This opinion piece is written by Dr. George Atiim, Postdoctoral Fellow, Dr. Michelle Remme, Research Fellow and Prof. Pascale Allotey, Director of the United Nations University International Institute for Global Health (UNU IIGH).
Last month, world leaders reaffirmed their commitment to Universal Health Coverage (UHC) at a high-level UN meeting in New York. UHC is the promise to provide quality healthcare that is universally accessible and affordable and does not lead to financial hardship, especially among the most vulnerable and marginalised people.
The Political Declaration on UHC, which was adopted at the summit, has been hailed as a landmark for global health and development, but has also been met with scepticism and anticipated [concern that it undermines the importance of addressing the social and economic inequalities](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19%2931831-8/fulltext) and injustices that drive health risk, ill health and health inequity.
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These are all serious and relevant concerns, especially when it comes to [gender inequality and women’s rights](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19%2931815-X/fulltext), both as determinants of health-related behaviours and outcomes, as well as critical measures of health system performance. There is robust evidence demonstrating that gender equality and women’s empowerment are inextricably linked with UHC.
For example, countries with greater gender equality (measured by maternal education) achieve higher rates of child immunisation coverage. On the other hand, traditional norms around masculinity limit men's healthcare-seeking behaviour for mental health services, among others. And although women represent 70% of the health and social care workforce, deliver healthcare to about 5 billion people, [they are paid less than men](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19%2930652-X/fulltext) and harassed more. This affects their wellbeing, and health systems’ ability to expand the provision of quality care.
But such concerns have tended to be only marginally acknowledged in national and global institutional efforts towards UHC.
Pushing gender into the mainstream
Twenty-five years ago, the momentous Beijing Declaration and Platform for Action adopted gender mainstreaming as an additional strategy to push efforts to promote gender equality into the mainstream and ensure it became everyone’s business.
Global experience since then shows that, despite the plethora of policies, strategies, programming and implementation resources, including tool kits, manuals, checklists, and handbooks, produced by health actors, including the United Nations (UN), results have been limited – in terms of action, change and impact.
We know political commitments haven’t always translated into resources and sustained investments in gender programming. So, the critical question remains: how can we ensure that countries, health systems and international organisations act and deliver best on gender in policies and programming for UHC?
The international community must do more than try to maintain the status quo
Taking stock of our progress and identifying the factors that have already been a success or led to failure in programs and interventions is critical to accelerating the institutional and programmatic gender equality outcomes envisioned in the UHC political declaration.
Such learnings are particularly key for [the UN and its health agencies](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19%2930988-2/fulltext), given their global presence, broad reach and scope of programming that affects large populations, and its unique position to lead by example in addressing gender disparities in UHC.
Recently, the United Nations University International Institute for Global Health (UNU-IIGH) and the World Health Organization (WHO) convened an expert meeting to identify what has worked (and failed) in the UN’s experience in gender and health, and set an agenda to accelerate evidence-based action towards 2030. The report offers some important reflections that can inform how we could do things differently in global and country efforts towards UHC.
Focus efforts
Based on this report, we can say with some confidence that there are several promising ways for institutions and governments to promote gender mainstreaming. For example by:
Developing accountability frameworks and tools for monitoring and evaluation
Incentivising gender mainstreaming and capacity building through innovative certification and credentialing approaches
Building and leveraging leadership commitment and buy-in
Making the case that gender programming leads to better health outcomes
Using strategic entry points and strategic language to communicate on gender issues
Building multisectoral and civil society engagement
Fostering partnerships with governments, and with national and regional institutional mechanisms to localise and operationalise global commitment
If we are to make significant progress, we need to address gender injustices, unequal power relations and the lack of real investments in gender mainstreaming. For UHC, it will mean:
- Tackling the underlying structural gendered barriers to access and uptake. For example, poor treatment by healthcare providers, lack of control over household finances, or autonomy to make decisions about their own health are just some of the barriers women face in their use of health services, even where these are available and affordable. To achieve UHC by 2030, fundamental changes are needed, which require working outside the business as usual model, and challenging the status quo, modifying [restrictive gender norms](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19%2930652-X/fulltext) that affect women and men’s health behaviours, and transforming power relations that shape access inequalities.
- Refocusing and re-prioritising strategies. We need to go beyond process outcomes and checklists to assessing equity or institutional change. Rather than trying to “do” gender in everything, we should target and prioritize programmes and health system building blocks with the biggest potential for impact on gender equality.
- Strengthening accountability mechanisms. Gender may be everyone’s business, but accountability for resources, and enabling change often isn’t. Gender and UHC are inherently about power. A powerful strategy is to hold heads of health institutions, national or multinational, and programme leads accountable for addressing gender inequality and restrictive gender norms that undermine the effectiveness of UHC strategies. Preferably through independent mechanisms.
- Building a solid evidence base on what works in gender and health by systematically documenting and evaluating programmes and practices. There are success stories, but rigorous evidence and rich data is crucial to generating a deeper understanding and learning from what strategies have delivered results, why, and how.
- Building transformative partnerships, alliances and networks to engage with new actors (e.g. government, civil society, women’s rights groups, academia, men and young people) to tackle harmful gender norms, attitudes and behaviours. Such collectives can hold institutions, particularly health systems, accountable while advocating for investments in more inclusive gender systems in healthcare.
Moving the needle
It is against this backdrop that many health advocates and stakeholders expressed their disappointment during and after the negotiations when it became clear the declaration was devoid of strong, measurable and accountable commitments and investment targets. The same could be said of its commitment to address gender inequity and promote gender equality through health policies.
As could be expected, the Declaration includes the ubiquitous gender mainstreaming paragraph, pointing to the need to “mainstream gender on a system-wide basis when designing, implementing, and monitoring health policies, taking into account the specific needs of all women and girls (…) in health policies and health systems delivery” [para 69].
In a time of global backlash against gender equality, maintaining this paragraph, and the language on universal access to sexual and reproductive health and reproductive rights [para 68] is without a doubt, a critical and hard-fought win.
Yet, the international community must do more than try to maintain the status quo. And it’s highly doubtful that continuing down this road, and championing the same gender mainstreaming strategy and toolkits over and over again, will allow us to move the needle.
The recommitment to gender mainstreaming in UHC is important, especially given a growing political context of hostility to human rights and gender equality. The slow pace of progress over the years must be a reality check. The global community must choose to learn from our experience and let this backlash drive our collective agency and urgency to set the bar higher for gender equity in health, and UHC for all. — Dr. George Atiim, Dr. Michelle Remme and Pascale Allotey.
This is part of an article series exploring the intersection between health and gender leading up to the high-level meeting on universal health care taking place in New York, 23 September 2019. In the previous article in this series, Kui Muraya, a gender and health researcher, reflects on the state of equality in Kenya after a female legislator was kicked out of parliament for bringing her baby to work. Read that here and take part in the discussion on Twitter.
(Picture credit: Unsplash)
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