Bill & Melinda Gates Foundation

Making Universal Health Coverage Work for Women

May 30, 2013

Every Thursday here on Impatient Optimists, you’ll find stories, written by one of the Frontline Health Workers Coalition’s 30 member organizations, about the inspiring work of health workers on the front lines of care in developing countries and how United States leadership can help ensure that everyone has access to basic care by skilled, supported and motivated frontline health workers.

Note: This blog was originally posted on the Global Health Impact blog

Our Management Sciences for Health (MSH) colleague Lucy Sakala was an HIV counselor in Malawi. She worked with clients who were receiving HIV tests. When clients were diagnosed HIV positive, many were eligible for treatment and could begin antiretroviral therapy. HIV care had become available in Malawi because of transformative efforts to reduce antiretroviral drug prices and increase their availability, such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

But when Lucy was diagnosed with cervical cancer, her options were few. She needed chemotherapy, which she could hardly afford, and which eventually became unavailable when Malawi experienced stock outs. She needed radiotherapy, which wasn’t available in Malawi. MSH employees worldwide rallied to send her to Zambia for radiotherapy, but after completing one course, she died on November 24, 2011. She was only 28.

As global discussions around universal health coverage continue, I’ve thought of Lucy. Universal health covereage is about filling the tragic gaps that exist in health systems around the world: gaps in access, in affordability, and health needs that go unanswered. For Lucy, the right services didn’t exist; even if they had, they wouldn’t have been affordable for her.

We could honor Lucy by working towards universal, affordable access to cervical cancer, and we should. But the structures that would make this goal possible—systems of financing, delivery, and monitoring and evaluation—can only be established efficiently within a comprehensive universal health coverage program. More importantly, universal health coverage brings together the many health needs of women who, like Lucy, die needlessly, from preventable or treatable conditions: from HIV, tuberculosis, or childbirth, or the host of chronic diseases whose impact in the developing world continues to grow. We should learn from Lucy’s story that it’s time to stop addressing diseases one by one—and embrace the ambition to do more.

MSH has supported  universal health coverage as a sustainable development goal in the post-2015 framework. The report [PDF] of the Global Thematic Consultation on Health embraced universal health coverage as one of three major sub-goals for health.

Some in the women’s health community remain skeptical and have raised important questions about universal health coverage. They agree that a comprehensive package of health benefits sounds great—but not if it’s missing the services essential to ensure women’s health and reproductive rights. As Shannon Kowalski from the International Women's Health Coalition argues here, “core sexual and reproductive health services, such as family planning counseling and contraceptives and maternity care, are often excluded from benefits packages that determine what is and is not covered by insurance schemes.”

Indeed, it’s essential not only to get the right services into the defined benefits package, but to ensure that women don’t face denials or other barriers to care. Activists can play a key role on both fronts. First, activists can press for women leaders, at all levels of government and civil society, to hold influential positions in the design and implementation of universal health coverage programs. In low- and middle-income countries, the move toward universal health coverage usually means reforming and expanding existing services. This represents a major opportunity for expanding women’s health services, as long as the right leaders are at the table.

Second, we must insist that universal health coverage success will be measured according to health impact. Not just inputs like doctors and nurses (which are essential too), but meaningful service delivery measures like couple-years protection (for family planning) and antenatal care coverage, and outcome measures like reduced maternal and child mortality. We need these indicators at the global level in the sustainable development goals and at the national level in each country. Built-in indicators for key women’s health outcomes will make it easier to hold governments to account when they don’t deliver on the promise of health for all.

And finally, we must hold governments accountable when they don’t deliver. The Supreme Court of the Philippines recently postponed implementation of long-awaited legislation ensuring government-funded family planning, sexual education and maternal health services. But that fight’s not over. In the courts, online and on the streets, activists must shine the spotlight on governments that fail women and girls.

Kowalski and other advocates are right that the universal health coverage goal, in and of itself, won’t deliver equality and health outcomes for women. But with the right design and implementation, universal health coverage can improve reproductive health and much more. Universal health coverage is worth the fight because until we’ve got it, there will always be women like Lucy who are left on the sidelines while others receive care.

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