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.”

The Economist, April 7, 2011

Reproductive Morbidity/Mortality• One woman dies every 90 seconds• 30 more suffer permanent disability

http://womanstats.org/mapEntrez.htm

Lack of Physical Security

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: Treated in

past 2 w

eeks (if d

iagnosed)

Angina: Ever d

iagnosed

Angina: Treated in

past 2 w

eeks (if d

iagnosed)

Asthma:

Ever diagnosed

Asthma: T

reated in past

2 weeks (

if diagnosed)

Diabetes: Ever d

iagnosed

Diabetes: Treated in

past 2 w

eeks (if d

iagnosed)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 rece

ived care la

st time in

need

Adult rece

ived prescription fo

r medici

ne if rece

ived care

Adult satisfa

ction w

ith health

care sy

stem

Child < 5 re

ceived ca

re during la

st 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 le

ast 1 m

easles a

nd 1 DPT immuniza

tion

Child < 5 re

ceived at le

ast 1 Vita

min A capsu

le0

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 MaleAdults

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?

“Women Hold up Half the Sky”…