Health Inequalities Among Women in Developing Countries

Disparities or variations in the achievement of a person or a group in terms of health can be defined as health inequalities. Access to quality health services is restricted by gender inequality resulting in preventable morbidity and mortality in women. This paper will highlight the health inequalities among women in developing countries by analyzing the results of selected abstracts through scoping review. It will develop an understanding of how health services are prioritized and utilized by females in developing countries. In the developing world, men seek medical advice more often than women who prefer either self-management or delay seeking formal treatment only when their symptoms get worse. The efforts taken to reduce these inequalities and in addressing health-related issues are not sufficient and require more efforts by the implementers and policymakers. Investment in education and improving women in making their own decisions about health can support a reduction in inequality in health by changing the cultural and social environment of a country.


INTRODUCTION
Disparities or variations in the achievement of a person or a group in terms of health can be defined as health inequalities [1]. WHO constitution advocates "the right to the highest attainable standard of health" but its achievement entails favorable social conditions, which are lacking [2]. Norms, responsibilities and roles assigned to an individual based on gender affect the acquisition of mental, physical and social health and wellbeing [3]. Access to quality health services is restricted by gender inequality resulting in preventable morbidity and mortality in women [2].
During the last decade, the Millennium Development Goals (MDGs) have resulted in global improvement in gender equality and empowerment of women, still, females continue to endure iniquity and violent behavior all across the world particularly in developing countries [4]. WHO regards gender equality as an individual's fundamental right and the Sustainable Development Goal (SDGs) [5] strives to provide females with equal opportunities for education, health, job, and politics, which are the basis for a thriving and peaceful world [6,7]. WHO states that females have particular health requirements and improvement in their health conditions has become an urgent need, which the world's existing health systems are unable to deal with [8]. This paper will highlight the health inequalities among women in developing countries by analyzing the results of selected abstracts through scoping review. It will attempt to examine factors related to health inequalities and review the status of health among women in developing countries. Finally, it will develop an understanding of how health services are prioritized and utilized by females in developing countries.

SEARCH STRATEGY
A research question was outlined after a literature search. The search strategy focused on the connection between the notions of inequalities, women's health and developing countries. Researchers used possible options by using a number of keywords in the search query-discrimination, equality/inequality, disparity, low and middle-income countries, developing countries, health, wellbeing, and women/females. Using these search terms, researchers searched relevant electronic databases (PubMed; Google Scholar) for quantitative, qualitative, and mixed methods studies. There was inconsistency in research articles. Authors have chosen quantitative, qualitative as well as mixed-methods to give a more detailed insight on gender inequalities and what future researches can be done in these fields to improve women's health. The title framed to acquire adequate literature was "Health inequalities among women in developing countries". The search strategy was restricted to articles published from Jan 1999 to April 2019. During the initial search, 250 articles were identified. After a review of pertinent study titles and abstracts, initially after removing duplication a total of 51 articles were selected for review. During the quality assessment, 21 articles were excluded from the review. A final number of 30 articles were selected for the scoping review.

CRITERIA FOR SELECTING THE ABSTRACT
Following selection criteria was used for the scoping review ( Table 1).

QUALITY APPRAISAL
The method of articles was reviewed before including in the discussion. Articles with methodological issues while addressing gender inequality were excluded from the review. There were articles that were found relatable to the context and objective of the study, after reading the all articles some irrelevant results were found. These articles were also excluded from the study.

