This blog post is part of a wider HSG blog series to celebrate Internation Women’s Day 2018. In this series, HSG members provide their perspectives on why gender should be a critical component of UHC, and what we can do about it.
By Salla Atkins – Associate professor, New Social Research and Faculty of Social Sciences, University of Tampere & Vikash R Keshri – Health Policy and Systems Specialist, The Centre for Health Policy, ADRI, Patna, India (Members of the HSG SHAPES Thematic Working Group)
Gender is a social paradigm, critical for healthcare. Gender discrimination in healthcare starts right from the time fetus is in utero (womb). The incidence of female feticide in some countries, especially in India and other low-and middle-income countries (LMICs), is a stark example. Similarly, the gender gap in morbidity and mortality pattern is another indicator pointing towards an urgent need to keep the gender lens wide while planning for Universal Health Coverage (UHC), especially in LMICs. Coverage is essential, but while we strive toward this, Sustainable Development Goal (SDG) 5 on gender equality, should not be forgotten.
Women face more barriers in accessing healthcare
Biological and gender-based differences result in different health risks and health needs for women. This is further complicated by ongoing demographic and epidemiologic transition. Gender inequalities are present in all existing morbidities, and illness is most likely under-reported by women. Women consistently have more difficulty than men in accessing the healthcare they need. These access barriers can be, for example, lack of transport or funds for transport to the clinic to receive medications or for consultation with doctors or nurses, or childcare responsibilities.
Women also experience more stigma than men. In countries such as India, health insurance coverage is higher among males than females, as men also work more and thus have better access to care. And approximately 67% of women in India face at least one barrier in accessing healthcare, one of which is having to ask permission from husband or male guardian to seek treatment.
UHC ensures healthcare at the point of service, but it is not sufficient to remove these common barriers to access, many of which are exacerbated by the connection between gender and poverty. For this, gender-sensitive policies and gender-embedded UHC planning is needed. One such policy is social protection, which could be insurance or cash grants provided to patients at their time of need.
Tuberculosis: An example of poverty and gender determinant
Tuberculosis remains a major health threat in LMICs, with 10.4 million people becoming infected with, and approximately 1.7 million people dying from, tuberculosis in 2016. Although care for TB is nearly universally available and free, the associated costs of treatment (for example, transport costs, loss of income due to the need to attend clinic appointments) can drive patients into further poverty. When these costs exceed 20% of household annual income, they are considered “catastrophic” and can drive patients to non-adherence, and even death.
Is social protection an answer?
Social protection as an intervention to counter the costs associated with treatment despite UHC is not only necessary, it is a human right. Traditionally, TB patients receive food to support their treatment – but the World Health Organization’s (WHO’s) new End TB strategy underscores the goal of no families encountering catastrophic costs by 2020. Food alone is insufficient to reach this goal. However, there is not enough evidence to support policymakers to shift from nutritional support to cash, and there is some suspicion about how the money is ultimately used.
Additionally, when social protection is provided in the form of cash, it may also have a number of unintended consequences. A recent study shows that relationship power can mediate the outcomes of cash transfers on sexually transmitted infections. Further, in Ecuador, research indicates that cash transfers can potentially increase emotional violence in the household if the woman’s education level equals or exceeds the husband’s.
While social protection can help redress gender imbalances in UHC, such approaches should be carefully evaluated.
How can social science approaches address this challenge?
In implementing new initiatives, health policy and systems research (HPSR) is essential – particularly when aiming to correct existing, or prevent further, inequities. Social science approaches help us to tease out the intended and unintended consequences of social protection interventions and how they relate to gender, and to start finding ways to counter them. In order to provide the support required by patients with poverty-related diseases, policymakers need evidence of health outcomes, poverty levels, economic impacts of the disease, and how these may be different for women and men. They need evidence on how men and women use social grants, to enable evidence-informed decision making. And they need activism and support, to change mind-sets about the need for social support and to support gender equity. UHC will take different shapes in different countries and move in different directions at different speeds, but cannot be achieved anywhere without addressing gender equality and particularly, the role of women in health.