This opinion article was written by Veronica Magar, Team Leader for Gender, Equity and Human Rights at WHO, Divya Parmar, Senior Lecturer in Public Health at the University of London and Gerardo Zamora, Programme Officer at WHO. This article is the first in a series of opinion articles that will focus on gender and health leading up to the UN High-level meeting on Universal Health Coverage in September 2019.

In the Sustainable Development Goals, all countries have committed to achieving Universal Health Coverage (UHC) — meaning that everyone receives the essential health services they need without experiencing financial hardship — by 2030. We are a long way from that target.

At least half the world’s population lacks access to essential health services, and every year more than 100 million people are pushed into extreme poverty because of paying for health care out of their own pocket. This is not acceptable.

Gender and equity are central to universal health coverage. In many countries, women face the biggest barriers in accessing health due to gender discrimination. At WHO, we will not be satisfied until everyone in a population has equal access to quality services that are affordable, effective and gender-responsive.

Women’s life-long health needs

Social, cultural, financial and legal barriers along with gender inequality, discrimination and gender-based violence create critical challenges for women’s health, especially sexual and reproductive health. Women have limited control over resources, less decision-making power and lower health literacy which affects their access to health care.

Men have a shorter life expectancy than women in every country, and are more likely to die prematurely due to smoking, alcohol use and other harmful behaviours

Globally, about 40% of women aged 15-49 years miss out on WHO’s recommended four health visits during their pregnancy and 38% sexually active women are not using modern contraceptivesLimited access to sexual and reproductive care is one of the reasons for persistently high maternal mortality, particularly in Africa. Cardiovascular diseases are also a major cause of death among older women -- 7.7 million women over 60 years died from cardiovascular diseases in 2016. Due to gender norms and roles, girls are typically less physically active than boys in childhood, they are at higher risk of obesity, a gender gap that persists throughout life.

Many women also lack social health protection such as maternity benefits and health insurance, creating additional health risks and financial barriers for women.

Health outcomes and access to health services are worse among disadvantaged women, such as women with low incomes, in rural areas, migrant women, and women belonging to minority ethnic and religious groups, who face considerably more barriers.

Gender gaps also harm men

Conversely, men enjoy privilege and status in the patriarchal system which gives them better access to resources, power and position.

But they also face health challenges related to gender norms and harmful masculinities. They are more likely to take risks with their health. They may have poor access to health services and may be less willing to seek and use health care.

Men have a shorter life expectancy than women in every country, and are more likely to die prematurely due to smoking, alcohol use and other harmful behaviours with significant health risks. Tobacco and alcohol industries have historically targeted men, spending billions of dollars fostering the notion that smoking and drinking are markers of manliness.

More men die from suicides, and men have a much higher burden of tuberculosis because of delayed detection and low treatment completion rates.

The bigger picture

But people’s health cannot be addressed in isolation – the gender gaps between men and women they are inextricably linked. Premature mortality among men causes loss and grief for the family while also increasing the burden of care for family members — particularly women — and reduce household income, increasing the risk of impoverishment, especially for the vast majority of households not covered by social protection schemes.

To truly achieve universal health coverage, countries need to identify the groups that are being left behind and why

Unless explicit attention is paid to gender norms and inequalities, health systems will not be able to achieve universal health coverage in an equitable manner and address harmful gender norms, roles and relations.

That applies within the health system itself. Health systems need to recognise the major role of women in delivering care. They are typically the primary caregivers in households, usually unpaid. They also make up 70% of the health and social care workers but are paid less than men. They also have fewer leadership roles, decreasing the likelihood their realities be taken into account in health system decision making.

We know little about the health status, health needs and barriers that people face due to their sexual orientation and gender identity (SOGI) including lesbian, gay, bisexual, transgender and intersex (LGBTI) persons. In the context of sexual health we do know, however, that they face multiple barriers caused by marginalisation, and stigma and discrimination in society and health care systems, resulting in chronic stress, poorer mental and physical health, and reluctance to seek health services for fear of disrespect and discrimination or refusal of services.

What it takes

To truly achieve universal health coverage, countries need to identify the groups that are being left behind and why. They need gender and equity analyses to understand the gender-related and other barriers faced by disadvantageous groups.

But analysing data is just the first step. Prioritising and implementing a set of actions to address gender and other structural barriers is critical. This must be done through participatory endeavours, engaging communities and relevant sectors. Social and financial protection schemes need to consider their implications within households, communities and government institutions, taking into account gender power relations and resource allocations.

Few countries have taken a systems approach to addressing gender as we describe. We have aligned ourselves with a newly formed gender and UHC alliance, with 85 members who are forging new ground.

WHO cannot travel this road alone. We work alongside governments and civil society to ensure the High-Level Meeting on Universal Health Coverage at the United Nations General Assembly in September 2019 is translated into policy and ensures action with a strong emphasis on addressing gender norms and ensuring gender equality.

We have invited a set of gender and health experts to provide a diverse set of perspectives on series of articles published in Apolitical that will highlight key trends and new ideas in gender and policy change given the importance of the high-level meeting on UHC in the UN. Each article will focus on an angle within the broader topic of gender and health.

We invite you to take part in the discussion with us. After all, it is the health of everyone on the planet that is at stake. — Veronica Magar, Divya Parmar, Gerardo Zamora

*We declare no other interests. The views expressed in this commentary are those of the authors and not the policies or views of the World Health Organization.

(Picture credit: Unsplash)