• Katherine Hay, Lotus McDougal, Valerie Percival, Sarah Henry, Jeni Klugman, Haja Wurie, Joanna Raven, Fortunate Shabalala, Rebecca Fielding-Miller, Arnab Dey, Nabamallika Dehingia, Rosemary Morgan, Yamini Atmavilas, Niranjan Saggurti, Jennifer Yore, Elena Blokhina, Rumana Huque, Edwine Barasa, Nandita Bhan, Chandani Kharel, Jay G Silverman, Anita Raj, and Gender Equality, Norms, and Health Steering Committee.
• Bill & Melinda Gates Foundation, Seattle, WA, USA.
• Lancet. 2019 Jun 22; 393 (10190): 253525492535-2549.

AbstractRestrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.Copyright © 2019 Elsevier Ltd. All rights reserved.

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