Why equitable financing for NCDs starts with inclusion

Equitable access to non-communicable disease care must be designed into health financing systems from the ground up. This means centring the needs of women and others too often pushed to the margins.

Health financing can advance equity for underserved and marginalised groups, including women. Photo: Access Accelerated

Health systems around the world aspire to care for all. But for too many people—especially those living with non-communicable diseases (NCDs) in low- and middle-income countries (LMICs)—quality, timely healthcare remains a privilege rather than a basic right. Multiple barriers stand in the way: lack of health facilities, geographic inaccessibility, health workforce shortages, cultural stigma, limited health literacy, and others. Among these, financial barriers are perhaps the most deeply rooted and persistent.

That is why we believe that strong, resilient health systems must be built on financing strategies that acknowledge the most excluded—and address their greatest unmet needs and the barriers that perpetuate inequities. Too often, health financing systems are not designed to adequately reach or support the very people who rely on them the most: rural communities, low-income families, informal workers, and unpaid caregivers—with women and their families often at the intersection of these groups.

Across contexts, the financial burden of managing NCDs falls hardest on those least able to bear its weight. The cost of long-term chronic care, compounded by lost income, transportation expenses, and the cascading effects of late diagnoses, can push families into poverty and lock them out of care altogether.

Women’s experiences offer a particularly sharp illustration of how inequities in health financing play out more broadly. Globally, over three-fifths of women of prime working age do not participate in the labour force, and those who do are more likely to work informally, which often excludes them from health insurance. In South Asia, over 80% of women in non-agricultural jobs are informally employed; elsewhere, this number ranges from 54% to 74%.

While conditions, such as job informality, income insecurity, and geographic distance, are not unique to women, their experiences expose broader systemic failures in how care is financed and delivered. When health systems fail women, they almost certainly fail others, too.

The good news is that health financing—how resources are raised, pooled, and spent—presents a promising and powerful opportunity to advance equity for underserved and marginalised groups, including women.

Mobilising resources with equity in mind

When it comes to funding healthcare, some countries still rely on flat-rate contributions or user fees. But this approach is not always fair, and we know these are often regressive in practice. For example, a flat-rate premium takes a far greater share of income from someone earning US$3 a day than from someone earning US$30. And when people must pay at the point of care—even modest amounts—they may delay treatment or avoid it entirely. For those with chronic conditions, these recurring costs can lead to financial hardship.

Fortunately, there are more equitable alternatives. Progressive taxation, where higher-income groups contribute more, allows countries to raise resources sustainably without penalising lower-income populations, especially for long-term conditions like NCDs.

Some countries are already leading the way. Thailand’s universal coverage scheme, funded through general taxation, covered 47 million people as of 2024. It includes both basic and high-cost services like chemotherapy and radiation therapy, and requires individuals to register with a local primary care network, which often leads to better continuity of NCD care. In the first decade following the scheme’s rollout in 2003, healthcare access increased and instances of catastrophic spending dropped—especially among the poorest and young women of reproductive age.

In India, the first nationally funded health insurance scheme, Rashtriya Swasthya Bima Yojana, helped reduce out-of-pocket expenditure for women hospitalised for non-maternal health services. Its successor, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme, specifically targets the country’s most vulnerable populations, expanding its reach to include migrant workers, urban informal sector employees, and vulnerable rural communities, with particular attention to women, children, and the elderly. 

Pooling resources to strengthen financial protection

Pooling resources to pay for care helps spread financial risk across a population and reduce out-of-pocket costs. But when pooling is linked to formal employment, large parts of the population, including informal workers, part-time labourers, and unpaid caregivers—many of whom are women—often lack access to employer-sponsored health insurance. This leaves them either unprotected or dependent on underfunded schemes.

A more inclusive approach focuses on a unified, publicly financed national health insurance system that is open to all, typically featuring income-based contributions, government subsidies for those unable to pay, universal access to core benefits, as well as automatic or simpler enrolment mechanisms.

Rwanda offers a compelling example where community-based health insurance pools resources at the household level and offers tiered contributions based on income, supported by public subsidies. This model has led to high health service utilisation among those with the lowest income while reducing out-of-pocket costs and catastrophic expenditure, notably benefiting women: in 2020, 77% reported relying on mutual or community-based insurance. 

Strategic purchasing aids accessibility

In health financing discussions, we tend to focus on how to mobilise funds, overlooking the equally important question of how those funds are spent. Strategic purchasing—which decides what services are covered, where they are delivered, and who provides them—can shape the accessibility and affordability of care. Key avenues for using strategic purchasing to address equity gaps include benefit specification (defining the services included in a benefit package, identifying access points, and outlining cost-sharing policies) and contracting arrangements (for example, engaging local or non-state providers can help extend care to remote or underserved areas).

We have seen how strategic purchasing decisions can make a difference. In Tanzania, faith-based organisations play a major role in reaching remote communities and reducing out-of-pocket costs. In Thailand and China, contracting providers to serve specific geographic areas has reduced travel times and improved uptake of health services.

How funds and resources are allocated and distributed is a powerful lever for advancing equity. When informed by evidence and rooted in need, strategic health purchasing decisions can improve health systems outcomes by expanding equitable access, reducing out-of-pocket costs, and strengthening financial protection for the most vulnerable, including women.

Collaborative, country-led approaches

Country-led efforts like these serve as powerful examples of the fact that, even in resource-constrained settings, inclusive health financing for NCDs is not only possible but essential to achieving the universal health coverage (UHC) goal of equitable access to quality care without financial hardship.

Yet progress remains uneven. To accelerate meaningful change, we need deliberate strategies and ongoing assessment, measurement, and monitoring, as well as continuous learning. What is often missing is not knowledge, but the opportunity to share lessons and mechanisms to translate them into action.

Through our work at Access Accelerated, we have seen how technical, country-driven learning platforms—like the Financing Accelerator Network for NCDs (FAN)—can help bridge the gap between commitment and implementation. As an initiative of the Access Accelerated and World Bank technical partnership, working in close cooperation with Results for Development, FAN brings together ministries of health, ministries of finance, and local partners in LMICs to foster cross-country learning, offer technical support, and provide catalytic seed funding to support and scale initiatives that advance sustainable health financing for NCDs.

Ultimately, if we are to build truly inclusive health financing systems, we must do so from the margins inward. A system designed to serve those who are most often left behind is far more likely to work for everyone—and be stronger and more resilient in the long run.

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The opinions expressed are those of the authors and do not necessarily reflect the position of Re:solve Global Health.

Aura Vilhelmsen is global health equity lead at Novo Nordisk, a leading global healthcare company working to defeat serious chronic diseases. She works with partnerships and initiatives to address the global crisis of NCDs, particularly in LMICs, through promoting primary prevention, improving access to NCD care, and advocating for sustainable financing models for NCD interventions.

Ruth Musila is director, global public affairs at Takeda. She brings a multifaceted perspective, having collaboratively championed solutions to overcome patient access barriers to enhance health outcomes in different sectors through policy shaping and health systems strengthening initiatives. She is an advocate for private-public partnerships striving to expand access to quality healthcare for patients.

Saba Husain is senior director of global health initiatives at Lilly, where as part of her role she supports Lilly’s global health external stakeholder engagement coalitions to address gaps in NCD access. 

Saba Husain, Ruth Musila, and Aura Vilhelmsen make up the executive committee leading Access Accelerated.