Blueprint to close the women’s health gap: How to improve lives and economies for all

The core elements of the women’s health gap indicate a need for better data, more effective interventions, improved care delivery, including all women, and increased investment.

Taking the following steps in 2025 and beyond may help close the women’s health gap:

1. Count women. Improving the accuracy of data collection and standards could aid understanding of the true burden of disease, particularly for women-specific conditions and those that affect women differently or disproportionately. Further, accurately counting maternal health conditions is essential for understanding the implications for the long-term health of all women and children.
2. Study women. Research that includes and emphasizes women and their unique needs could help dispel misperceptions and unknowns about conditions that affect women specifically, differently, or disproportionately. Research could shed light on conditions specific to women and illuminate disparities. Sex-disaggregated analysis of existing and future research could help reveal how women are affected by many conditions disproportionately or differently than men. Sex-disaggregated results enable understanding of treatment effectiveness and possible sex-related differences. Additionally, studying the second X chromosome, hormonal health, and hormonal cycles and the role they play in women’s health outcomes is needed. Research funding and focus on women-specific conditions that affect adolescent girls is a large gap and opportunity.
3. Care for women. Delivering gender-appropriate and evidence-based healthcare, through healthcare delivery systems designed for women and equipped to address health-related social needs (including resources such as food, safe housing, child care, or transportation), could improve health outcomes for women. The current healthcare delivery system often perpetuates preventable disability and mortality for women worldwide. Need exists for rapid translation of known evidence-based medicine into clinical education and clinical practice guidelines (CPGs) that reflect sex-based differences.
4. Include all women in research and efforts to improve care. No number of attempts to count, study, analyze, or deliver better care to women will work without concentrated efforts to address racial, ethnic, geographic, socioeconomic, and other disparities within countries and on a global scale. Stakeholders can consider how to acknowledge and address these differences and promote solutions that achieve health equity.
5. Invest in women. Additional funding—whether for clinical and translational research, public health education led by women in their communities, or the development of innovative interventions—is needed to accelerate progress. Public and private investments in care delivery, education, and social support services can prevent and treat disease and improve healthy longevity.

1. Count women

Improving data collection and standards could increase the understanding of women-specific needs.

Women’s health data are often not collected, not published in the public domain, or incomplete, as highlighted in a Forum and MHI analysis of clinical trial results, CPGs, and global data sets. When data do exist, such as data intended to track condition prevalence, reporting across different data sets is variable. For example, the World Health Organization (WHO) estimates that around 10 percent of women of reproductive age are living with endometriosis, while the Global Burden of Disease estimates this figure to be 1 to 2 percent. That variation means between 24 million and 190 million women could have endometriosis—or even more when accounting for underdiagnosis. Data discrepancies lead to difficulty with estimating and describing the health of women across the selected conditions. These discrepancies are particularly evident in LICs and LMICs, in which lack of modern data infrastructures can lead to missed opportunities for data capture.

Patient registries are critical elements of data collection, resource allocation, and service planning. They collect data on symptoms, medication use, service usage, procedures, and patient-reported outcomes. Health researchers and policymakers can use this information to observe the course of the condition, understand variations in treatment outcomes, and assess effectiveness across and within populations. The Forum and MHI analysis found that many countries lack condition-specific patient registries for the selected conditions. Even when widely used and accepted registries exist, gaps persist: for example, international data collection standards are absent for many conditions. Population-level tracking of breast cancer stage and breast cancer recurrence is particularly poorly and inconsistently documented within the registries.

The ultimate outcome measure, death, is neither consistently nor accurately counted. No comprehensive source to track global mortality rates exists. Countries often self-report into mortality databases, and data are often missing, particularly data from LICs and LMICs. Stakeholders could explore how to standardize, collect, report, and update mortality data between and within countries to develop a comprehensive picture of disease burden, aid the allocation of resources, and support healthcare systems to improve health outcomes.

Life span data is poor; health span data availability and quality are worse

The Forum and MHI, in collaboration with the Global Alliance for Women’s Health working groups, developed proxy measures to understand the scale of the data gap. These measures assessed global medication tracking of evidence-based treatments for the selected conditions. Inaccuracies—specifically, not knowing how, why, or when women are either taking medications or missing opportunities to take medications—undermine a chance to inform investments in interventions or improve care delivery. Lack of data can often impede monitoring and surveillance of medications and the effects on women.

Notably, no single database comprehensively tracks the use and distribution of medications or medication quality. This has implications for the supply chain and patient access. And while knowing if recommended medications are tracked in global pharmaceutical data is important, the sparsity of relevant and accurate data needed for the analysis is reflective of broader challenges with data collection, standardization, and collaboration between stakeholders for conditions that contribute to the women’s health gap.

