Why Does Gender Matter for Immunization?

"By considering the impact of gender, more effective immunization programmes can be implemented to increase coverage."

There are multiple ways in which gender roles, norms, and relations influence resource allocation, decision making, access, and health outcomes, including for immunisation programmes. Gender impacts immunisation both on the demand side, through people's health-seeking behaviours, and the supply side, through provision of health services. To that end, gender is an important cross-cutting consideration for all seven Immunization Agenda 2030 (IA2030) strategic priorities, especially #3: Coverage & Equity. By applying knowledge about gender and examining ways to design gender-responsive interventions, this paper hopes to contribute to more effective immunisation programmes and increased coverage for all.

As outlined here, the seven strategic priorities of the IA2030 are anchored in four core principles, which express gender equality as a fundamental value:

1. People-focused: Responding to the different needs of women, men, girls, and boys - The design, management, and delivery of immunisation services should be shaped by and responsive to the needs, experiences, preferences, and vulnerabilities of women, men, girls, and boys of diverse backgrounds. Programme design should be led by and inclusive of communities that programmes are seeking to reach (e.g., marginalized or missing communities where zero-dose children are often found). Community-based approaches should be favoured over one-size-fits-all national or regional solutions. Furthermore, the principle of do no harm should be applied in programming to avoid creating adverse impacts or reinforcing harmful gender norms and roles contributing to marginalisation, sexual harassment, exploitation, and other forms of gender-based violence.
2. Country-owned: Driving progress through country gender equality commitments - Country ownership and accountability should be promoted at all levels, ensuring that countries recognise the potential and importance of addressing gender-related barriers to accessing and utilising healthcare and that they are equipped with the resources to identify and address intersecting social barriers in health services. Immunisation programmes should be targeted and tailored based on country context, as well as rooted in an understanding of context-specific gender norms, roles, and relations and their links with health outcomes.
3. Partnership-based: Aligning efforts to maximise impact for gender equality. Immunisation partners should align and coordinate their actions to increase efficiency, build on complementarity, and involve sectors beyond health for mutual benefit in identifying and addressing gender-related barriers to immunisation and increasing women's meaningful participation at all levels of the health system. Local communities and civil society, especially women's and adolescent girls/youth-led groups and organisations, should be engaged and involved in planning, implementation, and oversight of immunisation interventions to strengthen accountability and sustain impact.
4. Data-guided: Promoting evidence-based decision-making informed by sex-disaggregated data and gender analysis. Particular efforts should be made to generate evidence and data via qualitative studies and behavioural science inquiry.

Next, the paper examines the role of gender mainstreaming in immunisation, which involves integrating the concerns and experiences of women as well as men into the design, implementation, and monitoring and evaluation (M&E) of immunisation policies and programmes with a view to promoting equality and not perpetuating inequality. For example, it is necessary to acknowledge and seek to dismantle the gender-related barriers that can prevent people, both women and men, from getting vaccinated. These barriers operate at multiple levels and are compounded by other dimensions of inequality, all of which underpinned by unequal power dynamics. The paper discusses some common gender-related barriers to immunisation, such as:

• Factors related to the quality, acceptability, and accessibility of health services that may deter women and men from attending immunisation services for themselves and their children in different ways;
• Low education level and health literacy;
• Limited autonomy in decision-making and household dynamics (e.g., mothers who perceive that spousal permission is required for their child's immunisation);
• Lack of access and control over resources and mobility (e.g., due to religious or cultural norms); and
• High prevalence of gender-based violence and harmful practices such as child marriage and son preference.

The approaches developed and used to tackle gender barriers can be categorised along a continuum, which is depicted in Figure 2 in the paper. Adapted from WHO's Gender-responsive Assessment Scale (GRAS), this figure provides an overview of each level, with illustrative examples related to immunisation programming. In short, immunisation interventions should, at a minimum, be gender-specific, and ideally and when possible, gender-transformative. An example of the latter would be a community programme that encourages fathers to take on equal and active roles in child health and immunisation and/or strategies for enabling women, men, and youth equally to participate in immunisation delivery, design, and implementation at different levels.

A 2021 WHO/UNICEF/Gavi guide entitled "Why Gender Matters: Immunization Agenda IA2030" lays out in detail gender-responsive approaches and actions for mainstreaming gender in immunisation programmes and policies. See Related Summaries, below, as well as Table 1 in the paper, which provides a high-level summary of the guide. One suggestion: Design immunisation materials, messages, and interventions to challenge harmful gender norms, roles, and/or stereotypes. For example, portray women as equal and active participants, not only as mothers and caregivers.

In conclusion: "To make progress in line with the IA2030, policymakers and practitioners cannot ignore the importance of mainstreaming gender across the immunization programme cycle - from the policy, management and design of immunization systems through to the implementation, monitoring and evaluation of the services. Adopting a gender perspective in all steps towards the goals of IA 2030 must be ensured, at all levels."