Confronting discrimination for health equity

IPU One Air, the Interpolumentary Union's podcast. My name is Lorraine Kefergli. I'm a senator from Ireland in the chair of the IPU Advisory Group on Health. Today we continue our discussions on pressing issues impacting people and societies worldwide. Throughout our lives we experience both inclusion and exclusion. Exclusion is not always visible. It can be stottling deeply embedded in social and cultural norms, institutions and even laws. Discrimination, exclusion and inequality are closely connected and their impact on people's lives are significant. Today we want to explore how these factors influence health behaviors and access to health care. We are privileged to have with us today for this discussion Honourable Catherine Gattani-Hara, the speaker of the National Assembly of Malawi and Dr. Claire Somerville lecturer on International Affairs at the Graduate Institute of International and Development Studies and Executive Director of the Graduate Institute's Gender Centre. It's truly an honour to host you both on this podcast today and to learn from your experiences and it's a deep experience that you have on these issues, both of you and your both very, very welcome to the podcast. Gender inequality is a discrimination, remains systemic and persistent across the globe. Claire, I know you feel very strongly about this and see an urgency in addressing gender discrimination in health. Can you talk to us about this? Absolutely and thank you for inviting me to this podcast. Yes, I am very passionate about this, particularly the need to include an intersectional gender perspective in really every aspect of health research and science in health service delivery and access at the front line. And the reason is the evidence is really conclusive. When we include an intersectional gender lens in the development of all of our health services and policies, we can really deliver improved health outcomes for everyone. And I think I really want to emphasise here this is everybody gains. Gender isn't just about women and girls and gender minorities, gender is also about men and boys. When we design our research and our health systems with this in mind, we get better outcomes. So that's my first point really that gender is everywhere. It impacts every dimension of our health. And if we want to advance health outcomes and address the inequalities in health outcomes, we really have to address the awareness and approach that really enables evidence-based analyses that can sometimes be described as the intersecting axes of discrimination and inequality. So I really believe that a gender analysis provides us with some of the tools, one of the tools of many to improve global health. I think it's also really important to think about the gendered inequalities in health and how they can unfile in many different directions. Now we have known for a long time that across the world women typically live longer than men. And men's life expectancy in most places is lower than women. Women, however, the evidence suggests, live in greater greater number of years in poorer health. But it's not really just about the differences between men and women. We really want to move beyond that. We need to think about the experience of health. We need to think about the experiences of accessing services and the differential impact they have on different groups and society in different communities. So really that everyday experience of being ill, seeking access and receiving care, when we understand the intersections of discriminations that can occur through that patient journey, we can improve upon the service delivery. So as you know, I'm a primarily a researcher and a medical anthropologist. And I guess for over 25 years now, I've worked on interdisciplinary health research. And I think from all of my work, from my early work on heart disease and angina in the UK, through to studying aging in Ireland and more recently HIV in Malawi, in all of these cases and all of this research, I have found that using a gendered analysis, having a gendered dimension has enhanced the quality of the research and therefore the evidence and the policy making we can make around it, with of course the objective to really improve the health of everybody. And that's why I'm passionate. Thank you very much, Claire. You're already raising many fascinating and important points for our discussion. And I'd like to at this point highlight gender based violence as a significant public health issue with consequences that extend beyond immediate physical harm to long-term mental and reproductive health and social well-being. And gender based violence obviously leads to injuries including fractures, burns, head injuries and internal trauma, disabilities and sometimes even death. And it can also result in chronic health conditions for survivors such as chronic pain, disorder, gastroenteritis issues and cardiovascular diseases due to prolonged stress and trauma. And gender based violence obviously also increases the risk of sexually transmitted infections including HIV as well as unintended pregnancies and survivors of sexual violence may also face reproductive coercion, forced pregnancies or unsafe abortions. So it's really, really wide-ranging and evidence even shows us that pregnant women who experience gender based violence are more likely to suffer from complications such as miscarriage, stillbirth, premature birth and low birth weight in infants. So it's really significant. And we must also, of course, consider the mental health consequences of gender based violence such as post-traumatic stress disorder, depression, anxiety, substance abuse due to many survivors of gender based violence turning to alcohol or drugs as a coping mechanism. And then this increases their risk of addiction and related to health problems. So it's really, really wide-ranging. And gender based violence often leads to barriers to health care for survivors, fear of stigma, retaliation or financial dependence on an abuser often prevents survivors from seeking the medical care that they need. And many parts of the world, the lack of trained healthcare providers are culturally appropriate services, impacts further on the access to healthcare. So we also know that girls who