GENDER EQUALITY & UNIVERSAL HEALTH COVERAGE
“All roads lead to universal health coverage—and this is our top priority at WHO.”
-Dr Tedros Adhanom, Director General, World Health Organisation (1)
Universal Health Coverage (UHC) is currently the most hotly debated and visionary goal in global health. In 2015 all UN member states committed under the Sustainable Development Goals (SDGs) 2016- 2030 to:
“Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” SDG Goal 3, Target 3.8
This UHC Day, 12th December 2017, a high level UHC Forum opens in Tokyo to drive achievement of UHC by 2030. However, there is a major gap in the agenda – gender equality and its central role in the achievement of UHC.
A big idea is needed to drive a step change in global health and the new DG of WHO, Dr Tedros, has set achieving UHC as the key objective of his tenure at WHO. UHC is not a new idea but it now has a powerful global champion, a timetable for delivery and wide support amongst women’s health advocates. With this momentum growing, UHC has a real chance globally, however, addressing gender equality will make or break achievement of UHC.
WHO defines UHC as “ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.” (2). UHC is a broad set of parameters that should be adapted to local circumstances. There is no UHC blueprint that can be copied from countries that have it and pasted into countries that don’t.
It goes without saying that healthcare is one of the most politically contentious issues for governments everywhere. Introducing UHC has major political and financial implications with people living longer, young populations in some lower income countries, developments in medicine and technology, the epidemiological transition from infectious diseases to non-communicable diseases and the ever-present threat of pandemics all adding pressure to health budgets. To reach UHC government funding will be needed to subsidise those unable to pay.
And significantly, the definition of UHC governments adopted in the SDGs includes prevention and health promotion, and therefore goes wider than the remit of Health Ministries alone. UHC will entail addressing social, political and commercial determinants of health including sex and gender based health determinants. Implementation at country level is likely to be a dynamic process, rolled out over time.
UHC will take different forms in different countries and move at different speeds but one thing is clear - UHC will not be achieved anywhere without addressing gender equality and particularly, the role of women in the global health workforce.
Gender Equality Impacts on UHC
All Roads Lead to Universal Health Coverage –and Women Will Deliver It
Ann Keeling, Policy Fellow, Women in Global Health
“At present, no government in the world is systematically applying a gender lens to its UHC system.”
- Rodin (3)
1. The ‘Universal’ in UHC means that it must reach everyone regardless of gender, ethnicity, caste, income or any other social or personal characteristic. UHC must reach all women and girls everywhere. Success in achieving UHC will be measured by who is included and can access the care they need. This is fundamentally different from the Millennium Development Goals (MDGs), forerunners of the SDGs, which measured aggregate progress by country. Those average national figures, on maternal deaths for example, could and did mask huge variations within one country between women in cities and rural areas, rich and poor women, women from different racial groups etc. In many countries women and girls have the least access to health services, particularly those from marginalized social groups, and will be the hardest to reach. Extending health coverage to all women and girls everywhere will determine achievement of UHC at national and global levels.
2. Women are the majority of the world’s poor and therefore less able to afford health care than men: UN Women reports that women are more likely to live in poverty than men in 41 out of 75 countries with data. Globally, women are less likely to be in paid employment than men and where they are employed, women globally earn on average 24 per cent less than men (4). Female headed households are particularly vulnerable to poverty, as women are less likely to own land and other assets than men and women enter old age less likely to have their own pension. Since women are the majority of the world’s poorest people and there are large lifetime income inequalities between men and women, women will be less likely than men to be able to pay for health care. Women are likely therefore to be the major beneficiaries from UHC and it makes sense for governments to start UHC with women and girls in the poorest families and social groups. UHC will bring major change to the world’s poorest women, evening up life chances and relieving families of the crippling health bills that often mean they go without treatment they desperately need.
“…the key question of universal health coverage is an ethical one. Do we want our fellow citizens to die because they are poor? Or millions of families impoverished by catastrophic health expenditures because they lack financial risk protection? Universal health coverage is a human right”.
