Summary

It is broadly agreed that sexual and reproductive health and rights (SRHR) and universal health coverage (UHC) are intimately linked. UHC has been described as a pragmatic means for advancing SRHR, and SRHR is considered an essential component of UHC. SRHR is universally recognized as a fundamental dimension of health and well-being and a human right. Ensuring SRHR requires a comprehensive, intersectional, and life-course approach, recognizing the layers of privilege or vulnerability that may influence one’s sexual and reproductive health needs and opportunities to fulfill one’s sexual and reproductive rights, as well as the shifting needs of individuals across the life course. UHC, on the other hand, implies that all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative, and palliative essential health services. UHC also entails access to quality medicines and vaccines while ensuring that the use of these services does not expose the users to financial hardship. In 2019, the Political Declaration on UHC stipulated that access to SRH services as a key aspect of UHC was to be achieved by 2030. The declaration also reaffirmed commitments to the International Conference on Population and Development Programme of Action and Beijing Platform for Action. While SRHR is integral to the UHC agenda, and the delivery of both SRH services and UHC relies on functioning and quality primary health care systems, there are limitations of the UHC agenda for advancing SRHR.

The aspiration of UHC and to what extent it has integrated SRHR under its ambit and advanced it from a gender and rights perspective can be revealed by a set of cases reflecting the experiences of people in vulnerable situations, which illustrate different shortcomings in the current UHC framework and its translation on the ground. These shortcomings include systematic exclusions and discrimination of persons currently belonging to marginalized groups, inadequate investment in and respect for women health workers, violations of autonomy and dignity, lack of accountability, and power of politics. These shortcomings, which limit access to and experience of quality health services, cannot be removed by narrowly focusing on addressing the “ability to pay” or reducing the financial barriers alone. Therefore, the current framing of UHC is insufficient to progressively realize SRHR and thus demands a reconceptualization and/or extension of current framing and design.

To address the shortcomings, an intersectional feminist approach to UHC is proposed. Shifting mindsets and including gender and power analysis in UHC design, operationalization, and measurement of UHC outcomes will allow for achieving the UHC objectives of financial protection, equity in access, and service quality. Taking an intersectional feminist approach to UHC would improve not only SRHR outcomes but also health outcomes at large. It will furthermore offer a pathway to truly deliver on the objectives of UHC—equitable health care for all.