experience gender based violence including child marriage often drop out to school limiting their opportunities for economic independence and better health outcomes for their whole life. So many women who leave their abusers then face housing insecurity, increasing their risk of further violence, poor mental health and adequate healthcare access again for the rest of their lives. So all of this just touches the surface of the issue of gender based violence as a public health issue. And we could actually spend the whole podcast just discussing this. It's a major threshold to women and girls' health limiting their ability to live safe, healthy and fulfilling lives globally. An ending gender based violence not only as a matter of human rights, but it's also essential for improving global public health and sustainable development. And it's something I'm really, really passionate about. And as I said, we could spend the whole podcast, our whole podcast series discussing the seriousness of it as a health issue, but it's a really significant issue that we need to bear in mind when we're discussing discrimination and access to health care. Catherine, what would you say are some of the key challenges in accessing health care in Malawi for women and girls? Thank you very much indeed. As you know, Malawi is one of the countries where most of the population lives on less than a dollar a day that just shows you the extent of poverty levels in the country. Now, access to health is one of the biggest challenges because the distance is that people have to travel, especially women, between health facilities is very high. Some have to go as far as 20 kilometers on foot. Some even more than 20 kilometers on foot just to access a health facility. And that health facility in the first place might not even have all the required equipment or the required personnel to actually give them the best diagnostic or given the best medical care because they just don't have those necessary tools at those health facilities. So the challenges are the distances that women have to travel and access in terms of the facilities themselves having the necessary equipment, necessary personnel, necessary numbers of nurses and doctors available to attend to them. At the same time, in places where you have a little bit better health facilities, you need to pay most of the women are not economical empowered and therefore can't afford to pay for any services, for example, if some of those to get an MRI scan, you are talking of maybe very few facilities in the whole country can give you an MRI scan or even sometimes indeed simple scanning machine for a pregnant woman. It's not every health facility that has a scanning machine at a health facility. That means the women and the population in Malawi will get yes services but not the best services that is available and that makes the women especially to be much more vulnerable because you know women get pregnant, they need specialized service, they have babies, they need specialized service and you have women who have been abused, that need a lot of specialized service but they end up not getting that because we just don't have those facilities available. The number of doctors that we have visors, the population, they are very few doctors and it means they have to cater for a lot of people, obviously they end up not giving the best service because the population is high, the number of doctors is low, the number of naysals is also very low, the availability of drugs and medicines is also very very critical issue, most of our facilities just have the basics, they don't have a lot of the antibiotics and because people do a lot of self-medication because they can't afford to go to health facilities, these are also led to a lot of resistance in terms of antibiotics, there's a lot of resistance because people are just doing self-medication because that looks like it's a cheaper way of treating yourself because you can't afford to go to health facility, it is very far away from your home, the best you can do is to do self-medication or that has had a lot of impact on the health quality service that the people are getting in the country and a lot of women especially are not educated and some of them might not appreciate the reasons why they have to go to hospital early enough and culturally they've been told that if you go to the hospital sometimes they end up for example for those that are pregnant, they'll do a cesarean section and for them a cesarean section is not an option, it's because the hospital just feels they want to do a cesarean section, some of those women will die when they shouldn't have died because they are giving birth at home, they feel it is safe at home than going to the hospital and because the hospitals are overwhelmed, they care, the attendance and the care that the nurses are giving to these women is not great and sometimes they get depressed to say I'm better off at home because they go to the hospital, there's only one nurse who has 17, 20 women already to give birth and some of them are still giving birth on their own in a health facility, next time they say Amarazal gives birth at home because it is the same, so there are quite a number of challenges because the health facilities that we have are not properly staffed, they don't have the drugs, they don't have the equipment that we need and access to those health facilities is also not easy because of the distances, we don't have enough ambulances available for the people to use, you can't go on ambulance, ambulatory services as and when you wish all those are challenges that women and population of Malawi is facing. Thank you Catherine, that's a really clear picture of the landscape in Malawi between poverty, education, cultural barriers and under-resourced health system, does misinformation and disinformation also play a role in relation to access to health care Catherine and Malawi? Yes it does, just as I said earlier for example if we look at a birth control, the people who believe that birth control, if you take them, they'll end up having cancer or you never have children for those that have not have not born any children, they thought don't take them, if you do you never have any babies, in the process you have young girls who don't want to take