OIT - Social health protection for gender equality

 ILO Brief 1 Social health protection for gender equality  Social Protection Spotlight Brief March 2026 Social health protection for gender equality1

At every stage of life, women are disproportionately affected by gender-specific barriers to accessing healthcare and income security. This challenge underscores the need to integrate a gender dimension when designing and implementing social health protection schemes. In addition, women’s healthcare needs are not always prioritized. Women’s access to healthcare may be impeded by a lack of financial resources, social norms, differential treatment from healthcare providers, and the de-prioritization of their healthcare needs within limited household budgets. At the same time, in many countries, women’s out-of-pocket expenses are higher than that of men. Social health protection aims to ensure effective access to quality healthcare without financial hardship, as well as income security in the event of sickness and maternity. Schemes that address genderspecific healthcare needs and social determinants of health inequalities contribute significantly to advancing gender equality in both access to healthcare services and health outcomes. Achieving gender-responsive social health protection requires addressing a range of issues:  Progress needs to be made to extend effective coverage. One in five individuals globally live in a country where social health protection entitlements are not legally recognized, and this share is much higher in low-income countries. It is equally important to ensure that women are aware of their legal entitlements and how to access them, since four in five people living in low-income countries are not effectively protected.  Hiring, training and retaining health workers is crucial to ensure the availability, accessibility, acceptability and quality of care. The shortage of health workers remains a significant barrier preventing many women from seeking essential healthcare services near their home.  Financial protection to promote women’s access to needed services is crucial to achieve progress

crucial to ensure the availability, accessibility, acceptability and quality of care. The shortage of health workers remains a significant barrier preventing many women from seeking essential healthcare services near their home.  Financial protection to promote women’s access to needed services is crucial to achieve progress towards SDG targets 3.1, 3.2, 3.8, 5.4 and 5.6. Although international social security standards emphasize financial protection for maternity care, the level of financial protection has not been prioritized equally across countries and childbirth remains a significant financial burden in too many countries.  Broad risk pooling is needed to ensure that women’s health needs are supported by the society as a whole. Additionally, sustainable domestic financing is essential for maintaining and supporting access to quality services.  Income security during sickness and maternity must be scaled-up. They are amongst the ones with lowest coverage rates globally and tend to rely on mechanisms such as employer liability, which are less robust.  Coordination across pension, health, employment and care policies are essential to ensure women can enjoy healthy ageing in dignity.

1 This brief was prepared on the basis of the ILO Working Paper “Making social protection work for gender equality: what does it look like? how do we get there?” (Razavi et al. 2024). Key points ILO Brief 2 Social health protection for gender equality  Social health protection and gender The right to social health protection Social health protection provides a rights-based pathway towards achieving Universal Health Coverage (UHC) (ILO 2020b; 2024c). As a core part of comprehensive social protection systems, social health protection aims to achieve effective access to quality healthcare without hardship and provides income security in case of sickness and maternity (ILO 2008). The absence of affordable, quality healthcare significantly impacts vulnerable populations, especially women, reinforcing the vicious

protection systems, social health protection aims to achieve effective access to quality healthcare without hardship and provides income security in case of sickness and maternity (ILO 2008). The absence of affordable, quality healthcare significantly impacts vulnerable populations, especially women, reinforcing the vicious cycle of poor health and poverty (ILO 2021c; 2024c). Thus, international social security standards have consistently emphasized the principle of universality of coverage (ILO 2020b) (see box 1). The Sustainable Development Goals (SDGs) include Universal Health Coverage (UHC - SDG 3.8) and Universal Social Protection (USP - SDG 1.3) as interconnected priorities essential for sustainable development and social justice. The ILO Social Protection Floors Recommendation (No. 202) explicitly identifies effective access to essential healthcare without hardship as one of four social security guarantees people should enjoy throughout the life cycle. This aligns with the international consensus established by the 2012 UN General Assembly Resolution on Global Health and Foreign Policy, recognizing UHC and social protection floors as crucial components of national health systems, especially through primary healthcare.  Box 1. Social health protection: definition and main standards ILO Convention No. 102 calls on States to provide social protection to cover healthcare interventions needed to “maintain, restore or improve” health and the ability to work and to attend to personal needs. According to the Medical Care Recommendation, 1944 (No. 69), the range of services covered should be comprehensive. The determination of scope of such healthcare package should be defined through a national dialogue process