- Dr Tedros Adhanom, DG WHO (1)
3. Women and men have different health needs based on biology: UHC is based on the principle that people should receive health care according to their health needs. Individuals will have different health needs throughout their life cycle with children, women of reproductive age and older people generally needing more health services than other age groups. Clearly, there are differences between men and women in health and disease patterns with certain diseases such as cervical and prostate cancers being specific to one sex. But the most significant difference between the sexes is women’s greater need for health care related to pregnancy and childbirth. UHC applies to everyone but does not mean treating all people the same.
“girls and women’s health and rights are more than a measure for progress on UHC. They are a prerequisite.”
- Iversen and Myers (5)
4. Gender based determinants of health: Each gender plays different roles in society and are subject to different gender norms that impact their health. Large numbers of women and girls, for example, are subject to harmful cultural practices in some countries that seriously damage their physical and mental health. These practices include and are not limited to Female Genital Mutilation/Cutting seclusion, menstruation taboos and early pregnancies following early forced marriage (6-7). Adolescent deaths rates are higher for boys than girls, with higher mortality related to interpersonal violence and road injuries (8). A transgender woman is 49 times more likely to be living with HIV than other genders of reproductive age. (9) Prevention of the gender based drivers of ill health lie largely outside the health sector and must be addressed in context for successful implementation of UHC.
5. UHC includes prevention and health promotion which are driven by both gender and biological sex. The most fundamental example of health prevention based on biological sex is the impact of the health of a mother on the health of the fetus, particularly in the ‘first 1,000 days’. Health is a human right for women, as it is for all other people but in addition, investment in better health for girls and women of reproductive age will impact positively on the health of children they bear. Many, including the Elders (10) argue that UHC therefore must start with primary care services aimed at the poorest women, children and adolescents. And beyond biology, genders play different roles in health promotion and prevention within their families and communities. As NCDs receive more attention in global health, obesity and overweight affecting around 2 billion people globally, is an urgent priority for action. Mothers are important decision makers in the nutrition of their families. Women may also play a critical role in health promotion, often informal or as volunteers, in their communities. Decision makers implementing UHC need to understand the different roles that genders currently plays and can play in health prevention and promotion.
6. UHC applies to all people everywhere including those affected by conflict and emergencies: All genders have different roles and unique health and security needs in emergencies. Although men are more likely to be injured or die during armed conflict as combatants, women are more likely to experience the harm and lasting trauma of sexual violence and unwanted pregnancy. Vulnerability continues for women and girls even when they reach the ‘safety’ of refugee camps. Pregnant women in forced migrations are particularly vulnerable to unsafe delivery and maternal death. There are also gendered differences in non-conflict related emergencies with more women than men, for example, dying in floods because they cannot swim.
7. Women are the majority of the global health workforce but men hold the majority of senior roles: Globally, women in the health workforce provide health care for over 5 billion people. To achieve UHC and SDGs projections estimate around 40 million new health and social care jobs globally will be needed by 2030, and an additional 18 million health workers will be needed, primarily in low income countries. In many countries women hold over 70% of jobs in the health sector (11) but are greatly underrepresented in senior and decision-making roles and over represented in lower ranking, less well-paid jobs and sectors. An investment in UHC means an investment in women in the health workforce. Governments will need to ensure decent working conditions, particularly for frontline women health workers at community level, who are often the backbone of the health system but also often underpaid and marginalized within it. Priority must be given to ensuring safe conditions for health workers and to working conditions that enable all health workers, regardless of gender, to achieve work-life integration. Effective health systems will ensure gender parity at all levels of decision making to harness women’s perspectives and talent. Women currently make an essential contribution to delivering global health and will be equally essential to delivering UHC. This will not happen, however, unless women are fully recognized as drivers of change in global health, and not only as beneficiaries.
