Thoughts on Links between Gender and Universal Health Coverage

  • By: Willow Gerber

Almost a year ago, at the June 2012 Rio+20 UN Conference on Sustainable Development, a resolution was adopted to call attention to universal health care (UHC).[1]  It stated that, “We [also] recognize the importance of universal health coverage to enhancing health, social cohesion, and sustainable human and economic development. We pledge to strengthen health systems towards the provision of equitable universal coverage.[2] Many countries have agreed that providing UHC is a worthy investment for their population’s development and prosperity. Links between gender and UHC—and in particular how universal health coverage can have a positive effect upon the health of women and girls—are an important consideration in advancing this agenda. Health leaders, managers, and those who govern in low- and middle-income countries play a vital role in this effort, especially in how they negotiate the gendered social determinants of health within their respective areas of responsibility.Malian woman health worker.

Social determinants of health are “the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are influenced by gender, and shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries.”[3]  Without understanding the ways in which socially constructed inequalities (i.e., female-headed households tend to have fewer resources than male-headed households, and have less money to spend on everything, including health-related services), affect the health of women and girls, there can be no real promise of UHC.

Attitudes and expectations related to economic status, social stigma, and other societal beliefs limit women and girls’ access to resources, the treatment they receive from health providers, and the skills they gain that are associated with better health.  Such health-related vulnerabilities have social and financial costs that hamper the consistency and quality of available health services and are linked to poorer health outcomes for women and girls.

In order to advocate for UHC and make the most of a country’s effort to carry out this goal, health leaders, managers, and those who govern must recognize their part in reinforcing gender inequality in the healthcare system and work to end social biases and gender-based discrimination, whether deliberate or unintentional. Among other things, health leaders must support the hiring and promotion of women; advocate for gender-sensitive employment and working conditions; help to reduce women’s out-of-pocket healthcare payments[4] (that are generally higher than men’s due in part to the high costs of newborn deliveries and reproductive health services); adjust clinic hours to accommodate women and girls’ mobility constraints; and consider how even unexpected health provider bias can make female clients hesitate to seek the services they need in a timely fashion. Anyone who is responsible for expanding health coverage must consciously examine possibilities of institutional gender bias and discrimination that impede program effectiveness and outcomes.

With considerable advances being made in understanding how gender inequalities affect health,[5] and in efforts to promote health systems strengthening with gender equity in mind, the LMG Project is working to support and advocate for gender-equitable systems that allow more women to move into health leadership and governance positions. The expectation that having more women is such positions could in turn result in more gender-equitable health planning and service delivery is an exciting prospect, and one that will be closely watched and reported on by myriad groups. More specifically, the hope is that having women in positions of leadership will help healthcare institutions actively address the things that get in the way of women getting care.

Approximately 50 countries have attained near-universal health coverage, and emerging economies and populous countries such as Indonesia, China, India and South Africa, are working to institute government-funded programs of health care.[6] Low- and middle-income countries such as Ethiopia, India, Mexico, and Rwanda have also developed UHC plans.[7] This progressive movement toward UHC is due to the Ministers who have signed relevant political statements and declarations (Bangkok, January 2012 and Mexico, April 2012) reaffirming people’s right to healthcare and the state’s role in realizing this right. Credit is also due to all of the health leaders, managers, and governors—past, present, and future—who tenaciously continue to make social inclusion and health service access a realizable goal for women and girls around the world.                                                                                                                                                                          

In keeping this global movement toward UHC in mind, health leaders can consider how they and their colleagues can take action to help key players in the health system focus on social (namely gender-focused[8]) determinants of health according to the 2011 Rio Political Declaration.[9] Ask yourself how you can help by:

  • Adopting improved governance for health and development
  • Promoting participation in policy-making and implementation
  • Further reorienting the health sector towards promoting health and reducing health inequities
  • Strengthening global governance and collaboration
  • Monitoring progress and increasing accountability

Look for a forthcoming paper authored by leading gender experts—including LMG project staff—that will present the state of the evidence, research gaps, and a perspective on what the health systems research agenda must include related to the relevant conditions for UHC, including gender equitable practices and good governance.

Willow Gerber is the Knowledge Exchange and Innovation Senior Technical Advisor for the Leadership, Management & Governance Project.

[1] Though multiple definitions exist for UHC, for the purposes of this text, we use a broad definition of UHC as “a well-functioning health system, with some financial protections and some basket of services,” where “well-functioning” assumes the system is trying to reach everyone.

[2] United Nations – The Future We Want: Outcome Document Adopted at the Rio+20 Conference. Available at:

[3] . Accessed April 12, 2013.

[4]  Ravindran, TKS. 2011. “Universal access: making health systems work for women,” BMC Public Health 2012, 12(Suppl 1): S4.

[5] Margaret E. Greene and Gary Barker. 2011. “Masculinity and Its Public Health Implications for Sexual and Reproductive Health and HIV Prevention,” in Routledge Handbook of Global Public Health, ed. Richard Parker and Marni Sommer. New York: Routledge.

[6] From World “Momentum Builds for Universal Health Coverage,” Yale Global Online:

[7] International Labour Office. 2008. Social Health Protection: An ILO strategy towards universal access to health care. Geneva: ILO.  Available at

International Labour Office. 2010. World Social Security Report: Providing Coverage in Times of Crisis and Beyond. Geneva: ILO. see Table 27, page 267; Table 29, page 275

[8] In this context, “gender-focused” determinants of health are the socially constructed experiences that shape women and girls experiences, including the economic, cultural, and political inequities they face by virtue of being female.

[9] The Rio Political Declaration on Social Determinants of Health was adopted during the World Conference on Social Determinants of Health October 21, 2011. The declaration expresses global political commitment for the implementation of a health approach that reduces health inequities as one of the ways to achieve a number of global priorities. The Rio declaration can be accessed on the WHO website (downloadable in eight languages) here:

Photo courtesy of: Willow Gerber

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