The Lancet Commission on peaceful societies through health equity and gender equality

Abstract

The multiple and overlapping crises faced by countries, regions, and the world appear unprecedented in their magnitude and complexity. Protracted conflicts continue and new ones emerge, fuelled by geopolitics and social, political, and economic pressures. The legacy of the COVID-19 pandemic, economic uncertainty, climatic events ranging from droughts to fires to cyclones, and rising food insecurity add to these pressures. These crises have exposed the inadequacy of national and global leadership and governance structures. The world is experiencing a polycrisis—ie, an interaction of multiple crises that dramatically intensifies suffering, harm, and turmoil, and overwhelms societies' ability to develop effective policy responses.

Bold approaches are needed to enable communities and countries to transition out of harmful cycles of inequity and violence into beneficial cycles of equity and peace. The Lancet Commission on peaceful societies through health equity and gender equality provides such an approach. The Commission, which had its inaugural meeting in May, 2019, examines the interlinkages between Sustainable Development Goal 3 (SDG3) on health; SDG5 on gender equality; and SDG16 on peace, justice, and strong institutions. Our research suggests that improvements to health equity and gender equality are transformative, placing societies on pathways towards peace and wellbeing.

Four key messages emerge from our research. First, health equity and gender equality have a unique and powerful ability to contribute to more peaceful societies. This Commission recognises the complex web of factors that contribute to conflict. Moreover, health equity and gender equality are themselves shaped by social and economic processes that are complex, contextually specific, and unfold over long timescales. Even accounting for this complexity, our Commission provides evidence that improvements in health equity and gender equality can place societies on pathways to peace.

Health equity and gender equality are powerful agents of transformation because they require definitive actions, namely tangible and sustained policies that improve health and gender equality outcomes. We refer to these definitive actions as the mechanisms of health equity and gender equality. Health equity requires countries to embrace the right to health, acknowledge disparities, and recognise that universal access to health-care services is crucial for human potential and dignity. Gender equality requires laws to protect the rights of women and sexual and gender minorities. All individuals need equal access to education, resources, technology, infrastructure, and safety and security to enable participation in the economy, civil society, and politics. Processes to advance health equity and gender equality are more powerful when they operate together, through access to comprehensive sexual and reproductive health services. Advocacy is also an essential component as it builds a social consensus that the principles of health equity and gender equality apply to all individuals, regardless of their gender or other forms of identity.

These tangible actions or mechanisms transform capabilities, a term that we define here as what people are able to do and to be. With improved health equity and gender equality, individuals can access economic resources and assets, live in safety and security, and exercise greater agency. Through these changes, human capital improves and economic growth becomes more inclusive. Social capital is strengthened and social norms are altered to inhibit violence and aggression. Although political processes are characterised by short-term dynamics, the institutionalisation of gender equality and health equity improves the quality of governance and can strengthen the social contract between the government and the citizenry.

These processes interact with each other in self-reinforcing feedback loops creating beneficial cycles that influence the dynamics of economic, social, and political systems. For countries locked in harmful cycles of inequity, conflict, and instability, our research suggests that improvements in gender equality and health equity help nudge them onto pathways towards peace.

Second, to deliver the promise of the Commission's research, health equity and gender equality principles and processes must be led by communities and tailored to their context. Local and national actors must drive improvements in health equity and gender equality, a process we refer to as change from the inside out. Although communities benefit from evidence from other contexts, we highlight the danger of importing policy models from other contexts. Health and gender systems are social systems, deeply intertwined in culture, contexts, and politics. Tangible and sustained improvements require gender equality and health equity mechanisms to be led by national actors, rooted in the local context, shaped by data, sustained through national systems, and accountable to communities. Efforts to improve gender equality are always contentious, but are transformative, enabling the recognition of the equal rights of women, girls, and sexual and gender minorities within the private and public spheres. Our Commission supports the call from decolonisation advocates for structural reform of global development processes to enable locally driven, context-specific change. However, we also stress that these local and national efforts should leverage and build upon the global scaffolding or architecture of norms, initiatives, funding, and institutions designed to advance health equity and gender equality.

Third, within the health sector and beyond, the Commission calls on policy makers to embrace, advocate for, and advance health equity and gender equality. In the health sector, services and systems must adopt, implement, and be accountable to benchmarks for gender equal health responses. The health sector is a key social, economic, and political institution. Individuals engage with health services throughout their lifespan. Health professionals are respected leaders within their communities. Given their reproductive and caregiving roles, women are a majority of users as well as providers of health care. Yet health services and systems can reflect and reinforce implicit biases that undermine access to and delivery of services and the effectiveness of health policy decisions. The gender-blind response to the COVID-19 pandemic and the tolerance of sexual exploitation within humanitarian contexts are examples of the failure to integrate gender equality principles within health sector strategies and responses. Our Commission provides definitive benchmarks for gender equal health services and humanitarian action. If policy makers advance these benchmarks, health outcomes as well as the level of gender equality would improve.

Finally, given the evidence we present in this Commission, health equity and gender equality must form an integral part of national and global processes to promote peace and wellbeing. The beneficial cycles of health equity and gender equality unfold over long time scales. Conflict management and humanitarian efforts understandably prioritise short-term interventions to reduce human suffering and stop violence. However, given the path dependencies established by such engagement, gender equality and health equity must be built into these short-term interventions. When integrating health equity and gender equality into humanitarian and conflict management interventions, we need to better analyse conflict dynamics and understand what conditions foster backlash, including when and how best to confront, counter, navigate, and minimise backlash. Gender equality and health equity processes must also recognise how gender norms impact men and boys, and not assume women and girls have the power to single-handedly transform their environments. Policy processes from the UN Sustainable Development Goals to the Group of Seven and Group of 20 Agendas present an important opportunity to advance this agenda. Although global initiatives can provide financial and technical support, gender or health outcomes cannot be instrumentalised or pursued for the interests of external actors rather than for the benefit of communities.

The Lancet Commission provides an agenda for a path forward, rooted in a vision of our shared human dignity and collective responsibility to build a more equitable world. This agenda takes communities, governments, and international agencies on a challenging and sometimes contentious journey forward. We can accept the challenge and leverage this moment of opportunity to advance this agenda, or our politics and policies can entrench inequities and create the conditions for a more conflictual world. The choice is ours.