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MOMENTUM Routine Immunization Transformation and Equity
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 JANUARY 2023: ISSUE 3
Gender and Immunization: Recognizing and Reducing Barriers
When a mother in Mozambique’s Nampula Province was asked why her child was only partially vaccinated, she replied that the last time she brought her child for immunization, the clinic had run out of vaccines. She further explained that returning to the clinic once vaccines were available could not be a priority because it would be too difficult to negotiate with her husband for more money for transportation and more time away from household duties. Her child’s incomplete vaccination status was due not to negligence, lack of knowledge of the importance of vaccination, or vaccine hesitance. Instead, her intention to vaccinate her child was thwarted by service deficiencies, compounded by gender-related barriers.
This issue of Immunization in Focus provides an overview of gender and immunization within the landscape of the COVID-19 pandemic. It suggests ways that USAID Missions and projects can help reduce gender-related barriers to vaccination and links to practical tools and websites to support gender-aware programming for immunization.
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A SUMMARY
Current landscape for gender and immunization: Why does it matter?
In the 10 years prior to the COVID-19 pandemic, global vaccination coverage had plateaued at approximately 85 percent, with substantial variations across and within countries. In 2018, the Equity Reference Group—an action-oriented think tank managed by UNICEF to review and synthesize data on obstacles to improving equity in immunization—produced a seminal paper, A gender lens to advance equity in immunization. This gave rise to increased recognition by the global immunization community that such barriers lie on a critical pathway to increasing coverage for both boys and girls while reducing the number of zero-dose children. Previously, the gender dimension of immunization was under-recognized because most countries register only small differences between boys and girls in national vaccination coverage rates.
However, access to and utilization of immunization services are often limited by common gender-related barriers, including:
- Prohibitive social norms that limit women’s mobility.
- Limited decision-making power and control over household resources.
- Low levels of women’s educational attainment, associated with low vaccination coverage in their children.
- Harsh treatment from health care providers that deters caregivers, predominantly female, from seeking immunization for their children.
- Inequitable policies and regulations that fail to recognize the needs of female caregivers.
- Gender-blind approaches to governance and stakeholder engagement with little female representation.
The COVID-19 pandemic has exacerbated gender-related barriers to immunization and other health services. Women comprise the majority of frontline health worker positions and caregiver roles, thus are at elevated risk of exposure to and illness from the virus. Pregnant women in particular, if infected, are at high risk of both severe illness and delivering pre-term babies. Lower levels of literacy among women limit access to accurate information on COVID-19 and vaccination against it. Women continue to have less access than men to digital channels, such as mobile phones and the internet, which are increasingly used to convey information about the pandemic and vaccination. For example, a 2021 study in Bangladesh by Gavi, The Vaccine Alliance and GSMA found gender gaps between women and men of, respectively, 29 percent in ownership of mobile phones and 52 percent in the use of mobile internet. While these and other barriers have led to lower levels of COVID-19 vaccination among women in some places, gender-related barriers have resulted in lower COVID-19 vaccination levels among men in others.
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GENDER AND IMMUNIZATION
How does gender affect immunization?
Gender-related barriers in health refer to the challenges and obstacles created by deep-rooted social and cultural norms about the roles and responsibilities of men, women, and those with diverse gender identities that prevent the access to and use of lifesaving health services. Such barriers to immunization affect both caregivers and health care workers, influencing the delivery of, demand for, and utilization of immunization services.
While child-caregiving responsibilities primarily fall to women, decisions on the use of household resources are commonly made by men. This limits a woman’s autonomy in seeking services for her family and herself. Further considerations, such as safety, distance, and access to transportation, often constrain women’s mobility and perpetuate power imbalances, restricting their ability to access health services.
Similarly, female health workers—who make up 70 percent of the global health workforce but serve in only 25 percent of health leadership positions—face gender-related barriers that are often rooted in systems and policies. The gender pay gap, occupational safety hazards, the prevalence of violence or sexual harassment in the workplace, and conflicting responsibilities (including family duties) severely impact women’s ability to deliver high-quality health services.
In many post-conflict and fragile settings with low immunization coverage, the percent of front line vaccinators who are female is low. This situation further limits female caregivers’ and clients’ access to immunization in places where they are prohibited or deterred from interacting directly with men. Despite efforts, progress with hiring more female health workers in such places has been slow.
