Accelerating action towards universal health coverage by applying a gender lens

There is a burgeoning movement towards universal health coverage (UHC) – both at the national and the global political level – that seeks to ensure that all people everywhere receive the health services they need without experiencing financial hardship. The 25 wealthiest nations all have some form of universal coverage, as do several middle-income countries, including Brazil, Mexico and Thailand, and lower-income nations, such as Ghana, the Philippines, Rwanda and Viet Nam, are working towards achieving UHC.1 Action to accelerate work towards UHC is also taking place at the global policy level as evidenced by the 2011 World Health Organization Resolution on UHC, the 2012 United Nations Resolution on UHC and the inclusion of UHC in debates on the post-2015 agenda. In many ways the UHC movement builds on the 1978 Declaration of Alma Ata, which reaffirmed that health is a human right and identified primary health care as the means for attaining “health for all”. However, UHC does not necessarily guarantee universal access to health services. Thus, as countries develop strategies for transitioning towards UHC, it is critical that government leaders and policy-makers take into consideration the unique health needs of women, who make up 51% of the world’s population and 60% of the world’s poor. Biological and gender-based differences between women and men result in differences in health risks, disease incidence and health service needs. For example, women are 1.2 times more susceptible to infection with the human immunodeficiency virus (HIV) than men and this difference is even more marked in adolescence.2 Gender-based differences exist in terms of access to and control of household resources; power and decision-making within and outside the home; and roles and responsibilities within the family, the community and the labour market. In addition, in some places women are less able to move about than men because of social norms that prohibit them from travelling alone, lack of money for transportation or the opportunity cost associated with travel time. All of these gender-related factors have a decisive influence on health-seeking behaviour, health status and access to health services. Millennium Development Goal Three – to “promote gender equality and empower women” – seeks to address the barriers that hinder equal access to health services for men and women. Thus, if countries are to accelerate action towards achieving UHC and meet their targets for increasing access to health services, it is imperative to pay attention to the differential health needs of women and men, and especially to women’s health needs beyond those related to childbearing. Two other forces, in addition to the biological and gender-based differences already mentioned, make it important for policy-makers to incorporate women’s health needs into UHC schemes. The first is the demographic transition, in which decreased rates of birth and death result in delayed childbearing and smaller family size and in longer life expectancy. This transition means that an increasing number of women will have to care for their children and elderly parents, and possibly even their grandparents, simultaneously. This expected increase in women’s role as caretakers and “invisible health workers” for the growing elderly cohort – in addition to the intrinsic value of a woman’s health – is yet another reason why governments should apply a gender lens to the design of their universal health systems, thereby optimizing the effectiveness of these systems. A second force is the epidemiological transition and the concomitant growth in the incidence of noncommunicable diseases, especially among women. Cardiovascular disease (CVD) is commonly viewed as primarily affecting men, yet it is the leading killer of women worldwide. More than 80% of the 9.1 million annual deaths in females due to CVD will occur in low- and middle-income countries.3 Similarly, breast cancer is the most common cancer among women worldwide. According to estimates, there will be 1.7 million cases in 2020 – a 26% rise in incidence relative to 2009 – and most of them will occur in developing countries.4 Research shows that although smoking is known to account for 50% of lung cancer cases in women worldwide, smoking rates in women in less developed countries are projected to increase from 12% in 2010 to 20% in 2025. By contrast, smoking rates in men have peaked globally.3 With regard to stroke, the third leading cause of death in the United States, women have different risk factors than men, including pregnancy, oral contraceptive use and the use of exogenous hormonal treatment for menopausal symptoms. Women who have suffered a stroke are usually left with poorer outcomes and greater mental impairment than men and therefore have a greater need for rehabilitative care.5 For these reasons, it is critically important to view UHC systems through a gender lens when setting priorities and developing a benefit package. Doing so will ensure that the services provided for women address those health needs that lie outside the sphere of reproductive and sexual health.