The Collateral Health Impacts of COVID-19: a Disproportionate Impact on Girls and Women

COVID-19 is not just a pandemic: for the last 18 months, the world has faced a far-reaching crisis that extends well beyond the number of cases or deaths. COVID-19 has created a systemic shock to systems and changed behaviours, with shifts in morbidity and mortality in multiple areas of health. These impacts are known as collateral health impacts or indirect health impacts. In previous work, CGD has estimated the magnitude of collateral health impacts—see our summary findings from four country projects in Africa and Asia.

In the last year, CGD has collaborated with the Center on Gender Equity and Health’s Evidence-based Measures of Empowerment for Research on Gender Equality (EMERGE) project, based at the University of California San Diego, to identify and review literatures on the collateral health impacts of COVID-19 in low-and middle-income countries (LMICs), applying a gender lens. In this policy paper, we examined 247 studies published between January and March 2021 that contained empirical analyses and covered gender-focused aspects of mental health, COVID-19 knowledge, attitudes and practices, COVID-19 clinical outcomes, maternal and child health, and sexual and reproductive health.

We find that the pandemic exacerbates existing vulnerabilities and inequalities, and as a result causes disproportionate negative impacts on the well-being of women and girls relative to that of men and boys. Here are some of the main considerations:

1. Disaggregated analyses by gender (or population groups) are essential to capture the true impact of COVID-19 on societies

   While the literature on collateral health impacts has grown significantly, few studies (in proportion) report disaggregated impacts by gender or other population groups, especially in LMICs. This is problematic: single estimates produced at the population level can sometimes mask heterogenous impacts across those different population groups.

   For instance, studies looking at mental health showed that women generally experienced worse mental health during the pandemic than men in many LMICs. Factors contributing to this difference include increased financial and health risks, such as increased burden of unpaid care, job and income loss, and marital problems. There were also several studies showing worsening of mental health (depression, anxiety) among pregnant women. For instance, a study in Brazil by Nomura and colleagues showed that pregnant women in Brazil feared contracting the disease (and resulting impact on their babies) and delivering on their own (without their partner). Disruptions in access to care for maternal and child health services and sexual and reproductive health were also reported in many studies.

   Disaggregated analyses are not always possible, especially when relying on data sources such a health information system, which  often don’t capture demographic information about patients. More than 80 percent of the studies reviewed relied on online or in-person surveys, where personal information is more commonly collected.

2. Few studies document collateral impacts in low-income countries, where the disruptions in provisions of care and vulnerabilities are likely to be the most significant

   In our review, only 6.8 percent (or 17 papers out of 247) of all papers covered low-income countries—and only five of them: Chad, Ethiopia, Mozambique, Syria and Burkina Faso. By contrast, respectively 43 and 28 papers covered China and Turkey.

   But the pandemic resulted in severe disruptions in many low-income countries. For example, in Uganda, restrictions in internal and international travels, closing of businesses and schools and social distancing were imposed to curb the spread of COVID-19. Those disruptions are likely to have rippling effects across society, and to complicate the delivery of services in already fragile health systems.

3. Many important health areas are missing from this literature

   Our goal was to include in the review all studies addressing gendered aspects of health. Close to 60 percent of studies covered mental health, and an additional 25 percent covered knowledge, attitude and practices relating to COVID-19. This is surprising, as there is a general paucity of mental health research in LMICs discussed in other reviews. Many gaps remained on several health areas that may disproportionately impact girls and women. For instance, we found no study on collateral health impacts on other infectious diseases other than HIV and non-communicable diseases that presented disaggregated analyses by gender.

Preparing the post-pandemic recovery: developing targeted mitigating strategies to support girls and women

The research we identified focussed primarily on describing and quantifying the burden of gendered health impacts.

Our work largely confirms the trends identified in other reviews (see previous CGD working paper, EMERGE reviews for July-September 2020 and October-December 2020 literatures, and CGD review on social and economic outcomes): we find that COVID-19 has exacerbated existing vulnerabilities for girls and women in many ways, although it is worth noting that the results are mixed in some health areas (e.g., pregnancy outcomes, COVID-19 mortality).

Going forward, this literature should seek to learn from effective mitigation strategies that are targeted to girls and women. Many countries quickly put in place policies to mitigate those collateral health impacts, for instance, using social media and telehealth innovations (in China, targeting maternal mental health through telehealth messaging) or changes in care provision modalities (in Kenya, using multi-month dispensing for antiretroviral drugs). We need to learn what has and has not worked from those experiences to protect girls and women in LMICs. This should be part of long-term strategies to strengthen commitments to Universal Health Coverage and build resilient health systems.