contraceptives and they end up getting pregnant when they are young, there's misinformation sometimes about going to health facilities because they feel that if they go to those health facilities the service that they'll get instead of them getting better, they end up dying, there are those that catch a belief in traditional medicine and vis-à-vis what they co-western medicine or the medicine that we take, the normal medicine that we get in the hospitals and you have people who will not go to the normal hospitals, it is their belief that they are better of being treated at a traditional healer and that in the process, not that the traditional healers don't have some of the drugs but they might not diagnose you properly and they end up treating you for things that maybe are not suffering from in the process you have issues to do with treating the problems, we've had a number of people who have been given traditional medicine but because they're not having proper measurements in the quantities of what they're supposed to give you, we've had people die, they've lost their kidneys because of concussions that they'll get from this traditional healer so there's quite a lot of misinformation in terms of what they should expect when they go to health facilities and what they get but also the belief that some drugs will for example make them infertile just like the issue of COVID-19 immunization, a lot of people were against it they felt that that's what was killing people early and it gave people a lot of problems, it meant those that were young would never have children in future so there are other things that misinformation and can affect people in terms of them making decisions on whether they should get a medical help or not. Thanks to that Catherine and we said a lot on gender discrimination and we could continue talking about it really because there's not a lot more to talk about but other factors are driving health inequality and discrimination and care, I know that you've been working particularly on this for a long time, can you talk to us about this? Absolutely and in fact Catherine just very nicely gave us some examples of the ways in which there are multiple factors of discrimination and inequality that impact final health outcome. So it's the mid-2000s really, we've had a growing body of evidence that tells us about what was termed as the social determinants of health. So these are all the terms about where we're born, where we grow up, where we age and live and work. That impact our final or ongoing in fact health outcomes and just as Catherine was saying very nicely there that whole patient journey is one that is can be facilitated and have many barriers as a patient goes through it and I think picking up there on Catherine was saying you know the first place we go and we have symptoms is usually our family friends and community and the health literacy of the people around us immediately the educational level will impact some of our decisions about whether to access care. So our first sort of social determinants I would say and intersects with this is education as we develop symptoms and we might decide to access care I think some of the the really important points that Catherine has raised already is about access to care. If you're in a rural area or an urban area or access to care in a distance you have to travel the resources you need to be able to travel the time it requires time is very important. In gender analysis and health we often look at time use because in order for women to access care they often have to find somebody to look after their children or take on other tasks. Equally when men need to access care who are in wage labour they may have to take time off work and then engage in other work and lose hours in that if that's their bread when they're rolling some societies. So again we have obstacles and barriers to care. Increasingly we see people start to use the internet Google chat to GPT to self-diagnose after Google absolutely before seeking care. Now on the one hand this can be great but there are generational differences in that my elderly father wouldn't have a clue how to use the internet whereas my teenage daughter is the first place she goes. So we have digital inequalities that are not only about different places and connectivity but about the generations as well. So ageing and discrimination I think are really important factors, digitalisation and inequalities associated with that. Of course there are other areas and once you arrive at the clinic the sort of treatment you get and the interventions may have been the product of some quite gendered evidence-based making. For many years I did research on anjaina in East London. The diagnostic of anjaina is a set of cardiac symptoms that you're in the criteria or out of the criteria. Now it's built on a huge wealth of evidence from the 1950s and 1970s on two cohorts, one in the US, US veterans and one in London. In fact the Whitehall study, Whitehall people who is described as the place where civil servant traditionally used to work and it's called the White Hall study. There are three characteristics therefore about the evidence base upon which a cardiac diagnosis of chest pain can be made. They were mainly male, they were mainly white and the cohort is from high income countries. So the generalizability of that data and that diagnostic testing is limited and what I found in some of my research in East London is that there were many missed diagnoses because of ways in which different groups describe their symptoms differs and therefore they were not fitting the classic diagnostic canon of anjaina. So I think the data on which we are working in health practice, we think is gender neutral perhaps as one of the phrases but actually there's a lot of baked in bias and discrimination within the data upon which medical decisions are made. This is a historical thing. This is less so the case now, although women are often excluded from randomized controlled trials, particularly ones which are drug interventions because of their reproductive cycles and a genuine fear of a risk to pregnancies. So it's not all, by no means all intentional analysis is with good intentions to do no harm that sometimes our evidence has inbuilt biases. And then finally I think it's not