The human right to health

An oft-repeated mantra in gender and deve­lopment circles is that while the Millennium Development Goal 3 (gender equality) is critical for promoting women’s empowerment, gender equality itself is critical for achieving all other MDGs. Gender analyses of Goal 5 and Goal 6, the “health goals”, illustrate why this is the case. Both the World Health Organization (WHO) (2003) and the United Nations Deve­lopment Programme (UNDP) (2005) have published substantial reports on these matters. MDG 5 is about reducing maternal mortality and MDG 6 about stopping the spread of HIV/AIDS, malaria and tuberculosis.

The WHO paper identifies a number of ways in which gender inequality is linked to maternal mortality. Women’s and girls’ poor nutritional status, caused by discrimination, increases the chances of serious complications during pregnancy. High illiteracy rates and low rates of school attendance among women and girls contribute to maternal mortality. Women's education is strongly correla­ted with positive maternal health outcomes.

The gendered division of labour adds to the risks associated with maternity. Women and girls often bear the burden of reproductive and care work, as the UNDP paper points out. This includes caring for children and elders, cooking, cleaning, collecting water, in addition to productive work such as unpaid contributions to the family business and wage labour outside the home. Such tasks are often continued through pregnancy. On top of such health hazards, discriminatory social norms which control women's mobility can be lethal in the event of an obstetrical emergency.

Both reports also link these social norms and women’s subordinate status with the fact that today women constitute the majority of people with AIDS. Contributing factors include women’s lack of agency to negotiate safe sex (prevention of HIV transmission commonly requires the cooperation of male partners) or to resist sexual violence, resulting in physical and emotional trauma, unwanted pregnancies and higher rates of sexually transmitted infections including HIV. Other issues include social norms which encourage men to have more sexual partners than women, and women’s lack of access to information on how to protect themselves from infection. Women and girls bear the brunt of the consequences of the HIV epidemic, experiencing greater stigma and carrying the burden of care in terms of looking after the ill, orphans and other family members.

The gender dimensions of malaria are hardly discussed – but they exist. The WHO report notes that pregnant women have particularly high incidence and mortality rates for malaria. The document also addresses the gender norms relating to sleep and work patterns, the use of bed-nets, and to access of medicines and medical care, all of which may affect malaria prevention and treatment.

Both reports point out that TB prevalence rates are generally higher for men than for women. But a closer analysis of the data reveals that TB remains a leading cause of death among women of reproductive age, and that “in high-HIV-incidence settings like Africa, more young women between the ages 15 and 24 are notified with TB than young men of the same age group” (WHO 2003: 6). There are also fears that the apparent lower overall TB prevalence rate for women may reflect a lower rate of women’s reporting (as opposed to disease prevalence).

Gender-sensitive strategies

While it is not difficult to analyse the gender dimensions of the MDGs – as discussed with regards to goals 5 and 6 above – it is much more challenging to identify exactly how gender equality needs to be realised to achieve every single MDG. It is promising to look at the MDGs from a women’s human-rights perspective, as is elaborated in a collection of essays edited by Carol Barton and Laurie Prendergast (2005).

In her contribution, Lee Waldorf (2005) argues that international human-rights treaties can be used in two ways to support gender-sensitive MDG implementation:
– First, they can be used to provide normative guidance, analysis and authority, especially when combined with observations and re­commendations of treaty bodies and special rapporteurs.
– Second, human-rights treaties can be of operational use, as monitoring and enforcement procedures are already in place in many countries. Waldorf emphasises that such synergies need to be enhanced.

In another essay in the same collection, Lynn Freedman (2005) debunks the premise that a woman’s death in childbirth is a somehow ‘natural’ part of life. She argues that maternal mortality is not random, but occurs overwhelmingly in poor countries with inadequate and inequitable health-care systems. Such deaths are not inevitable, as the solutions are well understood. They are not only a biological but also a political phenomenon. Adequate policies can reduce their number if adequately implemented.

Apart from rights, funding matters too. As Arabella Fraser (2005) of Oxfam points out, health-care systems need legal, managerial and human-resources reforms, which will only succeed if adequately funded. Donors should therefore reassess the finance they provide. For example, unlike one-off capital investments, funding must be predictable and long-term, in order to cover the recurrent costs, services and maintenance of health systems.

From a gender-sensitive and rights-based perspective, it is also key to assess to whom financing should be provided. Typically, state capacities are weak in developing countries; and health services are commonly provided by non-governmental organisations and the private sector. As Fraser argues, however, leaving provision of health services to the market means that the poorest people must put aside a larger share of their incomes for fees for health services, thus increasing inequalities in access and income. Once more it is women who are likely to suffer most, as they do not decide on their families’ spending priorities. All too often, women’s health needs are no priority.

D. Shaw (2006) also addresses health systems in the context of women’s right to health and the MDGs. Her focus is on the potential of partnerships, including those between professional organisations and health care systems to combat a particular issue such as post-partum hemorrhage or obstetric fistula. One example comes from Bangladesh, where the government, WHO and the national society of obstetrics and gynecology partnered in the training of midwives to meet maternal healthcare needs.

Shaw also points to partnerships with the legal system, which have been successful in changing laws which discriminate against women and girls. For example, a change in the law in Mexico “resulted in emergency contraception being deemed an essential drug and its incorporation into the public health system so that it could be provided free” (Shaw 2006: 213).