Authors: Shubhangi Mishra, Archi Singh, Prajesh Konchady, Lidiya Alehelgne, Tanisha Tushir, Vedika Dhanvi, Ananya Sarangi

Abstract

This paper argues that the main divide in women’s health policy is not simply between rich and poor countries, but between systems that treat women’s health as a short reproductive episode and those that organize care across the life course. Using a qualitative comparative policy analysis of 28 countries, the study compares national policy architectures through four variables—accessibility, affordability, quality, and agency—across adolescence, reproductive years, and mid-to-late life. The analysis finds that many countries in South Asia, Sub-Saharan Africa, and parts of Latin America and MENA remain locked into a maternal trap in which financing incentives, vertical programme design, and weak gender-responsive governance sustain strong maternal services while leaving mental health, non-communicable diseases, and ageing-related care underdeveloped. By contrast, several Global North cases and a smaller set of higher-performing Global South cases show that life-course integration is more feasible when universalist financing, stable governance, and primary-care-based delivery align. The paper concludes that reform must shift from listing women’s programmes to redesigning incentives, institutions, and accountability mechanisms that shape women’s health outcomes over time.

1. Introduction

Over the past two decades, global health policy has placed a strong and sustained emphasis on reducing maternal mortality. This focus has produced substantial gains, and global maternal mortality declined by nearly 40% between 2000 and 2020, driven by expanded antenatal care, skilled birth attendance, and emergency obstetric services (World Health Organization [WHO], 2024). These gains are widely framed as a success of the Millennium Development Goals and later Sustainable Development Goal (SDG) 3.1.

Yet this progress conceals a deeper structural imbalance in women’s health policy. In much of the Global South, women’s health remains operationally synonymous with maternity, focusing narrowly on pregnancy and childbirth while neglecting health needs across adolescence, mid-life, and older age (The Lancet, 2024). Although maternal-centric policies are essential and lifesaving, they reduce women’s health to reproductive functionality and obscure the growing burden of non-communicable diseases (NCDs), mental health disorders, and ageing-related conditions (UN Women, 2023).

Evidence from the WHO indicates that women in low- and middle-income countries spend significantly more years in poor health than men, largely due to chronic and non-reproductive conditions that remain under-diagnosed and underfunded (WHO, 2024). In contrast, several Global North countries have begun adopting life-course approaches that integrate sexual and reproductive health with mental health, NCD prevention, and geriatric care (European Commission, 2024; Government of Norway, 2024).

This paper seeks to explain why life-course women’s health policies remain limited in the Global South and uneven even in high-income contexts. It argues that the divide is institutional rather than financial, shaped by donor incentives, health-system siloing, governance stability, and socio-cultural norms.

2. Conceptual Framework

The study is grounded in a life-course approach to women’s health, which conceptualizes health as a cumulative process shaped by biological, social, and institutional determinants across different stages of life (WHO, 2016). This approach challenges vertical health systems that prioritize short-term, measurable outcomes, particularly maternal mortality, over continuous and more comprehensive care.

To operationalize comparison, the study adapts the Co-Impact three-driver model of accessibility, affordability, and quality by adding a fourth pillar, agency, to capture women’s autonomy, voice, and decision-making power within health systems (Malhotra, 2021). Together, these four pillars enable assessment of whether women can reach services, afford care, receive appropriate treatment, and exercise control over health decisions.

The persistent dominance of reproductive-centric policy in the Global South is conceptualized as the maternal trap, wherein institutional incentives lock health systems into pregnancy-focused service delivery while excluding non-reproductive health needs (The Lancet, 2024). In this paper, the maternal trap is not treated as a metaphor alone; it is used as an institutional concept that links financing incentives, programme design, and policy visibility. For example, in Bangladesh and Nigeria, donor-supported maternal health packages have expanded facility births while leaving hypertension, diabetes, and depression services weakly integrated into primary care, leading to high unmet need among mid-life women. In contrast, Sri Lanka’s Well Woman Programme shows how adding NCD and cervical cancer screening to long-standing maternal and child health platforms can gradually ease this trap by keeping women engaged with the health system after childbirth.

From a life-course perspective, women’s health is cumulative and path dependent. Risks that are unaddressed in adolescence often shape reproductive-age vulnerability, and untreated conditions in the reproductive years can deepen disability and exclusion in mid-to-late life. The life-course lens is therefore not just descriptive; it is the evaluative standard used throughout the paper to judge policy continuity and institutional depth.