Even if therapeutic products exist, knowing if they are accessible or used is impossible today

The Forum and MHI developed metrics to reveal whether medications for the selected conditions are tracked globally. Analyses were conducted to understand if and how comprehensively the medicines for the selected conditions are tracked in global pharmaceutical data. If a medicine is on a Model List of Essential Medicines, the WHO considers treating the condition and accessing the associated therapeutics as essential for a country’s health system. CPGs are standardized recommendations clinicians follow to diagnose and treat conditions. This analysis demonstrated the presence—and absence of global pharmaceutical data across CPGs and essential medicines lists for the selected conditions and, subsequently, the lack of prioritization of treatments for women’s health conditions (Exhibit 3).

In carrying out this analysis, the Forum and MHI used comprehensive sources of global pharmaceutical volume data, knowing that no single-source database exists to provide details for all generic medicines, over-the-counter medicines, and branded therapeutics. After consulting with experts in working groups, the IQVIA database was used for this analysis to provide the most complete picture. While this database is one of the most comprehensive sources of global pharmaceutical data, some caveats for the analyses are important:

1. Medication volume data are not indicative of the quality of medications, availability of medications, or patients’ ability to access medications across countries.
2. Limited data coverage for generic medications likely compounds the data gap from regions in which most medications used are generic, particularly for LICs and LMICs.
3. Nonpharmaceutical interventions indicated in treatment guidelines are not tracked. Nonpharmaceutical interventions include surgical procedures, which are particularly important to note for conditions such as endometriosis (for which laparoscopy is used for diagnosis and treatment), breast cancer (for which mastectomies may be performed), or cervical cancer (for which loop electrosurgical excision procedure [LEEP] therapy is a common treatment). Diagnostic tools also are not covered.

Overall, Forum and MHI analysis found that medications recommended in CPGs are not comprehensively tracked in global pharmaceutical databases for 33 percent of the selected conditions: migraine, PMS, and ischemic heart disease.

The Model List of Essential Medicines, published by the WHO, includes medications for only six of the selected conditions (ischemic heart disease, breast cancer, cervical cancer, migraine, maternal hypertensive disorders, and postpartum hemorrhage). This implies that only 67 percent of the selected conditions are determined to have medicines that offer the greatest benefits to a population and should be available and affordable. Even for the selected conditions present in the Model List of Essential Medicines, Forum and MHI analysis found that only one-third of the medicines included in the Model List are comprehensively tracked in global pharmaceutical data.

Women-specific conditions that affect the health span—PMS, menopause, and endometriosis—lack essential-medicine lists. This may reflect lack of understanding of the burden of these conditions on women, families, communities, and economies. As a result, there is limited information for assessing how (and how well) women are managing pain. In other words, for some of the most prevalent conditions in the world, the WHO does not recommend that countries include the treatments for these conditions as essential medicines, and tracking for the treatments that are being used (for example, over-the-counter pain relievers) is limited.

The Forum and MHI analysis found that 83 percent of medications referenced in menopause CPGs are tracked in the global pharmaceutical data; these medications include estrogen, progesterone, and other hormonal treatments. While specific medications are tracked in global pharmaceutical data, limited data are collected on compounded hormone therapies and tailored dosing of hormone therapies. Therefore, treatments used may be underestimated, and the understanding of the effectiveness and side effects for women using compounded and tailored therapies is limited.

Additionally, the quality or availability of medications for women is not reflected in this analysis. Understanding whether providers and patients can obtain recommended medicines in different geographical areas, even for medications deemed essential, is challenging. Furthermore, data do not reflect whether therapeutics are reimbursed by payers, through either national mandates or individual payer formularies and coverage guidelines, which highlights additional questions regarding access.

In contrast, on the upside, Forum and MHI analysis found that all breast cancer pharmaceutical therapeutics recommended in global CPGs and the WHO’s Model List of Essential Medicines are tracked in global pharmaceutical data. Notably, the comprehensive set of interventions for breast cancer (for example, radiotherapy, chemotherapy, and surgical interventions) are not comprehensively measured across data sets. The breast cancer analysis demonstrates that collecting this type of data is possible and a potentially achievable goal for other conditions.

Publishing sex-disaggregated data could help the understanding of sex-related differences for conditions and their treatments

Women are not small men: sex-disaggregated data and analyses allow better understanding of why and how interventions work differently in men and women, as well as the different effects of interventions attributed to sex and sex-specific physiology. The Forum and MHI analysis found that only around 10 percent of clinical trials for ischemic heart disease and migraine published sex-disaggregated data. Limited understanding of how women and men may respond differently exacerbates the efficacy gap observed in most health interventions.

