Gender-specific Health Coverage In European Insurance: Closing Healthcare Gaps – Analysis of women’s health and gender inequality Employment-based health financing does not support gender equality in universal health coverage 2020; 371 doi: https://doi.org/10.1136/.m3384 (published 27 October 2020) cite this as: 2020;371:m3384 Read our collection on women’s health and gender inequality
Global commitments to improve women’s access to health services have been made repeatedly, most recently through the Sustainable Development Goals and the 2019 Political Declaration on Universal Health Coverage. These commitments echo the vision of the 1995 Beijing Declaration to ensure that women have access to equitable, adequate, affordable and quality health services throughout their lives. However, 25 years later, women remain disproportionately affected, and their basic health needs remain unmet.
Gender-specific Health Coverage In European Insurance: Closing Healthcare Gaps
In low- and middle-income countries, 45 million pregnant women (37%) have no access, or inadequate access, to prenatal care, 214 million women (13%) who want to avoid pregnancy do not use modern contraceptives, and 266,000 women die of cancer Cervical cancer is highly preventable (90% of global mortality from the disease).1 In high-income countries, women forego medical care because of cost – for example, 26% of women in Switzerland and 38% in the United States.23
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In addition to the general challenges preventing universal health coverage, women’s access is further limited by health systems and the broader political economy, which reflect and reinforce restrictive gender norms, unequal power relations, and systemic discrimination.4 Women’s unpaid care work is higher, lower. Income, and often limited decision-making authority over household resources and their health services, combine to create significant barriers to health care.
This dynamic is exacerbated when funding and health care entitlements are tied to employment, as women experience unequal and disrupted participation in employment. Employment-based health financing mechanisms can translate gender gaps in employment into unequal access to health services, further disadvantaging women.
Employment-based health financing includes any form of health financing or entitlements related to a person’s employment status and type. Generally, pooled contributions from an employee, his employer and/or the state are transferred to service providers for a defined set of health benefits for the individual contributors, and sometimes their dependents. Such programs include mandatory contributions to national social security (Thailand), registration of informal and non-standard workers (ie, part-time and casual employment) into health insurance programs (Ghana, Vietnam), and voluntary or semi-mandatory health provision. Insurance by employers for their labor market (US). Examples of employer-provided health insurance include the South African government employee medical scheme with five levels of benefit packages, where entitlements (beyond the basic package) are linked to paid premiums5; and the US policy B. To provide health services only to full-time employees who work for employers with more than 50 full-time employees. 6
There are many criticisms of employment-based health financing. First, he points out that healthcare is an occupational benefit, not a human right. Second, by tying health care eligibility to employment status or related contributions, it undermines the goal of universal health coverage to gradually ensure equity and continued access to high-quality health care. In some cases, people in higher-level positions are more entitled to health care or can pay higher insurance premiums to receive higher-quality, more expensive health care. Ideally, arrangements for universal health coverage should begin with poorer populations that have higher unmet health needs. 7 Although countries may combine employment-based health financing with fully subsidized care for vulnerable groups, there is a greater risk of excluding people who drop out or move. Between, different categories of entitlements, such as those defined by socio-economic status, poverty lines and pregnancy status. Finally, as a source of health income, employment-based health financing is unstable, fragmented, and inequitable, especially during economic crises.89 During the U.S. Covid-19 pandemic, approximately 47.5 million people lost access to employment-related health services due to family job loss. True By May 2020, 27 million of them are likely to remain uninsured due to ineligibility for other health plans.10
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Universal health entitlements, mandatory inclusion in national programs, general tax contributions to pool resources, and moving away from voluntary programs or contributions linked to eligibility for benefits are recommended to address these challenges.11 However, there was resistance to this change. Employment-based health financing remains an important source of revenue, especially for low- and middle-income countries that need to mobilize additional domestic resources. It is also possible to use existing wage infrastructures.8 In countries with established employment-based health financing systems, the influence of existing beneficiaries often prevents reforms of these arrangements, which continue to disadvantage women.811
