- Gender-related barriers in health access and delivery are rooted within political, economic, social, and legal systems
- These include restrictive gender norms, resource constraints such as for time and finances, and the distribution of power, autonomy, and participation in decision-making, at domestic, community, institutional and structural levels.
- Comprehensive and cohesive action plans must be implemented that counter the gender-related barriers and inequalities in vaccine delivery and access
- A guidance note and checklist is provided to undertake this work
Many governments have inadequately included gender considerations in the COVID-19 vaccine delivery plans and strategies. In March 2021, only 5 of 58 countries with COVID-19 vaccine policies referred to gender in the policy or strategy documents.(4) This oversight impedes effective and efficient outreach, since lessons from past vaccination programmes and broader health system research highlights the importance of gender-responsive vaccine deployment and broader health ecosystems that address the gender-related barriers of health-seeking and delivery.(1-3) Fast and effective vaccinations can also contribute to the reversal of exacerbated gender inequities and inequalities, by enabling the safe return to employment, schools and alleviating the pandemic-induced increase in caregiving activities.(5)
Broadly speaking, many of the gender-related barriers in health access and delivery are rooted within the political, economic, social, and legal systems. These include restrictive gender norms, resource constraints such as for time and finances, and the distribution of power, autonomy, and participation in decision-making, at domestic, community, institutional and structural levels. For women for instance, gender norms influence the divisions of care work and autonomy or decision-making over household resources for health-seeking often limit women’s health access. For men, culturally ingrained notions of masculinity influence men’s health-seeking behaviour. Transgender and other often criminalized communities, including sex workers, and irregular migrants, have long reported experience of disrespect, stigma, and discrimination within health facilities.
On Health Access
Of course, the COVID-19 pandemic and protective policies also amplifies the gendered challenges in health-seeking within the broader economic, social, and health systems through disruptions in employment, income generation, and access to health services for sexual and reproductive health, mental health, and chronic conditions. Many people – women, girls, transgender individuals, men, and boys, and particularly those who also face other accumulating and intersecting challenges – already have less access to adaptive mechanisms that facilitate their social, health and economic resilience.
Despite the recognition and vocal discussions of these experience in the global space, there has been a mixed record of how low-and-middle-income countries have accounted for gender in COVID-19 policies, including for vaccinations. For example, Chile is one of the few countries that report sex and age disaggregated data on vaccine coverage, where slightly more women have received vaccines than men(6), also contributed by prioritizing the health workforce, which is a women-dominated field. Chile was one of the early countries to initiate vaccination among pregnant women(7), and achieved relatively quick deployment of the vaccines, leveraging the country’s primary care facilities, early government initiatives to procure the supply of vaccines, and use of mobile units to reach isolated communities.
In another example, India has included a reference to gender in the vaccination policy and has a good record of successes in implementing mass vaccination programmes in the past. However, fewer women are receiving or choosing to receive COVID-19 vaccines than men, and multiple reasons contribute to this difference.(8) While recently reversed by the Prime Minister, dependence on private out-of-pocket financing ignores established gender-related barriers to health access. Women are concerned with adverse events, including those perceived to be associated with menstrual cycles and fertility.(9) Men working in urban or semi-urban areas are getting vaccinated quicker than women engaged in care work, who stay home, especially in the rural areas, that have also been faced with vaccine shortages as some states are more able to procure vaccine supplies than others.(8) The use of Smartphone App-based registration and processes can marginalize those without access to Smartphone, the internet, or who do not read or understand English- the languages predominantly used in the apps.
Transgender and other often criminalized communities, including sex workers, and irregular migrants, have long reported experience of disrespect, stigma, and discrimination within health facilities.
Recognizing that there is still time to adapt plans, to include comprehensive and cohesive actions that counter the gender-related barriers and inequalities in vaccine delivery and access, The SDG3 GAP Gender Equality Working Group in partnership with the Gender and Health Hub at the United Nations University International Institute for Global Health, have published the Guidance Note and Checklist for Tackling Gender-related Barriers to Equitable COVID-19 Vaccine Deployment.(10) This document outlines a set of suggestions to better understand the challenges related to gender, and practical actions for countries to consider, address sex and gender among other broader equity considerations, and focus on how these intersect with other health, demographic, or social categories to produce marginalization, barriers to access, and risks of harm.
The checklist and guidance emphasize the need to uphold human rights and address power inequalities, stigma, and discrimination at both the delivery and access sides. Accountability towards the process and impact achieved through adequate data collection, evaluations, and adaptive or iterative implementation that is informed in real-time by consultations and partnership with a range of stakeholders that have lived experience, expert, and tacit knowledge, and have cultivated trust and relationships with the various communities or groups of people.