really just thinking about the patient journey about this, it's about the systems that we have and the need for us to maintain an awareness of the many, many factors that can influence how we design a health system, how we make it accessible and the knowledge in which we impart in that system. And that's even before we're even thinking about the financing. So of course one of the biggest discriminations in access to care is, well, first of all, poverty but also the type of insurance system or type of out of pocket expenditure that is required for you to access care. So that's just a little snippet of it of a patient journey but I think what I wanted to highlight is that there are many touch points for discriminations can play a part in that journey to, for an individual patient to access care, from transport to access to services, to cost of services, to the evidence base on which the treatment they receive will have been based and all the other factors to do with access seen in terms of your own time use in your family and household life. So there's a little snippet of sort of a very complex area of trying to unpack and I think that's why, this is why I advocate for analyses like these to be built into our research and to be built into our policies because it's only by raising the questions and thinking through that patient journey, can we then address them because all of these things we can address and I think that's the important point to take away. These are not insurmountable barriers. There are ways in which these discriminations can be dealt with and can be faced and can be changed through policy action. And based on what you've said there are clear, how do you feel about legislation? Legislation is really important. It is definitely this structural girder that could underpin actions to eliminate those discriminations but it's not everything. I would also say that legislation thinking about global health and globally women's rights, women's rights of women and girls we can also think about some of those big conventions like CEDAW as important places for setting some good pointers as to how a legislation at the national level can be developed and then implemented. Legislation can also be quite problematic and I think we're facing some particular challenges right now in the world on key gendered health issues. So from access to abortion, full bodily autonomy and comprehensive sexuality education, these have become contested points in legislation and in some countries there have been some changes in legislation that will put women and girls at risk and will result in the deaths of women and girls. So legislation certainly has a role. We, the role can can unfel in more ways than one and we need to maintain a really robust eye on the way that legislation is implemented and the consequences for women and girls and their health. Catherine, can you tell us your experience on working on these areas and these issues and how compartmentarians drive change? Yes, but medarians can help in moving change on these issues because our role as part of the medarians is oversight, legislation and representation and if we can use these three properly, that will change quite a lot of things. For example, on representation, if we can ensure as members of parliament that issues to do with health inequalities, especially for women should be discussed or debated on the floor as many times as possible, that brings a lot of awareness to it. But I also am sure that we allocate enough resources to the health budget and specifically looking at reproductive health budgets which affect women and general health care budget. I'm glad to say that in our parliament, we've been fighting to make sure we fulfill their budget declaration which say that at least we should ensure that our percentage health allocation should be at least 12%. It has been 8.8. I'm glad that the budget that we are discussing now, we are going to have a 12% from 8.8, 12% of the national budget is going to be allocated to health. That's what as members of parliament should be doing, allocating as much resource as we can to the health sector, but allocating resources to the health sector on its own without checking on whether those resources are being used for the intended purpose is another thing because allocating resources is one thing, ensuring that those resources as being spent on what to have agreed for me is what is very critical. So as a speaker, I've always ensured that my committee's do follow-ups with the executive arm of government. Of course, we're not doing it to the best that we should, but that's something that I think is worth investing in, ensuring that the little resources that are located efficiently and effectively used on the right budget lines on the things that we have agreed because sometimes what ends up happening is your locating resources, but government decides to divert some of those resources and do other activities, for example, buying more vehicles for headquarters, for us, that's not priority. Getting the drugs to the most remote areas of the country is more of a priority. Getting ambulances to the most rural part of the country is more of a priority. So as parliament, that's I think something that we need to invest more on, ensuring that the little resources that are available are being used efficiently and effectively. And as parliament also needs to ensure that some of the policies, but not everything can be laid down in legislation, but policies as well. What is government policy on construction of new health facilitators? What is the minimum requirement? You're first saying this is a health center. What should it have? Does it have, does it meet those minimum requirements? That as members of parliament, we should be doing as well, getting governments to be very accountable on what they have made commitments and what we have agreed. So as members of parliament, we have to be advocating for policy and direction to change where we think it's not benefiting the women, especially. But also, mindset change. I know we're talking of legislation, legislation, legislation, legislation, but I think as members of parliament, it is also our duty to start advocating for mindset change. It's not just about bringing laws. It's about us as citizens changing the