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Medicines Need and Access: Are there Gender Inequities?
Anita WagnerPaul Ashigbie
João CarapinhaAakanksha Pande
Dennis Ross-DegnanPeter Stephens
Saul WalkerCatherine Vialle-Valentin
WHO Collaborating Centerin Pharmaceutical Policy
Washington Post, January 27, 2007
“Well, if you're not fully utilizing half the talent in the country, you're not going to get too close to the top.”
Reproductive Morbidity/Mortality• One woman dies every 90 seconds• 30 more suffer permanent disability
More social and statistical data are needed … to fully understand the impact of gender on access to and
use of medicines.
Improving access to essential medicines will be possible only if
countries introduce a gender perspective in their medicines
policies.
Selected Medicines & Gender Projects*
1. Household need for and access to chronic adult medicines and preventive care for children – World Health Survey, 2002, 53 mostly LMIC
2. Household access to acute and chronic medicines– MeTA/WHO Medicines Survey, 2007-2008, 5 African LMIC
3. Physician prescribing for diabetes, depression, and upper respiratory illness– IMS Health prescribing data 2007-2010, 15 LMIC
4. Gender in the HIV, TB, and malaria literature– Literature review, 126 studies, 1990-2010
*Supported by the UK Government
No. of Countries with Gender Differences: Access to Adult Chronic Care
Wagner et al, work in progress
Arthriti
s: Ever d
iagnosed
Arthriti
s: Tre
ated in
past 2 w
eeks (if d
iagnosed)
Angina: Ever d
iagnosed
Angina: Tre
ated in
past 2 w
eeks (if d
iagnosed)
Asthma:
Ever diagnose
d
Asthma: T
reate
d in past
2 weeks (
if diagnose
d)
Diabetes:
Ever diagnose
d
Diabetes:
Treate
d in past
2 weeks (
if diagnose
d)0
10
20
30
40
50
F vs. M significantly >1.0 F vs. M not significantly different F vs. M significantly <1.0
No.
of C
ount
ries
No. of Countries with Gender Differences: Access to Adult and Child Care
Wagner et al, work in progress
Adult re
ceived ca
re la
st time in
need
Adult re
ceived pre
scription fo
r medici
ne if re
ceived ca
re
Adult sa
tisfacti
on with
health ca
re sy
stem
Child < 5 re
ceived ca
re durin
g last
reporte
d illness
Child < 5 re
ceived m
alaria tr
eatment f
or fever d
uring la
st illn
ess
Child < 5 re
ceived at l
east 1 m
easles a
nd 1 DPT im
munization
Child < 5 re
ceived at l
east 1 Vita
min A ca
psule
0
10
20
30
40
50
F vs. M significantly >1.0 F vs. M not significantly different F vs. M significantly <1.0
No.
of C
ount
ries
Adjusted Gender Effects Among AdultsOdds ratio
(95% CI)
Self-rated health moderate, bad, very bad 1.36 (1.33, 1.38)
At least one chronic condition 1.41 (1.38, 1.44)
Arthritis diagnosis or symptoms 1.46 (1.43, 1.50)
Needed care within past year 1.51 (1.45, 1.57)
Treatment for all reported chronic conditions 1.00 (0.96, 1.04)
Arthritis treatment 1.22 (1.16, 1.28)
Acute care when needed in past year 0.95 (0.85, 1.06)
All or most medicines needed during last visit 0.98 (0.93, 1.03)
High satisfaction with health care in country 1.15 (1.13, 1.17)
Perceived discrimination in outpatient care due to gender 1.00 (0.88, 1.14)
Females coded as 1. Models control for household size; having a member age 60 years and older or a child under 5 years (adult models only); highest education of any household member; household poverty; urban location; insurance coverage; respondent age, marital status, education, and health status.
