Ten arguments for why gender should be a central focus for universal health coverage advocates

To make universal health coverage (UHC) truly universal we need an approach which places gender and power at the centre of our analysis. This means we need a discussion about who is included, how health is defined, what coverage entails and whether equity is ensured. To celebrate Universal Health Coverage Day RinGs has put together a list of ten arguments for why gender should be a central focus within UHC. If you agree, spread the word. Mail this list to a colleague or put it up on your website. If you think of other arguments in favour of a gender approach do let us know!

1. Gender affects both vulnerability to illness and access to health care.

Gender influences how women, men, and people of other genders perceive, behave, interact and this impacts the social experience of being sick, seeking and receiving care. For example, gender norms and relationships in the Dominican Republic mean that women with lymphatic filariasis experience more social exclusion and shame than men, which in turn affect their health care seeking.

2. Gender combines with other social determinants in varied ways.

How gender is experienced can change when interacting with other forms of inequality, such as age, poverty, geography, caste, race, ethnicity, disability, and sexuality. Women and men from different socio-economic or ethnic groups can have vastly different experiences of the health system, which influences their access to health care, their treatment by health professionals, and their health outcomes. In rural India, while nonpoor men and poor women were at opposite ends of ability to access care, among middle groups, non-poor women and poor men had similar health care seeking outcomes, but their decision-making and pathways differed significantly.

3. Recognise power if you want to tackle inequalities in health systems.

Marginalized people (ethnic minorities, inhabitants of informal settlements, people employed in illegal occupations, etc.) may have different access to health care or receive different treatment by health care workers compared to others. Power relations between individuals (for example, husbands and wives or health care professionals and patients) influences the effectiveness of policies and programmes to achieve universal health coverage. Despite being inclusive of the poorest, community based insurance in India still generated inequities among rural populations with those more financially better off, closer access to care and men submitting more claims than other populations. Moreover, access facilitated by insurance was not always appropriate with insured women having higher rates of hysterectomies and hospitalisation for fever due to the lack of effective and quality primary care services.

4. Coverage can’t be universal if some services and service users are routinely left off the list.

Financial protection packages (i.e. prepaid health services under universal health coverage schemes) often exclude essential and routine sexual and reproductive health services, such as delivery and emergency obstetric care, family planning, and safe abortion. Where sexual and reproductive health care is offered, it often exclusively focuses on maternal health and doesn’t address the needs of adolescent girls and older women or men. Trans people all over the world survive despite inadequate provision of services and financial coverage.

5. Coverage can’t be universal unless it extends to all contexts.

Universal health coverage will not be achieved without additional research, resources and health system development in fragile and conflict affected contexts. Realising universal health coverage in these neglected contexts means understanding and addressing the ways in which gender, power and conflict shape the experiences and needs of different communities and their ability to access services, as well as ensuring efforts to support and rebuild health systems meet the needs of all citizens.

6. Paying out-of-pocket expenses for services adversely effects women.

This reflects hardship and injustice as women tend to have less income and less control over it and yet have to pay for health services that are more likely to not be covered by financial protection schemes.

7. Health system researchers must factor gender into their research.

To properly understand whether health systems are universal, we need data disaggregated by sex as a matter of good practice, regardless of whether sex or gender is perceived to be a factor. Once identified, inequities need to be recognised and addressed. If this doesn’t occur we will continue to put in place policy and programmes which are inefficient and discriminatory.

8. Policy makers need to use evidence that incorporates gender and power in their decision making around access to services.

For example, social roles for women in many societies include childcare and infant feeding and a potential consideration would be whether health facilities provide services for women and children at the right times (daylight, after school timings), with appropriate conditions (shelter from sun/rain in the waiting area, functional toilets, separate lines or waiting rooms for men and women), and with appropriate staff (breastfeeding consultants, female clinicians). When health centres are predominantly seen to cater to maternal and child health, mechanisms need to be explored to ensure access for men and other people.

9. Gender permeates all aspects of the health system and must be dealt with on different levels.

Gendered norms affect the health workforce (whether informal care provided at home is recognized and supported, recruitment and retention policies, staff security in remote areas or slums, maternity policies, workplace harassment policies and procedures). We need to address the gendered needs of all health workers, including close-to-community health providers who act as bridges between marginalised communities and health systems and are critical to universal health coverage. Gender also affects health financing (budgets for gender audits, the extent of financial protection available to different groups, out-of-pocket expenditures of different groups); and governance (representation of women and men in planning and oversight of all areas of health care; male involvement in maternal and child health).