way we do business, changing the way we are tackling problems. So the citizens have to change the way they're looking after them. So for example, in Malawi, most people go to hospital only when they're sick. When I know in other parts of the world, it's a routine you do preventive health. That is sometimes much more beneficial than only going to hospital when you're almost on your deathbed. So we need to start having mindset change. In the villages, if I just wake up and say I'm going to the hospital because I just wanted doctors to check on me, everyone who think why waste your time. So we need mindset change and as legislators, because we represent the people, for example, the 193 members of parliament that I have, are representing 20 million Malawians. We should also be advocating for mindset change. Apart from the legislation oversight and representation, thank you. Catherine, that's really powerful. You touched on so many topics from the resource allocation, the accountability of parliament, the representation, and the change of mindset. And it's only when we do all of these things together, can we make real progress. And if I could just touch on Ireland, my own country, we've made significant strides in improving access to healthcare for women and marginalised populations in recent years. And these improvements have come through legal reforms, policy changes, and increased investment in healthcare services, particularly for women. The legalisation of abortion was a major step forward for women's reproductive rights. And since January 2019, abortion services have been available up to 12 weeks of pregnancy. And in limited cases thereafter, and abortion services are free for everybody who needs to access them. And this has been a really transformative change for women in Ireland. We also have free contraception, and it's available currently for women age 17 to 35, and we're planning to expand it further. We also have state funded IVF schemes. And just to touch on the point that you made Catherine about preventative measures, we have free cervical cancer screening. And this has been expanded in recent years. And we also have free breast cancer screening. And we are on target to eliminate cervical cancer by 2040, which is a really, really significant milestone for our country. And that's because of the mindset change that you spoke about Catherine. It's getting the message across to women that you might not like going for a smear test. It's uncomfortable. You have to take time off work. You need to get your children looked after. But it is so important because something simple like that can save your life and just to get into the habit. And you might feel well, but you might have the early signs of cervical cancer. So it's to go get it checked. And targeted health campaigns addressing higher maternal mortality rates among migrant women and higher rates of certain diseases, among various ethnic minorities are also being developed in our health service. And we have also built cultural awareness within the health professional community to break down barriers for minority and marginalized groups within our Irish society. We have improved access to healthcare for people on low incomes with expansions of medical cards, GP visit cards for all children, regardless of the family income up to the age of eight. And then people on limited income, them beyond that. And this has been really significant. Again, this is primary healthcare. And it's encouraging people to go not less a crisis, develop and end up in hospital, but to go visit a doctor in the community. And it's making sure that people don't have that financial barrier. So these are just some of the examples in Ireland. We've done a lot. There's certainly a lot more to do, but it is improving the healthcare. And it's improving the life expectancy for people in Ireland. We've one of the highest life to expectancies now in the world, but it's the health span that you spoke about. Claire, while you're living longer, that you're healthier so longer. And that's really, really important. Claire, we have seen what parliaments can do in terms of legislation and budget allocation, but society change requires concerted efforts for many stakeholders. Who are allies and how can academia support policy change? Thank you. That's a really great question. I'll set a question. I think like parliaments, many people who work in academia share the sense of duty and responsibility. And I think that's something we have to take seriously. And that's what I mean is that we conduct research and we need to make sure that we communicate that to parliamentarians. We need to gather the evidence and communicate that in ways that can be that lend themselves to policy recommendations. And I think sometimes we fall short on this as academics, but it's certainly an area that we need to improve. And picking up on that prevention, I mean, our evidence base on prevention is absolutely crystal clear. We know that prevention is the way forward. So I think in terms of us thinking about the ways what we communicate this evidence better, to those that are in the positions of power to make those decisions and to develop those policies. In terms of allies, I think we as a thinking from a sort of gender and a feminist perspective, allies are in our communities in our grassroots. And I think that's where the lobbying and the activism can happen from. We need to make those demands as citizens, as Catherine just said, as citizens, we have the possibility, the privilege of being able to act and make those demands upon our parliamentarians to bring health up the agenda in ways that you've just very nicely described. And I also think we shouldn't forget here the role of men and boys and there are a lot of excellent, very active groups of networks of men and men who are working in health. And I think of Pramondo as one of them, men engage as another around the globe, engaging men and boys in to preventative health activities and engaging them as allies in getting health for all and better health outcomes is really important. And in fact, I've done quite a lot of work interestingly in Malaria as well on engaging men and boys in Malaria to men's only day clinics on the Saturday. So hosting clinics for men where they can go for