Thematic focus

Despite vaccine roll-outs gathering pace across the EU by mid 2021, the COVID-19 pandemic has continued to take lives, shattering initial hopes that the crisis would be short-lived. As the toll on human health and lives has grown, the intertwined social, economic and health dimensions of our lives have come into sharp relief. Although health was designated the thematic focus of the Gender Equality Index 2021 prior to the pandemic, COVID-19 has led to two important conclusions: challenges affecting people’s health relate to their social and economic situation and socioeconomic inequalities are ultimately reflected in differentiated health outcomes.

This focus aims to bring together evidence on gender inequalities as a determinant of health and to explore how converging inequalities affect health outcomes. As reasons for unequal health outcomes between women and men vary, this chapter examines the role of social constructs, including masculinity and work–family roles. The focus also touches upon other broad causes of gender inequality, such as economic and public policy factors. Gender inequalities in health status, including mental health, risky health behaviours, access to health services and SRHR, are explored, while data and evidence are provided on the gendered impacts of the pandemic.

Defined by WHO, the SDH are the economic, social and environmental conditions in which people are born, grow, live, work and age, with these shaped by the global, national and local distribution of money, power and resources (WHO, 2008). Some of these factors promote health, such as better education, access to clean water and safe housing. Others can be detrimental, for example gender-based violence or gender inequalities in accessing medical services.

Different models have been proposed to understand and systematically analyse SDH. Common to these are the inclusion of a very wide range of individual social circumstances – income, education, employment, housing, neighbourhood conditions and social networks. Similarly, various structural factors, such as public policies on education, housing, health and the economy, as well as cultural contexts, are included. Social factors, individual or structural, typically receive much attention from academia and policymakers because these can be more easily modified through policy.

Individuals experience life in a gendered body with its biological endowment, implying that some health issues are sex specific, such as ovarian and prostate cancers. Gender inequality and gendered norms have an impact on health because exposure and vulnerability to disease and injuries, health-related behaviours and access to care differ between women and men. Gender-biased health research and healthcare systems also reinforce and reproduce gender inequalities (Heise et al., 2019; Sen and Östlin, 2008).

Living in a community also suggests that gender is socially constructed by norms upheld by institutional factors. This ‘gender system’ interacts with other power and privilege axes, for example race, class and ability, influencing an individual’s social position in relation to others. Generally, a cross-cutting approach to health asserts that various factors are simultaneously at play when explaining health outcomes (Hankivsky and Christoffersen, 2008). This approach in health research, with gender an important dimension, is being increasingly taken in health inequality literature on European countries (EuroHealthNet, 2020; JAHEE; WHO, 2008, 2019e)

All domains of the Gender Equality Index have direct or indirect linkages to health inequalities, with sources of inequalities ranging from individual to national levels (see Chapters 2–6 and 8). Employment, income and education are closely related and widely recognised as SDH, with gender being a significant layer to better understand inequalities in relation to these dimensions. Time use and unpaid care work, as measured by the domain of time, and access to decision-making, as reflected in the domain of power, are increasingly identified as important determinants of health (see Chapters 5 and 6). Violence per se has a direct effect on various dimensions of health, be it physical or mental. At the national level, it has also been argued that inequalities in population health, such as a gender gap in the health of older people, is more evident in gender-unequal countries (Bracke et al., 2020). A recent report also notes that, in countries with greater representation of women and greater gender equity in politics, men’s health appears to improve and life expectancy increases for both women and men, with the benefit being greater for men (WHO Regional Office for Europe, 2020c).

Gendered patterns in the labour market are similarly reflected in health inequalities. Factors associated with unemployment that affect health include a lack of financial and social network resources, social isolation, stress and loss of self-esteem.

Employment can affect health directly through the physical work environment, for example exposure to toxins. Occupational cancers are estimated to account for more than 100 000 deaths a year in the EU (ETUI, 2018). Physical strain and psychosocial demands can lead to musculoskeletal disorders. According to EU-OSHA (2019), three out of every five workers in the EU report musculoskeletal complaints, with prevalence rates higher for women workers than for men. The mental health of employees can be adversely affected not only by discrimination, bullying and stress at work, but also by the financial strain that accompanies precarious employment conditions and a lack of rights and protection (Ferrante et al., 2019; Rönnblad et al., 2019). Gender differences in employment and working conditions have a major impact on work-related health outcomes for women and men. However, work-related risks to women’s safety and health have been both underestimated and neglected compared with research on the work-related risks faced by men, and their prevention (EU-OSHA, 2013). Occupational health policies and prevention practices also continue to be built on a gender-neutral model of ‘workers’, although the referent is implicitly male (ETUI, 2021). The gender mainstreaming of occupational safety and health is, therefore, very important (ILO, 2013).

Income, material resources and education affect access to important factors directly influencing health. These include access to medical treatment, housing, food and knowledge on health and healthcare systems. The gender role here is often unexplored. In the rare cases where it has been explored, a systematic review of the effect of income change on health, for example, argues that higher income does not always mean significant positive change for women (Gunasekara et al., 2011).

The primary responsibility to provide health and social care lies with Member States. While the EU can complement and support national policy, it is unable to determine it except in a few areas, such as research and cross-border threats (E. Brooks et al., 2020).

Ensuring universal access to appropriate, affordable and quality healthcare is an EU policy priority. The European Pillar of Social Rights demonstrates this by making such access a right (European Commission, 2019). Universal healthcare coverage is also a target of Goal 3 of the UN Sustainable Development Goals (SDGs) (UN, 2015). To implement the SDGs in the EU, the Commission adopted a sustainable development package in 2016 to help Member States achieve this goal. In 2020, the EU gender equality strategy reaffirmed the commitment to integrate a gender perspective in all Commission health initiatives, for example the EU’s Beating Cancer Plan (European Commission, 2021c).

To help address the growing need for health and social care among older people in an ageing population, the EU has implemented policies focused on ‘active ageing’. These aim to improve older people’s health, ensure that health and social care systems are sustainable, and contribute to the competitiveness of EU industry (European Commission, 2018). The Green Paper on Ageing calls for reforms and investments in long-term services, as well as renewed efforts to reduce gender gaps in employment, pay and pensions to prevent old-age poverty and social exclusion, especially among women (European Commission, 2021g).

Access to mental healthcare has also been an EU priority for many years. The European Framework for Action on Mental Health and Well-being highlights the challenge of meeting the mental health needs of women, while stressing the need for health services to be gender sensitive (EU Joint Action on Mental Health and Wellbeing, 2016). In addition, a European Parliament resolution on promoting gender equality in mental health and clinical research emphasised the gendered aspects of mental health and called for further action by the Commission and Member States. It highlighted the importance of clinical trials reflecting the needs of those who would use the products, and called for the collection of sex-disaggregated data to identify gendered differences in side effects (European Parliament, 2017). The implementation of the Clinical Trials Regulation[1] may help address ongoing inequalities (EIWH, 2018).

Following reverses on women’s rights and gender equality in the EU, a 2019 European Parliament resolution found that regression on key areas, such as SRHR, was common across Member States (European Parliament, 2019).

Yet another European Parliament resolution, in July 2020, on the EU’s public health strategy post COVID-19, acknowledges that access to SRHR services has been affected by the pandemic, and that women, children and LGBTQI people have faced a higher risk of violence and discrimination (European Parliament, 2020). The European Parliament calls on Member States to guarantee learning on the cognitive, emotional, social, interactive and physical aspects of sexuality (sexuality education), ready access to family planning for women, and the full range of SRH services during or outside crises, including modern contraceptive methods and safe and legal abortion.