Address gender barriers in delivery and demand to catalyse COVID-19 vaccine equity: The Asia Pacific context

In December 2020, several global regulatory agencies, and the WHO listed or authorised the first COVID-19 vaccine for emergency use.^1,2 Nearly one year later, about 54% of the world’s population has been fully vaccinated against COVID-19- only 6% in low income countries in contrast to 68% in high income countries and 48% in Asia. While some Asian countries, such as Singapore, Japan, South Korea and Malaysia now report vaccination coverage of over 70% and above- higher than the coverage achieved by USA and EU³ (October 2021), supply to low and middle income countries was not prioritised early by developed countries who have the bulk of the resources and means of access. In June 2021, just over 3% of Asia was fully vaccinated.⁴  Vaccination rates in the Pacific reflect similar regional disparities with countries such as Palau and the Cook Islands fully vaccinating over 95 % of the eligible population since October 2021, compared to Papua New Guinea where less than 1% of the population is vaccinated.^4,5

Supply and demand are at the crux of the disproportionate vaccination coverage, and inequities between and within nations. At an international level, global initiatives such as the Coalition for Epidemic Preparedness Innovations (CEPI), the Access to COVID-19 Tools Accelerator (ACT-A), and the COVID-19 Vaccines Global Access (COVAX) Facility still confront the long-standing power, and profit-maximising motivations held by industry, and other key stakeholders through the trade deals of several countries, that impede timely and equitable access. Procurement and national supply negotiations, manufacture licensing and capabilities, patents, and the lack of intellectual property rights waivers, have limited the global south’s capacity to meet the supply needs.^6,7

Further to this within countries, multi-level and ‘end-to-end’ dynamics contribute to low and delayed vaccinations. These include delivery challenges and limitations from cold-chain requirements, transport infrastructure, shortage of syringes and resources, administrative and data requirements such as poor internet connectivity. From the demand side, fear of side-effects, people’s safety concerns and the early lack of data in specific populations such as pregnant women, lack of access to reliable vaccine information especially in accessible and inclusive formats, travel costs and productivity losses from vaccinations, negative cultural beliefs and sociocultural resistance also influence vaccine hesitancy and uptake.^8,9

Gender barriers in delivery and demand amplify vaccine inequity. Gender inequities and inequalities, amongst other forms of intersectional vulnerabilities across the life course and life domains such as education, employment, ethnicity, disability, age, sexual identity and orientation, geographical location and access to technology, influence health and health access. These same dynamics also influence vaccine demand and delivery. The common general and gender-related COVID-19 vaccination barriers that have been reported by civil society organisations in the Asia Pacific include literacy, access to technology, registration, current and valid documentation.¹⁰ Behavioural insights studies in the Asia Pacific region highlights issues of violence, the fear of vaccine side-effects, absence of risk communications which incorporate cultural and social concerns and rely solely on a biomedical approach, the perceived or believed effect on fertility coupled with fear of stigma if this fear is articulated, and wait time in vaccine deliver centres/ sites etc.

Other known gender-related barriers in vaccine delivery and demand include:¹¹

• Women’s care roles and responsibilities including from requiring alternate care for children, time poverty from household demands,
• Constrained decision-making power on health seeking and use of resources in households
• Lower education and literacy
• Access to credible and trusted information, digital technologies, and internet which provide misinformation, and rumors of vaccine use
• Limited mobility from access to safe transport, need for chaperone, etc
• Anticipated or perceived discrimination in health care settings
• Cultural preference for same-sex vaccinators
• Security concerns, and experience of harassment and violence by female health workers, including community health care workers

Within communities and households, women’s access to vaccines is sometimes deprioritised. In India for example, vaccine roll-out started in January 2021, and in the early months, programmatic data and reports on the ground suggested that men were prioritised at family and community levels, with women in urban areas and between 18-44 years least likely to be vaccinated.^12,13 With targeted attention especially from the government, COVID-19 vaccination coverage of women has now changed- more than 48% of doses administered have been for women- close to the population gender-ratio in India.¹⁴ As of November 2021, about 26% of the Indian population (approximately 1.4 billion) has been fully vaccinated.⁴

Some of the measures undertaken in India include:

• Active engagement of the self-help groups (SHGs) and women panchayat (village council) leaders to potentiate demand.
• Efforts to improve access such as dedicated booths for women (pink booths), flexible session timings (9am-9pm) and cluster approach (in Uttar Pradesh) aimed at saturating blocks by taking the campaign close to homes have been put in place.
• Walk-in vaccination, and multi-person registration from a single mobile phone number
• Review of gender disaggregated data at state and district review meetings and advocacy efforts through compilation and sharing of best practices have also been undertaken by the states.
• Door-to-door vaccination- through the recent launch of the “Har Ghar Dastak” (a knock on every door) campaign with focus on states with less than 50% vaccination¹⁵

