According to a report published by the Global Health 50/50 initiative earlier this year on gender equity among organizations focusing on public health, “[g]ender determinants of health are among the most significant social determinants of health outcomes.” But even as countries around the world are becoming increasingly aware of the dangers of noncommunicable diseases, and the need to adopt policies to prevent them, few NCD policies take gender into account.
This is problematic for a number of reasons: While both men and women can be affected by NCDs, they have different levels of exposure and vulnerability to risk factors. For example, women are slightly more likely to become obese than men, according to the World Health Organization 11 percent of the global population of men and 15 percent of women were obese in 2016. Women are less likely to be diagnosed early with certain NCDs, such as cardiovascular disease, because women often display symptoms differently, and most of the studies on NCD diagnosis have been done on men, which can lead to higher rates of fatality and complications in women.
“There is a real need for gender-responsive approaches to NCDs,” said Priya Kanayson, a senior advocacy officer at the NCD Alliance. “We know that a lot of the studies done on NCDs and risk factors and symptoms are done on men — we also need similar studies on women. Also, when we are talking about best-buys, or other interventions, these should also take gender into account.”
“There is a real need for gender-responsive approaches to NCDs. We know that a lot of the studies done on NCDs and risk factors and symptoms are done on men — we also need similar studies on women.”— Priya Kanayson, senior advocacy officer at NCD Alliance
Factoring gender into the equation
According to Ken Buse, co-founder of Global Health 50/50, the lack of gender-sensitive NCD policies is reflective of a larger global pattern of gender inequity in public health.
“There is a dearth of gender-sensitive policies and interventions for quite a number of reasons,” Buse told Devex in an email exchange. “First and foremost, it reflects the reality that by and large, the global health community is gender blind.”
This observation is backed up by research: According to the Global Health 50/50 report, almost half of the 140 sampled global health organizations made no specific commitment to gender equity. Only one in three defined gender, and more than half of the organizations do not mention gender in their programmatic strategies. Finally, two in three fail to report sex-disaggregated data.
“If they don’t do the latter,” Buse said, referring to the lack of disaggregated data, “how can they possibly begin to have gender-responsive programs?”
Dr. Anil Kapur, member of the pregnancy and NCD committee at the International Federation of Gynecology and Obstetrics, commonly known as FIGO — an NGO that works on building linkages between NCDs and reproductive health — believes that it should become standard practice for medical centers to put gender-sensitive NCD protocols in place, such as take women’s higher risk of developing diabetes into account, and routinely test for higher blood sugar levels during pregnancy.
“There are a lot of things that medical professionals could do, but then often the question of cost-effectiveness comes up,” he said. “My response to that is, ‘If a man got pregnant, would we be asking those questions?’ I believe that it really comes down to gender equity, and the society’s perception of the relevance of women’s health.”
“Often the question of cost-effectiveness comes up. My response to that is, ‘If a man got pregnant, would we be asking those questions?’ I believe that it really comes down to gender equity, and the society’s perception of the relevance of women’s health.”— Dr. Anil Kapur, head of the pregnancy and NCD committee at the International Federation of Gynecology and Obstetrics
Making NCD care and education accessible to women
One of the first ways that NCD policies can address gender inequity is by ensuring that women have adequate access to health care facilities where they are screened, and are educated about NCD risk factors, said Kapur. While this may seem basic, for many women — particularly those from lower socio-economic backgrounds — such access is by no means guaranteed.
“There is a real issue with gender equity in low- and middle-income countries, where women tend [to] have less access to care,” he said. “Even when they do get care, women tend to get less aggressive treatments due to a lack of gender-specific guidelines on NCDs, and as a consequence, are at risk for higher rates of complications.”
There are many reasons for lack of access: Women in rural areas often rely on family members for transportation. There’s also the issue that women are often the primary caregivers for small children or ailing relatives, and put their own welfare second.
According to the NCD Alliance’s Kanayson, women from lower socio-economic backgrounds often give up accessing care for themselves or funds for their own medicines to provide food or education materials for their children.
“This can result in illnesses being detected at a later stage for women because of barriers to access for screening, which leads to an increased likelihood of deaths,” she said.
Physical activity is another area where women often have less access than men, in part due to safety concerns. This contributes to their risk of developing diabetes and cardiovascular disease.
