Gender and Immunizations within the Covid-19 Landscape


Many experts agree that any hope of returning to a pre-Covid-19 sense of normalcy, bringing the global economy back up to speed, and escaping the grim routines of social distancing—including wearing face masks outside or staying at home—is directly tied to the successful development and introduction of a vaccine.

To date, 185 countries/regions worldwide have confirmed infections. With case counts and deaths mounting in lower and middle-income countries, those with fragile health systems are at particular risk for experiencing widespread outbreaks and prolonged economic impacts. As efforts to develop a vaccine to prevent infection with Covid-19 advance, ensuring plans are in place for any new product to reach the world’s poorest and most vulnerable communities is essential.

In lower- and middle-income countries, women are most likely to be the ones making decisions about health services for their children—and sometimes for their spouses and older parents or in-laws, as well. Research suggests that when women do not have access to education or have low political and social status, their family members are less likely to be immunized. Poverty and other factors linked to social marginalization, such as religious affiliation, race, or ethnic identity, also influence a woman’s ability to secure immunizations for her household members. A woman’s own health status, her role within the family, and the way in which she experiences interactions with male and female health care professionals all influence decisionmaking when it comes to health

Acknowledging the critical role that societal expectations about the roles women play in shaping the access of children, adolescents, and adults to vaccines, two new efforts are focused on removing gender as an obstacle to immunization access. Immunization Agenda 2030 (IA2030), the global strategy to guide countries’ efforts to enhance access to vaccines over the next 10 years, emphasizes the importance of dismantling gender-related barriers and using immunizations as a way to reduce gender disparities. And Gavi, the Vaccine Alliance, is placing a strong emphasis on gender equality in its 2021-2025 work plan, known as Gavi 5.0.

Gavi has had a gender policy in place since 2008. The policy, which was updated in 2014 and is currently under review, defines gender as “those characteristics of women and men which are socially constructed.” Gavi posits that these social roles are “changeable, rather than fixed” and differentiates between gender equality, which it defines as the distribution of benefits or services without discriminating on the basis of sex, and gender equity, which it frames as “fairness and justice in the distribution of benefits and responsibilities between women and men.”

Gavi supports countries’ efforts to tackle gender-related barriers to health care by providing them with funds to undertake health system strengthening (HSS) activities. Through this HSS support, Gavi encourages countries to collect evidence regarding how gender either serves as an obstacle or facilitates access to immunization services. It also supports countries’ efforts to design communications and awareness-raising activities to engage mothers, as well as fathers, in family decisions about immunization.

At its next replenishment conference , currently scheduled for early June, Gavi hopes to secure an additional $7.4 billion in donor investments to carry out work between 2021 and 2025. As the five-year work plan is finalized, the Alliance is working closely with UNICEF, the World Health Organization (WHO), and other partners to support a vaccine demand hub to advance understanding about how cultural attitudes, including ideas about gender roles, influence access to vaccines in diverse settings.

IA2030, which is expected to be approved as health officials convene for an abbreviated version of the annual World Health Assembly in May, outlines a global vision for “a world where everyone, everywhere, at every age, fully benefits from vaccines for good health and well-being.” Focused on the period between 2021 and 2030, the agenda builds on the lessons of the Global Vaccine Action Plan (and associated Decade of Vaccines, 2011-2020) and provides a strategy for guiding national programs and regional collaborations in improving the access of children and adults to immunizations. Unlike Gavi 5.0, IA2030 applies to all countries, not just those classified as lower income. But in recognizing the critical role women play in ensuring their families are vaccinated, and in acknowledging that vaccination can lead to improved health, educational outcomes, and economic opportunities for women and girls, IA2030 aligns with Gavi 5.0’s emphasis on removing gender-related barriers to immunizations. Both frameworks will play an important role in providing guidance to countries implementing a Covid-19 vaccine, once one is available.

