For Women and Young People, Universal Health Insurance Is Not Enough

Next week, leaders from governments and civil society will meet in Gaborone, Botswana to discuss how health will feature in the development agenda that will succeed the Millennium Development Goals after 2015. Should it be construed as a “single health goal”? If so, what would that goal be, considering the plethora of health issues that still require urgent action, such as HIV, maternal mortality, tuberculosis, and diabetes?

One proposal on the table would group all these concerns under the objective of “universal health coverage.” In my two-part blog series, I will discuss why this proposal falls short when it comes to women and adolescents.

Universal health coverage is defined in the draft discussion paper for Botswana as “two inter-related components: coverage with needed health services (prevention, promotion, treatment, and rehabilitation) and coverage with financial risk protection, for everyone.” Universal health insurance is considered critical to achieving universal health coverage because of the protection it can provide against catastrophic health costs and its contribution to sustainable financing. But is it enough?

Economic barriers (“financial risk”) certainly pose formidable obstacles to women and adolescents seeking sexual and reproductive health care; universal health insurance can help to address this.  But alone, it is not sufficient. In fact, health insurance schemes may contain their own barriers to care, particularly for marginalized women and adolescents.

For example, 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.

Abortion services are largely excluded from coverage, despite the fact that abortion is legal (on one or more grounds) in a majority of countries worldwide. Coverage of contraceptives and sexual health services for adolescents may be likewise constrained due to political sensitivities.

The level of financial protection provided by health insurance can also vary and may not be sufficient to insulate women against economic hardship.  Women consistently experience a higher burden of out-of-pocket costs for health care services than men who have similar levels of insurance coverage, largely due to non-coverage or limits on coverage for sexual and reproductive health services. Even nominal co-pays, common in many insurance programs, may pose a significant barrier if women do not have access to or control over cash.

Concerns about confidentiality and privacy may also impede access for adolescents and women when their own insurance coverage is tied to their parents’ or spouse’s coverage.  In the United States, adolescents and young women and men enrolled as dependents under their parents’ health insurance policies often choose not to use their insurance coverage to pay for sexual and reproductive health services, for fear that their parents will receive notification that they sought such care. Women covered as dependents under their husbands’ insurance policies may likewise be hesitant to seek much-needed care, such as contraceptives or treatment for violence.

Finally, the most marginalized women often fall through the cracks of so-called “universal” health insurance schemes for a number of reasons including lack of autonomy and decision-making power, or lack of information.  Women who are employed in the informal sector, women living in poverty, adolescent girls, and older women are often those least able to obtain good quality health insurance.

How do we make sure what is recommended at the Botswana meeting addresses these concerns?

I suggest a way forward in my next post.

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