“Malaysia is getting more urbanized — over 75 percent of the population now lives in urban areas, so there’s a lack of green spaces, which is an issue for people of all ages,” said Dr. Feisul Mustapha, consultant health physician and deputy director of the NCD section disease control division of the Malaysian Ministry of Health.
“However, women have the added issue of personal safety when looking at being active in an open space,” he said.
There’s also the issue of financial exclusion: A report from the Pan American Health Organization found that women, who represent the vast majority of the world’s poor, are often the least able to allocate funds for NCD treatments. When health care funds do exist, the report found that men’s health care was often prioritized over women’s, and that women often had a lesser say in how funds were spent.
FIGO’s Kapur believes that one opportunity to increase access to NCD prevention and treatment for women is by ensuring that NCD education and screening is combined with reproductive health care.
“Women who don’t usually access health centers will go for reproductive health care, so it’s an excellent opportunity,” said Kapur. “It’s vital that sexual reproductive health and NCDs need to be linked in a more comprehensive way to ensure that women … can achieve their social and health outcomes.”
Some countries have begun to do just that: In India, Prime Minister Narendra Modi announced in February that he would be introducing 150,000 health and wellness centers in rural areas — around one center for every 5-10 villages.
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The program builds off pre-existing infrastructure: Currently, most rural areas in India have access to “subcenters” — health centers primarily used for children’s immunizations and to provide women with information on reproductive health. Under Modi’s plan, these centers will be upgraded to also provide NCD screenings and education, and yoga classes to encourage women to be more physically active.
One of the objectives was to boost NCD screening and education access to vulnerable populations — particularly women. The aim is to remove this gender imbalance, explained Bulbul Sood, country director for Jhpiego, an international NGO that focuses on reproductive, maternal, newborn, child, and adolescent health in India, and that provides technical assistance to the government at the state and regional levels.
“Women are used to going to these community centers for antenatal care, but they don’t always go to the bigger district hospitals. This way we are bringing the screenings to them.”
The larger payoff: A potentially catalytic population
Another benefit of taking a gendered-approach to NCD policies is the generational payoff, making women of reproductive age a potentially catalytic population when it comes to NCDs.
According to Kapur, women’s health is directly linked to the health of her unborn children, which means that NCDs in women should ideally be treated prior to pregnancy. If a woman becomes hypoglycemic during pregnancy, her baby is more likely to become obese later in life, and if the baby is a girl that child will be at higher risk of getting gestational diabetes — a form of diabetes that is contracted during pregnancy — if they become pregnant, continuing the cycle.
“The intrinsic link between maternal health and the health of the baby, and the future burden of NCDs is very important for people to understand,” said Kapur. “Understanding that linkage has tremendous consequences both for her health and the health of the next generation.”
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Another reason stakeholders are beginning to focus on educating women about NCD risk factors is because of the influence they often wield on their family’s nutrition — particularly in lower- and middle-income countries.
“In many developing countries, women are still the primary providers of nutrition in homes, so they are very well positioned to drive proper nutrition for the entire family,” said Kanayson. “They are also often the primary caregivers, so will be the most affected if someone in the family contracts an NCD.”
Educating women about the importance of proper diet in isolation may not be enough. According to said Susann Roth, senior social development specialist at the Asian Development Bank, there’s an overall need to better understand factors that affect the vulnerabilities of different populations — including by gender and socio-economic context — to various NCDs.
For example, most NCD experts advocate diets with lots of fruits and vegetables. However, whether families are able to follow such advice has as much to do with access as it does with education.
“In many developing countries, fruits and vegetables can be very expensive because of the cost of transportation,” said Roth. “So it’s important to be aware of potential structural barriers, and take steps to address them.”
For any of these policies to be truly effective, Kanayson stressed that stakeholders and governments should consult with the affected population before implementing policies and interventions.
“Women are a really critical population when it comes to NCDs,” she said. “It’s important to remember not to talk about them as victims of NCDs — but as agents of change. Governments and stakeholders need to ensure that they are creating policies that are responsive to the needs of these communities, and we need to make sure that we are consulting with the people these policies are meant to affect.”
This is the second piece of a two-part series that focuses on how to target "catalytic populations" — youth and women — to help reduce NCDs.
For more coverage of NCDs, visit the Taking the Pulse series here.
Update, Sept. 17, 2018: This article has been updated to clarify that Dr. Anil Kapur is a member of the pregnancy and NCD committee at the International Federation of Gynecology and Obstetrics, commonly known as FIGO.