Proportionate participation by women in clinical trials, relative to their share of the burden, and transparent sharing of sex-disaggregated trial outcomes, side effects, and therapeutic dosage could allow scientists to evaluate the efficacy of a treatment. Additionally, none of the clinical trials for ischemic heart disease and migraine accounted for hormonal fluctuations or menopause in women participants (Exhibit 4). This impedes understanding of treatment effectiveness and differences in therapeutics throughout a woman’s life and hormonal stages.

A deeper look into heart disease and migraines

Ischemic heart disease is the world’s number-one cause of death for both men and women, responsible for the deaths of nine million people annually (roughly 4.97 million men a year and 4.17 million women in 2019).

Analyzing the results of clinical trials by sex could illuminate sex-specific differences, including different responses to treatment, different side effects, and potentially different cardiovascular biological factors. However, Forum and MHI analysis showed that only 17 percent of ischemic heart disease clinical trials completed in 2022 and open to both sexes published sex-disaggregated results.

Funding is needed, alongside regulatory reporting shifts, to publish sex-disaggregated data and analysis and encourage sex-specific research. Forum and MHI analysis found that National Institutes of Health (NIH) funding for ischemic heart disease increased overall between 2020 and 2022, though the share of NIH research funding for female-specific ischemic heart disease research decreased from 26 percent in 2020 to 21 percent in 2022.

Migraine, which affects almost 21 percent of reproductive-age women, impairs productivity and quality of life for women around the world and accounts for a large portion of the women’s health gap. However, Forum and MHI analysis found that only two trials out of the 52 completed in 2022 (4 percent) published sex-disaggregated data. The Women’s Health Innovation Opportunity Map, among others, has highlighted a need to research sex-related differences in the presentation and evolution of migraine, given the sparsity of sex-disaggregated research published.

Women who are pregnant and lactating are often excluded from clinical trials for migraine and other conditions. While testing new medications on pregnant women may not be advisable in many circumstances, a consequence of research safety measures is a lack of understanding of how pregnant women may respond to migraine treatments. For example, a knowledge gap exists on how to manage migraines that get worse with pregnancy. Additionally, those with migraine in pregnancy have a higher risk of preeclampsia and maternal stroke. When pregnant women with migraine who developed preeclampsia in pregnancy were followed over time, they were discovered to have a higher risk of stroke later in life as well. The lack of knowledge and limited clinical trials around sex-specific research drives the treatment efficacy gap in migraines, particularly for women, throughout their entire lifetimes, especially during stages of hormonal fluctuations, lactation, and pregnancy.

Additionally, given the low participation of men in migraine clinical trials and limited sex-disaggregated results, both men and women suffering from migraines could benefit from sex-disaggregated data that can reflect treatment efficacy, effectiveness, and side effects.

2. Study women

Conditions affecting women could benefit from more research funding and focus.

Research on the sex-distinctive elements of the selected conditions is needed. Lack of research limits knowledge about differences in outcomes in diverse groups (critically, in women and girls) and impairs understanding of the selected conditions and their pathophysiology.

Analysis of research funding can be used as a proxy for understanding research topics being funded and research priorities of funders. Global research funding is tracked in the NIH’s World RePORT database. This database covers both governmental and nongovernmental funding bodies and may not cover all funding from life sciences companies, private investors, and local funders. Other analyses may be considered for tracking research attention and support, such as cumulative peer-reviewed publications about conditions; within this scope, global research funding was prioritized.

The Forum and MHI compared the value of global investment in research with the size of the global disease burden (measured in DALYs) for each of the selected conditions. The result is a metric that estimates the dollars per DALY of research funding allocated to the selected conditions. This metric reveals the extent to which research funding reflects fair allocation of research resources if all DALYs were considered equally important. Additionally, disaggregating funding by type—such as basic science research, clinical trials, translational research, and implementation science—helps to identify areas of greater investment need. For example, research on how treatment effectiveness changes within the context of a country or community, particularly in LICs and LMICs, is relatively underfunded.

Among the selected conditions, funding does not match disease burden

What and who is studied and how investments are made illuminate research priorities and health equity concerns.

Women-specific conditions are relatively underfunded. PMS, menopause, maternal hemorrhage, maternal hypertensive disorders, cervical cancer, and endometriosis constitute 14 percent of the total women’s health gap, as measured in DALYs. Collectively, Forum and MHI analysis found that these conditions received less than 1 percent of cumulative research funding in 2019–23 granted to all 64 conditions that drive most of the women’s health gap. Comparatively, diabetes makes up 2 percent of the women’s health gap and received 12.5 percent of the research funding granted to all 64 conditions. The funding per DALY for diabetes is nearly double the funding per DALY of PMS, menopause, maternal hemorrhage, maternal hypertensive disorders, cervical cancer, and endometriosis combined. While investments in diseases and conditions may not always mirror the pain and suffering those diseases and conditions cause, questioning the large gaps between funding and health burden is worthwhile (Exhibit 5).

