What evidence is there about the effects of health care reforms on gender equity, particularly in health?





The issue

In most countries the pressure for health care reform is aimed at improving the efficiency, equity and effectiveness of the health sector. Emerging evidence shows that health care reforms can affect men and women differently, as a consequence of their different positions as users and producers of health care. This review assesses the impact of four key health care reforms – decentralization, financing, privatization and priority setting – on gender equity in health.


Literature on health sector reform and gender equity is sparse and often focused on low-income countries. Moreover, gender-related papers are predominantly concerned with women’s health issues and focus on adverse health effects. These limitations affect the generalizability of the findings.

Rapid decentralization of responsibilities without corresponding devolution of authority and requisite human, institutional and financial resources may lead to difficulties in providing affordable, accessible and equitable health services, as has been the case in many low-income countries. Decentralization may also inadvertently support more conservative reproductive health agenda, particularly in services for adolescents.

There is substantial evidence from both high-income and low-income countries that taxes and social insurance schemes provide the most equitable basis for health care financing. Other schemes, such as private insurance or direct out-of-pocket payment, are likely to increase inequities, particularly in access to care and health-seeking behaviour and this may affect women more, as they generally have fewer financial resources.

Privatization, accompanied by emphasis on reducing costs and maximizing efficiency, may have an important impact on gender equity in health care access and financial protection. In some countries patient/staff ratios have been raised, personnel have been shifted, duties have been reassigned to less skilled workers and the use of casual workers has increased. The negative consequences of these policies affect women more than men since women are over-represented among both patients and health care personnel.

A range of gender biases have been revealed in some priority setting methodologies, such as DALYs, which lead to the underestimation of women’s burden of disease. These systematic gender biases are generated through various technical and conceptual limitations.

Policy considerations

Gender equity in health requires that men and women will be treated equally where they have common needs, and that their differences will be addressed in an equitable manner. This should be a consideration particularly in the planning and delivery of services at national, regional and local levels.

Decentralization of responsibilities in health care should be accompanied by a corresponding devolution of authority and adequate human, institutional and financial resources.

Well functioning and wide-ranging public health services provide equitable and affordable services to the less privileged, many of whom are women. Shifting from taxes to direct user fees to finance health services may increase the burden of payment among economically less privileged groups, reduces access, and may generate a serious poverty trap. When health insurance schemes are introduced, assurances are needed that vulnerable and marginalized groups, including poor men and women, will be adequately covered.

Efficiency and equity need to be assured when privatizing health services. Incentives may encourage the commercial health care sector to invest in public health and preventive care. If private sector management practices are adopted, steps should be taken to ensure that the working conditions of health personnel do not deteriorate.

The priority-setting methodologies require good quality evidence and data free from systematic gender biases and investments in high quality, gender sensitive, medical and social research.

Type of evidence

The report is a synthesis of systematic reviews, narrative reviews and individual articles. As it focuses on the impact of health policies, the quality of the evidence has not been judged formally, but reference is made to the quantity of evidence and its generalizability.