Gender Equality and UHC: Default or Afterthought?

If you ever go on a safari ride, you will probably be driven in a vehicle with open sides, no glass, nothing between you and powerful animals like lions and leopards, so close you could reach out and touch them (not advised) – they can smell you, they know you are there and yet they don’t attack. Hold that thought.

For Women in Global Health, after coming back from stalking big political beasts at the UN General Assembly, attending the landmark UN High-Level Meeting on Universal Health Coverage (UHC), and appearing at breakfast to dinner side events in New York, it is time to reflect on battles won and those yet to be won.

Our four key takeaways from the High-Level Meeting on UHC:

1. Gender Equality and Women’s Rights are central in the UHC Political Declaration

Number one takeaway from the HLM is that we count the Universal Health Coverage Political Declaration as a victory for women and girls and therefore, for the whole of humanity. It has stronger commitments on gender equality and women’s rights than previous political declarations we have seen from other high-level meetings; and it echoes many of the points in the Call to Action issued by WGH in March. It is the step forward we hoped it would be for gender equality, women’s rights, recognition of sexual and reproductive health and rights and the role of women in the health workforce. A step forward for all of those is, by definition, a giant leap forward for UHC.

When UN Member States unanimously adopted the political declaration at the HLM on 23 September 2019, the 107 member NGOs of the Alliance for Gender Equality and UHC, co-convened by Women in Global Health, International Women’s Health Coalition, and Women Deliver, issued a joint statement welcoming the Declaration as ‘A Bold Commitment to Gender Equality and Health for All’. As the Alliance, we supported the process every step of the way at national and global levels (see the blog by International Women’s Health Coalition’s Neha Sardana). The declaration provides a strong foundation for delivering the UHC that will change the life chances of billions of people, the majority of them women and girls.

But gender equality and women’s rights were not the default in the UHC process and were dismissed at various points as ‘special interests’ and not seen as the issues that would make or break UHC implementation. Following the UHC political process of the last year, it was by no means obvious that the UHC Political Declaration would contain strong commitments to gender equality and women’s rights. Rights that are essential to reaching the most marginalised women and girls who can least afford and access any health services, let alone the quality services the world’s governments have committed to deliver. They were missing from early drafts of the political declaration and, as UHC watchers will know, women’s rights, including Sexual and Reproductive Health and Rights (SRHR), were the main reason negotiations on the Declaration were stalled over the summer. We therefore appreciate the Member States who stood firm against considerable pressure to push back women’s rights in the HLM process and we applaud the 58 Member States who signed the Statement delivered by the Netherlands stating we ‘strongly believe that SRHR is an integral part of Universal Health Coverage and the SDGs’.

The final Political Declaration, adopted by all UN Member States, commits governments to ‘mainstream a gender perspective on a systems-wide basis when designing, implementing and monitoring health policies, taking into account the specific needs of all women and girls, with a view to achieving gender equality and the empowerment of women in health policies and health systems delivery.’ (Paragraph 69 HLM UHC Political Declaration).

That commitment alone, has the potential to produce health systems that address the gender determinants of health originating outside health systems that impact negatively on the health of all genders, including men.

2. Female health workers were recognised in the Political Declaration as agents of change

The second takeaway is that the UHC Political Declaration addresses our Call to Action, issued in March, to recognise the urgency in the shortage of 18 million global health workers critical in achieving UHC, and the wider global need for 40 million new health worker jobs by 2030.

Moreover, it recognises the role of women in the health workforce and commits to: ‘[Providing] better opportunities and working environment for women to ensure their role and leadership in the health sector, with a view to increasing the meaningful representation, engagement, participation and empowerment of all women in the workforce, addressing inequalities and eliminating biases against women, including unequal remuneration while noting that women, who currently form 70% of the health and social workforce, still often face significant barriers in taking leadership and decision making roles’. (Paragraph 63 HLM UHC Political Declaration)

WGH strongly supports these commitments.

WGH also applauds the commitment by the world’s governments in the Declaration to protect health workers ‘from all forms of violence, attacks, harassment and discriminatory practices and to promote their decent and safe working environment and conditions at all times…’ (Paragraph 64 HLM UHC Political Declaration)

In March, WHO launched a hard-hitting report reviewing the position of women in the global health workforce with recommendations on urgent steps needed to tackle the gender inequities that are barriers to women in their work but also to the health systems denied women’s talent and expertise. That report, authored by WGH and produced with the many expert partners in the Gender Equity Hub of the Global Health Workforce Network co-chaired by WHO and WGH, is the foundation for future policy action at country level. The UHC Political Declaration marks the first time we have seen strong commitments made at the highest political levels, by Heads of State and Government, to strengthen the status of women in the health workforce by addressing gender equity. These commitments were not in the early drafts of the Political Declaration and again, we commend the Member States who argued for their inclusion because when implemented, they will enable women to play a leading role in delivering UHC.

