Prof. Sally Theobald and Ms Laura Dean from COUNTDOWN gave a keynote at the International Federation of Anti-Leprosy Associations meeting on Wednesday, 18th October 2017.

1. Gender and Leprosy: Why it
Matters
Prof. Sally Theobald and Ms Laura Dean
sally.theobald@lstmed.ac.uk laura.dean@lstmed.ac.uk

2. https://www.youtube.com/watch?v=4viXOGvvu0Y
Defined as the “socially constructed roles, behaviors, activities, and attributes that a given
society considers appropriate for men and women and people of other genders” (WHO 2015)
UnderstandingUnderstanding Gender

3. Gender operates on various levels simultaneously
3
Forms
individual
identities and
values
Encompasses interpersonal
relationships between
individuals
Influences how society is organised more
broadly in terms of social norms,
institutions, structures, resources within all
social systems: families and households,
communities, economies and states
Gender is negotiated by
individuals and societies;
it changes over time and
across contexts
Gender interacts with other social
stratifiers, such as class, race,
education, ethnicity, age,
geographic location, (dis)ability,
and sexuality

4. Why is gender important in health systems?
4
• Health systems are not gender neutral – gender is a key social stratifier which affects health
system needs, experiences, and outcomes.
• As a power relation, gender influences:
o Vulnerability to ill-health
o Household decision-making and health seeking behavior
o Access to and utilization of health services
o Design and use of medical products and technology
o Nature of the health labor force
o Implications of health financing
o What data is collected and how it is managed
o How health policies are developed and implemented
Photo Credit: Carlo Rainone
(Standing 1997; Nowatzki & Grant
2011; Vlassoff & Moreno 2002;
Sen et al. 2007; George 2008;
Percival et al. 2014)

5. 5
Why is gender important in health systems?
Human Resources for Health – Gendered Profile (Newman 2014)
Percentage of students by cadre training programme and sex, Kenya 2010 (N = 42 institutions)

6. 6
India (2005-06) – Percentage of women who do NOT have control over how
they spend their earnings
Residence Wealth IndexAge Education
(Ravindran 2015)

7. 7
Lessons from Gender Mainstreaming for Leprosy
Lesson 1
Tailored Gender
Frameworks help make
focus on gender explicit
Lesson 2
Gender does not operate in
isolation: Intersectionality
Lesson 3
Gender Power and
Participation: who are
community representatives
and why it matters?
Lesson 4
We need to unpack gender
and power dynamics at the
household level
Lesson 5
We need a critical gender
lens to data at all times

8. 8
Lesson 1: Tailored Gender Frameworks

9. 9
Lesson 1: Tailored Gender Frameworks
What constitutes gendered power relations
Who has what Access to resources (education, information, skills,
income, employment, services, benefits, time, space,
social capital etc.)
Who does what Division of labour within and beyond the household and
everyday practices
How are values
defined
Social norms, ideologies, beliefs and perceptions
Who decides Rules and decision-making (both formal and informal)
How power is negotiated and changed
Individual/ People Critical consciousness, acknowledgement/ lack of
acknowledgement, agency/apathy, interests, historical
and lived experiences, resistance or violence
Structural/
Environment
Legal and policy status, institutionalisation within
planning and programs, funding, accountability
mechanisms

10. 10
Lesson 2: Gender does not operate in isolation
Intersectionality promotes an understanding of human beings as
shaped by the interaction of different social locations (e.g., ‘race’/
ethnicity, indigeneity, gender, class, sexuality, geography, age,
disability/ability, migration status, religion). These interactions
occur within a context of connected system and structures of power
(e.g. laws, policies, state governments and other political and
economics unions, religious institutions, media). Through such
processes, interdependent forms of privilege and oppression
shaped by colonialism, imperialism, racism, homophobia, ableism
and patriarchy are created. (Hankivsky 2014)

11. 11
Lesson 2: Gender does not operate in isolation
The ‘intersectionality’ wheel adapted for a Liberia context from Simpson 2009.

12. 12
Lesson 3: Gender, Power and Participation
Community Health Volunteers are critical in the delivery of many health
interventions, including those targeting leprosy, but we need to consider:
How do power
dynamics influence
CHV selection?
How gender influences
CHV interactions and
performance?
How do we support
CHVs of differing
genders?

