In our blog in June, we brought together empirical evidence to show that women in low- and middle-income countries (LMICs) systematically access healthcare less often than men. The review of the literature suggested that these gender disparities observed at the health facility level are likely a manifestation of households preferring to invest in the healthcare of men rather than women.
It is possible that households in a resource-constrained settings are simply making a ‘rational’ economic choice by assigning greater priority to the health of members who put food on the table. As is well known, the primary breadwinners tend to be men1, with women disproportionally bearing the burden of undervalued, unpaid domestic work2. An alternative explanation is that the differential treatment of women and men in the household is driven by innate pro-male bias. This may be thought of in terms of Becker’s (1957) theory of “taste-based discrimination”, portraying discrimination as a preference or taste that some individuals have against certain social groups, even when it imposes personal economic costs. If this mechanism is dominant, women who contribute economically to households may still be discriminated against in the allocation of household resources towards their healthcare. Further, the bias may be imbibed by the women as well, making them feel unworthy of care (Chamberlain et al. 2007).
Within this framing, it is instructive to look at the interplay between women’s work participation and healthcare-seeking behavior in LMICs. However, this is complicated by the fact that a lot of the same factors plausibly shape both dimensions, such as social and cultural norms, unequal sharing of domestic work, limited physical mobility and networks, and safety concerns – with working status potentially serving as an instrument of empowerment and agency for women (Maxwell and Vaishnav 2021). A clutch of studies seek to measure women’s intra-household bargaining power in different ways, with contributing factors including women’s education, income, and assets, among others (Doss 2013). Further, these studies examine the relationship between women’s ability to negotiate with the family and how decisions are made regarding their healthcare.
Intra-household bargaining power and health decisions
Majlesi (2015) posits that an increase in the relative number of labour market opportunities available to women improves their “outside option” in a marriage, in turn raising women’s bargaining power in the household. Using data from two panel waves of the Mexican Family Life Survey, his study proxies intra-household bargaining power by the relative decision-making power (number of decisions made by the wife minus the number of decisions made by the husband) in 12 different categories. The key finding is that the demand for female labour in the manufacturing sector leads to relatively more decisions made by the wife in the household – whether or not the wife is actually employed. In the context of health, the types of decisions considered in the analysis, and over which women gain more control, include the use of contraception and children’s health and medicine. While the study covers other decisions directly pertaining to the wife’s own life such as her work status or money that is given to her parents, it does not shed light on decisions pertaining to her health.
In sub-Saharan Africa (SSA), Zegeye et al. (2023) uncover a positive relationship between married women’s decision-making autonomy and their health insurance coverage, based on data from Demographic and Health Surveys (DHS) of 29 countries. In the surveys, one of the three components of the measure of decision-making autonomy is based on married women being asked about who makes decisions related to their health. Being older, educated (secondary or tertiary level relative to no formal education), and employed increases the chances of married women having health insurance. Since overall health insurance coverage among married women in SSA remains low, this research provides insights into the types of policy interventions that can bring about an improvement.
Using 2018 data from the Nigeria DHS, Imo (2022) assesses the impact of women’s decision-making autonomy on their utilization of antenatal care (taking into account the timing of the first visit and the total number of visits, in relation to guidelines of the World Health Organization) and institutional delivery services. Women’s autonomy is determined on the basis of who the decision-maker is in matters relating to women’s healthcare, spending of women’s earnings, large household purchases, and visiting family or relatives. The study concludes that women’s control over their healthcare and earnings is associated with having an adequate number of antenatal care visits during pregnancy. However, contrary to expectation, women’s decision-making autonomy on how their earnings are spent served as an inhibiting factor to initiating antenatal care early. The researcher contends that this may reflect “how women’s perceived benefits of behavioural intentions influence the performance of such behaviours”. They may feel constrained to financially take care of other urgent family issues.
In the context of rural India, Maitra (2004) examines whether relative power within the household has implications for healthcare usage, specifically prenatal care and hospital delivery. Leveraging data from the National Family and Health Survey (NFHS), 1999, bargaining power is predicated on the educational attainment of the husband and the wife, and sociological/demographic measures of the status of the wife in the household (for example, if the wife needs permission to visit family and friends) – rather than economic resources such as asset ownership. It is found that a woman’s education has a stronger effect on healthcare usage relative to that of the husband. Further, a woman’s control over household resources (ability to keep money aside) has a significant positive impact on the demand for prenatal care and the probability of hospital delivery.
Overall, there is evidence on the link between women’s intra-household bargaining power – in some cases, determined by their work status or availability of job opportunities – and healthcare usage. Yet, the focus on women’s healthcare outside of maternal and child health remains limited.
When work disempowers
While working women may feel more empowered to seek healthcare when needed, the dual responsibilities of home and work may make them more susceptible to “cognitive overload”. In her Harvard Business Review article, Ashraf (2013) highlights various biases, and limits on cognition and motivation that lead people to make suboptimal health choices. In particular, focusing on the factor of “limited attention”, she gives the example of a parent who may miss early symptoms of a child’s illness because their focus is on providing basics such as water and fuel for the family by nightfall. This may also apply to working women with regard to their own health, and they may have a higher threshold of what warrants a doctor’s visit. Given the nature of non-communicable diseases, which are increasingly affecting women – as discussed in our blog last month – such gendered differences in healthcare-seeking behaviors can negatively impact women’s well-being.