On March 11, the WHO declared the Covid-19 outbreak to be a pandemic. As of April 27, there have been nearly 3 million confirmed cases and more than 207,000 associated deaths. As the pandemic evolves, available information suggests that men appear to be more vulnerable than women to complications from the infection, although it’s not yet clear whether this is due to a higher level of underlying health problems, such as chronic conditions and cardiovascular disease, or some other reason. Men also appear to be overrepresented among the dead. And yet some experts warn that the longer-term effects of the pandemic, and its impact on educational institutions, economic performance, labor opportunities, and mobility, will pose particular challenges for women and girls. Indeed, with pandemic-related disruptions to agriculture and trade threatening to increase the numbers of people at risk for hunger and malnutrition, and the weakening of distribution networks for some essential medicines and family planning commodities, there is a risk that the recent gains in women’s health, schooling, and economic empowerment may be wiped out altogether. With women making up the majority of health workers globally, and with women bearing the greatest burden of caring for ill spouses and other household members, they may also be at greater risk of being infected with Covid-19. Higher rates of gender-based violence have also been reported within communities experiencing lengthy stay-at-home orders.

To enable the lowest-income countries eligible for Gavi support (currently those with an annual gross national income (GNI) per capita of $1,630 or less) to prepare for and respond to the outbreak, the Gavi Board has recently authorized countries to apply to use a percentage of their HSS and immunization system strengthening funds for outbreak response, including surveillance activities, testing, purchasing protective equipment, and training health workers. At its mid-March meeting, the Gavi Board also expressed support for using the International Financing Facility for Immunizations (IFFIm) and Advance Market Commitment (AMC) mechanisms to incentivize research on an effective vaccine.

Mindful of the losses to immunization coverage in West Africa during the 2014-2015 Ebola outbreak, and noting the rise in measles cases in the Democratic Republic of Congo (DRC) during the more recent Ebola outbreak there, Gavi and partner organizations, such as the WHO and UNICEF, have also stepped up calls to ensure countries try to maintain routine immunization activities or prepare to resume them and “catch up” as soon as possible if they must be interrupted or suspended during the pandemic.

As work on a vaccine that protects children, adolescents, and adults from infection with Covid-19 advances, it is important to set the stage now to ensure equitable availability and uptake of any new products. Approaches that acknowledge the important roles women play in family immunizations that take gender differences in vulnerability to infection with Covid-19 and access to health care services into account should include:

  • Supporting the collection of data to determine the ways in which gender roles or expectations may influence vulnerability to infection with Covid-19 and access to health services to prevent or treat Covid-19. This can help policymakers better understand where, and for whom, the need for a vaccine is the greatest, which social sectors are most vulnerable, and how to prioritize the distribution of a vaccine once available.

  • Strengthening immunization systems overall, including addressing existing weaknesses or disruptions in supply chains and data collection as a consequence of the pandemic. Recruiting, training, and retaining health professionals, including nurses and community health workers, who can administer vaccines, and collecting data to better understand gender differences in demand for and access to routine immunization programs should also be a priority.

  • Building and reinforcing global agreement through such mechanisms as the G20, the G7, and the World Health Assembly (WHA) on how to prioritize the availability and distribution of a new vaccine (or vaccines), ensuring affordability and accessibility to lower and lower-middle income-countries and recognizing the role gender plays in demand, access, and uptake. The recent UN General Assembly consensus on strengthening the "scientific international cooperation necessary to combat Covid-19 and to bolster coordination," is an important first step. And the fact that the members of the International Coalition of Medicines Regulatory Authorities (ICMRA) have recently acknowledged the need for regulatory flexibilities and harmonization around the development of treatments and vaccines against Covid-19 is encouraging.

  • Preparing and refining print, radio, and graphic communications, as well as social media messages, for use in diverse contexts that resonate with the women and men who make decisions about family health in anticipation of a vaccine (or vaccines) that protect against infection with Covid-19. Advance planning and testing can help ensure that adults, as well as children, are informed and prepared to access a Covid-19 vaccine (or vaccines), once available.

As the world enters another month of social distancing, escalating case counts, and continuing economic disruptions, the fact that there are multiple Covid-19 vaccine candidates in the research and development pipeline, with clinical trials getting underway over the next several months, is good news. Paying attention now to the ways in which expectations about gender in diverse contexts promote or restrict access to, and demand for, vaccines will help ensure a smooth rollout and uptake of new products, once they are ready.

Katherine Bliss is a senior fellow with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2020 by the Center for Strategic and International Studies. All rights reserved.

Katherine E. Bliss
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center