Ravindran BMC Public Health 2012, 12(Suppl 1):S4 http://www.biomedcentral.com/1471-2458/12/S1/S4 30-66% was not willing to go alone, and a majority in all countries except the Philippines were concerned that no female provider may be available [36]. A gender-sensitive health system can help women overcome many, though not all, of these barriers to health care access. This sec- tion presents information on health system-related bar- riers to access that women face. Location and timing of services and modalities of delivery Services available closer to home or workplace and at times of the day suitable to women are more likely to be utilised, and could make a big difference to identification of morbidity and effective treatment and cure. For exam- ple, studies from Bangladesh and Vietnam indicate the possibility of under-diagnosis and under-notification of women with tuberculosis, contributing to a lower-than- actual reported prevalence of tuberculosis in women [37-39]. A 2005 study carried out in a high TB incidence area in Peru found that when house-visits were made to the households of tuberculosis patients and their immedi- ate neighbours, the odds of case-detection (as compared to self-reports) was 5.5 for those aged above 55 year and 3.9 for women [40]. Another example of the need for alternative strategies in order to be able to reach women is in the case of catar- act-blindness. A much smaller proportion of women than men access cataract surgery, although the prevalence of cataract is found to be similar in men and women. In Southern China, an intervention providing free cataract testing in the community followed by low-cost and high quality surgery found that after five years of exposure to these interventions (2001-06), women were as familiar as men about cataract surgery and as willing to pay for sur- gery an amount of 500 Renminbi (RMB) or US$ 65. The gender differences found in the base-line had been reversed at the end of the five years [41]. Services that are much-needed and often unavailable at the primary care level are child-delivery services. The proportion of institutional deliveries in Tamil Nadu, India, increased from about 80% to 98% between 2004 and 2008. Almost all the increase in institutional deliv- eries was accounted for by deliveries in the newly opera- tionalised 24x7 Primary Health Centres. The new users of institutional delivery services were from the poorest and most marginalised communities [15]. Simple changes in the organisation of services at the health facility level could also enhance access to care. In Nepal, the availability of DOTS services for tuberculosis in the same facility as maternal and child health care has been found to have increased case finding and suc- cessful treatment [42]. Integration of some services could enhance privacy and/or reduce stigma: as for example, when STI or HIV/AIDS services; abortion; or infertility services are made available in the sexual and reproductive health clinic. Page 5 of 7 Patient-provider interactions For most patients, providers represent powerful authori- ties that are by training and social position far removed from their own lives and realities [43]. Patient perspec- tives on quality of care are shaped profoundly by the nature of their interaction with the health care provider. Availability of a woman provider could make the dif- ference between seeking and not seeking care for many women [37]. While this may be more widespread in tra- ditional societies where segregation between the sexes is the norm, preference for a physician of the same sex is found also in other settings. A Netherlands study found that for physical examinations that required complete disrobing, were invasive or required examination of the genitalia, both women and men preferred to have a phy- sician of the same sex [44]. There is a large literature on the physical and verbal abuse of women in labour and women seeking abortion and STI services by women health workers. A number of possible reasons for the abuse have been identified: the overworked health worker may be passing on her frustrations to patients; it may a case of discrimination against women from low-income or marginalised com- munities; and in the case of services such as contracep- tion, abortion or STI/HIV care, the health worker may be judging the patient as having transgressed gender norms [43]. Immediate attention to preventing such abuse in the health care setting could make a big differ- ence to women’s willingness to return for further care. Conclusions Evidence examined in this paper, while not conclusive, indicates that universal coverage is likely to exclude more women than men, and even when achieved unli- kely to translate into universal access to health care for women unless factors contributing to inequalities in affordability, availability and access to health care by women are systematically addressed. Based on the find- ings about the nature of barriers that women face, the following is a tentative agenda for action to make health systems work for women. When implementing insurance reforms, such as introduction of Social Health Insurance /Micro-Insur- ance, special attention is to be paid to coverage of women. Partially or fully subsidising premium payments for those who cannot afford to pay, and being aware that women, even when they belong to better-off house- holds may fall within this category, would be important. Making households as the unit of enrolment in insur- ance schemes would help extend insurance coverage to women and other household members with low deci- sion-making making power and financial resources. Social Protection Health Schemes and Conditional Cash Transfers should be free of conditionality and