The reform of health systems has failed to fully consider its impact on gender equity, and is hindered by significant research gaps. The input of policy-makers, donors, researchers and advocates is needed to ensure that future health systems foster gender equity and help build gender equality in society.
All are working towards a shared goal: more effective and efficient health systems for both women and men.
After conflict has ended, encouraged by the UN, governments often embark on ambitious reforms of the health system. These reforms are highly challenging. Policy-makers grapple with questions such as: how should health care be financed? How will health data be collected? How should the workload be shared? The decisions taken are critical as they will shape the future health system.
This post-conflict phase offers extraordinary opportunities to rebuild the health system so that it better serves women as well as men: not only those using the services, but those employed in the health sector. To do this, reform must:
Identify the different health needs of men and women resulting from conflict and beforehand. Appropriate indicators should be used, including data which is broken down by sex. Consultation should take place with the people affected by conflict – and this should include women.
Understand why men and women’s health needs differ. Health is not only influenced by biology but also by the gender norms that undermine women and girls. Women and girls often bear the brunt of the impact of conflict.
Respond to these differences effectively both in providing health care and restructuring the health system.
To answer this, the World Health Organisation’s six building blocks of the health system was used as a framework. These are:
Two fundamental aspects of health service delivery are covered here: the integration of service delivery and a basic package of health services:
Health system reform usually entails integrating health services with the aim of improving cost-effectiveness, efficiency, quality and convenience for patients. There are, however, research gaps into the effects of integration on gender equity in health. Where reproductive health services are concerned, there is a risk that integrating services may compromise quality.
Since the early 1990s, many developing countries have contracted out the delivery of a basic package of health services (BPHS). Research indicates, however, that, as with integration, this model may not enhance the provision of comprehensive reproductive health services. The BPHS in Ghana, for instance, only covers family planning.
A priority in post-conflict health reform is to address the shortage of health workers, however, policy-makers have paid little attention to gender in planning the health workforce. Although the workforce is predominantly female, women are less likely than men to hold senior, well-paid jobs.
In developing recruitment and promotion strategies, reforms have failed to take on board gender, in particular overlooking men and women's different roles in the family. This is partly because women have not been consulted in human resource planning.
In addition, the burden mostly falls on women to provide unpaid care in developing countries.
WHO states that health systems should produce, analyse, disseminate and use reliable up to date information on health. In order to provide health care that meets the needs of women as well as men, having information available which is broken down by sex and age is key.
Measuring the impact of health reform on gender equity requires appropriate indicators but researchers have not yet reached consensus on the best indicators to use.
The availability and use of health care is to a large extent determined by health financing. As women make up the majority of the poor, they tend to be adversely affected by financing mechanisms. Financing reforms have, however, scarcely addressed their impact on the different health needs of men and women. A variety of mechanisms exist, including government funding, user fees and insurance schemes:
Government funding from tax revenue can expand health coverage, thereby benefiting the poor, including women. Nevertheless, budget decisions are at the whim of politicians who may hold conservative views, and may not prioritise women's health such as comprehensive sexual and reproductive health care.
Introducing user fees for health services is commonly adopted in post-conflict countries in spite of the fact that this financing mechanism discriminates against the poorest, with a heavy burden on women and girls. Studies in Nigeria, Tanzania and Zimbabwe show that user fees have resulted in a decrease in the use of maternal and child health services and higher rates of illness among mothers and babies.
Health insurance can discriminate against women. Women may not be eligible for social insurance schemes as they are less likely than men to be employed in the formal economy. What's more, as women need health services more than men, they are expected to pay more for private insurance.
Gender shapes male and females’ access to medical products and technologies. From an early age, parents treat ill girls and boys unequally. A study in India found that they were more likely to give boys suffering from diarrhoea oral rehydration solution than girls. Diagnosis of disease is also influenced by gender bias.
Although women access antiretroviral therapy for HIV more than men, they are less able to exercise control over technologies which could prevent them becoming infected in the first place.
Key decisions about how the health system is run tend to be taken chiefly by men. Evidence suggests that when this is the case, local health priorities will not reflect women's health needs and sufficient resources will not be assigned.
Decentralising health services to the local level is often part of health reforms. Decentralisation can, nonetheless, have a negative effect on women's health, for example in restricting women's access to reproductive health services locally.
Advocates must ensure that the health needs of women as well as men are taken into account in the governance of health systems. This is vital in post-conflict countries, where opportunities are created for social reform, including promoting women to senior positions in the health system and government.