2 Cost-sharing is the mechanism in which protected persons pay a portion of the cost of healthcare services or medicines. and be regularly revised to ensure they remain sufficient to ensure a life with dignity. States should also seek to provide higher levels of protection as soon as possible using guidance provided by Convention No. 102 and more advanced standards,

and be regularly revised to ensure they remain sufficient to ensure a life with dignity. States should also seek to provide higher levels of protection as soon as possible using guidance provided by Convention No. 102 and more advanced standards, notably Convention No. 130. Convention No. 102 provides guidance regarding a minimum package of healthcare which should include general practitioners’ services to provide a basic package of primary healthcare services. Moreover, a minimum package of healthcare should include reproductive, maternal, newborn and child health (RMNCH) services, including antenatal care, confinement, postnatal care and hospitalization (if required), specialist and hospital care and essential prescription pharmaceuticals. This is to be complemented by dental care and medical rehabilitation (including prosthetic and orthopaedic devices), as highlighted in Convention No. 130. The responsibility of national authorities is not only to regulate such entitlements but also to ensure that the services provided meet the criteria of availability, adaptability, acceptability and quality. ILO standards stipulate that institutions responsible for social health protection shall make a proactive effort to encourage protected populations to utilize population health interventions and more generally promotion and prevention services. When it comes to financial protection, ILO standards allow cost-sharing2 within limits – “the rules concerning such cost-sharing shall be so designed as to avoid hardship” – and not for maternity care, as reflected in the following instruments: ● Medical Care Recommendation, 1944 (No. 69). ● Social Security (Minimum Standards) Convention, 1952 (No. 102). ● Medical Care and Sickness Benefits Convention, 1969 (No. 130) and Recommendation, 1969, (No. 134). ● Maternity Protection Convention, 2000 (No. 183). ● Social Protection Floors Recommendation, 2012 (No. 202). ILO Brief 3 Social health protection for gender equality Barriers to access healthcare faced by women and girls

● Maternity Protection Convention, 2000 (No. 183). ● Social Protection Floors Recommendation, 2012 (No. 202). ILO Brief 3 Social health protection for gender equality Barriers to access healthcare faced by women and girls Gender considerations are critical to designing and implementing effective social health protection schemes (ILO 2020b; Tessier et al. 2013). Recognizing the genderspecific healthcare needs and the access barriers women and girls face is crucial, including regarding sexual and reproductive health and rights (RMNCH), but also addressing the rise in non-communicable diseases (NCDs) more broadly, which have become the leading cause of death for women and girls in lowand middle-income countries (WHO 2024a). Equally important is addressing broader social determinants of health inequities, such as socioeconomic inequality, gender-based violence and discrimination (see figure 1) (ILO 2020b; Tessier et al. 2013; WHO 2025; ILO forthcoming b). Some of the healthcare services needed by women and girls are specific, particularly RMNCH services. Access to reproductive healthcare services is essential for empowering women and adolescent girls to make informed choices about reproduction (Temmerman, Khosla, and Say 2014). The absence of adequate medical care in the prenatal, delivery and postnatal periods puts women’s lives, and their children’s, at risk (see figure 2). Access to RMNCH remains unequal and is affected by both the availability of services and the social gradient in society. These disparities are further amplified by intersectional discrimination. For instance, women with disabilities often face exclusion from sexual and reproductive health services and are at higher risk of involuntary sterilization (UN 2019). Gaps in service availability and financial barriers combine in practice with a range of social norms that reinforce issues of access to healthcare for women. United Nations Population Fund

disabilities often face exclusion from sexual and reproductive health services and are at higher risk of involuntary sterilization (UN 2019). Gaps in service availability and financial barriers combine in practice with a range of social norms that reinforce issues of access to healthcare for women. United Nations Population Fund (UNFPA) estimates that 45 per cent of women globally were not empowered to make choices over healthcare and contraception in 2021 (UNFPA 2021). Women and girls need to access a range of healthcare services for which they may also face additional barriers. For instance, women’s lower socioeconomic status and restricted opportunities in many societies can result in increased vulnerability to health issues, including higher lifetime risk of depression and other mental health disorders (GBD 2019 Mental Disorders Collaborators 2022). Women with disabilities face even greater financial hardship due to higher healthcare needs, greater access barriers and limited economic opportunities combined. Women and girls often face significant barriers to access healthcare in general, including limited financial resources, social norms, such as discouraging access to a male healthcare professional (sometimes the only available service provider), differential treatment from healthcare providers, and the neglect or de-prioritization of their healthcare needs within limited household budgets (WHO 2009). Even within countries, health inequalities are evident across income and education levels, as well as geographical location (urban/rural). Women in low-income households are disproportionately affected by financial barriers, geographical distance, and lack of female healthcare providers (WHO and World Bank 2023). Studies based on the analysis of demographic and health surveys in lowand middle-income countries have found that country and household income levels, geographical location (rural vs. urban), marital status and health insurance access were all important factors in determining the likelihood of facing barriers to accessing healthcare for women (Terefe et al. 2025). Although women tend to live longer than men, social and economic determinants mean that they do not necessarily