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Lesson 4: Gender and Power Dynamics in Communities
Gender, Stigma and Isolation
‘Coping’: Moses, a Liberian man
affected by leprosy’s safe space
“The best thing let me do such a thing to myself at least, let
everything finish. Because how can human live, the way how y’all
lived together first, y’all do everything together, at last because of
condition now, you just look that kind of way, they neglect you.
That kind of bad feelings can come to you. That how you can just
say, but let me just harm myself let everything finish because I
don’t want to live I, alone …I live alone.” (Lisa 26-49)
“When I am alone, I don’t want to be thinking too much. So when I
put my radio on and listen to it. In the night, my radio is on until the
battery is low, that the only way… I put my radio on throughout
until I sleep. In the morning, do the same thing.” (Gabriel, Over 49)

14. 14
Lesson 4: Gender and Power Dynamics in Communities
Gender, Poverty and Abandonment
‘Abandonment’: In DRC, Neema
and her mother were abandoned
by their father and husband.
“When I was accused as witch craft- in 96, I received heavy beating,
excused me please….the switch that hit my nut seed [scrotum] it
caused me…I was out of my sex. In 2003, they took out the thing. I
just like that. So she too, she can’t be like that. So she went back to
her old husband.” (Gabriel, Over 49)
“You have no place to go. Then your family who will say come sit
down near me here. Now they say “go away from me”, then where
are you going to go?” (Emine, Over 49)

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Lesson 4: Gender and Power Dynamics in Communities
Whatever it takes: consequences of struggling to survive
‘Resilience’: In Liberia, Jon and his wife make and sell
brooms for 25 cents (USD) to survive day to day.
“I force myself to cook for them to eat. If I don’t do
it they either go outside or end up with different
things, stealing this and that. So I force myself.
Even if I’m crying I force to strain myself, I drag in
front the fire.” (Lisa, 26-49)
“Sometimes I have the zeal to do the work. I will be
shaping my cutlass this and that. But when I get up
in the morning sometimes I can feel very weak that
I could not do anything. For the whole day I won’t
be able to work.’’ (John, 18-25)

16. 16
Lesson 5: We need to bring a critical gender lens
to data
‘Tanya Wood from the International Federation of Anti-Leprosy
Associations raised an important concern relating to how data is
collected. She provided an example of how leprosy data has been
disaggregated demonstrating that in some contexts, more men
have leprosy than women and that this has been taken at face value
in the figures that are reported by WHO and others. She explained
that in reality, women were not showing up in the data because of
the multiple challenges they face in accessing care and treatment.’

17. 17
Concluding Thoughts
Photo from Dr. Paluku Sabuni, beneficiaries of the leprosy
mission DRC
Gender responsive programmes are more
likely to be equitable and sustainable

18. References
18
• Hogan, E. (2017) “An intersectional approach to the psycho-social burden of leprosy: A Liberian case study” Masters dissertation,
Liverpool School of Tropical Medicine. WHO. 2015. “What Do We Mean by ‘Sex’ and ‘Gender’?”
http://www.who.int/gender/whatisgender/en/ (May 4, 2015).
• Morgan, R., et al., How to do (or not to do)... gender analysis in health systems research. Health Policy Plan, 2016. 31(8): p. 1069-78
• Newman, Constance. 2014. “Time to Address Gender Discrimination and Inequality in the Health Workforce.” Human Resources for
Health 12(1): 25.
• Nowatzki, Nadine, and Karen R Grant. 2011. “Sex Is Not Enough: The Need for Gender-Based Analysis in Health Research.” Health
Care for Women International 32(4): 263–77.
• Ravindran, Sundari TK (2015). Health financing mechanisms in India and their implications for women’s access to health care
(presentation). In Health Systems Financing – What’s gender got to do with it?.
• Standing, Hilary. 1997. “Gender and Equity in Health Sector Reform Programmes: A Review.” Health Policy and Planning 12(1): 1–18.
• Simpon, J. (2009). Everyone Belongs: A Toolkit for Applying Intersectionality. [Intersectionality Wheel] Available at: http://www.criaw-
icref.ca/sites/criaw/files/Everyone_Belongs_e.pdf (Accessed 8 August 2017)
• WHO. 2015. “What Do We Mean by ‘Sex’ and ‘Gender’?” http://www.who.int/gender/whatisgender/en/ (May 4, 2015).