RESULTS
30 articles in accordance with the inclusion criteria were reviewed and analyzed. The results are taken from selected articles were compared for the inconsistency and consistency of the methodology used in studies. It is evident from the review that global gender inequality is declining but it still exists in the developing world. Gender inequalities are assessed by employment status, healthy life years, income, and education and health services utilization [9,10]. A cross-sectional study to assess gender in countries using data of United Nations Development Program (UNDP) and WHO shows an association between gender inequality index (GII) [11] and various health conditions, showing that gender inequalities are related to health factors. The mean GII was found notably greater in African than European countries [12]. Social inequalities provide evidence of widening disparities in health among low, middle and high-income countries. A review article based on studies done in Korea, Togo, Sierra Leone, Nigeria, Jordan, Algeria, Syria, and Egypt explored that modern health services provision is more accessible to boys than girls [13]. A study in Chile showed that women had to pay more for reproductive health services in public and private sectors due to high co-payments expenses, which affects the health of the entire society [14]. A study supports that males and females react differently to illness [15]. In the developing world, men seek medical advice more often than women who prefer either selfmanagement or delay seeking formal treatment only when their symptoms get worse [16,17].
Maternal Health is a major concern for public health. 350,000 women die each year due to pregnancy and childbirth [18]. A systemic review shows variations in utilization of maternal health care across populations among the developing countries due to policies, funding, the organizational structure of health care, beliefs and preferences relating to access to formal and informal maternal health [19]. In South Asian countries, women have to abide by cultural norms like not going out without male members, making it difficult to receive appropriate health services [20]. They are also restricted from making their own healthcare decisions. Data from three South Asian countries showed that in Nepal 72.7%, Bangladesh 54.3% and India 48.5% of households do not allow women participation in their healthcare decisions [21]. An exploratory study in Maharashtra India explores the financial dependency of women which limits their mobility to access health and other resources [22]. The gender gap causing society influences, cultural norms and legal policies cause women's dependence for their health rights [23]. In certain regions of Africa, women fail to receive malaria treatment and antenatal care. Consequently, these pregnant women are at two to three times higher risk of contracting a severe malaria infection [24]. Within developing countries, Afghanistan has made considerable improvements in maternal and child health since 2001. Still significant social, economic and geographic health service inequities exist among women in the country [25].
Likewise, Pakistan is also challenged with gender disparities influencing health, education and employment opportunities [26]. Women are culturally at a disadvantage right from birth, discriminated and neglected during their entire life course. Females are forced into early marriages without essential education, making them financially and socially dependent thus limiting their role and productivity. The nexus of early marriage and pregnancy makes them vulnerable to poor health outcomes such as anemia, premature and low-birth-weight infants [27,28]. Gender-specific health priorities are more common in Pakistan. Children are given more priority for health than females and in children, privileges are more to a son than to a daughter [27,29]. Pakistan is known as one of the countries where gender bias against females is conjectured to exist in every walk of life [30]. Efforts are being made to promote "women's and girls' empowerment (GEWE)" which leads to better health and development outcomes. Women's health has been recognized after the "Women's Health Movement" in 1970. In terms of health care utilization, women in developing countries like Ghana and India utilize fewer healthcare facilities as compared to men due to their child-raising duties, domestic obligations and cost [31].

DISCUSSION
Women in South Asian countries are found to be more dependent on men. They are socially, economically Health inequalities among women in developing countries -and culturally inferior to men in their societies [32]. A woman's poor health affects not only herself but also the well-being of her family. The gender bias in terms of healthcare, immunization, treatment and nutrition is responsible for the exceeding mortality rates of women [29,33]. In developing countries, women in rural areas are deprived of knowledge, quality health services and decision-making rights [34]. Therefore, innovations in the health system are required to tackle structural inequalities and improve the quality, coverage and completeness of health services for women [35].
A shift in the population dynamics towards a more aging population has further increased the complexities of the global disease burden. Other factors include gender and societal norms and women's roles [36,37]. In Pakistan, the government's "Lady Health Worker Program" is a positive step for empowering women to provide health care facilities at the doorstep, increasing accessibility to health care facilities for children, both male or female [38]. "Gender equality is more than a goal in itself [39]. It is a precondition for meeting the challenge of reducing poverty, promoting sustainable development and building good governance." UN Secretary Kofi Anan.
The literature findings highlight that gender inequalities in developing countries are the key contributor to health disparities. Empowering girls and women may lead to health and development outcomes [40]. Recent literature suggests that health behavior, gender, ethnicity and socioeconomic status are the key determinants of health inequalities.
The majority of the literature suggested interventions focusing on education, awareness, economic development, media awareness and urbanization to improve all aspects of women's status. However, there are comparatively fewer publications on policy grounds and experience-based intervention to tackle these inequalities. It is essential to analyze data to assess gender biases, which increases health risks and limits opportunities for women. There is a dire need to develop gender-responsive health programs, which are appropriate to be implemented in developing countries. It is suggested that broadening of qualitative and quantitative methodologies are required to include policies and real-life examples to implement those policies should be published regarding health inequalities in women. It is believed that it may be significant to question whether any innovative policy/system is witnessed and its implementation that researchers can use to draw upon the incorporation of health in all policies. Gender discrimination is a top priority issue that should be taken into consideration before it is too late to improve the social and economic status of women.

CONCLUSION
There are many adverse concerns regarding health inequalities among women and these are deep in the roots and culture of a country. The efforts are taken to reduce these inequalities and in addressing healthrelated issues are not sufficient and require more efforts by the implementers and policymakers. Gender equality in health needs to be addressed especially when developing strategies and programs for health. The foremost important step for improving health can be educating the communities. Investment in education and improving women in making their own decisions about health can support a reduction in inequality in health by changing the cultural and social environment of a country.

FUNDING
This review has no external funding.