Wagner et al, work in progress
Wagner et al, work in progress
Odds ratio(95% CI)
At least one Vitamin A capsule in past 12 months 1.03 (1.00, 1.07)
At least one measles and one DPT vaccine received 1.01 (0.98, 1.04)
Fever, severe diarrhoea, or other illness 0.93 (0.90, 0.97)
Care received for last illness 0.98 (0.94, 1.03)
Treatment for malaria during last episode of fever 1.01 (0.96, 1.06)
Females coded as 1. Models control for household size; having a member age 60 years and older or a child under 5 years (adult models only); highest education of any household member; household poverty; urban location; insurance coverage; respondent age, marital status, education, and health status.
Adjusted Gender Effects Among Children
Equally Poor Access for Women & Men
Female Male
Adults
Diabetes treatment, last 2 weeks 53.9(37.8, 64.0)
54.6(42.8, 69.3)
Depression treatment, last 2 weeks 30.5(23.4, 38.0)
27.9(17.2, 43.7)
Children <5
Vitamin A capsule, past 12 months 57.1(30.6, 76.3)
55.3(30.7, 73.3)
Measles and one DPT vaccine 39.2(27.0, 58.4)
39.6(26.8, 58.7)
Median (25th, 75th percentiles) across households in 53 countries
Wagner et al, work in progress
Pande et al. ICIUM2011 abstract #854
Acute Care for Children < 5 Years in 5 African Countries*: No Systematic Gender Bias
Symptom recognition Male FemaleFever, headache, hot body 74.3 72.7
Care seekingOutside home 91.2 91.2
Medicine accessMedicine taken 94.4 95.6Number of medicines (mean) 2.7 2.7Medicines prescribed by doctor, nurse 56.1 48.9Medicines from private pharmacy 32.1 34.9
Adherence Took all medicines recommended 86.7 84.4
*Gambia, Ghana, Kenya, Nigeria, Uganda
Stephens et al. ICIUM2011 abstract #954
Across Countries, More and Less than Expected Consultations for Depression
Women higher than expected
Women lower than expected
Gender & Medicines in the HIV, TB, and Malaria Literature
• N=105 studies of gender effects on outcomes (HIV/AIDS: 68; TB: 26; malaria: 11)
• Most studies assess access and adherence
Carapinha et al. ICIUM2011 abstract #640
Men>Women Women>Men Men=Women
Access 6 5 5
Adherence 4 10 21
Aggregate Analyses, Based on Different Data Sources, Suggest:
• Women frequently report more need for chronic illness care
• When controlling for need, no consistent gender inequities in access identified
• Access to care is equally poor for women and men in many countries– Need for measures of quality of care
• Situations in individual countries vary widely– Need for country and regional analyses
Possible Explanations?• Masculinity concept – “Real men don’t get
sick (or seek care or take medicines).”
• Women have contact with the system– Care givers– Reproductive care
• Equally poor access for men & women
Recommendations to Inform Decision Making
• Assess content of health and essential medicines policies and programs with an equity focus– International, national, and institutional level
• Monitor effects of policies and programs– By gender, socio-economic status, education, caste
• Present results from medicines research by gender and assess gender impact on outcomes– In households, facilities, systems
• Conduct sound comparative global and national research to address equity questions– Multi-disciplinary, multi-method
International manufacturers
Drug importers Domestic manufacturers
SUPPLY OF MEDICINES
Manufacture & importKey questions:• Are products for gender-
specific conditions licensed?• Are they quality-controlled?
`
Wholesalers and distributors
Pharmacies and retail outlets
Private physicians/other providers
Private health facilities
Private sector care
Government procurement
systems
Government health facilities
Public sector care
Consumers and patients
Insurance and risk carriers
Consumer demand
DEMAND FOR MEDICINES
Key questions:• Does household decision making on care
seeking and treatment differ by gender?• Can women and men access, afford, and
adhere to needed medicines?
Key questions:• Are budgets allocated for
gender-specific medicines?• Do distribution channels bring
medicines to where women and men need them?
Key questions:• Do women and men access
different parts of the system?• Do Standard Treatment
Guidelines consider potential gender differences?
• Does quality of care differ for women and men?
• Are trained male and female health workers available, accessible, used?
• Do all health workers treat all patients with respect, regardless of gender?
Key questions:• Do risk protection schemes cover women and men
equitably?• Do they pay for gender-specific care and medicines?