Legal pluralism and tribalism: Drivers of gender and health inequalities

statutory law reforms – in conformity with international treaties – and the strengthening of formal justice systems. The lack of impact of these reforms on the lived experience and health of women and girls in these countries, as

T he United Nations Convention on the Elimination of all Forms of Discrimination Against Women was adopted on 3 September 1981, committing the signing countries to the advancement of women's status by 'guaranteeing them the exercise and enjoyment of human rights and fundamental freedoms on a basis of equality with men' [1].Four decades later, despite the significant human and financial resources that have been invested by the international community, most states have yet to deliver on this commitment, as reflected in the widespread gender inequalities associated with health harms [2,3].For this reason, a paradigm shift is needed in the way the international community designs global and national gender equality and health responses.Greater recognition is needed of how culture, religious precepts, social norms, values, and beliefs -which ultimately motivate and bind individual and collective actions -can be at odds with views of human rights for equality, equity, fairness, and human dignity.Socio-cultural issues need to be brought center-stage into the processes through which gender advocates reframe the challenges and devise solutions to address gender inequalities and promote health [4,5].
The differing world-view of many in the global South or East is often inadequately considered by those in the North or West in the design of public health interventions, leading to 'top-down' approaches that are not understood or adopted and fail to impact health or development [6].For many in the South and East, their main allegiance is to their extended family/tribe or community values.Many gender advocates have tended to focus their efforts on engaging in-country with educated elites, who adopt more familiar human rights principles and values promoting gender equality.In many cases, such as in Arab and African countries (except Tunisia), this has served to deepen a divide between a country's constitutionally established legal systems which instill principles of human rights, and parallel informal, customary, or religious and judicial systems which uphold traditional patriarchal values, beliefs, and systems [7,8].
Govermental efforts have focussed on statutory law reforms -in conformity with international treatiesand the strengthening of formal justice systems.The lack of impact of these reforms on the lived experience and health of women and girls in these countries, as Multilateral agencies should review the way they design their programmes and strategies to ensure that they work to address social, cultural, and religious factors and norms alongside laws, policies, and judicial systems, and to influence governments to follow the same path to accelerate gender equality and promote health and well-being for all.
described recently for Ethiopia [8,9], was predictable.In those countries where parallel customary and religious judicial systems flourish alongside the formal ones (i.e.legal pluralism), deeply rooted traditional social norms and harmful practices -such as child marriage, female genital mutilation/cutting (FGM/C), honour killing, gender-based violence, child trafficking -are enabled to persist [10,11].Ironically, even in developed countries such as the UK, some immigrant communities are allowed to have recourse to their informal/religious justice system for family matters such as divorce cases, which are largely resolved in favour of men.
Specific to the Arab region, a major challenge that needs to be overcome to change people's values regarding women's rights is to separate the State from religion.In such contexts, where the idea that human affairs in a democratic society should be governed by civil laws that emerge from public debate gives way to religious precepts, the values, beliefs and principles of governance in that state will remain tied to canonical interpretation of laws in the Qur'an -the 'Islamic Sharia.' There, supreme legislation instructs that not only is Islam the religion of the state, but that the principles of the 'Islamic Sharia' are the principal source of legislation.This gives free rein to fundamentalist political factions to enact legislation that violates women's rights, upholding health-harming practices such as child marriage, repudiation, polygamy, FGM/C, gender-based violence, and the treatment of women as powerless and in need of permission to exercise their sexual and reproductive rights.
A key approach to changing people's beliefs and attitudes regarding gender equality is to engage religious/ tribal leaders who serve as gatekeepers of social and cultural norms that perpetuate gender inequality [12,13].
Redesigning global and national gender equality and health initiatives toward targeting root causes such as patriarchal value systems will require working closely with religious leaders to empower them to embrace a compassionate and value-based approach that promotes and protects the integrity of women's bodies and recognises their reproductive health and rights.The dialogue should also be broadened to other social actors to debunk fallacies about certain beliefs and interpretations of religious text.In the Arab world, such reframing is crucial to eradicating the practices of honour killing, FGM/C, child marriage, and gender-based violence, as well as any religious precept interpretation that harms women's bodily integrity and health.Other intersecting aspects of identity such as ethnicity, socioeconomic status, or age which become targets for marginalisation and denial of rights and opportunities must also be addressed alongside gender.In parallel, the way mainstream media and social media 'commodify' girls and women needs to be tackled, regulated, and ultimately transformed.School curricula should also be reviewed and revised accordingly.Multilateral agencies should review the way they design their programmes and strategies to ensure that they work to address social, cultural, and religious factors and norms alongside laws, policies, and judicial systems, and to influence governments to follow the same path to accelerate gender equality and promote health and well-being for all.Only through such 'radical transformational leadership' [13] can global and national gender equality and health initiatives come into harmony with customary and religious systems and truly achieve gender equality for all.
Authorship contributions: KTM and GLD conceptualised the paper; GLD acquired funding, and managed project administration and resources; KTM led writing of the original draft; GLD provided critical input to paper drafts; all authors contributed to writing review and editing.All authors contributed intellectual content and approved the final draft for publication.KTM and GLD had full access to the data in the study and take responsibility for the integrity and accuracy of the writing; GLD had responsibility for the decision to submit the manuscript for publication.

Disclosure of interest:
The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.