1. Gender, Medicines, and the Road to Equity #AreWeThereYet? Emily Delmotte Management Sciences for Health March 7, 2014 Global Health Mini-University

2. Outline Introduction to the human right to health Overview of gender and access to medicines Access to medical products and services framework Challenges Opportunities Key messages

3. Background: Health and Human Rights Legal rationale Universal Declaration of Human Rights (1948) International Covenant on Economic, Social and Cultural Rights (1966) Convention on the Elimination of All Forms of Discrimination Against Women (1979) Image source: © 2008 Arup Haldar, Courtesy of Photoshare Reference: WHO 25 Questions, 2002; IESCR, 1966; CEDAW, 1979

4. Why Focus on Access to Medicines? Intersection of health and other human rights Access to medicines is recognized as one of the minimum components of the right to health Reference: WHO Linkages; WHO Right to Health Factsheet, 2013; WHO Access to Essential Medicines, 2014. Image source: http://healthandrights.ccnmtl.columbia.edu/human_rights/human_rights_ and_health.html

5. State of Global Access to Medicines Average availability of selected essential medicines in developing countries (2007-2011): Public sector: 51.8% Private sector: 68.5% Image source: Médecins Sans Frontières' Access Campaign Reference: MDG Taskforce Report, 2012

6. State of Gender and Access to Medicines Context matters Different evidence from different settings Different evidence for different conditio ns Reference: MDG Taskforce Report, 2012; Gender, women, and primary health care renewal, 2010; Wager, 2013; Stephens, 2013 Image source: © 2009 Gabrielle Elkaim, Courtesy of Photoshare

7. Why Focus on Gender? Sex vs. gender Gender inequities can result in differential access to and control over health resources Focus on equal access to resources, rather than equity in health outcomes Image source: © 2000 Liz Gilbert, Courtesy of Photoshare Reference: IOM, 2011; Courtenay, 2000; WHO Gender, Women, and Health; Vlassoff, 2002; WHO Women an HIV Factsheet; WHO Women and Health Today, 2009; Doyal, 1991

8. What Does Differential Access to Health Resources Look Like? Refusal of health care for transgender persons in the US Men’s access to ART in Southern and Eastern Africa impeded by masculinity Delayed diagnosis of TB in women, despite similar care seeking in Vietnam Reference: Grant, 2010; Nyamhanga, 2013; Long, 1999

9. Access to Medical Products and Services Image source: Management Sciences for Health. 2011. Toward Sustainable Access to Medicines. In: MDS-3: Managing Access to Medicines and Health Technologies. Arlington, VA: Management Sciences for Health. http://www.msh.org/resources/mds-3-managing-access- to-medicines-and-health-technologieshttp://www.msh.org/resources/mds-3-managing-access- to-medicines-and-health-technologies

10. Accessibility Among patients who defaulted TB treatment in rural Pakistan, women disproportionately cited constraints around duration/cost of travel and inability to travel alone as factors contributing to default Differential access to health education in rural India may have resulted in delayed recognition of TB symptoms and delayed presentation of care among women Reference: Khan, 2000; Atre, 2004

11. Availability Studies in the US have found that providers: Spend less time with men Provide men with fewer services, less health information, and less advice Are less likely to talk to men about the need to change behaviors for better health Reference: Courtenay, 2000 in Williams, 2003

12. Acceptability A qualitative study in Vietnam found that men and women cited different primary causes of delayed care seeking for TB: Men: fear of individual costs of diagnosis and treatment Women: fear of social isolation from family or the community Reference: Johannson, 2000

13. Affordability A number of studies emphasize that women have higher direct costs for TB than men because they: Often need somebody to accompany them Are less mobile and have less financial resources Experience greater loss of income potentially because of more lost work days Reference: KNCV, 2008

14. Reproductive Health Women and men face different reproductive health needs Table adapted from: “Table 1: Snapshot per commodity of barriers, recommendations and impact” in United Nations. (2012). UN Commission on Life-saving Commodities for Women and Children. Commissioners’ Report.

15. The Challenges (1) Gender inequities do not exist in a vacuum: socioeconomic disparities Image source: World Health Organization. Women and health: today's evidence tomorrow's agenda. Geneva, World Health Organization. 2009.

16. The Challenges (2) Gender inequities do not exist in a vacuum: racial disparities Image adapted from: Table A. National Indicator Rates for Men Ages 18 to 64, by Race/Ethnicity, 2006-2008 in James C, Salganicoff A, Ranji U, Goodwin A, Duckett P. (2012). Putting men’s health care disparities on the map: Examining Racial and Ethnic Disparities at the State Level. The Henry J. Kaiser Family Foundation. United States National Indicator Rates for Men Ages 18 to 64, by Race, Ethnicity, 2006-2008

17. Gender mainstreaming Policy advances Programming advances Opportunities

18. Key Messages  Differences in the accessibility, availability, acceptability, and affordability of medical commodities can result in unequal access across genders  The impact of gender on access to medicines can best be understood through the lens of social, economic, and cultural context s Image source: © 2013 Arturo Sanabria, Courtesy of Photoshare

