Gender and Social Health Insurance: Putting the “Universal” in UHC


Blog by Clara Affun-Adegbulu, Institute of Tropical Medicine, Antwerp October 4th, 2018

In the 2015, world leaders adopted Agenda 2030, setting out 17 sustainable development goals (SDGs) and

169 targets as a plan of action to eradicate poverty and ensure sustainable development. One of these, target

3.8, aims to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”1

The achievement of this target requires the mobilisation and pooling of financial resources, and is usually done through mechanisms such as social health insurance (SHI), tax-financing, private health insurance and community insurance. In many African countries where private health insurance is beyond the means of most of the population, government health expenditure is inadequate, tax collection is ineffective, the informal economy is large and tax revenues are therefore low2,3, SHI is seen as a viable mechanism for mobilising and pooling resources for health financing. This is, however, not always the best solution, because it can exclude certain populations such as women, and violate the principles of equity and universality, which are inherent to target 3.8.

Women in lower and middle-income countries in general, and sub-Saharan Africa in particular, tend to be disproportionally affected by exclusion from social health insurance schemes for two main reasons: (un)employment and sociocultural factors which may impact on the status of women in such societies.

Countries that are initiating SHI typically start with people who are employed in formal jobs, within the formal economy, yet the gendered nature of labour market participation in many African countries means that this does not usually apply to women. This is because they are more likely to either be excluded completely from the formal labour market or experience periods of exclusion, for instance during maternity leave. All this is compounded by the fact that women, because of their gender, are either often barred from working at all or from working in certain jobs4, and a lower proportion are sufficiently educated and thus able to compete on an even footing with men, particularly in highly competitive labour markets with high unemployment levels.

Women’s status in many societies can also affect their chances of having access to SHI. The tendency for women to take on unpaid labour, which is not seen as being a valuable contribution to the economy, and societal norms, which result in women being viewed as second class citizens4, can also mean that they are likely to be the last ones to be insured in any voluntary insurance scheme.

This is illustrated by two recent studies which compared health coverage in Kenya, Tanzania, Nigeria and Ghana. In the three countries where healthcare is financed with money from premium payments, coverage rates are low, ranging from 15% in Tanzania to only 4% in Nigeria. Ghana, which finances healthcare through tax revenues had a coverage rate of 38%, in spite of starting its health insurance scheme at about the same time as Nigeria5. The country was also the only one of the four, where coverage was higher among women than among men. In Nigeria, which had the lowest overall coverage, men were three times more likely to be insured than women6. This is consistent with the fact that level of education, residence, wealth status, and occupation are some of the determinants of insurance coverage for healthcare, and these are areas where women are traditionally at a disadvantage7.

Clearly, SHI by itself is an inequitable method of mobilising and pooling resources for financing the health system. Instead, tax-based financing should be prioritised7, and governments should increase their health spending in line with the Abuja Declaration. This would go a long way in addressing the low coverage rates that common in many African countries, and it would ensure that access to health care is equitable and universal for vulnerable groups such as women.



2. van der Molen, P (2018), Informal economies, state finances and surveyors, Survey Review, 50:358, 16-25, DOI: 10.1080/00396265.2016.1216922

3. OECD  (2014),  Development  Co-operation  Report  2014:  Mobilising  Resources  for  Sustainable Development, 91-97, Paris: OECD Publishing, DOI:

4. Ulrichs  M.  Informality,  women  and  social  protection:  identifying  barriers  to  provide  effective coverag London; 2016.5. Umeh CA. Challenges toward achieving universal health coverage in Ghana, Kenya, Nigeria, and Tanzania. Int J Health Plann Mgmt. 2018;1–12. 

6. Amu H,  Dickson KS,  Kumi-Kyereme A,  Darteh EKM  (2018)  Understanding  variations  in  health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania: Evidence from demographic and health survey PLOS ONE 13(8): e0201833.

7. Uzochukwu BSC, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe Health care financing in Nigeria: Implications for achieving universal health coverage. Nigerian Journal of Clinical Practice. 2015;18(4):437–444. pmid:25966712