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In the context of universal health coverage, gender takes on two dimensions and, without due consideration to both, the movement’s progress will be severely limited
By Ilona Kickbusch
Universal health coverage, as the essential foundation for attaining health for all, has long been seen as an issue for national or even sub-national governments. At the international level, it has largely been left to the World Health Organization, its regional affiliates and the members’ health ministers that govern these bodies to provide the necessary encouragement and practical support.
Universal health coverage is a very tangible thing – its presence (or absence) is experienced by people in a community in so many ways. First, when available, it provides a feeling of security. In its essence, it means that there is support available should a person experience a health problem – support that will not endanger the economic survival of the household, and will not hinder access based on factors such as sexual orientation, ethnicity or migrant status. We look too frequently to health policies only to ensure the right to health, whereas a complex web of policy decisions requires attention as many elements intersect.
That is why it is important that heads of state and government are fully aware of the many political dimensions of universal health coverage. The political choices they must make include many different and often highly controversial policy agendas.
One central and often overlooked policy dimension is gender. Economists and development specialists highlight the historical opportunity of a youth dividend in many developing countries. Yet the gender dividend – particularly relevant for health – has not yet gained the attention it deserves.
Universal health coverage is inextricably linked to many other features of a society – especially its economic development and social cohesion. The economists in this book argue forcefully for this. That is why the strategy of many health advocates has been to reach out to finance ministers to invest more in health. This is also a key feature of Japan’s G20 activities in 2019 to support universal health coverage.
But if we consider that countries must also invest better, there is one defining feature that moves to the centre: gender. It has two key dimensions: addressing gender equality in health systems design and delivery and in the health workforce. ‘Women in Global Health’ has summarised this in a simple message: universal health coverage will not be achieved anywhere without addressing gender equality, women’s rights and the role of women in the global health workforce.
Economic growth, finance, employment and education
The World Bank draws attention to the fact that societies can only substantially boost their gross domestic product if they increase female workforce participation. Most of the people working every day delivering health care – front-line health workers, community health workers, community nurses, service delivery providers – are women. Half of women’s contribution to global health is unpaid as part of their family duties. Health workers play an integral role in improving health and supporting the wider economy.
A deeper understanding of the gendered composition of the health and social workforce is imperative to achieve efficient, effective, resilient and sustainable health systems. Unless societies invest in the education and workforce participation of their girls and women, they will not be able to resolve the challenges they face in expanding universal health coverage, which in turn relies on being able to meet other demands for economic growth. In health – as in other workplaces – work needs to be decent and well paid and workplaces need to be safe.
And a wide range of ministries need to be engaged far beyond the health sector to address social norms – such as the age of marriage, women’s right to decide to work, the gender division of labour as well as many of the other structural barriers that keep women out of the workforce. Ministries of justice and constitutional courts can play a pivotal role in taking these agendas forward.
The World Health Organization recently reported that globally total health spending is growing faster than GDP. It is increasing more rapidly in low- and middle-income countries (close to 6% on average) than in high-income countries (4%). The global health economy is one of the fastest growing investment sectors, and global healthcare expenditures are likely to continue rising as spending is projected to increase from $7,724 trillion in 2017 to $10,059 trillion in 2020.
In middle-income countries, average per capita public spending on health has doubled since 2000, as these countries progress in their transition to domestic funding. With this health coverage expansion, the demand for health workers is expected to double to 80 million health workers by 2030. But if present trends continue, that expansion may well be thwarted by a shortfall of 18 million health workers, primarily in low- and lower-middle income countries.
This situation applies especially to nurses and midwives, who account for nearly 50% of the global health workforce.
Already today 50% of WHO members report having less than three nursing and midwifery personnel per 1,000 population, and about 25% report having less than one per 1,000. As policies for universal health coverage are put into place, the role of the health sector as among the biggest and fastest growing employers of women – estimated at 70% of the health workforce – must be central to any development plan.
Investments in the health and social workforce creates much-needed jobs for women, contributes to their economic independence and is part of a societal dynamic to improve their role in society. This requires the full involvement of the education sector to ensure that girls are provided with the educational opportunities and the professional training to participate in the health labour force.
