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Out-of-pocket payments reinforce inequalityMost countries finance health care from acombination of sources, including governmentrevenue, social insurance, community-basedinsurance, private insurance and out-of-pocketpayments (OPPs). Each of these mechanisms hasdifferent implications for access to health services,for equity and for protection from the financialconsequences of illness.OPPs at the point of service delivery are a highlyinefficient and inequitable way of financinghealth care. 151 In Africa, OPPs by householdsexceed public expenditure on health, while inricher regions such as Western Europe and NorthAmerica they amount to only a small fraction oftotal health spending. In many countries, thoseliving in poverty incur higher OPPs than othergroups of the population because they are moreoften affected by sickness. Targeted measures toaddress the needs of poor and vulnerable groupsin commercialized health systems—such as feewaivers or subsidies—have been put in place buthave often proven ineffective in reducing outof-pocketexpenditures. 152 Current cutbacks inpublic health expenditure threaten to increasethe financial burden on households. For example,between 2007 and 2011, OPPs for health careincreased by 35 per cent in the United Republic ofTanzania, 8 per cent in the Ukraine and 6 per centin Sri Lanka. 153OPPs have also been found to reinforce women’sdisadvantage in access to health care. Women’sOPPs have been found to be systematicallyhigher than men’s in a number of countries,including Brazil, the Dominican Republic, Ecuador,Paraguay and Peru, not only because of genderspecifichealth needs but also due to the greaterprevalence of chronic illness and some mentalhealth conditions among women. 154 This alsoincreases the likelihood of women not seekingcare because of their lower capacity to pay. 155Although women from poor households are mostlikely to forego treatment, a study from Latvia alsofound significant gender gaps in unmet need forhealth services among higher-income groups. 156 Arecent ethnographic study in Mali further showedthat, where medical treatment requires copayments,access to health care for women andchildren hinged on the readiness of male partnersand fathers to provide the necessary cash. 157Making health care affordable: The questfor universal coverageOver the past two decades, several countrieshave started to roll out universal health coveragereforms, using a variety of approaches andfunding sources to enhance affordability. 158Universal health coverage is defined as ensuringthat all people can use the promotive, preventive,curative, rehabilitative and palliative healthservices they need, of sufficient quality to beeffective, while also ensuring that the use of theseservices does not expose the user to financialhardship. 159 These experiences highlight both thepotential and pitfalls of different approaches interms of achieving substantive equality for womenand girls. 160 Gender equality outcomes can beassessed in terms of the numbers of women andmen covered, as well as the types of services anddegree of financial protection offered. 161Whether or not the specific health needs ofwomen and girls are adequately addressed isparticularly important when universal coveragereforms define ‘essential service packages’ (ESPs).Decisions on what health conditions are includedcan be heavily gender-biased. In the late 1990s,for example, an assessment of publicly financedESPs in 152 countries found that delivery care andemergency obstetric care were often missing. 162Although unsafe abortions claim the lives ofthousands of women each year, safe abortion israrely included in ESPs, even where it is legal. 163Where reproductive health needs are included,this is often done selectively, focusing on maternalhealth and safe delivery while ignoring thereproductive rights of adolescent girls and olderwomen.Affordable health care in the United StatesThe approval in 2010 of the Patient Protection andAffordable Care Act (ACA) in the United States161