Building back better: why and how countries can apply a gender lens to accelerate UHC

In the wake of the COVID-19 pandemic, calls for universal health coverage (UHC) are growing around the world. So, too, is the recognition that because gender equality and women’s rights are foundational drivers of health, efforts to achieve UHC should incorporate a gender lens.

Even before the pandemic, experts made it clear that standard approaches to achieving UHC were failing women by often excluding or marginalizing gender concerns "when framing problems, identifying and gathering data and evidence and designing programmes and policies.” By ignoring or downplaying the fact that women need different health care, experience health care differently, and face unique challenges in accessing health care and information about their health, they said, traditional approaches to UHC have undermined the very goals of UHC and made health gains more fragile.

Health systems that do not prioritize access to family planning or prenatal care in their delivery of primary health care are the most obvious example of these failings. However, health systems also need to recognize that women often find it harder to access all types of primary health care because they typically have less money, less free time, less autonomy, and less information.

Now, in the wake of the COVID, the pandemic’s regressive impact on gender equality has demonstrated how health policy decisions do not impact everyone equally, said Ann Keeling, a senior fellow at Women in Global Health, and one of the experts calling for gender responsive universal health coverage. Efforts to achieve UHC that do not start with a gender lens and intentional goals of inclusion, she said, will by default become mechanisms of exclusion and further inequity. “No one is safe until everyone is safe” is true both for pandemic response and UHC, she said.

So as health leaders set their sights on "building back better" following the pandemic, Keeling said, they need to adopt a gender lens in their work towards UHC – promoting a vision of society that is both healthy and equitable.

A good example of gender responsive efforts towards UHC is Pakistan’s Lady Health Worker Program, said Keeling. The program, which serves as the backbone of health care delivery by training women health care providers to go door-to-door to provide women with primary health care, has helped reduce maternal health and infant mortality, and improve vaccination rates.

In 2019, every country in the world affirmed a commitment to achieving UHC by 2030 as part of the Sustainable Development Goals. Relatively few have made significant progress on this front since that declaration, but a longer view provides reason for optimism. Typically, crises have prompted progress toward UHC and more broadly, created momentum toward addressing underlying inequity. Many health leaders hope the pandemic will serve as a similarly transformative event, ushering in an era of progress toward a gendered approach to UHC.

Research is rife with examples of crises sparking social movements to address inequity. For example, Brazil’s Sanitary Reform Movement, sparked by research revealing the depth of inequity in access to health, helped establish the Unified Health System, SUS, the largest, universal, free public health system in the world, covering nearly 160 million people, or 60 percent of Brazil’s population. The SUS helped reduce under-five mortality by more than two-thirds and maternal mortality ratio from 143.2 to 59.7 per 100 000 live births between 1990 and 2015. Another example is Peru’s childhood stunting crisis, which united civil society around specific and achievable targets to reduce stunting. The civil society coalition successfully advocated for extending the health system to poor women in particular. Their efforts gave rise to Peru’s insurance program (SIS) which covers more than 70 percent of the poor and 40 percent of the country’s population, and is credited with expanding health seeking behavior and improving health generally in Peru with a special emphasis on improving rural women’s access to health.

With that in mind, Keeling, Divya Mathew of Women Deliver, and Chantal Umuhoza from Rwanda's SPECTRA (whose organizations are co-conveners of the Alliance for Gender Equality and Universal Health Coverage), have developed five recommendations, summarized below, to ensure that post-pandemic progress on UHC is gender-responsive:

1. Design policies and programs with an intersectional lens that place sexual and reproductive health and rights (SRHR) and girls and women at the center of UHC design and implementation. This requires addressing the ways in which race, ethnicity, age, ability, migrant status, gender identity, sexual orientation, class, and caste multiply risk and impact health outcomes.
2. Ensure UHC includes comprehensive SRH services, and provide access to SRH services for all individuals at all ages. These services must be free of stigma, discrimination, coercion, and violence and be affordable. The World Health Organization provides guidance in their UHC Compendium of interventions. Nepal is an example of a country that treats sexual and reproductive health care as an essential part of primary health care.
3. Prioritize, collect, and utilize disaggregated data, especially gender-disaggregated data. UHC policy and planning can only be gender-responsive when informed by gender disaggregated data. What we count matters.
4. Foster gender equality in the health and care workforce and catalyze women’s leadership. Safe, decent, and equal work for women health workers, as well as equal footing for women in leadership and decision-making roles, must be central to the delivery of UHC. Ethiopia’s community health worker program is an example of a program that tries to achieve gender equity in its health workforce.
5. Advance SRHR, gender equality, and civil society engagement in UHC design and implementation with funding and accountability mechanisms to reduce inequalities between and within countries — and address gender inequality, all of which undermines social and economic rights and resilience.

 A February meeting of ECOWAS Health Ministers resulted in a WAHO declaration --reviewed and endorsed by the 12 member states' Ministers of Health and Ministries of Finance guaranteeing “access to sexual and reproductive health services (including family planning).” Importantly, the declaration included an accountability mechanism, a biennial summit to assess progress against the implementation of the declaration.

Another country that is taking steps towards achieving gender responsive UHC is Chile. The country, now led by a cabinet that is majority women, has vowed to both achieve UHC in the next 4 years and mainstream gender across the board. Its new health minister, a woman, takes office on March 11th.

“Many countries’ response to COVID demonstrated exactly what not to do,” said Keeling. “Countries shut down their SRH services. As a result, they saw maternal mortality increase. They saw an increase in unplanned pregnancies. They will likely see an increase in childhood stunting. Governments around the world have signed up to do better. Putting it into practice is a stretch. But it can be done.”