10. We need this conversation to take place within and beyond the health system.

For example, men usually have more power and privilege than women, but they also have particular health needs. Men may be more likely to do dangerous jobs which can cause illness and disability, they are often influenced by harmful gender norms which encourage risk-taking, and in many settings they are less likely to visit a doctor when they are ill. Addressing these harmful manifestations of gender norms will require work beyond the health sector. We need to work with government ministries tasked with dealing with financing, gender, employment, education, and equality. Universal health coverage truly is everyone’s concern.

Want to read more? This article is based on:

Baker P, Dworkin SL, Tong S, Banks I, Shand T, and Yamey G (2014) The men’s health gap: men must be included in the global health equity agenda. Bulletin of the World Health Organization 92(8): 618-20.

Desai S, Sinha T, Mahal A, Cousens S. (2014) Understanding CBHI hospitalisation patterns: a comparison of insured and uninsured women in Gujarat, India. BMC Health Serv Res. 2014 Jul 26;14:320. doi: 10.1186/1472-6963-14-320.

O’Connell T, Rasanathan K, Chopra M (2014) What does universal health coverage mean? Lancet. 2014 Jan 18;383(9913):277-9. doi: 10.1016/S0140-6736(13)60955-1.

Khanna R (2012) Gender and universal health care in India http://uhc-india.org/uploads/RenuKhannaUHC12April.pdf 

Percival V, Richards E, Maclean T, Theobald S (2014) Health Systems and Gender in Post-Conflict Contexts: Building Back Better? Conflict and Health, 8(19).

Person B, et al., (2008) “Can it be that god does not remember me”: a qualitative study on the psychological distress, suffering, and coping of Dominican women with chronic filarial lymphedema and elephantiasis of the leg. Health Care Women Int,. 29(4): 349-65.

Raj A. (2011) Gender equity and universal health coverage in India, The Lancet, January 12, 2011 DOI:10.1016/S0140- 6736(10)62112-5.

Ranson MK, Sinha T, Chatterjee M, Acharya A, Bhavsar A, Morris SS, Mills AJ (2006) Making health insurance work for the poor: learning from the Self-Employed Women’s Association’s (SEWA) community-based health insurance scheme in India. Soc Sci Med. 2006 Feb;62(3):707-20.

Ravindran, TKS (2012) Universal access: making health systems work for women. BMC Public Health, 12 Suppl 1(Suppl 1), S4. Sen G and Iyer A (2012) Who gains, who loses and how: leveraging gender and class intersections to secure health entitlements. Soc Sci Med. 2012 Jun;74(11):1802-11. doi: 10.1016/j.socscimed.2011.05.035.

Vlassoff C, and Moreno CG (2002). Placing gender at the centre of health programming: challenges and limitations. Social Science & Medicine, 54(11), 1713–1723.

Image of men and women dancing in DRC courtesy of André Thiel 

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Community engagement to tackle maternal mortality in South Sudan

By Sally Theobald

With 2,054 maternal deaths per 100,000 live births, South Sudan has the highest maternal mortality in the world.

South Sudan is in transition. With years of conflict and the construction of a new nation, existing gender norms which mandate women bear many children have been intensified in order ‘to replace the ones that were lost’. Gender and societal norms are in transition. Elders complain that the young no longer listen to and respect their elders, couples do not keep to the traditional three years birth spacing, and marry younger and younger. Parents worry that their girl may get pregnant before marriage so they marry her off early, especially if she is not in school. Girls and boys have very limited access to sex education or contraceptives. These factors can lead to early pregnancy.

The SHARP Programme: community engagement for change

Korrie de Koning (Royal Tropical Institute) and Kingsley Chikaphupha (REACH Trust) have been working on the community participation component of the ‘SHARP’ programme in South Sudan. They provided some insights into how it is altering community norms around maternal health.

The SHARP programme aims to improve maternal health and is funded by the Dutch Government and is a collaboration of the South Sudanese Ministry of Health, Royal Tropical Institute, IMC, Healthnet TPO and Cordaid.  .

As part of the programme the Royal Tropical Institute developed a curriculum for the training of community facilitators to support dialogue and reflection on norms and values shaping maternal mortality and health service access and use. The curriculum was shaped by various sources, but drew substantially on the GTZ developed generational dialogue The curriculum was further adapted with input from the Community District Health Department in Wau, WBeG and Aweil North in Northern Bahr el Ghazal, REACH Trust, Malawi, International Medical Corps, and Healthnet TPO . Training of facilitators focussed on dialogue between older and younger women and men, comparing social and gender norms and practices between present and past, sharing knowledge on maternal health and discussing what needs to be changed for maternal health to improve.

