This article is written by Ann Keeling, Senior Fellow and Dr. Roopa Dhatt, Executive Director of Women in Global Health.

The World Health Organisation (WHO) estimates that around half the world’s population (in low, middle- and high- income countries) lack full coverage for essential health services and about 100 million people are pushed into extreme poverty each year due to their health costs.

It is against this backdrop that the world celebrated the first UN-recognised International Universal Health Coverage (UHC) Day a year ago today.

Since then a historic and monumental commitment was made on 23 September 2019 at the United Nations with the adoption of the Political Declaration of the High-Level Meeting (UN HLM) on Universal Health Coverage.

The High-Level Political Declaration on UHC has the potential to change the health and lives of millions of people, the majority of them women, who currently cannot afford quality health services.

It also has the potential to improve the lives of the women who form the majority of the global health and social care workforce. Female health workers currently deliver services to around 5 billion people and will deliver UHC.

How far we’ve come

Over the last 25 years many global commitments have been made to make gender equality and the rights of women and girls central to health — ICPD, Beijing, MDGs and SDGs to name just a few. The achievement of health for all rests on reaching the most marginalised women and girls, not just with services but with the rights that will ensure they can access those services. Surely it wouldn’t be necessary to say it all again for UHC?

But we live in a world where, despite great words and some great intentions, the most marginalised women and girls are not at the heart of health systems; the gender determinants of health (for all genders) are not widely understood; and decision makers fail to acknowledge that the majority of health workers are female.

Our role as advocates is to speak the same truth to power like a broken record until those with power prioritise gender equality in health as a given and the default. And that was especially true in the lead up to the UHC High Level Meeting since when we had already seen a push back against women’s rights in many multilateral fora. There was every reason to believe it would be the same for UHC.

Women’s rights is a choice — not a technical issue

One year ago our concern was that UHC was being approached as a purely technical issue.

Dr Tedros Adhanom Ghebreyesus, Director General of the World Health Organisation (WHO) who has led the global push for UHC has always been clear that UHC is a political choice, not a technical matter. But it is not a political choice that those most in need of UHC are able to make, since they lack the power and voice to influence such major political decisions.

Although women account for more than half the world’s population, they make up only 24% of the world’s parliamentarians who decide health budgets, the overall design of health systems and the rights framework for their citizens.

At the beginning of 2019, however, the reality was that there were and are people in power willing to deny women and girls their rights

In 2018, only 31% of health ministries were headed by women and only 25% of Member State Chief Delegates to the World Health Assembly 2015-2018 were female. There are huge inequities within countries and between countries in whose perspectives are heard in health decision making. UHC has long lacked women’s perspectives, particularly women from the Global South.

Political choices are made by the powerful. The September 2019 UN High Level Meeting on UHC was a landmark event in convening Heads of State and Government for the first time to make commitments on UHC. It was critical to ensure that the Political Declaration agreed by Member States that would be the future high level roadmap for UHC, contained strong and unequivocal commitment to gender equality and the rights of women and girls.

At the beginning of 2019, however, the reality was that there were and are people in power willing to deny women and girls their rights, especially their sexual and reproductive health and rights (SRHR ), which are of course essential to their health and wellbeing.

Keeping health for all on the agenda

As the process and preparations leading up to the September High Level Meeting unfolded in 2019, it became clear that, once again, the goal of gender equality would not be mainstreamed unless we worked with others to make it so. Women in Global Health published articles, ran events, spoke on panels, lobbied at meetings including the WHO Executive Board, contributed to UHC consultations and in March 2019, issued a Call to Action ‘Gender Equality and Women’s Rights in UHC Drive Better Health for All’ for the Multistakeholder Meeting held to gather NGO perspectives for the September High-Level Meeting.

