VALUING THE INVALUABLE

CONTRIBUTIONS OF WOMEN
TO HEALTH AND THE HEALTH SECTOR

Lecture
Friday March 24, 2016
Dr. Felicia Marie Knaul
Miami Institute for the Americas and Miller School of Medicine,
Please Note:
The presentation cannot
be used without
appropriate citation
Citation:

Knaul, Felicia. Valuing the Invaluable Contributions of Women

to Health and the Health Sector. Special Topics Course. Miami
Institute for the Americas and Miller School of Medicine
Department of Public Health Sciences. March 2016.
 Not a Vicious Cycle, but rather
Less health for men,
women and children
Unhealthy women invest Reduced Unhealthy children
time ineffectively in an economic learn less and adults
attempt to prevent disease growth are less productive
and loss of life
Less
education

Unhealthy, poor, Inequality of

opportunities
disenfranchised women
produce less health care

Poor health and less

More
education means reduced
poverty
economic growth
Less money to
invest in health and
human development
 We aspire to a Virtuous Cycle
women, health and the economy
through gender-transformative policies
Healthy women invest time
effectively in producingReduced
health and preventingeconomic More health is
disease produced for men,
growth women and children
Economic
Less
growth education
Healthy and more
educated women More equitable
Inequality of
produce more health opportunities
opportunities Children learn
and health care better and adults
Poverty are more
reduction productive
More
More economic poverty
growth means more More health and
money to invest in education mean more
health and human economic growth
development
 Women produce
the majority of health care

- paid & unpaid

- in a context of adversity
 Key Findings & recommendations
Women's contributions to health are valued at $US 3.1 trillion or
almost 5% of GDP. Approximately 50% is unpaid.
Unpaid contributions are unrecognized, unaccounted for, unregulated
& deprofessionalized: a hidden subsidy to health.
The total value of the health sector exceeds what is reported in
official statistics or through national health accounts.
Countries invest more in health than reported: official statistics
ignore the huge unpaid contributions by women & men
Health labor markets need to be reformulated to encompass and
embrace home-based health care & made adaptable to women and
men over the life cycle.
Effective, fair health systems offer equal opportunity & incentives
for men to participate in caregiving & health promotion and actively
engage in family life and well being.
Outline
Social, labor and economic
transitions
Analytical framework: the numerous
contributions of women to health and the
health sector
The economic value of women's contributions
to health and the health sector
Global
Mexico
 Increase in the years of
schooling of women
Average Years of Schooling Women's

12
1950 2010
10

Source: Barro & Lee, 2014 (http://www.barrolee.com/data/yrsch.htm).

 Economically Active Population growth rate in the period

0
100
200
300
Mexico
Brazil
Venezuela
Honduras
Guatemala
(1970 - 2010)

Costa Rica
Peru
Men

Colombia
Nicaragua

Trinidad & T.

Source: ILO, 2013. ( http://www.ilo.org/ilostat/faces/home/statisticaldata/data_by_subject )

El Salvador

Paraguay
Ecuador
Jamaica
Panama
Women

Dominican Rep.
Canada
Guyana
Uruguay
Average LAC

Argentina
United States
Increased labor participation of women
 Labor participation rate by gender in
LAC, (1990-2012)
90

80
Costa Rica (Male)
Labor participation rate

70 Mxico (Male)

LAC (Male)
60
Costa Rica (Female

Mxico (Female)
50
LAC (Female)
40

30
1990

2010
2000

2005

2012
1995

Source: Banco Mundial, Indicadores del Desarrollo Mundial 2014.

 Women in Medicine
Women as % of all physicians 1980-2012, select countries
60
Women physicians as % of total physicians

50

Australia
40
Canada
Czech
Republi
30 c
Denmark

Israel
20
Portugal
United
10 Kingdom
United States

0 2005
1980

1985

1990

1995

2000

2010
2012
Source: OECD Statistics.
Nobel Prizes Awarded to Women
1901 - 2014

Women (4.9%) Women Men

women/t
Period otal
No. No. %
47
1901 - 1920 4 101 4%

1921 - 1940 5 99 5%
1941 - 1960 5 113 4%
1961 - 1980 5 176 3%
922
1981 - 2000 11 286 4%
2001 - 2014 17 147 10%
 Demographic and epidemiologic
transitions have been rapid and profound
In just over 50 Women's epidemiologic transition
years, LMIC
will achieve the
aging rates that
most European 75%
countries took 66%
Transmisibles
over two
centuries to No transmisibles
reach. Lesiones
Life expectancy 25%
has increased 13% 12%
from 30+ in 9%