 The calls for actions are categorized based on the domains already outlined in WHO & UNICEF’s guidance to COVAX- supported countries as they develop and implement their National Deployment Vaccination Plans.(11)
On the delivery side, 70% of the health workforce comprises of women. Still, across the board, women tend to be concentrated in lower-level positions with lesser decision-making scope within health systems.
Indeed, research, data collection and conversations to understand the gender-related barriers, inequities, and inequalities in COVID-19 vaccine delivery, and consequently evaluations of interventions that address these points is evolving across different countries, and dependent on multiple stakeholders that are engaging in this work. We are always keen to hear more about these experiences and insights and update the evidence and resource base that we can collectively draw for this work. We invite you to watch recordings of past webinars, such as on sex and gender in COVID-19 vaccines: data, policy, and communication, and participate in future events and discussions related to topics in this space.
- Download The Guidance note and checklist for tackling gender-related barriers to equitable COVID-19 vaccine deployment here: https://go.unu.edu/JpGuJ
- Download the Vaccine Deployment Checklist Infographic: https://go.unu.edu/2c200
- Join the UNU-IIGH and the School of Public Health at the University of the Western Cape in our collaborative gender and COVID-19 research agenda-setting exercise. To date, 900 people from over 60 countries (with 70% of respondents coming from LMICs) have engaged in the ongoing process.
- The Gender & COVID-19 Research Agenda Setting Prioritisation Survey is now available:
- French: https://go.unu.edu/sejdM
- Portuguese: https://go.unu.edu/ePHMr
- Spanish: https://go.unu.edu/vyufI
- English: https://go.unu.edu/1FsUO
- Word Health Organization. Breaking Barriers: Towards more gender responsive and equitable health systems. 2019. https://www.who.int/healthinfo/universal_health_coverage/report/gender_gmr_2019.pdf?ua=1
- Heidari S, Goodman T. Critical sex and gender considerations for equitable research, development and delivery of COVID-19 Vaccines: Background paper. 2021. https://cdn.who.int/media/docs/default-source/immunization/sage/covid/gender-covid-19-vaccines-sage-background-paper.pdf?sfvrsn=899e8fca_15&download=true
- Harman S, Herten-Crabb A, Morgan R, Smith J, Wenham C. COVID-19 vaccines and women’s security. The Lancet 2021; 397: 357–8.
- Evagora-Campbell M, Borkotoky K, Sharma S, Mbuthia M. From routine data collection to policy design: sex and gender both matter in COVID-19. The Lancet 2021; : S014067362101326X.
- Portnoy A, Clark S, Ozawa S, Jit M. The impact of vaccination on gender equity: conceptual framework and human papillomavirus (HPV) vaccine case study. Int J Equity Health 2020; 19: 10.
- Global Health 50/50. Chile: Vaccination coverage by sex and age- The COVID-19 Sex-Disaggregated Data Tracker. 2021. https://globalhealth5050.org/the-sex-gender-and-covid-19-project/the-data-tracker/ (accessed June 28, 2021).
- Reuters. ‘Pioneering’ Chile moves to cover pregnant women with COVID-19 vaccines. Reuters. 2021; published online April 28. https://www.reuters.com/business/healthcare-pharmaceuticals/pioneering-chile-moves-cover-pregnant-women-with-covid-19-vaccines-2021-04-28/ (accessed June 28, 2021).
- Jain R, Mishra M. Women falling behind in India’s COVID-19 vaccination drive. Reuters. 2021; published online June 9. https://www.reuters.com/world/india/women-falling-behind-indias-covid-19-vaccination-drive-2021-06-08/.
- Paul S. The effects of COVID-19 vaccines on women and a rising vaccine hesitancy. ORF. https://www.orfonline.org/expert-speak/effects-of-covid-19-vaccines-on-women/ (accessed Aug 3, 2021).
- SDG3 Global Action Plan for Healthy Lives and Well-Being: Gender Equality Working Group, Gender and Health Hub, United Nations University International Institute for Global Health. Guidance note and checklist for tackling gender-related barriers to equitable COVID-19 vaccine deployment. 2021. https://www.genderhealthhub.org/articles/guidance-note-and-checklist-for-tackling-gender-related-barriers-to-equitable-covid-19-vaccine-deployment/ (accessed April 21, 2021).
- WHO, UNICEF. Guidance on developing a national deployment and vaccination plan for COVID-19 vaccines. 2020 https://apps.who.int/iris/bitstream/handle/10665/336603/WHO-2019-nCoV-Vaccine_deployment-2020.1-eng.pdf?sequence=1&isAllowed=y.