Recommendation 1: Account for how gender-related division of labor, everyday practices, social norms, and beliefs within and beyond the household impact NTD risk

The division of labor within and beyond the household and everyday practices intersects with other determinants such as age and socioeconomic status to affect exposure to NTD risks. For example, in contexts such as the Republic of Congo (where fishing, farming, hunting are the main income activities), prevalence of lymphatic filariasis (LF) in men is higher, especially where men sleep outside during these activities [12]. However, where people have similar occupational activities, such as agricultural work (as found in rural India), LF infection patterns among men and women were almost equal [13]. Understanding who does what in paid and unpaid labor and in the everyday practices of people of different genders in relation to demographics and social determinants and their impact on NTD experience is important when designing effective health promotion campaigns, e.g., developing protective factors such as bed nets and vector control mechanisms and identifying hot spots for NTDs [13]. As shown in Fig 2, women, men, boys, and girls are exposed differently to urogenital schistosomiasis based on variation of reproductive and productive activities. Such activities are influenced by the broader social context and should be considered to enable context specific responses.

Recommendation 2: Account for how gender impacts the accessibility and acceptability of treatment

Recommendation 3: Address gender-related stigma and mental health impacts of NTDs

Understanding NTD-related stigma and how it is affected by gender norms will help to minimize the negative impact of stigma, reduce discrimination, support social acceptance, improve disease control and knowledge, and prevent disability [17]. Constructions of mental health often vary significantly across contexts and between genders [18]. For example, women suffering from onchocerciasis, leprosy, and LF describe feelings of embarrassment, shame, sadness, despair, and fear in studies from the Dominican Republic, West Africa, and India [15, 19, 20]. Gender analysis is critical when considering comorbidities between mental health and NTDs. Management of mental health and psychological stress caused by gender-related stigma as a consequence of NTDs should be integrated within health systems and services, including awareness of social stigma among health professionals [21].

Recommendation 4: Collect and use gender-sensitive and sex-disaggregated data and implementation research to continuously improve NTD programming and ensure equity

Collecting gender-sensitive and sex-disaggregated data is possible and useful. There is need to use this data to improve the gender equity and responsiveness of NTD programs, especially at district and community levels. Gaps in disaggregated data can be addressed by adding gender equity questions to coverage-evaluation surveys and data-quality assessments [22]. Funding research bodies could better promote research that links biomedical and social determinants of health with a focus on gender and equity analysis through the instigation of key indicators that are disaggregated by gender and other social stratifiers such as age and wealth [23]. Implementation research that is gender aware and built into programs will help ensure NTD programs meet the needs of people of all genders.

Recommendation 5: Promote intersectoral working and a person-centered approach to ensure community engagement is at the center of NTD programs

NTD programs could benefit from a health systems approach that identifies positive synergies between disease specific interventions, nontargeted health services, and other sectors [24]. An intersectoral approach is also required to address the social determinants of health—for example, in the case of schistosomiasis, repeated exposure to infected water.

Taking a person-centered approach means communities should be at the very center of NTD programs so that no sections of the population are left behind in striving towards control and elimination of NTDs. Health systems need to support community participation mechanisms that not only engage people of all genders (including women and girls) at risk or suffering from NTDs but ensure their views are listened to and applied within NTD program development and implementation. Civil society can help to ensure effectiveness and community accountability that challenges gender and other social determinants in NTD program design and implementation. NTD decision makers and program implementers should ensure that steps towards gender equity are an integral part of interventions on an ongoing and permanent basis.

Conclusion

Gender norms, beliefs, roles, access to resources, and decision-making constitute gender power relations [3, 4]. These relations intersect with other social determinants of health, such as age, socioeconomic status and structural and environmental dimensions of daily life that govern how power is embedded within social hierarchies [23]. As such, gender inequality and inequity in relation to NTDs is predominantly socially governed and therefore actionable, and the time is now. As laid out here, collecting data on gender, developing strategies to address gender inequities within all aspects of NTD programs, and building strategic cross-sectoral partnerships will support NTD goals, the SDGs, and UHC.

Acknowledgments

CMH, MOB, and OO are staff from the World Health Organization. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.