health insurance access were all important factors in determining the likelihood of facing barriers to accessing healthcare for women (Terefe et al. 2025). Although women tend to live longer than men, social and economic determinants mean that they do not necessarily experience healthier lives (WHO 2009; 2025). Gender inequality has been recognized as a significant social determinant affecting both mental and physical health. For women specifically, limited access to maternity, sickness, disability and other cash benefits, combined with inadequate occupational safety and health, often leads to increased morbidity, unmet healthcare needs, and insecurity during their working lives. Over time, these accumulated disadvantages contribute to poor living conditions, undermining women’s healthy ageing (Tessier, De Wulf and Momose 2022). A gender-sensitive approach to improve population coverage, adequacy of benefits, and effective access is vital to address disparities impacting women’s and girls' health and well-being. ILO Brief 4 Social health protection for gender equality  Figure 1. Inequities in access to maternal healthcare services: Share of live births attended by skilled health personnel by wealth quintile, selected countries by region, 2019 or latest available data (percentage)

Source: ILO (2024c, figure 4.45).

 Figure 2. Unequal advances in service coverage for reproductive, maternal, newborn and child health services, by region and type of service, 2023 or latest available year (percentage)

Note: To be interpreted with caution – estimates based on reported data coverage below 40 per cent of the population: ¹ Africa and Arab States; ² Europe and Central Asia; ³ Asia and the Pacific and Europe and Central Asia.

Source: ILO (2024c, figure 4.44). ILO Brief 5

Social health protection for gender equality  Inclusive population coverage Healthcare benefits Ensuring legal and effective access to social health

Source: ILO (2024c, figure 4.44). ILO Brief 5

Social health protection for gender equality  Inclusive population coverage Healthcare benefits Ensuring legal and effective access to social health protection is critical for gender equality, yet universal entitlements are not yet a reality. While 83.7 per cent of the global population is legally entitled to healthcare services without hardship, significant gaps remain, particularly in low-income countries (see figure 3) (ILO 2024). Coverage in practice is more limited: the ILO estimates that less than two third of the world population is protected by a healthcare scheme for their primary coverage, with important disparities across country income levels (see figure 3) (ILO 2024). For instance, in low-income countries, over four in five people remain unprotected.  Figure 3. Share of the population protected by social health protection (effective coverage) and legally entitled to access health care services without hardship (legal coverage), by region and income level, 2023 (percentage)

Source: ILO (2024c, figures 4.41 and 4.42).

Coverage estimates disaggregated by sex cannot be produced as many countries do not yet monitor effective coverage by gender. The absence of sex-disaggregated data in most countries makes it difficult to monitor gender disparities in healthcare coverage at the regional level or income-group level. While social health protection legal and regulatory frameworks usually provide entitlements to women and men without gender criteria, gender inequalities in labour market participation, employment patterns and other socio-demographic and socio-economic factors may lead to unequal outcomes: ● Women’s participation in the labour force remains relatively low in several regions of the world. In addition, employed women tend to be overrepresented in more vulnerable forms of employment, including as domestic workers, own-account workers or in agriculture, often in the informal employment. This may create gaps in effective coverage when

relatively low in several regions of the world. In addition, employed women tend to be overrepresented in more vulnerable forms of employment, including as domestic workers, own-account workers or in agriculture, often in the informal employment. This may create gaps in effective coverage when access to social health protection systems is related to ILO Brief 6 Social health protection for gender equality employment without adequate measures to subsidize contributions of low-income workers (ILO 2021b). ● Similarly, some social health protection schemes affiliate on an individual basis, not a household basis, leaving many spouses taking on unpaid care work (often women) and children uncovered, such as in the social security systems of Cambodia and Myanmar (ILO 2021b). ● Where social health protection systems are contributory, it is crucial that contributions be set at an adequate level and that partial or full subsidies are in place for those with limited or no contributory capacity. For instance, in Ghana, although the National Health Insurance Scheme (NHIS) covers certain categories of the population groups with full subsidies, gaps in coverage are still significant: the poorest groups among those who were not subsidized reported that they had not registered with the NHIS because the premium was still too expensive relative to their contributory capacities (Sen, Govender and ElGamal 2020; UN Women 2015). ● Where social assistance measures to subsidize contributions are available, women may be overrepresented in schemes targeting the poor, which often have lower levels of protection (ILO 2021c). ● In some resource-constrained contexts, governments have put in place programmes affording free care for pregnant women and young children or have lifted user fees for specific RMNCH services. Those efforts are laudable and contributed to the progress made on maternal and child health outcomes. Still, without a comprehensive system in place, such schemes leave women and girls uncovered outside of the pregnancy and early childhood periods (ILO 2021c).