Gender inequality and employment gaps have hardly changed over the past 25 years. Globally, only 47% of women were employed in 2019, compared to 74% of men.12 With this employment gap, and a gender wage gap of almost 20%, equality in employment has not been achieved.13
Unequal unpaid care and domestic work between men and women persists worldwide, negatively affecting women’s economic participation and opportunities. Women perform more than 80% of unpaid care work, and approximately 606 million women, compared to 41 million men, are unpaid nursing workers.1314
In the formal sector, women remain overrepresented in lower-level positions and receive unequal pay for the same position, skills, education and experience. Larger employment gaps persist for women with children. 14 The global proportion (about 27%) of women who are managers and in professional leadership positions has hardly changed for 30 years. 14 The most socioeconomically disadvantaged women are least likely to work full-time or in the formal sector. 15
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The informal sector provides employment for up to 90% of employed women in Africa and South Asia, and 75% in Latin America.14 Generally, young (15-24 years) and older (over 65 years) women are more likely to suffer informality. Employees, 16 and they are concentrated in professions with low wages, long hours and insufficient or no social protection.
The inequality between these sexes is expected to worsen in the future. A changing global employment ecosystem based on technological disruptions, macroeconomic fluctuations and diminishing levels of social and occupational protection is reducing opportunities for long-term and secure employment. 14 Non-standard employment arrangements, such as part-time and temporary contracts, are increasing in the formal sector. 1617 Similar to work In the informal sector, these arrangements usually lack health-related social protection and job security, through their framing as “self-employment”. Again, women are disproportionately affected. In Japan, where employment-based national health funding exists, women are four times more likely to be on a temporary contract.18 Women in developing countries make up one in five workers, who use digital platforms to generate task- or service-based income. 14 The online “haltura” economy is not expected to close gender gaps in employment or income. 14
Non-standard employment arrangements are often described as a way to support women’s involvement in paid employment by providing flexibility and allowing them to balance their economic productivity with domestic responsibilities.19 However, non-standard workers typically have an income gap as high as 60% compared to full-time workers, Even in high-income countries. 17 During economic crises and periods of recovery, women are disproportionately represented in non-standard employment, especially in industries or roles that depend heavily on women, such as service industry. 19
Socio-economic and cultural factors affect women’s ability to participate in paid employment throughout their lives.15 Women are less likely to accept long-term contracts, 20 and their working lives are often fragmented by transitions, due to reproduction, caregiving responsibilities and voluntary and involuntary unemployment.
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Employment-based programs often do not take into account these inequitable trends and changes in women’s employment, which often create discontinuities in coverage, benefits, and financial protection. Universal health financing arrangements should provide continuous coverage for all people throughout their lives to meet their changing health needs. However, approaches to employment-based health financing that depict employment as static, rather than a trajectory, can lead to patchy and fragmented coverage. Figure 1 draws attention to gendered work life and women’s discontinuous access to coverage, benefits and financial protection.
Unpaid care work is not always valued as much as paid work in employment-based models. Some countries have separate programs for workers in the formal sector and their dependents, including spouses engaged in full-time unpaid care work. In Vietnam, dependents are not covered by the national scheme based on compulsory employment, but they can enroll in a voluntary scheme, with fewer rights, also offered to workers in the informal sector.21 In Thailand, there are differences in coverage and benefits for dependents. across programs. The government employee plan includes coverage for parents of friends, spouses and up to two children.22 The plan for private sector employees, on the other hand, does not include dependents, who are covered by the universal coverage plan for the rest of the population.22
Within these systems, employment or movement across formal, informal and non-standard roles usually alters eligibility for medical care. In Mexico, for example, there are differentiated health access programs for workers in the formal and informal sectors. More women than men in Mexico become unemployed, and more often. Within a single year, women can move between the formal and informal sectors and between employment and unemployment.23 These changes
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