Decisions at every level and stage of local delivery trajectories that neglect to prioritise gender-sensitive COVID-19 recovery policies add to the gender-related barriers, inequities and inequalities of vaccines demand and delivery. As a result of the pandemic, new and existing structural vulnerabilities are emerging and exacerbated. Drivers of cumulative challenges and vulnerabilities include prolonged school closures, increased risk of gender-based violence, loss of income, reduced food consumption, rising debts, dwindling savings, and insufficient fiscal and resource support protective policy actions to buffer the crisis. While there is acknowledgement of the influence of gender, this knowledge is inconsistently translated into policy and programming interventions. For instance, only 5 of 58 countries with COVID-19 vaccine policies referred to gender in the early policy or strategy documents (March 2021).¹⁶  In Asia about 36% of COVID-19 policy measures are categorised  as gender-sensitive, or responsive towards gender-related dynamics (i.e. unpaid care, women’s economic security, violence against women).¹⁷ Only about 15% of COVID-19 taskforces are comprised of women in Asia.¹⁶

When countries neglect or inconsistently consider the influence of sex and gender, there will be fragmented delivery, demand, and access, that result in coverage gaps and delayed population protection. This leads to increased burden of preventable morbidity and premature mortality from COVID-19 and other conditions, delayed economic recovery, widened gender inequalities, and violations of rights in society.¹⁸ As it stands, countries that have contained the pandemic and actively rolled-out vaccines are economically benefiting from the recovery; conversely countries with low vaccination rates are compromising economic growth and productivity- further widening the income disparities between countries.

The goal is to vaccinate as many women, men, and gender-diverse people as equitably, efficiently, and effectively as possible to maximise the protective effect of COVID-19 vaccines.⁷ However, data gaps and lack of understanding of the complexities of how gender influences vaccines delivery, access and uptake still prevail in many parts of the world and the Asia Pacific, particularly within marginalised populations.

There are various guidance resources available to inform and support the broader integration of gender-responsive action in vaccine delivery, COVID-19 response, and health access in general. These include:

• UN interagency guidance note and checklist for tackling gender-related barriers to equitable COVID-19 vaccine deployment’ (co-developed by the SDG3 GAP Gender Equality Working Group and the Gender and Health Hub at UNU-IIGH)¹⁸
• WHO’s background paper- critical sex & gender considerations for equitable research, development & delivery of COVID-19 vaccines¹⁹
• Gender and COVID-19 Working Group’s Gender Matrix²⁰
• GAVI’s Guidance to address gender-related barriers to maintain, restore and strengthen immunisation in the context of COVID-19¹¹
• WHO’s Gender and COVID-19 Advocacy Brief²¹
• WHO’s Gender and health planning and programming checklist²²
• Gender Equality and Social Inclusion (GESI) Toolkit for Health Partnerships²³

Broad principles that can support the better integration of gender-responsive programme design and implementation include:¹⁸

• a nuanced understanding, and customised response to countering the gendered power inequalities, stigma, and discrimination, in the populations and communities,
• collaboration and engagement with broad stakeholders
• accountability and real-time monitoring in implementation
• iterative design, and responsiveness to new evidence, evolving lessons, in real-time.

Local context matters, and the blueprints of high income country roll-outs based on the architecture of their policy and structural ecosystems should not be replicated without local adaptations, and considerations of local contexts, resources, systems, demographics, and social-cultural dynamics and spaces. For example, multiple countries have used digital platforms to facilitate vaccination registration, not accounting for how the gender and age divide in digital literacy and access to smartphone technologies can influence ability to access vaccinations. The implementation of concurrent strategies such as walk-in appointments, multi-person registration from mobile devices, and paper-based records/ vaccination cards can support the needs of the population.

A bottom-up cohesive approach and continuous collaboration between experts or researchers, including most critically diverse community members themselves, and health system actors are crucial to identify gaps, priorities and needs. For example, the WHO Western Pacific Regional Office prioritises partnerships with communities/volunteer’s, actors/stakeholder within and outside the health system, and governments. Prioritising the focus on equity, the Gates Foundation has identified gender as a critical determinant for programming. This means applying a gender lens across the global work of the Foundation – into how problems are defined, solutions designed, and results measured. The effort is to remove gender-related barriers to how people access resources and services and, where possible, transform the gender power relations that give people unequal control over resources.

