and behaviour change frameworks and models. Two examples of such frameworks are below:

3. Gender in health and nutrition in development policies of India

Gender is a major determinant of health for women and men in India. Gender norms, roles and relations interact with biological factors, in turn influencing people’s exposure to disease and risks for ill health. Therefore, it is important for health policymakers to consider the different gender needs of all men and women. Tailoring health policies and programmes to take account of these differences and trends can improve their impact, reduce health inequities and advance the right to health for all. Health is significantly determined by social, economic, and environmental factors that lie beyond the health sector, such as poverty, education, employment and physical security. Gender inequality, an important determinant of health, remains a challenge in India, as elsewhere. Women lag behind men in many indicators of social well-being, such as literacy, opportunities to skill development and access to mass media. Women’s lower labour force participation and significantly larger time spent in unpaid care work also reflect gender inequality.

4. Gender addressal in health and nutrition programming

Despite the national policies mandating gender-based programming as part of all schemes and services, very few health and nutrition programs have taken a deeper dive into gender related issues to develop and implement a gender framework. It is commonly understood that a health program meant for women is naturally gender sensitive/transformative. However, most health programmes limit gender addressal to collection of gender disaggregated data, gender budgeting (assessed by the number of women reached) and conducting gender audits. It is seldom that a public health program, even one meant for women, actually addresses gender-based barriers.
As an example, a quick review of the flagship scheme for women Janani Suraksha Yojana (JSY) was undertaken. The JSY is a safe motherhood intervention that integrates cash assistance for with delivery and post-delivery care under the National Health Mission, India, with the objective to reducing maternal and neonatal mortality by promoting safe institutional delivery. By design, the scheme is for pregnant women from lower socio-economic strata of the society. It is assumed that provision of economic power to the targeted women will enhance their voice, choice and decision-making abilities. There is enough evidence to show substantial uptake of JSY leading to remarkable rise in institutional deliveries across the country, more so by the “at risk groups”. However, there remain pockets of poor performance of the scheme. A quick study of its implementation reveals that poor institutional delivery uptake is related to low literacy levels among young rural mothers, limited access of women to health care institutions and dependence on escorts, traditional health seeking behaviours of the family, socio-cultural factors, occupation and caste. A deeper look into these issues reveals a myriad of social norms that act as gender barriers, such as the influence of trusted sources of information on the woman (husband, mother-in-law, traditional healers, traditional birth attendants), gender roles within the household, lack of women staff at PHC‘s and their lack of sensitivity and insufficient numbers of ASHA workers to accompany each woman for delivery.
The operational guidelines of the scheme however do not touch upon these issues or ways to reaching out to these decision makers in a woman’s life. Though JSY is a part of gender transformative maternal health programme, there is a need to study how assets, women empowerment, occupation and decision-making power play a role in acceptance of JSY among more traditional families. To achieve higher intuitional delivery coverage in all regions and sustain the high levels, public health services need to direct interventions at changing social norms and breaking gender barriers.
On the other hand, the National TB Elimination Program appears to be one of the few public health programs that has an exclusive Gender Responsive Framework in place that looks at an equitable, community led and gender specific response to TB in the country. The TB programme framework below can be seen as an example for integrating and analysing gender components as part of Health programming vii.

5. Suggested actions to address gender issues wholistically

A roundtable of public health practitioners was organized in November 2022, at New Delhi to initiate a discussion on gender barriers that impact health and nutrition outcomes and what platforms can and have been used to address these. Some of the discussion points are presented here.
The consensus of the group was that all existing public health and nutrition guidelines must be looked at with a gender lens and gender mainstreaming interventions need to be included at the formative stage itself. The group identified some simple and doable actions that can be adopted to address current gaps.

6. Possible platforms through which gender issues / challenges and barriers can be addressed

Conclusion and Recommendations

Social norms are the root cause of gender-based disparities in society. While delivering health and nutrition services, these norms must be well understood and all efforts made to address them. Health policy and programming should have components of social norm change to create an enabling environment to the messaging and services that are being provided. Forward-looking policies, if effectively implemented through suitable community and institutional mechanisms to mainstream gender will enable change towards greater equity. Several tools are available for gender analysis, assessment and planning or programming, which can help to identify gender inequalities in health and tailor the design, implementation and monitoring of health policies and programmes to take account of these differences, for improved outcomes. Additionally, using a human rights framework in health planning and policy making can help in identifying and adequately addressing the biological and sociocultural factors that differentially influence the health of men and women. Gender norms and socio cultural and ecological factors that are deep rooted in the country are serve as barriers to better Health and nutrition outcomes should be addressed through suitable platforms.The power of women’s collectives and the network of Self-Help Groups (SHGs) need to be harnessed to fasten the pace of the implementation of developmental solutions with deep impact at household levels for women’s empowerment and gender equality, equity.