Ministries of labour also need to be fully involved in addressing the growing demand for health workers in all countries. Effective health labour market policies need to be developed and to consider the root causes – such as gender – of key workforce challenges. There will need to be strategic investment to remove structural barriers that presently do not allow women to take on senior leadership positions.
Migration, refugees and asylum seekers
Ministries of labour will also be confronted with regulating an increasing migrant health workforce, with female nurses globally making up the dominant number of health worker migrants. This often includes managing migration and improving the retention of health workers at the same time, or, as in some countries, explicitly training health workers for export.
Implementing the 2010 WHO Global Code of Practice on the International Recruitment of Health Personnel requires extensive intersectoral cooperation – including the ministry of foreign affairs, as bilateral agreements are crafted between countries that need to be based on it to ensure fairness and social justice for all health workers and professionals and to ensure their rights in the receiving and sending countries. New initiatives at the global level such as ‘Nursing Now’ are focusing on the required policies.
Tensions can emerge particularly in countries that receive high remittances from health workers abroad. Gender dynamics play out here as well: a not inconsiderable part of the estimated $465 billion in remittances flowing into developing countries comes from women health workers abroad. Women migrants tend to remit higher proportions of their income and do so more frequently than do male migrants. They also tend to allocate more resources for the benefit of their children, which is critical for the intergenerational effects of social development. Increasingly tax, banking and insurance laws are being adjusted to take these factors into account.
Countries will need to establish supportive working and living environments and opportunities for professional growth so that health workers are less likely to migrate. Unless this is done with a clear understanding of the role and needs of women in the health workforce, no such strategy will be successful. One way is to involve representatives from the extensive female health workforce in shaping these plans. This means including not only female doctors, nurses and midwifes but also the community health workers – paid and unpaid – in decision making.
The new initiative ‘Communities at the heart of UHC’ is leading an effort to elevate the visibility of community health in the context of universal health coverage and provide women community health workers with voice and leadership roles. That critical dialogue shines a light on the need to provide paid work for women. As one community health worker said, “In Ethiopia we have managed to push out a very strong community agenda with CHWs at the heart of health care delivery because Ethiopia as a country made a political commitment to integrate CHWs into the formal health system and compensate them. Therefore, we are held accountable by the fact that we are salaried, which in most African countries is not the case; CHWs are volunteers. Why don’t other countries pay their CHWs so that they can be held accountable too and deliver results for UHC?”
Addressing the gender dimension and dividend of universal health coverage lets us understand better the span of the challenge between community health care and the cross-border dimensions of universal health coverage. Such factors – which again are highly gendered – include in particular the global care chains and the growing number of migrants, refugees and asylum seekers, many of them women. A quick glance shows us that:
As the absolute numbers of those migrating to work in health and care abroad increases, a ‘care drain’ is created in the global South, in poorer parts of the European Union and other developing regions, and in the rural areas of countries with large internal (rural–urban) migration. This tilts care resources towards cities and the global North, as WHO’s Women on the Move illustrates.
Many of the 258 million international migrants and 763 million internally displaced people lack proper access to health services as well as financial protection. Many migrant, refugee and asylum-seeking women and girls have been exposed to various forms of gender-based violence. Due consideration needs to be given to their needs and circumstances and gender-responsive measures should be adopted.
The UHC2030 global asks call on political leaders to legislate, invest and collaborate with all of society to make universal health coverage a reality. If this is done with keeping the principles of gender equality and equity in access in mind and acknowledging the role of women as 70% of the health workforce when formulating policies, then societies will reap a tremendous gender dividend.
Investing in programmes that improve income-generating activities for women can return $7 for every single dollar spent. Apply this to the health sector, where the social benefits generated can be manifold if they are part of a strategy to build quality health systems that people and communities trust.
The Sustainable Development Goals – especially SDG 5 to ‘achieve gender equality and empower all women and girls’ – reiterate that gender equality is not only a fundamental human right, but a necessary foundation for a peaceful, prosperous and sustainable world. Advancing gender equality is critical to all aspects of a healthy society, from reducing poverty to promoting the health, education, protection and well-being of all. This is an agenda that the upcoming G20, G7, United Nations and other high-level meetings need to take up with determination.