three or four hours on the Saturday morning to have preventative health checks at a time when it's more likely that they can attend. And this has been really successful in terms of increasing health literacy, sending messages home and reinforcing some of the household things that we can do in terms of care in the household and a caring social justice approach. So indeed, you know, there are very specific things that we can do. But importantly, I think from my standpoint in working in research and academia is to make sure I translate those findings just to something that you as parliamentarians can act with. As a parliamentarian, I feel it's really important that researchers advocacy groups come to us and citizens and constituents come to us and engage with us and talk about what's important because I feel sometimes as a parliamentarian, we're dragged in a number of different directions. But if we have somebody that's coming to us on specific issues and saying this is a big concern, here is the research. It's packaged in a very accessible form because we're not experts in every area. So if we can understand as well and get the information, then we can take action as parliamentarians. So I would encourage any civil society groups or advocacy groups and researchers to engage with parliamentarians and it's something that we appreciate as well. Catherine, how do you approach your role as speaker of parliament in promoting dialogue and building political will? Of course, through the women caucus, we've tried to, because this is a, it's non-partisan, or women from all different political parties do belong and we have tried in our meetings to always advocate for us advancing issues to do with women, especially their reproductive health issues. And we have had civil society and Jews come to us. We go together to the community advocating for reproductive health issues, encouraging women to go for perhaps mere to go for cervical cancer, I mean, test breast cancer tests. We've done that obviously just to show that as women doesn't matter from which political party we come from, we all have the same issues that need our attention as women. But also when we go back now to our own political party scenarios and caucuses, we have advocated. For example, this time round, we were advocating for the increase in the budget to the Minister of Health. We needed to start from our own political parties to make sure that as the political party, we appreciate why we should have an increase in that health budget. And once that's done, you get the male support and everybody to support in the house. Obviously every woman goes back to their own political party and advocate for the same. And when we come back together as a house, it's much easier to pass those budget lines for increases, especially in the health sector, in the Minister of Gender because that will assist the women. It is not as easy because the numbers of women in the house, obviously, it's not as high. We're only at 23%. So obviously for us to lobby and convince our male counterparts, it's not sometimes as easy. But I'm glad to say that by and by, we're getting a lot of men appreciating why they have to support us because gender is not just about us because there are times that men feel when we're talking about gender equality, we're just talking about women and the gay or child. And this obviously puts a lot of men off. But we're saying, no, gender is not just about us. It's about the boy child as well. It's about gender-based violence, not just the women, because we do have men who have been abused. And what we've done that is that as a caucus, when we find men who have been abused, we are going out to them to lend us some services that we do if we get women who have been abused by a man. And that is slowly making the men feel that it's not just about us women, it's about gender-based violence. And in the process, we're getting the men themselves now to actually start giving us the support. Now politically, we've made statements, public, as women. And myself, as I speak of the National Assembly, have made statements to support women, to support boy child of going to schools that are boy, boys only schools just to encourage them on the importance of them being educated. And also supporting their spouses, if at all they ever get married. Because if you don't empower the young boy on how he should handle an empowered young, I mean an empowered woman, it would be very difficult. As much as the woman is now empowered, you have a man who doesn't know how to handle this empowered woman. Then you have a problem, you have a woman who says, I can't have children now because I want to go do my masters. The husband is like, no, I've married you, I want to have babies now. So you need to make sure that the man is also equally empowered in terms of how he should handle an empowered woman. And if we do that, then we'll get the best results. But if you're only talking to the girl child, talking to the woman only, and the man can't appreciate that, then we have a problem. Even in the rural areas, we're going out to the traditional leaders just to advocate on why they should protect the women, protecting the women means protecting themselves. For example, if the family is always sick, if children are always sick, that house is not productive. Even demand himself will not feel the beauty of being a married man because all the children are malnourished. The woman spends most of the time in hospital because the children are not well. So if you go out and advocate this event to the men themselves, and sometimes it's even better to do it in a certain way, the men only. So they can actually ask you the tough questions when you go there. They appreciate why you're saying advocating for women's rights, advocating for gender rights, advocating for girl child, for boy child is beneficial. You'll find that their response is quite good and I'm actually quite impressed that sometimes I think we've list them out and that's why we get these problems. Catherine, as you're speaking there, I'm really struck with the similarities between Malawi and Ireland, even though we're very different countries, but the role of the women's caucus within the parliament is very, very similar and the need to engage our male colleagues in