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This is the fourth in a Series of five papers about gender equality, norms, and health
IntroductionHealth systems are necessary for effective and efficient health-care delivery. Their strength is fundamental to achieving universal health coverage, a target of the Sustainable Development Goals (SDGs) shared by 193 nations.1 Gender inequalities and biases rooted in restrictive gender norms, described in other papers in this Series,1–3 are also reflected in health systems. Left unaddressed, gender inequalities can weaken or even incapacitate a health system's functioning, as seen in Taliban-controlled Afghanistan in the 1990s, where female health providers were denied the right to practice, compromising health-care access and quality.4 Other examples might be less extreme, but 20 years of cross-national research from high-income countries and low-income and middle-income countries shows that gender inequalities are embedded in our health systems,5–7 are rarely addressed,5–8 and impede our capacity to achieve universal health coverage.1
In this paper, the fourth in a Series on gender equality, norms, and health, we examine how to address restrictive norms and inequalities in health systems, through recognition and disruptive solutions. We used intersectional feminist theory to guide our approach,9,10 reviewing the literature and doing new empirical analyses. We aimed to determine how restrictive gender norms and gender inequalities manifest in health systems and how we can disrupt health systems in ways that address, reduce, or prevent gender inequalities and the underlying restrictive gender norms that maintain them. Findings from this work offer insights into how health systems leadership, policy makers, and community activists can work together to create more equitable and accountable health systems.
How do gender norms and inequalities manifest in health systems?To understand the implications of restrictive gender norms and inequalities in health systems, we consider both gender inequalities in the health system and the health system's response to them. Health systems are comprised of components (eg, clinical facilities, financing, governance, and workforce) to support health for populations at scale (figure 1, 2).11 Interactions within and between the health system and community are influenced by restrictive gender norms and inequalities (eg, power and trust), affecting the strength, efficiency, and health impact of health system components and the system as a whole.12...