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In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts. We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority. We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized. We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the ‘progressive universalism’ advocated for by the 2013 Lancet Commission on Investing in Health.
This paper draws on the expertise of the authors and on a rapid review of the health literature (grey and peer-reviewed articles). Although there are bodies of work on related topics in the economics and wider development literature, our interest was to capture the extent to which health practitioners had researched and reflected on this topic, so our focus was on health literature. With respect to universal health coverage, there were several primary documents and reports (i.e. grey literature) that were drawn on. These included WHO reports (i.e. 2010 report on universal coverage, the 2008 report on primary health care) and technical reports (Carrin and James 2004). With respect to gender and women, primary documents included reports by the United Nations (United Nations 2009,2010). In addition, we included reports and publications focusing on the gender implications of health financing (Witter and Ensor 2012), health-financing reforms (WHO 2010 b) and universal coverage (Witter and Ensor 2012; Sen and Govender 2015) that were relevant to this paper. The reference lists of these documents were also reviewed and relevant articles identified for inclusion in this paper. For published articles, both empirical and review, searches were conducted on PubMED and Google Scholar as well as specific journals focusing on gender and sexual and reproductive health (e.g. Reproductive Health Matters) and health policy (e.g. Health Policy and Planning, WHO Bulletin). The following key words were used for searches: ‘universal health coverage’, ‘universal coverage’, ‘health care financing’, ‘health financing reforms’, ‘insurance’, ‘community-based insurance’, ‘demand-side financing’, ‘gender’, ‘women’, ‘maternal health’, ‘sexual and reproductive health’, ‘access’, ‘equity’, ‘equality’ and ‘efficiency’. The search limits included all articles published since 2000 in English. The India case study was based on published articles and reports about health financing in India since 2000 available from the same databases and journals, and key Indian sources publishing policy related articles (e.g. Economic and Political Weekly). The key words for the search included, in addition to those already mentioned, names of specific health financing schemes (e.g. Rashtriya Swasthya Bhima Yojana (RSBY)).
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