1920, to 75+ 1980 2015

today
Fuente: IHME, Global Burden of Disease, 2015. ( http://vizhub.healthdata.org/gbd-compare/ )
Outline
Social, labor and economic transitions
Analytical framework: the
numerous contributions of
women to health and the health
sector
The economic value of women's contributions
to health and the health sector
Global
Mexico
 The many contributions of women
to health and the health sector
Paid work in the health sector
Paid and unpaid contributions to caregiving
Paid and unpaid contributions through civil
society and community action (only for Mexico)
Women are a motor of economic growth. e.g.
earnings of women are invested in health directly
or through taxation

Discrimina These contributions, even if paid, are often

tion undervalued and under-remunerated.
 Data: 32 countries
Employment and time use survey data for
Canada, Spain, Turkey, Mexico and Peru
Published reports of results of Time Use
Surveys for 27 countries
Represents 52% of the global population
Low income, 4%
Lower middle income, 91%
Upper middle income, 17%
High income, 33%
Counting strategies and estimations (14)
standard
valuation

DF=Gender discrimination factor

Net/Gross: Social Security and taxes
What could not be measured
Work preventing illness and disease
and promoting health in joint
activities in the home activities that
are only partially health related
Innovations and ideas
Increased economic growth due to
increased health dynamic
contributions
Outline
Social, labor and economic transitions
Analytical framework: the numerous
contributions of women to health and the
health sector
The economic value of women's
contributions to health and the
health sector
Global
Mexico
 Total value of women's
contributions to the health sector:
(Lancet, Women and Health, 2015)
PAID:
TOTAL: 51.2%
US$ 3.1 TRILLION
4.8% Global GDP UNPAID:
48.8%

Exceeds total US+UK health budget

2.9 times Mexican economy
20% of the US economy
Each and every woman contributes
$1,200 to health annually
Global Contributions of Women to the
Health Sector: Upper & Lower Bound Estimates

% GDP & trillions of $US

Upper bound 2.43% 2.85% Unpaid

Paid

Wages reported
2.35% 2.47%
in the survey
$1.49 $1.56

Lower bound 2.27% 2.17%

0 2 4 6
Proportion of global GDP (%)
Global Contributions of Women
to the Health Sector: wages scenarios
% GDP & trillions of $US,
by method of wage valuation
Wages adjusted by social
3.1% 4.0% $T4.5
benefits package and sex

Wages reported in 2.4% 2.5%

T$3.1
the survey T$1.5 T$1.6

Unpaid
Based on Country
1.1% 2.5% $T2.8
Minimum Wage Paid

0 2 4 6 8
Proportion of global GDP (%)
Estimated Value of Women's Paid and Unpaid
Contributions to the Health Sector
Canada, Spain, Turkey, Mexico, Peru
Detailed calculations using household surveys and several wage scenarios

Unpaid Paid

Canada 2.9 6.2

and sex differences
Adjusted by social
Benefits package

Spain 2.1 3.1

Turkey 0.9 0.9

Mexico 2.2 1

Peru 0.50.5

0 2 4 6 8 10

Proportion of GDP (%)

 Hours per woman per week dedicated to
caring for health at home,
by income region
Hours a week per capita devoted

3.13 3.12
3
to health care at home

Global average = 2.51

2.01
2 1.83

0
Lower Lower middle Upper middle High
income income income income
Source: Own estimates based on data from 32 countries
Outline
Social, labor and economic transitions
Analytical framework: the numerous
contributions of women to health and the
health sector
The economic value of women's
contributions to health and the
health sector
Global
Mexico
The proportion of professionals who are
women has increased substantially, Mexico
50
1990
2000
40
2014
%

20

Engineers Architects Lawyers Physicians

Percentage of physicians who are women,
1976-2010
70 60
% Men graduated and working as physicians

% women in relation to the total enrolled in

% graduated and working as physicians

60 50

50 % enrolled women

the medical career

40
40
30
30

20
20 % Women graduated and working as physicians

10 10

2010
1980

1985

2000
1990

1995

2005
1976

Source: ANUIES (www.anuies.mx)

