ROUND TABLE DISCUSSION
Equity and gender
Geeta Rao Gupta
President, International Center for Research on Women (ICRW), Suite 302, 1717 Massachusetts Avenue NW, Washington, DC, 20036, USA
Gwatkins paper provides an excellent historical review of the developments in thinking and research with regard to health inequalities and the health of the poor. More importantly, the paper provides a thought-provoking analysis of the impact of those developments on policy and its implications for health inequalities and the health of the poor. I agree entirely with Gwatkins conclusion that there has been a puzzling disconnection between policy discourse and the setting of health policy objectives and that this disconnection has severely limited the impact of health policies and programmes in reducing health inequalities or solving the health problems of the poor.
The central thesis of Gwatkins paper is that health goals based on societal averages without an effort to incorporate distributional differences in health conditions across the socioeconomic classes do very little to meet the needs of the poor. I would like to add that the setting of health targets based on societal averages also masks gender differentials and thereby fails to deal with the gender-based health inequities that take a great toll on the health of women. In India, for example, using under-five-year-old mortality rates in aggregate form as an indicator of health status would mask the fact that the deaths of girls in this age group exceed those of boys by nearly 330 000 annually (1). Although Gwatkin acknowledges gender inequalities in health status when discussing the dimensions of inequality that matter most, he restricts his recommendation for disaggregated goals to the socioeconomic dimension.
It could be argued that because women constitute about 70% of the worlds poorest people, disaggregation by socioeconomic status and the pursuit of health goals that specifically target the poor would automatically include the needs of women. But just as Gwatkin argues that using a pro-poor target, such as reducing under-five-year-old mortality by one-third, may not result in any appreciable improvements in the conditions of the poorest, it could be argued that a target to improve the health status of the poor without explicit goals to improve womens health may likewise run the risk of completely missing the health needs of the most vulnerable and the poorest of the poor women. Poor women suffer the interactive consequences of two of societys most persistent and damaging inequities, poverty and gender. If the goal of health policy is to reduce health inequalities, it is imperative to set explicit goals for improvements in womens health.
Meeting gender-based health goals, however, will only be possible with an approach that addresses the gender-specific sociocultural and economic factors that increase womens vulnerability to illness and infection and restrict their access to health care information and services. For example, womens use of health services has been found to be impeded by sociocultural norms that restrict their mobility or limit their participation in household decision-making (2). Research on human immunodeficiency virus/acquired immunodeficiency syndrome has also shown that economic dependence and income insecurity act as significant constraints for women who want to adopt preventive practices such as the use of a condom, if these go against the wishes of their male partners (3).
Likewise, gender-based violence against women, the most pervasive form of human rights abuse, is increasingly recognized as a profound health problem that needs policy attention because it is a significant cause of morbidity and mortality among women (4). Thus, ensuring that gender-based health goals are translated into action will require an approach that recognizes the importance of assuring womens health and well-being, and the only way to do that is by strengthening their economic and social capabilities.
In his recent book, Development as freedom (5), Amartya Sen argues that it is only by strengthening womens agency and voice, through measures such as increasing their earning power and assuring their literacy, that we can begin to remove the inequities that compromise womens well-being. He points out that the benefits of investing in womens agency accrue not only to women but to their children and their families, through improvements in child survival rates and a reduction in fertility.
Despite these proven benefits and the undeniable gender disparities that persist in indicators of health and well-being, it has been difficult to convince policy-makers that they should give high priority to the health of women. The persistence of an unacceptably high maternal mortality rate (more than half a million deaths a year from preventable causes) is vivid proof of this. The setting of gender and socioeconomic health goals is only one component of an approach that seeks to tackle health inequalities. What is required, as Gwatkin rightly points out, is "an impressive degree of political will," which can only come about if health professionals make clear the need for gender-based and economic equity in order to obtain positive and sustainable health outcomes. 
1. Chatterjee M. Indian women: their health and productivity. Washington, DC, The World Bank, 1991 (World Bank discussion paper 109).
2. Timyan J et al. Access to care: more than a problem of distance. In: Koblinsky M, Timyan J, Gay J, eds. The health of women: a global perspective. Boulder, Colorado, Westview Press, 1993: 217234.
3. Weiss E, Gupta GR. Bridging the gap: addressing gender and sexuality in HIV prevention. Washington, DC, International Center for Research on Women, 1998.
4. Heise L. Violence against women: the missing agenda. In: Koblinsky M, Timyan J, Gay J, eds. The health of women: a global perspective. Boulder, Colorado, Westview Press, 1993: 171196
5. Sen A. Development as freedom. New York, Alfred A. Knopf, 1999.