3. Important voices were not at the UHC HLM table

In the Modalities Resolution for the HLM UHC, the President of the UN General Assembly undertook to ensure that the speakers and panellists for the HLM on UHC would be chosen ‘taking into account gender equity, level of development and geographical representation.’ This commitment was delivered. Five of the nine panellists at the HLM were female and from a mix of geographies.

But WGH can confirm that only 24% of total speakers at the HLM UHC were women. The majority of speakers at the HLM were heads of state and government and member-state representatives delivering statements and comments, the vast majority of which were men. Since only 14% of world leaders and 24% of parliamentarians globally are female, it was extremely unlikely that women and men would be equally represented at the UHC table. Therefore, our third takeaway is that 3/4 of the voices heard at the highest global political forum on UHC were male. This indicates how women’s views, needs, and perspectives in UHC and health generally remain marginalised at both global and national levels. Since this was a high-level meeting of heads of state and government, only a handful of NGOs were invited to speak (the Alliance for Gender Equality and UHC was not invited to deliver a statement). As a result, the meeting lacked the views and passion of the patient representatives and NGOs closest to the people whose lives will be most transformed by UHC. It is a surreal thought that billions of people whose lives are blighted by their lack of access to quality health services had no idea a meeting was taking place in New York on 23 September 2019 to discuss extending those services to them.

Moreover, outside the inner HLM events, visa discrimination is making it even harder to bring those voices to the table. WGH has established a tradition of bringing frontline ‘Heroines of Health’ to the World Health Assembly to share their stories and extended the event to UNGA this year. One Heroine, a frontline community health worker from Liberia, was denied a visa to the USA on the grounds that she was a community health worker. Had she been a doctor it might have been granted. How can we ensure decision makers hear the perspectives of patients and frontline health workers when, added to all the other barriers they face, they are denied the opportunity to travel?

“Privilege is not what’s going to get us to #UHC by 2030.”

Full quote in the image:

4. Where next for UHC?

The HLM on UHC was a landmark meeting and we commend the WHO Director General, Dr. Tedros, for his leadership in moving UHC to the top of the global agenda for health and making it a key target in WHO’s ‘triple billion goals’. But the HLM is not the end of the process, it is the beginning and the next critical stage is implementing the commitments made in the political declaration at country level.

Our fourth takeaway from the HLM is that UHC implementation means accountability, real accountability that works for citizens of all genders, everywhere. Have they received what was promised to them? Have they received what they need for their health and well-being? The "What Women Want" exercise is a stark reminder of who we all should be accountable to and what we should be accountable for. UHC needs a proper independent accountability function, and there is a strong model to build on - the UN led process and Independent Accountability Panel (IAP) developed around Every Woman Every Child (EWEC) - which cuts across actors, agencies, partnerships, sectors, public and private actions.

Too often accountability is seen as little more than monitoring - agencies, donors, governments listing their institutional objectives and reporting on how they have met them. The IAP for EWEC has built 3 years of experience on holding the extensive collection of actors engaged in the global strategy goals for "every woman every child" to account, by looking at how accountability works in key areas of the strategy and making recommendations for remedy and action by all stakeholders involved. The focus on remedy and action is key, so that citizens receive what they have asked for. That is what accountability must do, not just call out problems and bad behaviour, but do something about them; including identifying how to fill accountability gaps in domestic democratic processes as well as internationally. The Panel has looked at complex accountability relationships, such as the private sector, which are not straightforward relationships, but which have to work if we are to achieve the SDGs, including UHC.

If UHC is to succeed, it must deliver for every woman and every child, leaving nobody behind. It would be a simple step to extend the IAP's mandate to cover UHC. With its experience and expertise in gender equality and women’s rights, we can be confident that gender equality would be the default this time and not an afterthought. It is said we can judge a society by how it treats its most vulnerable citizens and we will judge UHC by whether it delivers for women, girls, boys, and adolescents.

And finally…

We started this article on safari rides. So why don’t those powerful animals who can smell human beings (who probably smell like dinner) jump onto those open safari vehicles and attack the people sitting on them? Well, the animals see the outline of the vehicle as one animal, larger, and more powerful than they are. If one human being gets off the vehicle they will be seen as vulnerable and may well be attacked. But together we cast an image that is stronger and larger than any one of us as individuals - and that’s why we form alliances. Earlier this year, Women in Global Health felt we were not being heard when we said UHC could not be delivered without serious action on gender equality and women’s rights (including in the health workforce). So, we formed the Alliance for Gender Equality with the International Women’s Health Coalition and Women Deliver and just a few months later cast a much larger outline, emanating from the passion, expertise and power of 107 NGOs. At the HLM, Alliance members undertook to continue working together to make the political declaration’s commitments on gender equality and women’s rights a reality at a country level. We will ensure gender equality is the default, not the afterthought in UHC.

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