PMS is particularly underfunded. PMS accounts for 4 percent of the women’s health gap, equating to 2.1 million DALYs, yet research funding does not match the burden caused by PMS: almost zero dollars of research funding per DALY was allocated to PMS between 2019 and 2023, and only 16 clinical trials for PMS were registered between June 2023 and June 2024. No funding or initiatives related to PMS were reported from 2019 to 2023 in the World RePORT database, and only a handful were related to premenstrual dysphoric disorder from 2019 to 2023. Lack of research funding likely correlates with not having clear understanding of what a “normal” period is or how common irregular periods are for adolescents. One study measured the hormone levels of a large cohort of women throughout their menstrual cycles and found that not a single participant’s hormone levels matched “textbook” 28-day cycles. Another recent study examined variabilities in the menstrual cycle in demographic groups, age cohorts, and based on BMI; those who were Asian or Hispanic, older, or had obesity experienced more cycle variability.

Breast cancer receives the most funding of the selected conditions: cumulative global research funding for breast cancer is $393 per DALY. The impact of that funding on improvements in breast cancer mortality over the last 30 years reflects the power of focus and investment. Research, education, activism, and investment have led to huge gains overall. Breast cancer mortality rates in the United States, for example, decreased by 42 percent from 1989 to 2021.

Even for breast cancer, the need for research funding persists. The increasing breast cancer burden in LMICs and LICs requires a fresh look at where research is conducted, whether the research in different geographical areas is completely transferrable, and the areas of research that receive funding. Disaggregated data by funding type—such as research funding for basic science versus implementation science—are not available in the database and not covered in this analysis. These data are important, given that substantial work remains to understand effective ways to address socioeconomic and racial disparities, including in HICs. For example, Black women in the United States are 40 percent more likely to die from breast cancer than white women, despite the presence of life-saving and life-prolonging treatments in the country.

Research is needed across countries of all income levels to provide greater insight into the genetic, biological, social, and environmental factors of the selected conditions and to contribute to an understanding of different clinical outcomes. Enhanced research may translate into novel therapies, reduced disease burden, and greater economic benefit for families, communities, and countries.

More than three-quarters of clinical trials for the selected conditions are conducted in high-income countries

Clinical trials can assess effectiveness of new interventions, different ways to use existing interventions, or other variables that could have an impact on health. Reviewing what, how, and where trials are conducted illustrates one measure of industry and academic priorities. The analysis carried out by the Forum and MHI looks at active clinical trials with women enrollees registered with clinicaltrials.gov between June 1, 2023, and May 31, 2024.

Clinical trials for the selected conditions are not conducted in LICs and LMICs relative to the burden of those conditions in lower-income countries. Forum and MHI analysis found that women and girls in LICs and LMICs experience 54 percent of the women’s health gap, yet 23 percent of clinical trials for the selected conditions focus on these regions. Upper-middle-income countries (UMICs) and HICs have 77 percent of clinical trials and only half of the global burden. While evidence suggests that menopause symptoms may start earlier in women who live in LMICs, only 8 percent of the clinical trials identified for menopause are concentrated in LMICs. Similarly, 85 percent of cervical cancer cases arise in LICs or LMICs, yet only 9 percent of clinical trials for cervical cancer were conducted in these countries.

Treatment effectiveness in LICs and LMICs is difficult to understand when clinical trials are not conducted in those countries or communities. Notably, Forum and MHI analysis did not identify any clinical trials in LICs for 67 percent of the selected conditions: migraine, menopause, PMS, endometriosis, breast cancer, and ischemic heart disease. The answer is not more trials for trials’ sake but to evaluate whether clinical trials consider globally representative samples of the disease burden and whether or not their results can be extrapolated across populations and geographies (Exhibit 6).

Additionally, research and funding for a selected condition does not imply that unmet need no longer exists. Postpartum hemorrhage and maternal hypertensive disorders have the greatest proportion of trials in LMICs and LICs out of the selected conditions, yet significant morbidity and mortality from these conditions persist across these countries.

The first step in LMICs and LICs is more funding for wide-scale infrastructure, training, quality improvements, and implementation that can enable successful clinical trials to take place. Investment in local primary investigator-led trials can improve local participation and ensure the research questions and end points are aligned with local relevance and community needs.

In HICs, the outsize proportion of funding and clinical trials may mask disparities and inequities within those countries. Publication and funding bias may affect the rate of trials completed in LICs and LMICs, but even when clinical trials are conducted in HICs, patient access to these trials and representation across minority racial and ethnic groups remains imbalanced.

