At the global level, awareness is growing on the need to include gender considerations in health policy formulation, implementation, and research. Scientific publications, blogs, and to some extent even media coverage are drawing increasing attention to the fact that while women represent half of the global population, their voice is largely underrepresented in global health leadership and practice. This leads to the formulation and implementation of policies that under the label of “universalism” end up reinforcing, instead of counteracting, gender inequity by not explicitly taking account of women’s specific health needs, capabilities, and preferences. Feeding into this global momentum, the Women in Global Health movement is working to uncover sources of institutional gender discrimination that permeate both global health practice and research.
Within health systems, health financing has been particularly negligent in addressing gender inequality explicitly. As our colleague Clara Affun-Adegbulu stated so nicely in a recent blog, health financing reforms are often implemented with no explicit consideration of how they will affect women’s lives, within and beyond the health sector. It is against this background and motivated by the urge to make a personal contribution towards this global dialogue that we seized the opportunity to use the Global Symposium on Health System Research (HSR2018) to look at how gender inequity is addressed in health financing.
Our session in Liverpool brought together researchers, policymakers, and implementers to:
In line with the session objectives, five brief presentations provided the initial impetus for discussion through the description of cases (Canada, Ghana, India, Bangladesh, and Malawi) relevant to exploring the gender dimension of health financing reforms in LMICs. On the one hand, the presentations highlighted the contribution that different health financing reforms acting on either the demand (such as insurance and conditional cash transfers) or the supply side (such as performance-based financing) can make to voice women’s concerns and hence ultimately foster their empowerment. On the other hand, the presentations also displayed the limited reach for health financing reforms to stimulate greater gender equity when they are designed to be universal.
After the presentations, the audience split into two groups for a focused roundtable discussion. Below, we provide a brief outline of the principles and solutions identified to develop more gender-sensitive health financing reforms.
Key principles for designing reforms
*Addressing gender equity entails more than addressing women’s health and their right to health and needs to rest on a gender discourse that is inclusive of both men and women. In general, compared to men, across LMICs, women represent one of the most vulnerable segments of the population. Health financing reforms should actively counteract existing inequalities by explicitly addressing the sources of vulnerability women are exposed to along the lifecycle. Actively involving men is the only means of ensuring long-term gains for society as a whole.
*In reforming health financing, one ought to consider the costs and benefits of universal vs. targeted policies. The last few years have seen the rollout of many interventions specifically targeting women, but the gains achieved could easily be undone if attention to vulnerable groups is not kept alive. We thus need to move beyond targeted efforts and women’s health needs to be at the core of the universal health coverage (UHC) discourse.
*Consider the concept of intersectionality when designing health financing reforms, since women are often exposed to multiple sources of vulnerability. In many settings, gender inequality is coupled with ethnic-based or socio-economic It is important to listen to women’s own voices to understand how exposure to multiple sources of vulnerability affects their health and access to services within a specific context.
The roundtable discussions led to the identification of pragmatic solutions explicitly designed to promote gender equity in health financing policies. Examples of gender inclusive strategies included:
*Removal of a household ceiling to enrolment in health insurance, to avoid that male household heads privilege insuring male above female household members.
*Implementation of cashless systems, whereby beneficiaries are not asked to pay for treatment in advance (and receive reimbursement afterwards), to foster women’s empowerment by removing the need to discuss intra-household resource allocation with their male partners.
*Development of a benefit package that beyond cost-effectiveness considerations, is inclusive of services specifically addressing women health needs and preferences along the lifecycle.
*Endorsement of performance assessments for social health protection schemes that include explicit gender and equity indicators.
*Implementation of exemption schemes to avoid any co-payment for the most vulnerable groups, considering intersectionality concerns.
Our role on the way ahead
Our session concluded with a reflection on the responsibility that each one of us carries to ensure that the vision that emerged from our discussions is translated into a tangible reality. We recognized that while we all belong to the global health community, our roles and responsibilities within this community are different. For those of us working in policy and technical advice at the international level, responsibility lies in the capacity to move gender considerations at the core of the UHC discourse, explicitly recognizing health financing as a means to foster greater gender equity. For those of us working in policy formulation and implementation at the country level, responsibility lies in the capacity to act as gender-informed legislators, promoting the development of inclusive health financing strategies. For those of us working in research, responsibility lies in shedding light on existing inequalities, in offering a voice to those who have long been silenced, and in generating evidence on successes and failures of gender-inclusive health financing reforms.
No matter where we stand, it is imperative that we assume personal responsibility and realize that irrespective of the specific tools at our disposal, we can all become agents for change in promoting greater gender equity.