Importantly, addressing the gender dynamics in the delivery of vaccines is also required-about 70% of health and community workers are women. Health-workers should be provided a safe working environment with sufficient and continuous protection against violence and harassment., adequate rest-time, personal-protecting equipment that fit, and hygienic facilities. ^18,21

Beyond the immediate and direct focus on the vaccine demand and delivery, urgent and accelerated efforts are required to address the gender-disproportionate structural inequities and inequalities across the life course and all life domains. The social justice and human rights approach (or framework) is imperative in public and global health and needs to be reenergised. This is not the first or the last pandemic and it is critical that the global health community drive stronger achievement of solidarity and accountability at global, regional, and national levels.

Comprehensive and long-term research, data collection and strengthening of data systems support the overall pursuits and strategies referred to in this blog. These include:

• Gender and intersectionality analysis of end-to-end vaccine delivery and demand within local ecosystems, including on broader socio-economic impacts, intersecting vulnerabilities that have been introduced or amplified during the pandemic.
  GAVI’s Gavi Guidance to Address Gender-Related Barriers to Maintain, Restore and Strengthen Immunisation in the Context of COVID-19 outlines some examples.¹¹ Resources such as the Gender and COVID-19 Working Group’s gender matrix also provides framing to inform context-based analysis.²⁰
• Comprehensive sex-, age- and disability disaggregated data (SADDD) on testing, cases, mortality, and vaccines provides real-time visibility of the evolving situation at a population level. When reporting and understating SADDD data, it is important to compare the expected distribution (i.e., of the denominator) against the observed distribution (i.e., of the numerator) -—e.g., since if women predominate among both health workers and older people, and both these groups have been prioritised for Covid-19 vaccination in most countries, we would expect to see a higher proportion of women than men among those fully vaccinated overall, but this isn’t the case across countries in Asia-Pacific. WHO guidance on gender and Covid-19^19,21 recommends that data on Covid-19 cases and deaths (and now vaccinated people) should be sex- and age-disaggregated at a minimum, but countries’ implementation of this recommendation is very uneven. Other key stratifiers included in the case reporting form recommended by WHO to countries are individual co-morbidities and health worker status.\
• Surveys on dimensions and reasons of vaccine hesitancy: Vaccine hesitancy is a gendered phenomenon. For instance, there is lower COVID-19 vaccine acceptance and misperceptions about risks among women in low-and-middle-income countries.⁹  For instance in India, safety concerns, fear of side effects were more pronounced among females (>40%) as compared to males (>30%) while “others needing the vaccine more than me” being more predominant among males than females.²⁴
• Global south led and conducted clinical trials of diagnostics, therapeutics, and vaccines should also set the precedent and benchmark for sex and gender inclusive and responsive research, including the consideration of sex factors including in immune response, and risks of side-effects in product R&D, enrolment, and trial completion by a proportionate number of women and men, and sex-disaggregation and reporting of outcomes such as immune response, efficacy, and side-effects. While there is balanced, or sometimes women-disproportionate representation indicated in trial reports, there is little reporting of sex-disaggregated outcomes in COVID-19 vaccine trials.²⁵ Where available, sex-disaggregated side-effects tend to be women-disproportionate. ²⁵ Regional efforts for COVID-19 research, and vaccine R&D can help fill these gaps, and also benefit from the prioritisation of sex and gender responsive research. For instance, WHO SEARO’s research prioritisation exercise in 2020 has included considerations related to sex and gender and a focus on excluded groups. On similar lines, the Gates Foundation through the Design Analyze and Communicate (DAC) program advocates integrating sex-gender for informative clinical trials.²⁶
• Use of diverse research methodologies and timeframes of analysis including qualitative, longitudinal, and ethnographic data to unpack complexities of the diverse communities and their experiences of the pandemic. This is critical in the design of appropriate interventions and programmes.
• Research capacity and collaboration with community groups: Women’s and civil society groups are collecting data but more discussions, research and consensus is required on how this can be formally recognised this, and meaningfully used in policy and programming design.
• Representation and inclusion in taskforces and governance: It is important to review the composition of vaccine taskforces, and whether it comprises of a cross-disciplinary team of professionals, from researchers (social scientists), civil society, lawyers, medical professionals and government officials and service delivery partners.

Priority questions from the Gender and COVID-19 Research Agenda Setting process:

• Are there gender differences in the acceptance and uptake of COVID-19 vaccines?
• In what ways are sex and gender related variables integrated into national and global vaccines safety surveillance systems?
• Does safety, efficacy, optimal dosing regimens and protective duration of the different COVID-19 vaccines differ by sex, age & race?
• What are the effective strategies for addressing contextual gender related barriers in vaccine access and delivery to different populations of men, women, and gender-diverse people?
• Have vaccine deployment strategy plans included ways to consults and engage with gender experts, women’s, and high-risk marginalised groups?

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