How does it work?

Groups used drawings, statements and proverbs to explore the relationships between communities by gender and generation. For some women, this was their first experience of holding a pen or pencil but they were skilled in drawing images of maternal health decisions, dilemmas and outcomes throughout their life cycle. The ‘but why’ technique was used to probe and understand the rationale behind different cultural norms, their meanings and whether they were seen as fair.

Kingsley facilitated the men’s groups and explained at first there was complete refusal to even entertain the possibility of a discussion on contraception but use of the “but why” technique enabled discussion on the impact of multiple births on (especially young) women and child survival rates. This led to some shifts in viewpoints. Drama was also used, and women acted out what it is like to have obstetric fistula, and how women with urinary or faecal incontinence were treated within their communities. Following work in women and men only groups, the community fed back their ideas and experiences to each other, and for many women (who are very powerful within their own domains) this was their first experience of speaking publicly in front of men.

What changed?

Through the facilitated discussions between genders and generations statements for change were negotiated and agreed. Here are some examples:

  • “If a man with more than one wife is not looking after one of his wives and their children, the wife has the possibility to refuse to produce any more children without having to pay back the cows/bride price and also has the right to not be beaten.”
  •  “We don’t want daughters to marry or be pregnant before 18 years old and we in our family will do all we can –  we want to pledge this to our family and community.”
  •  “Married women should be allowed to use contraception and have three year birth spacing.”

This is an inspiring example of how community engagement can shift gender and societal norms and shows great facilitation skills from Korrie and Kingsley. Facilitators are being trained at local level and the approach will be rolled out and hopefully continue to challenge and change views and practices that undermine women’s maternal health.

We want your photos! Gender, ethics and health systems

The aim of this competition, organised by Research in Gender and Ethics (RinGs), a new cross-RPC partnership between Future Health SystemsReBUILD and RESYST, is to capture the everyday stories of the ways that gender plays out within health systems around the world. The winning entry will be exhibited at the Global Symposium on Health Systems Research, and be used to illustrate our website, and in other published materials with full credit to the photographer.

Gender-sensitive health policy is a feature of international commitments and consensus documents and national-level normative statements and implementation guidance in many countries. However, there are gaps in our knowledge about how gender and ethics interface with health systems. Our project shines a light on some of the ways that gender and health systems come together in a variety of settings. We are looking for photographers who can help us communicate this area of work visually. We welcome images of people of all genders from all areas of the health system, all around the world – be creative!

The deadline for entries is the 1 September 2014.
The judging

Photographs will be judged by a panel of gender specialists and a representative from the creative industry. They will be marked according to:

  1. Their content, i.e. their relevance to subject.
  2. Their ability to tell the story of gender and health systems, i.e. the message they contain, their creativity. We are looking for original and authentic visual representations of health systems in action.
  3. The technical merit of the photo, i.e. exposure, focus, colour, lighting etc.

We are looking for images which challenge stereotypes, encourage the viewer to learn more and act differently, and which respect the integrity of any people who may be photographed. There is a rich discussion on the ethics of photography in international development which should help guide entrants. Further information can be found here and here.

Who can enter and how to submit?

Those who have an experience of, or interest in, gender and health systems are very welcome to send images.

Send up to a maximum of three photos by email to RinGs.RPC@gmail.com

Submission requirements

  1. Size: At least 1MB
  2. Print resolution: 300 dpi
  3. Format: JPEG or tiff only
  4. Landscape and portrait images are acceptable
  5. Although some digital enhancement is acceptable we cannot accept images that have been digitally altered to change what is portrayed.

Send each photo separately and include in your message the following information:

  • Name of photographer:
  • Photographer email:
  • Photographer phone:
  • Title of photograph:
  • Location (country and city/town/village where the photograph was taken):
  • The date (if unknown, please provide the year) each photograph was taken:
  • The level of consent provided from any people pictured in the photo (see informed consent guidelines for more information):

Submit your entry

All images should be emailed to RinGs.RPC@gmail.com by the 1 September. We look forward to receiving your entries.

For more details please download the entry requirements and termsInformation about informed consent and a sample consent form are also available.

The image accompanying this story was provided courtesy of  UNHCR/S. Phelps