Besides, in most LMIC contexts, social and cultural norms discourage women from engaging in paid work outside the home. It is conceivable that working women – aware that they are going against tradition – may ‘overcompensate’ at home by willingly putting themselves in a subordinate position. A related norm pertaining to gender roles is that husbands should earn more than their wives. Bertrand et al. (2015) show that among couples where the wife earns more than the husband, the wife in fact takes on a greater share of house work, in an attempt to “assuage the husband’s unease with the situation”. In a similar vein, utilizing Indian microdata, Roychowdhury and Dhamija (2020) demonstrate that violation of hypergamy – when the wife’s economic status equals or exceeds that of her husband’s – causes a significant increase in domestic violence. Evidence of male backlash to female empowerment exists in developed settings as well (for instance, Ericsson’s (2019) analysis of data from Sweden). It is plausible that these factors also play a role in the seeking of healthcare by working women, tempering the positive impacts of their work status.
Entrenched norms trump economic means?
In central Malawi, Azad et al. (2020) bring together data from a hospital census and a community survey, to examine how gender attitudes and household decision-making influence the utilization of healthcare (excluding obstetrics and gynecology) among adults. They find that gender disparities in healthcare are driven by individual and societal attitudes that undervalue women and prioritize the health of men. Furthermore, women exhibit greater adherence to traditional gender norms relative to men. In such a situation, the authors put forth that women’s economic empowerment alone is unlikely to make a difference. Rather, there is a need for interventions that seek to enhance women’s sense of importance and prioritization of their health and that of their daughters.
The fact that putting more money in the hands of women in LMICs may not necessarily translate into greater utilization of healthcare by women, is also noted by Agrawal et al. (2024). While the positive relationship between income and healthcare is taken as conventional wisdom in the developed world, gender identity plays a role in the Global South. The researchers study an institutional change involving a reduction in the mandated rates of employee contribution to the provident fund in India. Counterintuitively, the resulting increase in take-home salaries among women is associated with lower healthcare expenses. A possible explanation is that a marginal increase in the income of a household member is treated differently based on gender. The expectation may be for women to contribute disproportionately to the household public good vis-á-vis men. With more disposable income, women are likely to spend more on the health and education of their children, rather than their own healthcare. Hence, similar to the Malawi study, the takeaway here is that solely increasing women’s economic empowerment may not be the answer.
Enhancing men’s knowledge of women’s healthcare
In their qualitative study in rural Burkina Faso, Nikièma et al. (2007) observe that “the effect of women’s disadvantage on their capability to purchase modern healthcare is mitigated by a kind of reallocation mechanism that derives from the same traditional norms that create gender asymmetry.” In principle, husbands have a responsibility for taking care of the needs of the wife, using available household resources. Yet, in practice, the unequal power balance means that various factors come into play: the husband’s perception of the health problem being severe, the wife being “well behaved”, women having to put in extra energy and time to convince others that they really need the care, and the uncertainty of this negotiation process reinforcing women’s inferior position. Social norms notwithstanding, this points towards the importance of public health measures that attempt to inform household evaluation of what justifies seeking modern healthcare as well as the negative outcomes of delaying treatment.
Hou and Ma (2012) emphasize the need to target other household members, including “influential males” in order to raise their awareness regarding the benefits of maternal health services. Their analysis of data from the Pakistan Social and Living Standards Survey, 2005-06, shows that in households where males exert more decision-making power over household expenditures on food, clothing, medical treatment and recreation3, women tend to use fewer maternal health services, with the exception of institutional birth. Males may not perceive such services as very important and hence, may discourage their wives from availing them.
Although the focus is on fertility decisions and not the use of healthcare services, in their 2021 paper, Ashraf and co-authors demonstrate how different outcomes are achieved depending on whether it is the husbands or the wives that are provided information on risk factors that influence childbirth outcomes. The researchers conducted an experiment with over 500 couples in Lusaka, Zambia, and observed that when the information is delivered directly to men, there is updating of beliefs for both spouses, greater alignment in the couple’s fertility preferences (number and spacing of children), and reduced fertility. On the other hand, women are unable to effectively convey their knowledge of maternal risk to their partners.
Unpacking the various influences on women’s healthcare-seeking – economic empowerment and intra-household bargaining power, behavioral aspects, women’s internalization of gendered norms and male backlash to their empowerment, and men’s knowledge of women’s healthcare – can guide the design and implementation of effective public health policies and programmes.
The family economics literature has traditionally focused on bargaining between the husband and wife within a nuclear household structure. However, patrilocality is prevalent in many developing countries, implying that family members besides the husband may play a role in the welfare of women. Academic work has begun to take this into consideration. We explore this aspect in the context of healthcare-seeking decisions in our next blog in October.
FOOTNOTES
1 Among working-age populations (15-64 year olds) in lower-middle-income countries, the labour force participation rate is 43.4% for females as against 79.6% for males (World Bank, 2024).
2 Globally, women perform about three-fourths of unpaid care work, dedicating on average 3.2 times more time to such work than men (International Labour Organization, 2018). A factor that may be important here is the structure/composition of the household – specifically who else is potentially available to carry out these tasks in the case of illness of the female homemaker.
3 Women’s decision-making power in the household is measured on the same basis in the study. While the authors acknowledge the relevance of women’s employment, they do not include this factor in the construction of the decision-making index because the female labour force participation rate in Pakistan is only about 10% (including unpaid family workers). This is more a function of the overall culture and limited availability of job opportunities for women, and not women’s decision-making power in their marital homes.
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