Partnerships between health systems and communities remain weak in many places, with female caregivers having no voice in determining where and when immunization services are provided. Further, health workers’ harsh treatment of women when they bring their children for vaccination has been widely recognized as a deterrent to completion of the child vaccination schedule.
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| Immunization Agenda (IA) 2030
The IA2030 agenda focuses on gender-responsive strategies, including “Tailored strategies that are necessary for understanding and overcoming barriers to vaccination, particularly the gender-related barrier preventing caregivers and health workers from accessing immunization services.”
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WHAT CAN BE DONE?
From theory to action: Identifying and addressing gender-related barriers to immunization
Recognizing that reducing gender-related barriers to immunization lies on a critical pathway to achieving immunization coverage and equity goals, Gavi, WHO, UNICEF, USAID and other global immunization partners have committed to action. To make these strategies operational requires a range of actions. USAID’s Gender Integration Continuum (Figure 1) provides a framework for informing action to address gender barriers in health.
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FIGURE 1. USAID’S GENDER INTEGRATION CONTINUUM
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By applying this framework for gender-aware programming in immunization, planners can assess whether immunization activities and processes are gender exploitative, accommodating, or transformative. As shown in Figure 2, sometimes well-intentioned attempts to address gender barriers may reinforce inequitable power relationships that put women at a disadvantage.
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FIGURE 2. EXAMPLES OF GENDER INTEGRATION FOR IMMUNIZATION
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ACTIONS
Practical actions for addressing gender-related barriers to immunization
Immunization programs should include activities that work toward gender transformative and equitable approaches that consider the needs of all gender identities in the social, economic, and political contexts in which they live and exist. Gender mainstreaming should be conducted at all levels of the program cycle, from assessment to design, implementation, monitoring, and evaluation.
USAID Missions and projects are well positioned to mainstream gender-sensitive programming into their strategies and approaches for immunization by:
- Measuring: Track vaccination coverage and doses administered disaggregated by sex. From population-based surveys, analyze data disaggregated by other factors related to gender equity (e.g., educational level, wealth, source of services, urban/rural).
- Assessing: For USAID, the U.S. Congress requires that all strategies, programs, and activities beshaped by a gender analysis and gives a detailed definition of what a gender analysis should include. When designing interventions, conduct formative assessments to actively seek the voices of women to identify and mitigate gender-related barriers to immunization.
- Advocating and communicating: Sensitize colleagues at national and subnational levels of the health system and from civil society and other organizations on why and how to reduce gender barriers to vaccination. Communicate regularly about gender-related barriers to immunization and progress overcoming them.
- Engaging: Increase female representation in co-creating interventions and designing activities to reduce zero-dose and under-immunized children. Two ways of doing so are to:
- include women in planning where and when vaccination services are provided
- partner with trusted local organizations that have expertise in gender equity.
- Increasing male support: Expand male involvement through a range of targeted, locally appropriate activities that men can take to improve immunization (such as advocating for convenient immunization services), highlighting why it will benefit them and their families. Support communication efforts to increase men’s understanding of practical matters, including the vaccination schedule and common vaccine side effects.
- Supporting the female health workforce: Promote the adoption and implementation of policies that recognize the needs of and risks to female health workers, and afford opportunities for professional advancement.
- Enhancing protection: Support the introduction and uptake of vaccines against diseases across the life course, such as human papillomavirus, which disproportionately affect women. Involve women and girls in the design of service delivery and communication strategies to help ensure that their needs are understood and met.
- Learning and sharing: Apply tailored, meaningful measures to both monitor and evaluate interventions to improve gender equity and adapt efforts based on learning. Share experiences across countries and with global and regional partners to amplify learning and strengthen strategies.
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Gavi 5.0 Strategic Plan for 2021-2025
The Gavi 5.0 vision includes gender as one its leading principles and uses equity as an organizing priority to strengthen vaccine programs and health systems. Gavi’s updated gender policy (2020) also focuses on identifying and overcoming gender-related barriers faced primarily by caregivers, health workers, and adolescents, who are central to reaching zero-dose and under-immunized groups.
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What tools are available to help?
Additional guidance on gender-aware programming for immunization is available at these sites:
For practical guidance and tools on gender and the COVID-19 response:
Experiences and lessons from the USAID MOMENTUM projects:
- This technical brief on gender describes actions taken across the MOMENTUM suite of projects to incorporate gender-sensitive programming into each award’s activities.
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