Medical Un- and underemployment
by Gender in Mexico, 2014
100%
9
14
26 10 5 Full employment
80% 2 3

11

60% 6 Quantitative
Unemployment (Hours)

40% 79 70
Qualitative
57 Unemployment (Other
activities)
20%
Inactivity and / or
unemployment
0
Women Men Total
Evolution of un- and underemployment
of female physicians in Mexico
100%
26
27
32 Full employment
80%
49% 43%
11
68% 10
60% 6 Quantitative
34 7 Unemployment (Hours)

40% Qualitative
7
Unemployment (Other
51 57 activities)
20% 32
Inactivity and / or
unemployment

0
1990 2000 2014
Medical under & unemployment: women
Mxico: 1990 - 2014 Peru: 2014
70

60

40
68%

49% 54%
43%
20

0
1990 2000 2014 2014
Quantitative Qualitative unemployment Inactivity and/or
unemployment (hours) (Other activities) unemployment
Source: Own estimates based on Labor force Surveys. Encuesta Nacional de Empleo, INEGI, 1990, 2000 & 2014: and
Encuesta Nacional de Hogares 2014, Peru.
Value of health contributions in Mexico,
by wage assumption and gender, 2010
Unpaid Paid Voluntary

20 0.045
Women Men

15 8.1 What are

0.032
men
US $ billions

doing?

2.3% GDP
0.015
10 5.8
0.026
1.6% GDP

5.8
1.3% GDP

4.9

1.0% GDP
5 10.9
7.8
5.0
3.8
0
Minimum wage Wage Adjusted wage Wage
reported in by benefits of reported in
the survey Social Security the survey
and gender
discrimination
Non-exclusive health promotion activities:
MUCH larger figures for unpaid work

Total contributions, Mexico, with non-exclusive,

joint health promotion/illness preventing
activities:
6.5-14-7% GDP
a) collection, preparation or storage of
firewood
b) sourcing of fruits and vegetables
c) carrying or collecting water
d) preparing, cooking and grinding corn or
flour for making tortillas
e) lighting or tending a stove for cooking
with firewood or charcoal
f) cooking or preparing food or drink for
breakfast, lunch, dinner, or between meals
g) warming food or drink for breakfast, lunch, dinner
or between meals
h) washing, drying or putting away dishes
i) cleaning the inside of the house
j) cleaning the exterior of the house
k) separating, discarding, or burning trash
l) washing and drying clothes
m) home repairs or installation of household items
n) shopping for household goods
o) waiting for gas, water, trash collection or other
utility service
Mexico: Unpaid work dedicated to health
activities in the home, w/ health promotion
Women, 15 years and older, average hours / week

Joint health
promotion 4.6%
with other
activities 7.2 hours 3.4% GDP
GDP
assuming 25%
of time-value (of
2.3 29)
=
is health
Unpaid time
2.3 hours 1.1% $ 47 b
devoted to
health care
GDP What
about
girls
<15?
 Mexico: the workweek
Men and women, based on a 168 hour week
Care giving
MEN Domestic work
Rest
WOMEN
Work outside ?
of the home
&
20 s t
9 e x ? ay 41
R la / d
R&R re rs
u
12 ho
6
hours/da 56
y 41 42

Source: Own estimates based on INEGI 2012 and CEPAL..

 Women's Contributions
to Health and the Economy - the choice:
Do we aspire to a Virtuous or a Vicious Cycle?
Virtuous Cycle Vicious Cycle
Less
health for
men, Unhealthy children
Healthy women invest More health is
women learn less and
time effectively in produced for men,
and adults are less
producing health and women and children Unhealthy women
children productive
preventing disease invest time ineffectively
in an attempt to prevent
disease and loss of life Suboptimal
development
of human
Healthy and more capital
Unhealthy, poor, Inequality of
education More equal
disenfranchised opportunities
women women opportunitie
women produce
produce more s Children learn less health care
health care More economic better and adults
growth means are more
Poor health and
more money to productive
More less education
invest in health poverty means reduced
and human
economic growth
development More health and Less money to
education mean invest in health
more economic and human
growth development
 VALUING THE INVALUABLE
CONTRIBUTIONS OF WOMEN
TO HEALTH AND THE HEALTH SECTOR

Lecture
Friday March 24, 2016
Dr. Felicia Marie Knaul
Miami Institute for the Americas and Miller School of Medicine,