By Francoise Girard
NEW YORK – Health care is a human right, yet roughly half of the world’s population – 3.5 billion people – forgoes essential health services due to financial constraints or lack of accessible facilities. Universal health coverage (UHC) could change this worrying statistic. But if its promise is to be fulfilled, sexual and reproductive health services must be included.
The UHC idea is simple and powerful: guaranteeing access to quality health services, essential medicines, and vaccines, and insuring people against catastrophic and routine health costs, would reduce poverty and improve health outcomes. That is why UHC was established in 2015 as a central tenet of the United Nations Sustainable Development Goals (SDGs).
The SDGs also enshrine sexual and reproductive health as an essential condition of gender equality; without it, women and girls cannot control other aspects of their lives. But sexual and reproductive health is often discarded from health-care strategies for the sake of political expediency, threatening to derail efforts to ensure UHC by 2030.
As it stands, women face disproportionate political, social, and financial barriers to health-care access. Their out-of-pocket costs are consistently higher than men’s, primarily due to non-coverage or limits on sexual and reproductive health services, and they are often prevented by law or custom from obtaining care. These barriers are particularly high for LGBTQI individuals, women with disabilities, indigenous women, rural women, and adolescents.
Instead of sidestepping the issue of sexual and reproductive health – and gender equality more broadly – governments must acknowledge their responsibility to address women’s needs. They must consider the central role that sexual and reproductive health plays in women’s lives, the integrated nature of women’s health, and its impact on communities. And they must design UHC programs accordingly.
For example, to reduce maternal mortality, it is not enough to provide antenatal attention, safe delivery, and postnatal care; women also need access to safe, legal, and affordable abortion services and post-abortion care. Likewise, reducing sexually transmitted infections (STIs), such as HIV and AIDS, is not possible without expanding access to testing, care, and prophylactics, as well as addressing the gender and power dynamics that increase transmission. Other vital sexual and reproductive health services include access to contraception; infertility prevention and treatment; treatment for reproductive tract infections and cancers; and services to address gender-based violence.
As governments negotiate a groundbreaking declaration on UHC this year, they should place the full range of sexual and reproductive health-care services at the center of UHC strategies. Doing so would reduce the burden of disease and mortality borne by women and girls, while empowering them to control their own health and reproductive lives. The result would be more women in education, paid employment, and politics.
If, on the other hand, world leaders omit sexual and reproductive health from UHC strategies, they will send a powerful signal that women’s health and lives don’t matter. Health-care costs for many women and their families would remain prohibitively high, and public-health costs would rise, as women sought treatment for the life-threatening consequences of poor maternity care, untreated STIs, and inadequate access to contraception and abortion services.
These expectations are confirmed by experience. Turkey’s Health Transformation Program was specifically designed to improve maternal health, and led to a significant decline in maternal mortality, from 61 deaths per 100,000 live births when implementation began in 2003 to 15.5 deaths per 100,000 in 2011.
Ghana’s UHC program, by contrast, was not developed with a focus on women’s needs, and did not lead to meaningful improvements in maternal mortality. A study of community health insurance coverage in West Africa confirmed that when maternal care is not covered, health outcomes do not improve.
The right choice should be obvious, yet many governments continue to resist providing sexual and reproductive health-care coverage. For some, it’s a question of money: they fear the costs of investing in women’s health, failing to realize that those costs are dwarfed by the costs of inaction.
For others, the opposition is ideological. In the United States, where a growing number of Republican state governments have been enacting draconian anti-abortion laws, President Donald Trump’s administration, which opposes UHC, is actively stripping sexual and reproductive health from public-health programs – for example, by seeking to cut funding for contraceptive programs for low-income populations.
Given such resistance from governments, the onus has often fallen on civil society and health-care providers to make the case for centering UHC on the needs of women and girls. At last January’s World Health Organization executive board meeting, for example, civil-society organizations advocated forcefully for the inclusion of sexual and reproductive health.
As the global push toward UHC intensifies, more opportunities to make this case are arising, including the recent World Health Assembly – where the Alliance for Gender Equality in UHC put forward a “7th Ask” to give higher priority to women’s and girls’ health and rights – and this summer’s political negotiations at the UN. These events will lay the groundwork for the UN’s High-Level Meeting on Universal Health Coverage in September, where governments will adopt a roadmap for establishing, financing, and delivering UHC programs worldwide.
Governments around the world have a once-in-a-lifetime opportunity to commit to providing quality, affordable health care – including the full gamut of reproductive and health services – to all. Seizing that opportunity will require strong political will. But one thing is clear: only by emphasizing the needs and rights of women and girls can any UHC strategy be truly universal.
Girard is President of the International Women’s Health Coalition.