In March, appreciating we needed a bigger voice, WGH joined with the International Women’s Health Coalition and Women Deliver to co-convene a new global Alliance for Gender Equality and UHC.  Within two months the Alliance had 107 NGO members working together at national and global levels. And when we saw that the UHC2030 Six Asks for the September summit did not include gender equality or the rights of women and girls, we called for a ‘7th Ask ‘Commit to Gender Equality and UHC ‘ issued with the Alliance in May.

Increased funding was allocated to gender equality in 2016-17 but only 1% of gender focused aid went to women’s organisations

Between May and September, Alliance members worked with like-minded Member States and many others to support strong commitments in the Political Declaration on gender equality and the rights of women and girls, against strong opposition by a small number of governments. We applaud these States who stood firm during negotiations.

The final Political Declaration on UHC, agreed unanimously by the world’s governments, contains strong commitments on gender mainstreaming, the rights of women and girls (including SRHR) and gender equity in the health workforce.  We are delighted with those commitments, which set a strong framework for UHC at global and national levels and were not in the original drafts of the Declaration. But we tell the story of 2019 to demonstrate that gender equality was not the default in the UHC process or global health generally. Women still struggle to get to the table and be heard. It is significant that only 26% of speakers at the September summit were women. So after a rollercoaster but successful year for gender equality and UHC, we have six key messages for governments and UHC partners going forward:

Seven point call to action for UHC Day:

We call on all governments and UHC partners to keep the promise on gender equality and the rights of women and girls in Universal Health Coverage (UHC). They should:

  1. Keep the promise on mainstreaming a gender perspective in UHC design, delivery and monitoring with a view to achieving gender equality and the empowerment of women in health policies and systems: this will require radical, deliberate action and will entail women playing an equal part in UHC leadership at all levels from community to global. Global health will look different and be different.
  2. Keep the promise on integrating SRHR into UHC and by 2030 ensure universal access to sexual and reproductive health care services: this will require action at national level to integrate SRHR into national UHC plans and to embed the wider rights needed to underpin this, particularly for women, girls and youth.
  3. Keep the promise on enabling and empowering female health workers and addressing barriers to leadership and decision making:  women account for 70% of all health and social care workers but hold only 25% of leadership roles. If women are to fill the 18 million health worker jobs needed to reach UHC, urgent action will be needed to address gender gaps in leadership and pay as well as the discrimination and bias that constrains their careers.
  4. Keep the promise on protecting health workers from all forms of violence and ensure safe working conditions: we urge all Member States to ratify and implement ILO Convention 190 on Violence and Harassment coming into force in 2020, to address the sexual harassment and violence experienced by a large percentage of female health and social care workers.
  5. Make a promise on women’s unpaid work in health and social care: commit to recording, recognising and rewarding women’s unpaid work in health and social care, estimated at half the $3trillion women contribute. One of the serious omissions in the UHC Political Declaration is that health systems are currently subsidised by this unpaid work, such as caring for elderly parents which predominantly falls on women, which takes women out of the paid labour market and girls out of school and needs urgent action.
  6. Make a promise to fund women’s organisations at community, national and global levels: OECD data shows that increased funding was allocated to gender equality in 2016-17 but only 1% of gender focused aid went to women’s organisations. The feminist organisations that have driven gender equality and rights for decades need substantial, long term funding to enable them to scale up their work in health and social care. The story of the UHC process over this last year highlights the political and technical role played by women’s movements and organisations, particularly those in the Alliance for Gender Equality and UHC, in keeping gender equality and the rights of women and girls on the UHC agenda.
  7. Make a promise to have women’s voices and leadership in all UHC conversations.  This includes gender parity, diversity and inclusion in all conversations. We must ensure that women and other underrepresented groups are at the decision-making table to ensure #LeaveNoOneBehind is being implemented from design to delivery.

We urge you to join the Alliance for Gender Equality and UHC and commit to gender equality and women’s rights. — Ann Keeling and Dr. Roopa Dhatt

(Picture credit: Thuyenho//Life of Pix)