20. References (1/4) Atre SR, Kudale AM, Morankar SN, Rangan SG, Weiss GM. Cultural concepts of tuberculosis and gender among the general population without tuberculosis in rural Maharashtra, India. Trop Med Int Health. 2004;9(11):1228- 1238. In Anandaraja N, Henning N. Infectious Diseases and Women’s Human Rights. 2010. In Murthy P, Lanford C (Eds.), Women’s Global Health and Human Rights. 329-352. Sudbury, MA: Jones and Bartlett Publishers. Convention on the Elimination of All Forms of Discrimination against Women. United Nations Entity for Gender Equality and the Empowerment of Women. Accessed from: http://www.un.org/womenwatch/daw/cedaw/cedaw.htm Courtenay WH. Constructions of masculinity and their influence on men's well-being: A theory of gender and health. Social Science & Medicine. 2000;50(10):1385-401. In Williams, DR. The health of men: structured inequalities and opportunities. Am J Public Health. 2003;93:724-731. Doyal L, Gough I. A theory of human need. London: Macmillan. 1991. In Doyal L. Gender equity in health: debates and dilemmas. Social Science and Medicine. 2000;51:931-939. Grant JM, Mottet LA, Tanis J. National Transgender Discrimination Survey Report on health and health care. National Center for Transgender Equality and the National Gay and Lesbian Task Force. 2010. Institute of Medicine (IOM). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academic Press, 2011.

21. References (2/4) International convenient on Economic, Social, and Cultural Rights. Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966. Accessed from: http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx. James C, Salganicoff A, Ranji U, Goodwin A, Duckett P. Putting men’s health care disparities on the map: Examining Racial and Ethnic Disparities at the State Level. The Henry J. Kaiser Family Foundation. 2012. Accessed from: http://kff.org/disparities-policy/report/putting-mens-health-care-disparities-on-the/ Johannson E, Long NH, Diwan VK, Winkvist A. Gender and tuberculosis control: Perspectives on health seeking behavior among men and women in Vietnam. Health Policy. 2000;52:33-51. Khan A, Walley J, Newell J, Imdad N. Tuberculosis in Pakistan: socio-cultural constraints and opportunities in treatment. Soc Sci Med. 2000;50:247-254. In Anandaraja A, Henning N. Infectious Diseases and Women’s Human Rights. 2010. In Murthy P, Lanford C (Eds.), Women’s Global Health and Human Rights. 329-352. Sudbury, MA: Jones and Bartlett Publishers. KNCV Tuberculosis Foundation. The tool to estimate patients’ costs. 2008. Accessed from: http://www.stoptb.org/wg/dots_expansion/tbandpoverty/assets/documents/Tool%20to%20estimate%20Patie nts'%20Costs.pdf Long NH, Johansson E, Lonnroth K, Eriksson B, Winkvist A, Diwan VK. Longer delays in tuberculosis diagnosis among women in Vietnam. Int J Tuberc Lung Dis. 1999;3(5):388-393.

22. References (3/4) Nyamhanga, TM, Muhondwa EPY, Shayo R. Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania. Glob Health Action. 2013;6:21821. Stephens P, Ross-Degnan D, Wagner AK. Does access to medicines differ by gender? Evidence from 15 low and middle income countries. Health Policy. 2013; 110(1):60-6. doi: 10.1016/j.healthpol.2013.01.016 Vlassoff C, Moreno CG. Placing gender at the centre of health programming challenges and limitations. Social Science and Medicine. 2002; 54: 1713-1723. Vlassov, C. Gender Determinants and Consequences of Health and Illness. J Health Popul Nutr. 2007;25(1):47- 61. Wagner AK, Graves AJ, Fan Z, Walker S, Zhang F, Ross-Degnan D. Need for and access to health care and medicines: are there gender inequities? PLoSONE. 2013; 8(3): e57228. doi:10.1371/journal.pone.0057228 World Health Organization. 25 questions and answers on health and human rights. Health and Human Rights Publication Series Issue No. 1, July 2002. Accessed from: http://whqlibdoc.who.int/hq/2002/9241545690.pdf World Health Organization. Access to essential medicines as part of the right to health. 2014. Accessed from: http://www.who.int/medicines/areas/human_rights/en/

23. References (4/4) World Health Organization. Gender, women, and health. 2014. Accessed from: http://www.who.int/gender/whatisgender/en/ World Health Organization. Gender, women, and primary health care renewal: A discussion paper. 2010. Accessed from: http://www.who.int/gender/documents/women_and_girls/9789241564038/en/ World Health Organization. Human Rights and Gender equality in Health sector strategies: how to assess policy coherence. 2011. Accessed from: http://whqlibdoc.who.int/publications/2011/9789241564083_eng.pdf World Health Organization. Linkages between health and human rights. Accessed from: http://www.who.int/hhr/HHR%20linkages.pdf World Health Organization. The right to health Factsheet No. 323. Reviewed November 2013. Accessed from: http://www.who.int/mediacentre/factsheets/fs323/en/index.html World Health Organization. Women and Health: Today’s evidence tomorrow’s agenda. 2009. Accessed from: http://www.who.int/gender/women_health_report/en/ World Health Organization. Women and HIV/AIDS Fact Sheet No. 242, June 2000. Accessed from: http://www.who.int/inf-fs/en/fact242.html