Authored by: Nandita Bhan and Anita Raj

In recent weeks, the COVID-19 pandemic shifted its sights towards low and middle-income countries (LMICs) as case reports from India, Nigeria, and Kenya, among others, indicate. This has put the already over-burdened health systems in these contexts under unparalleled pressures. Globally, women represent a large and growing proportion of the healthcare workforce, particularly on the frontlines of care – as nurses and community health workers – responding to and managing this crisis. These women at the frontlines are facing high burdens of COVID-19 exposure, but have limited voice in an often male-led health system. The pandemic has also exposed new kinds of social and economic vulnerabilities that disproportionately affect the lives, health, and wellbeing of women and girls, such as increased unemployment and economic insecurity, lack of access to services and programs, increased exposure to violence, and higher likelihood of experiencing stigma or discrimination, and yet we have little understanding of these issues. How can we use a gender lens to understand the impact of COVID-19 on women and girls, as well as on women as health care providers?

Take the case of India, where response to the spread of COVID-19 led to a three-week lockdown on March 25. This mitigation response called for social distancing, suspension of economic activity and public transport, and closure of state borders; only minimal essential services are functional. This strategy is expected to slow the progress of COVID-19, and a number of countries have used this approach to various degrees. However, in India—with a highly dense population, economic and social inequalities, informality of work, and strong role of sociocultural networks in all aspects of life—following these measures comes at a huge cost. In view of the challenges posed by the lockdown, building a gendered understanding of the following three areas of research can be critical in drafting and amplifying responsive programs for women and girls in communities and women in health systems.

Firstly, understanding the impacts of COVID-19 and the follow-up mitigation strategies on the lives of women and girls, and on gender-focused programs, will be useful in the short and medium term. The most acute effects of the pandemic are being felt by informal workers in India who comprise 90% of the workforce, of which a significant number are women. Women’s means of livelihood—in sectors such as agriculture, industry, services, domestic work, and health care—determine their own resources as well as the conditions and future of their families. The pandemic has directly disrupted these livelihoods and risks sinking women and their families into poverty and debt. At the same time, ongoing programs that directly benefit women and girls through income and food support, health services, and by building their human capital are being disrupted. These include school meals, higher education, nutritional supplementation for pregnant and lactating women, family planning services, antenatal care and delivery services; these disruptions directly or indirectly compromise the health and wellbeing of women and girls. Likely, these individual or programmatic vulnerabilities are worse for marginalized groups, such as Dalit or religious minority girls, which also needs our attention.

Global reports are also indicating rising cases of gender based violence in this time. This may resonate in India as media reports from the National Commission for Women in India point towards an increase in domestic violence, seen through increased helpline calls. Outpatient care services for illnesses unrelated to COVID-19 are being affected by this disruption as well. This can have greater consequences for women’s health-seeking, which is already low and may decline further in the short term. Careful review of the implications of this lower health seeking on women and girls’ morbidity and mortality are needed in the medium and long term.

The pandemic threatens to disrupt many of our ongoing interventions and evaluations that examine these issues of gender equity and health. How these evaluations bypass or account for this disruption, and what interactions or deviations are noted, will provide important lessons for evaluation methodologists.

Secondly, it is also crucial that we apply a gender lens to understand issues of power and agency facing women working in the health system who are potentially facing disproportionate exposure to COVID-19 as nurses and community health workers (CHWs) dealing with this crisis in LMICs. In India, reports have thus far shown a predominance of cases among men as well as greater mortality for men, but cases from the medical care system of those contracting COVID-19 include a number of women nurses and health staff. With inadequate personal protective equipment (PPE) available to providers, we also worry that PPE will be prioritized for the higher-ranking physicians, who are predominantly male, and less so, for nurses and CHWs, who are predominantly female.

Reports from cities have shown instances of discrimination, stigma, and threats of violence and housing evictions faced by women doctors and health staff. This highlights the deep-seated nature of bias, stigma, and misinformation that interact with gender inequitable attitudes; women are more likely to face these issues and be unsupported when they do. Our work from India has shown that women doctors are critical to reproductive and maternal care services, likely due to women’s greater comfort and ease of communication with women doctors, especially in rural settings.  Understanding the challenges and risks faced by women health providers both with their peers in the medical fraternity and with patient households will be important to strengthening the health system and the response to COVID-19.

Finally, beyond economic and programmatic impacts, amplifying and learning from the journeys of change and the lived experiences during this time using a gender lens will also be important. In India, social distancing and the lockdown have exposed fault lines within families, unequal gender roles and expectations, and the invisibility of domestic work. In more affluent, dual-income households, with women domestic workers becoming unavailable, responsibilities of housework and care have fallen on women even more than before. This has exposed the latent gender power dynamics within households. On the positive side, in many households, men are increasingly ‘pitching in,’ though the type and degree of domestic work performed can vary.

Women disproportionately perform duties of care for sick adults or older persons within Indian households, and this burden will increase as more COVID-19 outbreaks develop. Our work has shown that extended caregiving has implications for women’s mental health and wellbeing, apart from lost opportunity costs. Ironically, when women themselves get sick, hospitalization investments for women are lower relative to men. We believe that informal caregiving needs may increase further during times of COVID-19, implying greater pressures for women than before, without any outlets for relief.

 What areas should we investigate as we deal with the pandemic crisis?

Our work has consistently emphasized the importance of gender-disaggregated analyses, but in times of crisis such as this one, the following areas of research and action also need urgency:

1. Impacts of this pandemic on women’s labour market participation, buffers and stressors, sources of economic resiliency and economic agency.
2. Disruptions in and sources of social security, health and nutrition services; who the services are reaching and who is most vulnerable, including intersectionality with social factors of caste and identity.
3. Incidence of gender based violence (GBV), factors influencing change in GBV prevalence during the pandemic, and access to GBV response programs and support from social networks.
4. Issues and challenges faced by women in the health care workforce, vulnerabilities and bias faced in the health system, and access to support services provided to women health workers in times of crisis.
5. Gender roles and changing expectations within families and communities during the pandemic, burdens and types of pressures faced by women and girls, and positive stories of support.
6. Accounting for women’s needs at the macroeconomic and budgetary level be it through incentives for households or through industry via economic packages and gender-responsive financial stimuli.

Many of us in research and evaluation grapple with questions of inequality and marginalization on a daily basis. However, the COVID-19 pandemic and responsive mitigation strategies have increased the visibility and resonance of these questions. We in global health research have no time to waste in answering them.