Breast cancer has more registered clinical trials than all other female-specific selected conditions combined—1,697 in total. In comparison, 44 trials for postpartum hemorrhage were registered. Prevalence for breast cancer is close to 500 per 100,000 population, and prevalence for postpartum hemorrhage is 320 per 100,000 population. This highlights a one-third higher prevalence of breast cancer than of postpartum hemorrhage and a near 40-fold difference in the number of trials for breast cancer compared with postpartum hemorrhage.

In UMICs and HICs, ensuring diverse access to clinical trials across race, ethnicity, and geography and decentralizing clinical trial enrollment may provide equitable access to innovative research while helping to make the results of clinical trials more broadly applicable.

Ensuring that innovative research and clinical trial enrollment reach all women in all countries depends upon access to appropriate, high-quality care and care delivery systems.

3. Care for women

More than a third of the women’s health gap stems from disparities in care delivery. Even when evidence to support best practices exists, translating findings from evidence-based research into clinical guidelines and subsequently adopting them into clinical practice is challenging.

CPGs are evidence-based, nationally recognized, and standardized recommendations for healthcare professionals—doctors, nurses, or other healthcare practitioners—on how to diagnose and treat specific medical conditions. Evaluation of CPGs can illuminate the clinical standard set by a country and reveal whether that standard reflects evidence-based practice. The examination of CPGs for the selected conditions in 15 countries across all income levels helps create a scalable blueprint for all countries and all conditions that contribute to the women’s health gap.

Evaluating a country’s CPGs for the selected conditions aids understanding of whether evidence-based, high-quality clinical guidelines are being recommended. Outdated, incomplete, or missing guidelines can act as proxies to assess whether a country’s care delivery system is prioritizing the condition and spectrum of care associated with it. Yet this metric is only the first step: while CPGs are meant to reduce variability in care delivery, the implementation of guidelines may differ due to a lack of resources or insufficient or different care delivery environments. In well-resourced countries, CPGs may not encourage the best interventions available but instead aim for universally applicable recommendations (the lowest common denominator). When better technology and interventions are available (for example, imaging technology), CPGs could encourage them, and women could benefit from them.

Among selected conditions, less than 9 percent of CPGs in the studied countries met recommended global standards

The Forum and MHI analysis found that none of the selected conditions had comprehensive or complete CPGs in all studied countries. None of the studied countries had comprehensive or complete CPGs for all conditions. Practice-standard CPGs for women-specific conditions that affect health span were particularly sparse: In 25 percent of cases, there is either no CPG identified or no mention of any female-specific criteria across risk factors, diagnostic cutoff, or treatment protocols and pathways.

CPGs for cervical cancer are present in all 15 of the studied countries, a feat not achieved for the other selected conditions. However, the country-level CPGs for cervical cancer were often incomplete. For example, specifics regarding vaccination targets, screening, and time to treatment varied and were not always aligned with clinical evidence. Vaccination for human papilloma virus (HPV) almost entirely prevents cervical cancer, yet less than 25 percent of LICs have introduced HPV vaccination into their vaccine schedules, and fewer than one in five girls around the world have been vaccinated for HPV. Less than 5 percent of women in LICs and LMICs are screened for cervical cancer, reaching as low as 1 percent of women screened in parts of Africa. Screening coverage in HICs is at least seven times higher than it is in LICs and LMICs.

CPGs for ischemic heart disease met the standard for evidence-based recommended practice in only one of the studied countries, even though ischemic heart disease is the leading cause of death for men and women worldwide. Few country-level CPGs for ischemic heart disease acknowledge sex-based differences: 64 percent of CPGs for ischemic heart disease mention women-specific risk factors and risk scores (such as age, menopause, and hormone replacement therapy); 64 percent of CPGs for ischemic heart disease mention that women may present differently than men with acute cardiac events (for example, with dizziness, nausea, and fatigue); and 29 percent of CPGs for ischemic heart disease acknowledge that women may respond differently than men to treatment or may require a different treatment pathway (for example, blood pressure optimization, given that standard dosing of some medications such as ACE inhibitors and beta blockers can lead to increased side effects in women, and personalized adjustment of medication for women may need to account for physiological differences). Only the Brazilian guidelines mentioned evidence-based diagnostic cutoffs for women. One country completely lacked CPGs for ischemic heart disease.

Providers caring for women with ischemic heart disease often lack the education, guidance, and support needed to deliver sex-specific clinical care, and as a result, women are less likely than men to receive evidence-based recommendations and treatment for ischemic heart disease. This is further exacerbated by disparities and inequities in care delivery, including quality and access.