discussions and the recent example with Ireland, we've done a lot of work in relation to period poverty and menopause care and we have been emphasising how this actually benefits families. It's not benefiting women or girls, it's benefiting the whole family unit because if the the mother is really struggling with menopause, the wife is really struggling, it's going to impact on every member of that family. So getting good and timely and adequate care benefits every member of that family. So that's really similar to what you've spoken about. I was struck by a lot of my male colleagues as well who said to me that they never felt that they could ever even speak about these issues or advocate because it wasn't for them and they felt they would be stepping on women's toes by speaking about it instead. Now they feel empowered to do it and because we have a very low number of women in parliament as well, we need our male allies with the empowerment to advocate for change. So that is really powerful and very similar to your experience in Malawi. We've heard many different examples and strategies and that's giving us a lot of food for taught but I want to challenge you vote a bit further. If there was one thing you could do to address discrimination and health, what would that be? What's is the most impactful action in your view and I'll put that to clear first. Thank you. A great question and a difficult one to pick just one actually. But I would say what comes to the top of my head is, and one that concerns me deeply, is the inequalities of pay within the health systems across the world. It's everywhere. The gender pay gap is really stubborn. 70% of the world's front-lying providers of care are women. Half of them are unpaid. They are voluntary healthcare workers, voluntary workers. And this is something I find untenable in the 21st century. This is a discrimination in paying conditions that is global and that needs urgent attention. And I think it is something we can do something about, which is really important. It's a very actionable aspiration. Absolutely. Catherine, could I put that question to you? Thank you. As she said, a very difficult one. In this part of the world, I know it sounds different when you're in different parts of the world. But here, I feel education, education, especially for the girl child, is a big key to most of these challenges that we're facing. I'm saying this because we've seen it among those women that are much more empowered and much more educated, how they have responded to issues to do with their health, how they have responded to gender-based violence, how they've responded to access to health. Once they're educated, you find that the difference is there. Yes, they'll still face the gender inequality. They'll still face gender-based violence. But I think their response is different. For example, the women, if he's been beaten every day by a husband, because she can fend for herself, she's got her on home, she can walk out on a man, go and leave her on. Then a woman who is right in the village, her life is 100% dependent on the man, very difficult for her to walk away, even if she's festing a lot of challenges, but she feels where do I go? Will her community welcome her? No, because you are married, you're supposed to go back home, I mean to be in your husband's house, and we are told that a woman does not give up, you're not supposed to cry if you're beaten by a man, you're supposed to stand straight with your face up wherever you are. And that continues, it means you're accepting that you should be beaten every day. But for an empowered woman, they just have to leave her home, find somewhere else, starting your life. So for me, education, education, education is a big key, especially girl child education. Well, both of you raised some really good points, their pain, qualities in education, and I think there are two keys to accessing a greater equality for people accessing healthcare and thanks for that. And unfortunately we're coming to the end of our conversation, I think both all of us could sit here and continue talking about these topics, but we have to finish our conversation shortly. But I would like to ask you both, what your main takeaway from our discussion is, how can we inspire our listeners to champion gender equality and access to health for all? And Catherine, I will put that to you first. To all of you who are listening to us from me is to ask you to advocate for mindset change. If we all change our mindset in terms of how we value each other, be it a man or a woman, that's the beginning of a change. So we all need to advocate for mindset change, where we appreciate why we have women and why we have men in this world. And to appreciate if you have a healthy woman, you have a health family, you have a health and nation, you have a health society. So I'm pleading with you, let us all advocate for gender equality and especially equality in health. A healthy woman is a health and family and a health and nation. Thank you for that. And Clara, I'll put the same question to you. How can we inspire our listeners to champion gender equality and access to health for all? Thank you. Gender is about all of us. And I think that's really important. Awareness and action on gender can reap huge benefits in health for all of us. Health, I think, is also political. It's a political choice. Citizens, I think we have a responsibility to really engage in that political process through our voting, through our advocacy, through our research and even become parliamentarians ourselves, perhaps. But therefore, I really think that in any way we can to make sure that health is a political choice and that health justice sits at the top of the political agenda, wherever you are in your household, in your community, in your local, local area, in your region, globally. I would like to thank our amazing guests, Catherine and Clara, for taking time out of your very busy schedules to be involved in this very important discussion. We've had a great discussion today. We said at this beginning that we need to have this discussion and I hope we have contributed positively to promotion, constructive dialogue and that we will learn from each other. And thank you to our listeners for joining us today. Goodbye and take care.