user fees for specific RMNCH services. Those efforts are laudable and contributed to the progress made on maternal and child health outcomes. Still, without a comprehensive system in place, such schemes leave women and girls uncovered outside of the pregnancy and early childhood periods (ILO 2021c). Ultimately, these gaps in coverage negatively affect women’s ability to fully take part in the labour market, foster a more balanced sharing of domestic and family responsibilities, and access equal economic opportunities with men (ILO 2021b). In practice, healthcare services remain inaccessible to many women due to a lack of awareness of their rights, financial constraints, social norms and systemic challenges. It is therefore equally important to reduce access barriers and increase not only the entitlements to social health protection but also the awareness of rights to encourage service utilization amongst women and girls. Sickness and maternity cash benefits Sickness benefits ensure income security during sickness, quarantine or the sickness of a dependent relative. More than four in ten workers remain without any legal protection or entitlement to sickness cash benefits, with wide regional variations (ILO 2024c). Voluntary and employer-liability mechanisms can further hinder effective protection, particularly for women who tend to be disproportionately represented in vulnerable employment (ILO 2020a). Expanding sickness benefits to allow all workers to care for sick relatives or immediate family members for short periods is essential. It can be transformative as this responsibility often disproportionately falls on women (UNFPA 2025a). In addition, pregnancy and childbirth are often associated with time off work, which correlates with a loss of income at a time of increased costs. The absence of income security before and after childbirth forces many expecting women to work during the late stages of their pregnancy or to return to work prematurely – exposing themselves and their children to health risks (ILO 2024c). Cash benefits therefore play an essential role in comprehensive maternity protection. Yet, most women (63.6 per cent)

women to work during the late stages of their pregnancy or to return to work prematurely – exposing themselves and their children to health risks (ILO 2024c). Cash benefits therefore play an essential role in comprehensive maternity protection. Yet, most women (63.6 per cent) receive no income support during the perinatal period

(ILO 2024c).

Extending robust coverage of sickness and maternity protection in an equitable fashion is contingent on: ● Transitioning from employer-liability mechanisms to social insurance mechanisms to reduce income insecurity and risks of employment discrimination against women of childbearing age that may result in disincentives for hiring or retaining women workers. ● Ensuring that sickness benefits include all types of employment, especially those with a large share of women workers. ● Providing systematic adequate coverage of pregnancy and childbirth within healthcare benefits. ● Including paternity benefits into policies to facilitate a better balance of care and work responsibilities between parents. ● Ensuring that benefits are adequate in level and duration and include minimum guarantees, if necessary through a combination of social insurance and tax-financed benefits. ILO Brief 7 Social health protection for gender equality  Adequate and responsive benefit design The effectiveness of healthcare benefit entitlements relies on three key design elements: ● A comprehensive benefit package defining the range of accessible health services. ● A dedicated network of service providers ensuring healthcare facilities and professionals meet quality standards. ● Financial protection to reduce co-payments and user fees at the point of care and prevent financial hardship through high out-of-pocket (OOP). The adequacy of social health protection in advancing gender equality depends on how well these components are structured to address the specific healthcare needs of women as well as how they coordinate with adequate sickness and maternity cash benefits. Designing healthcare benefit packages that work for women A comprehensive benefit package that ensures entitlement to a full range of health interventions protects women against healthcare costs.  Primary healthcare. According to international social