CPGs for migraine lacked complete evidence-based and practice standards in all of the 15 studied countries. CPGs exist for ten of the 15 countries studied; of those, only seven country-level CPGs included migraine treatment guidelines adapted for menstruation, pregnancy, and lactation. Likely correlated, only about a quarter of adults in the United States with episodic migraine receive treatment. Even when medications are prescribed, clinical guidelines and healthcare payers often set a high bar for receiving them; patients often have to demonstrate failure to improve on multiple medications before access to third-line therapy is provided. For example, calcitonin gene-related peptide (CGRP)–targeted medications are now considered an early option for migraine treatment, but less effective and less well-tolerated generic treatment options are often prescribed first, sometimes due to prior authorization guidelines from payers. Many women’s healthcare providers reported in 2020 that they were not aware of nonmedication treatments with Level A evidence, including the effectiveness of biofeedback, cognitive behavioral therapy, and lifestyle changes as treatments for migraines used in conjunction with medications.

For the conditions affecting health span—migraine, PMS, endometriosis, and menopause—more than half of the studied countries were entirely missing CPGs describing either prevention, diagnosis, or treatment of the condition. Of the selected conditions, menopause was one of the lowest performing in the CPG analysis, despite affecting most women globally at some point in their lifetimes. For PMS, a condition that affects 20 to 40 percent of women of reproductive age, 60 percent of the studied countries lacked CPGs entirely; of the countries with CPGs, most had comprehensive guidelines.

Global benchmarks may mask disparities within HICs while often creating less feasible expectations in LICs

Breast cancer and cervical cancer have higher CPG scores in most countries, although the high scores and the presence of CPGs across geographical areas and income levels may not equate to equitable implementation of the guidelines. Mammography, for example, is a globally recognized guideline for breast cancer screening included in most CPGs, although in HICs, access to screening can differ across race, ethnicity, socioeconomic class, and geographical area. In LICs, access to mammography may be limited by the presence or lack of a mammography machine, reliability of electricity, and availability of a workforce of technicians and radiologists (and surgeons and pathologists for women with a positive screen). Some LICs and LMICs highlight the challenges and feasibility of mammography within their CPGs. According to India’s CPGs, for instance, “Population-wide mammographic screening … of asymptomatic women is neither feasible [nor] as useful.”

Additionally, CPGs may not reflect the evolution of clinical evidence that could help address these inequities. In LMICs and LICs, educating women and the broader society on the signs and symptoms of breast cancer and when and how to seek care or support someone to seek care may promote early detection and intervention. In HICs, in which mammography has become routine, more precise approaches to screening, diagnosis, and treatment may be beneficial, including earlier and easier access to stage-appropriate treatment and personalized, precision medicine. The sensitivity of mammography differs for women with dense breast tissue; both unnecessary biopsies and missed cancer can be risks when other technologies such as MRI are not made available or reimbursed. Implementation science and research and increasing awareness among communities can help reduce access and adherence challenges and demonstrate effective solutions. For example, using AI to identify and connect with patients with gaps in care, communicating through text and phone calls in a patient’s primary language, identifying and addressing health-related social needs, and enrolling women in rural areas or through primary care into decentralized clinical trials may help all women to find and adhere to the highest-quality care.

Adoption and implementation of CPGs can vary within and between countries

CPGs may not be realistic in a country’s current reality. For example, the HPV vaccine needs continuous refrigeration, which may be difficult during a widescale power outage, or those with heart disease may benefit from visiting a cardiac rehabilitation center but struggle with the accessible transport needed to get there. These cases reflect potential challenges in adopting CPGs for cervical cancer and for ischemic heart disease, respectively. Given the limited pragmatic research into the implementation of practice standards within LICs, CPGs—often developed based on research in HICs—may feel unattainable for some providers and health systems, creating a sense of futility.

Research on existing, locally relevant practices (known as practice-based medicine) may encourage clinically useful and achievable CPGs. In India, a randomized controlled trial in Mumbai demonstrated the effectiveness of education and clinical breast examinations to help achieve lower stage at presentation (also known as clinical downstaging or indicating less extensive disease) in parallel with mammography. Standardized protocols and discharge checklists, for example, support better consistency and compliance with higher-quality care. More research is needed to develop CPGs that are effective within and across countries, recognizing both clinical evidence and local feasibility.

Even when resources do exist, such as in HICs, CPGs may not be adapted in day-to-day practice due to other barriers, such as lack of education and training, overstrained workforces, local access and resource challenges, and structural discrimination according to race, gender, income levels, or other factors.