8. Women provide the majority of unpaid care globally: Per the Women and Health Lancet commission “Women provide over $3 trillion in care with nearly half of that is uncompensated care each year to their families and communities” (12). Much of this care for children, the disabled, older people and community members is unrecorded. We have no clear picture of women’s unpaid contribution to health care globally. The burden of this care may fall on girls and interrupt their schooling and future economic opportunities. Similarly, this burden of unpaid care work can keep women in poverty because they are unable to take paid work. Countries implementing UHC must recognize and address the unpaid health care work performed by all genders. It has implications for individuals but also has major negative impacts upon the economy and economic growth.
9. UHC is a political decision but only 23.5% of parliamentarians are women: UHC in itself is no guarantee of quality care or gender equity. Who has access to health coverage and the package of services offered will be politically driven by decisions taken in parliaments. Currently, women hold less than one quarter of seats in parliaments globally (13), ranging from 61.3% in Rwanda to 0% in Qatar, Papua New Guinea, Vanuatu and Yemen. In the majority of the world therefore life and death decisions about UHC and the health coverage of all genders are being decided overwhelmingly by men. This is not only inequitable, it is very likely to bias the coverage offered and who it reaches. We can assume that diverse, gender equal parliaments would make different decisions on UHC if all voices were equal. The voices of women are needed in health decision making at all levels, from planning and monitoring at community level to parliaments.
“By creating pathways for more women to hold seats in government and voice their concerns in the civic sphere, countries can ensure that gender equality is ever-present in policy negotiations.’’
- Iversen and Myers (5)
10. UHC brings major social change: UHC, when introduced effectively, will even up life chances between genders, between rich and poor women in the same society, and between women living in rich and poor countries. The clearest example will be elimination of the scandalously high and preventable maternal deaths in some countries. Where effectively and equitably implemented, UHC will have a particularly positive impact on the health and lives of the most vulnerable women and girls. As yet, we can only estimate the positive social, economic and political spin offs from such a radical change.
Call for a High-Level Working Group on Gender Equality and UHC
Given the importance of gender equality for UHC implementation and the impact of UHC for gender equality, Women in Global Health note with concern that gender equality is not a central and high-profile topic at the 2017 UHC Forum in Tokyo. Women health workers currently deliver health care to over 5 billion people worldwide. It is clear that as the global work force expands, women will deliver UHC.
We urge UN Member States, WHO, and international agencies supporting implementation of UHC to change the narrative and view women as drivers of change in global health, not only as beneficiaries.
As an important first step, we recommend that the Tokyo UHC Forum support:
“Formation of a High Level Working Group on Gender Equality and UHC, led by WHO with membership from UN Member States, UN and multilateral agencies and civil society to provide practical guidance on UHC implementation and particularly, gender equality and the health workforce”
UHC is indeed a game changer and the game means life or death for millions of vulnerable people globally. We can go down in history as the generation that ended fear, suffering and premature death for millions of people, via Universal Health Coverage delivered mainly by women.
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1. Dr Tedros Adhanom Ghebreyesus (2017), All roads lead to universal health coverage, The Lancet Vol 5 September 2017
2. WHO (2017) WHO website
3. Rodin J (2013) Universal Health Coverage Through a Gender Lens, Bulletin WHO 91:710–1
4. UN Women (2017) Progress of the World’s Women 2015- 2016 Chapter 1 UN Women (2017) Facts and Figures: Economic Empowerment
5. Iversen K and Myers M (2017) Opinion: Want to deliver on the promises of UHC? Invest in girls' and women's health and rights. Devex 09 October 2017
6. UNICEF (2016) Female Genital Mutilation/Cutting: A Global Concern|
7. UNICEF (2017) Is Every Child Counted? Status of Data for Children in the SDGs
8. WHO (2017) WHO website http://apps.who.int/adolescent/seconddecade/section3/page2/ mortality.html
9. WHO (2017) WHO website
10. The Elders Foundation (2016) Universal Health Coverage position paper. May 2016
11. ILO (2017) Improving employment and work conditions in health services. http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/publication/wcms_548288.pdf April 2017
12. Langer, A (2015) Women and Health: the key for sustainable development, September 2015
13. Inter Parliamentary Union (2017) Women in Parliament Ist October 2017
This article is also based on:
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