TB DIAH Gender Strategy

Strong gender-integrated health programs require sufficient high-quality data to assess program implementation and the gender and health outcomes of their activities, and to guide decision making at the local, subnational, and national levels. For tuberculosis (TB) programs, it's essential to understand how gender drives outcomes and influences transmission, testing, treatment, and adherence. Monitoring and evaluation (M&E) activities can help determine whether TB activities promote gender equity or exacerbate gender inequalities. Globally, TB affects men at much higher rates than women, with adult men accounting for 56% of all TB cases in 2020, compared to 33% for adult women and 11% for children. TB progresses more quickly in women of reproductive age than in men of the same age group. TB is the reported cause of 6-10% of all maternal mortality in settings with low HIV prevalence, and 15% in settings with high HIV prevalence. Gender-related risks and barriers to TB services take many forms and affect everyone. Notions of masculinity can negatively impact health-seeking behavior of men, leading to late or missing TB diagnoses and lower rates of TB treatment access and completion. On the other hand, women may have less access to TB treatment and prevention services than men due to cultural norms and inequalities. Women and girls may experience diagnostic delays and lower service efficiency due to increased stigma associated with having TB and the non-integration of TB services with other reproductive, maternal, and child health services. Women may have difficulty gaining access to TB services because male family members are unwilling to pay for these services, women's health may not be considered as important as that of male family members, or because TB in women is more stigmatized than in men. Studies from Vietnam show that women with pulmonary TB are diagnosed on average two weeks later than men due to healthcare provider delays. Negative social consequences have been shown to be more of importance to women, and stigma is still associated with TB disease. Because TB kills more women and men than any other infectious disease, including malaria and AIDS, it is essential to understand how the disease affects women, men, girls, and boys differently so programs and interventions can be tailored appropriately. The TB DIAH project is an Associate Award of the MEASURE Evaluation Phase IV Leader Award, which includes gender clauses developed in response to USAID's 2011 Gender Policy document. The MEASURE Evaluation Phase IV Cooperative Agreement states that gender equality and female empowerment are core development objectives, fundamental for the realization of human rights and key to effective and sustainable development outcomes. The project aims to reduce gender disparities in access to, control over, and benefit from resources, wealth, opportunities, and services, and to increase the capability of women and girls to realize their rights, determine their life outcomes, and influence decision-making. In 2020, USAID issued updated guidance in the Gender Equality and Women's Empowerment Policy, which makes specific comments related to TB and to requirements for USAID's operating units (OUs) to report on cross-cutting indicators related to gender. The policy states that there are important differences between men's and women's experiences with TB, and that TB programs should be designed to address these differences and promote gender equity.