Implementation of CPGs and clinical education are intimately linked. Medical education and training for the selected conditions—particularly around sex-specific differences across all selected conditions and the diagnosis and treatment of conditions that affect health span—is limited, even for those in specialized programs and in higher-income countries. For example, country-level CPGs for menopause and endometriosis are incomplete in the United States. One US study found that only a third of obstetrics and gynecology residency training programs have a menopause curriculum, while another found that of almost 200 respondents, 20 percent reported not having any menopause lectures during residency. Another study found that out of 67 residents in US obstetrics and gynecology training programs, most were comfortable diagnosing endometriosis but far less comfortable with treatment options or medical/surgical management.

Education and training about clinical best practices improve care. For example, one training for residents paired a podcast series on menopause with an in-class discussion, resulting in an 18.3-percentage-point gain (from 60.8 percent to 79.1 percent) in answering knowledge-based questions correctly, along with an increase in the residents’ self-ratings of knowledge, comfort, and preparedness.

CPGs for the selected conditions, even when present, are often not translated into clinical care for girls. For example, many of the selected conditions may affect children and adolescents, yet pediatric training on conditions that affect girls differently and disproportionately is minimal. Women-specific conditions often present with menarche and continue through adolescence as symptoms change and regulate. Lack of timely intervention may lead to longer-term consequences; for example, adhesions from endometriosis may lead to chronic pain and infertility. Pediatric history and physical exams often lack sexual and reproductive health, menstrual cycles and changes in sexual and reproductive health throughout adolescence are often not discussed in pediatrics appointments, and lack of focus in pediatric medical education and training on the selected conditions is a disservice to girls. For example, a 2020 survey of US pediatricians found that many reported not providing anticipatory guidance or discussing menstruation with patients, with male pediatricians significantly less likely to give patient education regarding menstruation or ask patients about their menstrual cycle. Among obstetrics and gynecology trainees in Europe surveyed in 2021, more than 40 percent said no pediatric and adolescent gynecology training (rotations, electives, or lectures) was offered in their curriculum. Ultimately, a lack of knowledge and training can mean missed diagnosis for health span conditions, resulting in girls missing school and having associated mental health conditions, chronic pain, and a sense of isolation. Puberty is starting earlier for girls, so ensuring provider knowledge and training on adolescent gynecological health is critical.

CPGs could be adaptable to populations and health systems while aligning with the latest evidence-based medicine. They could lead to sex-specific education and training, across country income levels. They could be understood, recognized, and implemented across specialties and age groups to ensure that women and girls receive evidence-based care. CPGs, when fully representative of evidence-based practice and implemented appropriately, could result in multidisciplinary clinical management incentivized by adherence to guidelines, timely and coordinated diagnosis and treatment, the highest-quality care achievable for a woman in her community, and pragmatic research into the effectiveness of CPGs and effect on clinical outcomes.

4. Include all women

All women should be included in efforts to improve care.

Based on recent Forum and MHI analyses and expertise from the Global Alliance for Women’s Health working groups, addressing inequity could have a greater impact on mortality for conditions affecting life span than any single treatment studied in recent clinical trials.

No number of efforts to count, study, analyze, or deliver better care to women will succeed without concentrated efforts to address structural inequities across race, ethnicity, geographical origin or residence, and other disparities within and between countries. Among the conditions affecting life span—breast cancer, cervical cancer, ischemic heart disease, postpartum hemorrhage, and maternal hypertensive disorders—eliminating disparities associated with race, gender, and geography could have a greater effect on mortality than the single treatments in completed Phase III clinical trials with reported results between 2021 and 2023 for those conditions.

By way of example, many of the recent treatment-related clinical trials for breast and cervical cancer focus on halting progression of metastatic disease. The reasons behind women’s mortality are often more complex than disease pathology alone, encompassing social determinants such as race, income, and educational attainment. One 2017 study found that when Black women died of breast cancer in the United States, a lack of private insurance was connected to more than a third of the risk of these deaths, while tumor characteristics accounted for 23 percent of the risk. For cervical cancer, Black and Hispanic women in the United States are more likely to experience delayed follow-up care after an abnormal Pap smear, and Black women are 60 percent more likely than non-Hispanic white women to die of cervical cancer. In one assessment of Indonesian patients diagnosed with cervical cancer in 2022, almost 90 percent said they were unaware of cervical cancer prevention.

Despite a decline in overall deaths from ischemic heart disease, women are more likely than men to die from an acute cardiovascular event, and the overall mortality rate for women with ischemic heart disease remains high. The disparity in complications is especially true of younger women: a study found that women between the ages of 18 and 55 with acute myocardial infarction experience more adverse outcomes than young men in the year after discharge. Within geographical regions, wide disparities exist: For example, the risk of dying from ischemic heart disease varies across Europe, with lower mortality rates for women in Germany than in Romania. In India, ischemic heart disease rates are increasing faster in women than men, attributed to factors such as greater body weight, tobacco use, diabetes, and periodontal infections, in addition to disparities in the delivery of healthcare by gender.

