Abstract
BackgroundOver the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy’s positive effects impact on health-related indicators, the repercussions on women’s empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women’s empowerment.MethodsA systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB s, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework.ResultsOut of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women’s empowerment, while the others address this issue indirectly —mostly by examining gender equality or women’s decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women’s capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women’s healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources).ConclusionUser fee removal policies alone are not enough to improve women’s healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women’s empowerment. A focus on “gender equitable access to healthcare” is needed to reconcile women’s empowerment and the efforts to achieve universal health coverage.
Highlights
Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage
This problem is salient in low- and middle-income countries (LMICs), where barriers to healthcare access are prioritized for intervention on the road to Universal Health Coverage (UHC) [4, 5]
It argues that user fee removal for obstetric care has a transformative effect on women through three different mechanisms
Summary
An increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Achieving gender equality and empowering women and girls, as well as achieving universal health coverage (UHC) are part of the 2030 Agenda for Sustainable Development [1]. Gender inequalities have been recognized as powerful determinants of health and well-being and, as such, should be targeted in the efforts to increase access to healthcare This problem is salient in low- and middle-income countries (LMICs), where barriers to healthcare access are prioritized for intervention on the road to Universal Health Coverage (UHC) [4, 5]
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