of women as well as how they coordinate with adequate sickness and maternity cash benefits. Designing healthcare benefit packages that work for women A comprehensive benefit package that ensures entitlement to a full range of health interventions protects women against healthcare costs.  Primary healthcare. According to international social security standards, institutions responsible for social health protection must actively promote population health interventions, including preventive and health promotion services. Due to its geographical proximity, holistic and human-centred approach, primary healthcare has potential to foster greater accessibility of services for women and girls. Similarly, specific health and social care services may be needed to tackle violence and harassment against women, as underlined by the Violence and Harassment Convention, 2019 (No. 190), for which primary care providers can play a referral role (ILO 2021b). Primary care facilities should also be the centre of coordination of the range of services that women and girls need and may access in the health sector at different levels of care as well as in educational institutions, in the workplace or in the home.  Reproductive, maternal, newborn and child health services have often been prioritized in legal coverage, in line with ILO instruments which prioritize free maternal care. However, the range of services related to RMNCH varies, with some countries adopting restrictive definitions that exclude some sexual and reproductive health services. Similarly, addressing men’s reproductive health needs can play a pivotal role in transforming stereotyped masculinity. Likewise, through recognizing the role of fathers in antenatal, childbirth, postnatal and child healthcare, a more equal sharing of childcare between parents can be encouraged. This can also foster non-violence at home, at work and in society more broadly (ILO 2021b).  Access to Sexual and reproductive health and rights (SRHR) is a precondition for young women to exercise real choice in family planning, be able to pursue their education or training and engage in employment.

at work and in society more broadly (ILO 2021b).  Access to Sexual and reproductive health and rights (SRHR) is a precondition for young women to exercise real choice in family planning, be able to pursue their education or training and engage in employment. Despite the critical role of SRHR in gender equality, women, including women with disabilities, continue to face significant barriers to accessing SRHR services due to misperceptions, stigma and discrimination (UN 2018; UNFPA 2021). Unsafe abortion remains a leading cause of maternal death globally and comprehensive abortion care is included in the list of essential health care services published by WHO in 2020 (Cresswell et al. 2025). Barriers to access family planning remain and legal frameworks in this respect are progressing slowly (UNFPA 2025b). Significant retrogression such as the reintroduction of abortion bans in Poland and the United States, have also marked a setback (Amnesty International 2022a; 2022b).  Mental health. Globally, the burden of mental disorders weighs more heavily on women than on men (GBD 2019 Mental Disorders Collaborators 2022). The mental health and well-being of women affect their own physical health as well as the health of their children, with lasting effects (WHO 2022a). Despite the significance of mental health disorders, often mental health services are unavailable at primary care level, or not available at all in health systems in developing countries (Patel et al. 2018). Even when they are, they are seldom included in social health protection benefits packages in those settings and may be accessed under a more restrictive set of rules (ILO 2021b). The above services are highlighted here because they are often given a lesser level of priority in benefit package design. Yet, overall, a comprehensive range of services needs to be included and accessible in a wide and welldistributed network of service providers with high levels of

2021b). The above services are highlighted here because they are often given a lesser level of priority in benefit package design. Yet, overall, a comprehensive range of services needs to be included and accessible in a wide and welldistributed network of service providers with high levels of financial protection to adequately respond to the needs of ILO Brief 8 Social health protection for gender equality women and girls (see next sub-sections). In addition, integrating care, adopting an approach that addresses risks holistically across the spectrum of preventive and curative health services but also linking with broader social programmes to address risk factors of NCDs is crucial looking forward (Akselrod et al. 2023). This approach needs to be taken into account when designing benefit packages for specific schemes to ensure continuity of care, particularly in lowand middle-income settings where health and social programs already face financial and human resources constraints and where fragmentation is a risk. Securing access to quality service providers High social health protection coverage does not always translate into equitable access to services and health outcomes, largely due to unequal distribution and gaps in acceptability and quality of facilities and healthcare providers. While efforts have been made to improve healthcare infrastructure in rural and remote areas, challenges remain in ensuring an adequate distribution of services and retaining skilled healthcare workers (ILO forthcoming a; 2021b; 2024a). The location of healthcare facilities is particularly important for women, as transportation costs and safety concerns can prevent them for seeking care, especially for women with disabilities (Geleto et al. 2018). Nurses and midwives play a central role in expanding healthcare coverage and advancing RMNCH progress (ILO 2022; WHO2024b). Hiring, training and retaining them, especially in rural areas, is a key building block in ensuring the availability, accessibility, acceptability and quality of care in line with international social security standards

healthcare coverage and advancing RMNCH progress (ILO 2022; WHO2024b). Hiring, training and retaining them, especially in rural areas, is a key building block in ensuring the availability, accessibility, acceptability and quality of care in line with international social security standards (ILO 2018a; 2023). For this, ensuring that the working conditions in the health sector are aligned with international labour standards remains crucial (ILO 2018b; 2019). Decent working conditions in the health and care sector notably include adequate wages, sufficient staffing levels, regulated working time, occupational safety and health (including psychosocial risks) policies, training opportunities, and protection against violence and harassment. Given that the health and care workforce is predominantly composed of women, strengthen