For maternal health, disparities are well known. Within HICs, Japan has 4.0 maternal deaths per 100,000 live births, the United Kingdom has 5.5 maternal deaths per 100,000 live births, and the United States has 22.3 maternal deaths per 100,000 live births. LICs overall have 430 maternal deaths per 100,000 live births. But the picture is more complex when looking deeper within a country. In the United States, rates of postpartum hemorrhage rose by 26 percent between 1994 and 2006 and exacerbated disparities. Black women in the United States are less likely than non-Black women to receive life-saving anti-hemorrhagic interventions. Black women in the United States are 2.6 times more likely than non-Hispanic white women to die from pregnancy-related complications, with 49.5 maternal deaths per 100,000 live births.

Health-related social needs limit access to healthcare delivery and are often a barrier to inclusion in research and clinical trials. Efforts to address health-related social needs and understand the implications of social determinants of health are critical to improving health span and life span. While social determinants of health are correlated with health outcomes, addressing health-related social needs can sometimes have an even greater impact on medical conditions than care provided, due to the effects of these needs on delayed presentation, delayed diagnosis, access to interventions, and trust in the healthcare system, as when health-related social needs are linked to delays in the diagnosis and treatment of cancer. When health-related social needs and mental health challenges are addressed, improvements in cancer care access and all-cause mortality are observed. Closing the women’s health gap will require provider education on the impact of social needs on clinical care and health outcomes, training on screening for social needs, and resources to support women with social needs and mitigate disparities.

Cultural barriers can lead many women, particularly those with lower levels of education and socioeconomic status, to avoid seeking healthcare. Feelings of shame and perceived stigma also affect care. In sub-Saharan Africa, “women reported fear of the cervical screening procedure and negative outcome, low level of awareness of services, embarrassment and possible violation of privacy, lack of spousal support, and societal stigmatization,” among other reasons for nonparticipation. Another example is menopause, an expected transition for almost all women: Globally, half of post-menopausal women believe menopause is a taboo subject, and only 46 percent go to their doctors for symptom management, while 28 percent have no plans to see their doctor. Similarly, menstruation is still perceived as a taboo subject by many, including women and girls, leading to meaningful levels of period poverty.

Dignity and trust between women and their providers are the foundation of clinical relationships and successful health outcomes for women. Awareness and education can encourage individuals to advocate for and institutionalize sex- and gender-responsive care, as well as ensure that providers deliver it.

5. Invest in women

Additional investments are needed to support the other actions.

The past year saw substantial public and private commitments for investment in women’s health around the globe, but the work is only beginning.

Innovative investment and funding approaches across public, private, and social sectors have recently launched. For example, Pivotal Ventures released an open call for organizations around the world that advance women’s health and health equity, with $250 million in allocated funding for grants within a broader $1 billion commitment to advance the global power of women. Advanced Research Projects Agency for Health (ARPA-H), a research funding agency of the US government, opened a Sprint for Women’s Health to support health and biomedical breakthroughs. Within six months of the announcement, $113 million was invested to support research on conditions that affect women differently or disproportionately, and 70 percent of the funded organizations are women led.

When investments are made, return is achieved. For every £1 of public investment into obstetrics and gynecology services per woman in England, there is an 11-fold return on the financial investment.

Research focused on the biology of health span conditions requires more funding. For example, a 2024 study found that genetically predicted levels of certain hormones were associated with endometriosis risk. While basic science investments may seem distant from treatment gaps and policy decisions, they are intertwined. When the diagnosis of health span conditions is delayed, fewer women are counted as having the condition, which can lead to less investment in research. Scientists, life sciences companies, and investors require adequate data on prevalence and potential market size to comfortably inform their investments.

Investment also means looking at who is leading the research and how a clinical research program or clinical trial is run. One recent analysis found that when the principal investigators leading cardiovascular clinical trials were women, they were more likely to enroll women. Investment is needed in professorships, funded chairs, and other dedicated research tracks for women’s health in academic institutions—beyond those in obstetrics and gynecology departments, recognizing that more than half of the women’s health gap is tied to conditions that affect women differently or disproportionately than men.

Investors, philanthropists, and government funders can also consider a holistic and comprehensive approach to health beyond the healthcare delivery system. This includes social factors—such as nutrition, education, housing, water, clothing, or transportation—and how they influence outcomes. For example, UNICEF estimates that more than 400 million children lack access to basic sanitation services at their school, and only about one in three schools offer bins for menstrual waste. The connection between unmet social needs and health stretches into HICs. A McKinsey survey found that employed individuals in the US with one or more unmet basic social needs were 2.4 times more likely not to receive needed physical healthcare and to have missed six or more days of work in the past year.