Minding the gaps: health financing, universal health coverage and gender

Abstract

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.

Health financing and family planning in the context of Universal Health Care: Connecting the discourse

“…Out-of-pocket (OOP) expenditure has continued to feature as part of domestic financing and comprises over 40% of average total health expenditure in low-income countries (WHO, 2017). Gendered inequities in service access and the disproportionate barrier that OOP spending creates for women and adolescent girls is rarely recognised or analyzed as part of domestic financing (Witter et al, 2017).…”

“…For example, the economic emphasis of UHC on domestic financing have conflated it with insurance, may make it vulnerable to political and financial pressure and privilege clinical over public health interventions (Hill, 2018;Schmidt et al, 2015). Additionally, less powerful groups, such as poor women, who have higher health needs and lower financing capabilities than men, may not be prioritized (Witter et al, 2017).…”

“…These may be more important over time, particularly if these are positioned as the main vehicles for UHC, as in the case of national health insurance in many contexts. Lessons emerging from Mexico and Thailand suggest that progress towards UHC in terms of developing effective financing mechanisms needs to be accompanied by attention to services which predominately affect women, such as SRH, and efforts to tackle the underlying political and social determinants that undermine access for vulnerable and marginalized groups, such as poor and marginalised women and adolescents (Witter et al, 2017). Where FP and other SRH services have been effectively included in national health insurance schemes, this has been associated with improved access to and uptake of modern FP methods, as demonstrated in the LAC region (Fagan et al, 2017).…”

Health financing and family planning in the context of universal health care: Connecting the discourse in Kenya

“…This approach assumes an ability to segment the market based on willingness to pay and may not consider the intersectionality of gender with other social stratifiers. For example, women already incur more OOP costs for health than men and OOP expenditure may prevent more women than men from utilizing essential services (Witter et al, 2017). While the global evidence on user fees as a barrier to FP is inconclusive, poorer and/or younger populations appear more price sensitive than the average population (Korachais et al, 2016).…”

Financial Inclusion and Health Shocks: A Panel Data Analysis of 36 African Countries

“…Researchers to date have made considerable effort in estimating the effects of health insurance and spending on health outcomes in developing countries (Alam and Mahal, 2014;Witter et al, 2017;Dake, 2018;Dorfleitner and Rößle, 2018). However, little is known about the extent to which financial inclusion affects health shocks in Africa, where formal health insurance is hardly accessible and limited.…”