Universal Health Coverage: Getting Women to the Decision-Making Table
Twenty years ago, when I was working for the UN, my unit was asked to investigate the high maternal mortality rate at the local state-of-the-art maternity hospital, newly built with Japanese aid money. The hospital was clean, modern, fully equipped with medicines and well-trained staff – quite different from any other hospital in the capital city. Everything, even the manhole covers, had been manufactured to the highest standard and imported from Japan. But mothers were dying, and the UNDP Gender Unit was contracted to discover why.
My first thought was to just go to the hospital, sit and watch how it functioned. I sat in Admissions and within a few hours, I had my answer. Mother after mother arrived in late stages of labour, accompanied by husbands, fathers, uncles, children, and some with female relatives; travelling in taxis, vans, and some carried on makeshift stretchers. Each small crowd of frantic, fearful people was greeted by medical teams who immediately went into overdrive – the way health workers do – when they recognise an emergency. My notes from that day read ‘Dead on arrival – obstructed labour’, ‘Died on admission – haemorrhage’, ‘Dead on arrival’, ‘DOA’, DOA’. Nobody needed to write a report.
All health workers know that building a top-notch health facility is a brilliant first step but delivery of universal health coverage (UHC) must be built on knowledge of (gendered) health-seeking behaviour in a social context. Women from poorer families in that social context lacked the mobility to attend prenatal checks so problem pregnancies were not identified. Attended to by female relatives, these women generally gave birth at home, and since a large percentage were anaemic, they risked haemorrhage. Moreover, female relatives generally lacked the autonomy to decide when to move a woman to hospital. All these factors and more led to two of the classic ‘three delays’ responsible for so many maternal deaths – delay in deciding to seek treatment for an emergency and delay in reaching an appropriate medical facility.
I don’t tell this story to cast myself as the ‘white saviour’ in a low-income country. I tell it because beneath the devastation I felt at witnessing avoidable deaths that day, I had another furious question ‘Why didn’t the people who designed this system ask the experts?’ Those experts were the nurses and midwives working in the hospital, every one of whom, knowing their own context, would have predicted those delays and deaths. Either they hadn’t been consulted or their views had been ignored, with tragic consequences for mothers, infants and their families.
Getting Women to the UHC Decision Making Table
As a general rule, the best way to make bad decisions is to ask the wrong people. I write this in the week that peace talks on the war in Yemen (that has pushed 14 million to the brink of famine) have been convened in Denmark with no women at the table.
I have sat at many decision-making tables in my career, the sole woman or one of a minority of women in the room trying to figure out how to make space for the voices and perspectives of women not present. The problem is particularly acute in global health since although women are 70% of the global health and social care workforce they only hold around 25% of decision making posts. Progress on gender parity in leadership varies by country and sector but generally, men hold the majority of senior roles in health from global to community levels. Global health is predominately led by men with 69% of global health organizations headed by men and 80% of board chairs. The Global Health 5050 report found only 20% of global health organizations have gender parity on their boards and 25% have gender parity at senior management level. These gender gaps in leadership mean women and their perspectives are generally underrepresented in global health decision making, including on UHC. Universal health coverage, and the quality of care and health systems will only be strong when the women who run them have an equal say in the design of national health plans, policies and systems.
In addition to the women who hold paid jobs in global health and social care, it is critical we bring to the table the women at the base of global health pyramid supporting the system with unpaid work within their families and communities. It is estimated that around half of women’s US$3 trillion contribution to global health is unpaid. A 2018 ILO report on Care Work  concluded that:
‘Across the world, women and girls are performing more than three-quarters of the total amount of unpaid care work and two thirds of care workers are women.’
This picture of women’s unpaid care work was supplemented recently by the ‘Who Cares?’ report from Age International  confirming that one in seven women aged 65+ in low and middle-income countries is in the workforce and in addition, older women provide an average of 4.3 hours unpaid care and domestic work daily. Demographic changes are increasing the demand for social care work and the burden carried by women and girls must be recognised as work, reduced and redistributed since it currently both reflects and drives gender inequality. ILO concludes: 
‘If not addressed properly, current deficits in care work and its quality will create a severe and unsustainable global care crisis and further increase gender inequalities in the world of work.’
Three Key Messages
On UHC Day 2018, Women in Global Health applaud the overarching theme of ‘UHC: Everyone, Everywhere’. We have three key messages:
The design and delivery of strong Universal Health Coverage rests on bringing everyone, everywhere to the decision-making table from local to global – it requires gender parity from all health sectors, geographies, and walks of life. Good decisions rest on including the right voices.
Serious investment is needed now in the female health workforce for the delivery of Universal Health Coverage and decent work for women to reduce the gender inequities in leadership and pay that weaken health systems now. This is especially urgent as 18 million new health sector jobs are required by 2030 in low- and middle-income countries
The delivery and sustainability of Universal Health Coverage requires recognition that the global health system rests on a fragile foundation of unpaid health and social care work by women and girls, which must be reduced and redistributed to provide a strong base for health for all.
If we get this right, the benefits will go beyond UHC. Investment in the female health and social care workforce will have a wider multiplier effect, offering a Triple Gender Dividend comprised of:
Health Dividend: Expanding women’s work in health and social care is the only way to fill the millions of new jobs that must be created to meet growing demand and reach UHC and health related SDGs by 2030.
Gender Equality Dividend: Investment in women and the education of girls to enter formal, paid work will increase gender equality and women’s empowerment as women gain income, education and autonomy. In turn, this is likely to improve family education, nutrition, women and children’s health and other aspects of development.
Development Dividend: New jobs created will fuel economic growth.
This gender dividend, if realised, will improve the health and lives of people everywhere. This is everybody’s business.
On UHC Day 2018, Women in Global Health call for:
Member States to show political commitment to UHC by taking action at the national level and adopting plans for UHC that address gender and inclusion.
Global Health Actors in the SDG3 Action Plan to link health and gender – without gender equality, we will not achieve UHC.
Global Health community to stay committed to changing the narrative, viewing women as drivers of health and untapped leaders of health in their communities.
With less than a year to go before the UN High Level Meeting, gender equality remains critical to the design and delivery of Universal Health Coverage, and to the the vision of the world we want.
 Global Health 50/50 ‘The Global Health 50/50 Report: How gender-responsive are the world’s most influential global health organisations?’, London, UK, 2018
 ILO ‘Care Work and Care Jobs for the Future of Decent Work’, June 2018
 Age International ‘Who Cares?’ November 2018 www.ageinternational.org.uk/whocares
 ILO ‘Care Work and Care Jobs for the Future of Decent Work’, June 2018