Research Questions

This study is guided by the overarching concern that global progress in reducing maternal mortality has not translated into equitable health outcomes for women across the life course, particularly in low- and middle-income countries. While women’s health policies have expanded access to reproductive and maternal services, there remains limited understanding of how national policy architectures address women’s health beyond pregnancy and childbirth, and why life-course approaches remain unevenly adopted across regions.

1. Under what institutional conditions do national women’s health frameworks move from maternal-centric design toward life-course integration?
2. How do tax-funded, insurance-based, and donor-dependent financing arrangements shape the inclusion or exclusion of non-reproductive services in women’s health policy?
3. How do governance stability and policy continuity affect a state’s capacity to sustain women’s health services beyond pregnancy and childbirth?
4. How does the maternal trap manifest differently across South Asia, Sub-Saharan Africa, Latin America, MENA, and higher-performing mixed cases within the Global South in terms of service packages, budget allocations, and coverage trajectories after childbirth?
5. How does women’s agency mediate the translation of formal policy coverage into actual continuity of care across the life course?
6. What policy lessons can be drawn from Global North countries and higher-performing Global South cases to support transition toward life-course women’s health equity?

Together, these questions guide the comparative analysis of women’s health policy architectures across countries, enabling examination of not only what policies exist, but how institutional arrangements, financing incentives, and governance structures shape women’s health outcomes across adolescence, reproductive years, and mid-to-late life.

3. Methodology

This research employs a qualitative comparative policy analysis to systematically evaluate national-level health frameworks and flagship programmes across 28 purposively selected countries. The sampling strategy was designed to ensure regional diversity, income-level variation, and divergent health-system models, focusing specifically on countries with explicit or traceable policy frameworks relevant to women’s health, gender-responsive care, maternal health, or universal health coverage.

The study synthesizes secondary data spanning 2000 to 2025, integrating national strategic documents with evaluative reports from international bodies including WHO, UNFPA, UN Women, the World Bank, and peer-reviewed literature. This range of material was selected because the policy question concerns institutional design and policy architecture rather than clinical effectiveness alone.

The country selection followed four criteria. First, regional spread: the sample includes South Asia, Sub-Saharan Africa, Latin America, MENA, East and Southeast Asia, Europe, and North America. Second, income and system variation: cases span low-, lower-middle-, upper-middle-, and high-income settings, and include tax-funded, insurance-based, mixed, and donor-dependent systems. Third, policy salience: selected countries had identifiable women’s health, reproductive health, maternal health, or gender-responsive frameworks available for analysis. Fourth, comparative leverage: the sample includes strong performers, transitional systems, and conflict-affected or fragile states to explain variation rather than create a simple ranking.

Countries were compared through a four-pillar analytical framework—accessibility, affordability, quality, and agency—at three life stages: adolescence, reproductive years, and mid-to-late life. Using deductive thematic coding, the analysis traced recurring mechanisms that linked financing arrangements to policy design, policy design to service packages, and service packages to continuity of care. This mechanism-based approach helps explain not only whether policies exist, but why they produce inclusion in some cases and post-maternal exit in others.

The method has limitations. It does not provide statistical proof of causality, and it relies heavily on secondary and English-language material, which may understate sub-national divergence and non-English policy debates. Still, it is well-suited to identifying patterned institutional differences across diverse policy systems.

4. Literature Review

Scholarship on women’s health policy is extensive but unevenly distributed. Research from the Global North largely emphasizes reproductive rights, preventive care, welfare-state health systems, mental health, and ageing, while studies from the Global South have more often focused on access barriers, resource constraints, and implementation challenges (Malhotra, 2021). This difference reflects not only scholarly emphasis but institutional history.

Global health frameworks have historically prioritized sexual and reproductive health, particularly maternal and child outcomes (WHO, 2016). While this focus produced substantial gains, scholars increasingly critique its neglect of women’s mental health, NCDs, and ageing-related conditions (The Lancet, 2024). The problem is therefore not that maternal health was overvalued in moral terms, but that it became administratively synonymous with women’s health in many policy settings.

Comparative research suggests that policy models effective in high-income contexts often fail in low- and middle-income countries because governance capacity, financing structures, and socio-cultural constraints shape implementation differently (Witter et al., 2017; Michel et al., 2019). Evidence from France and Finland illustrates gradual life-course integration, while Bangladesh, Venezuela, and Nigeria demonstrate persistent maternal-centric architectures shaped by donor dependence, political instability, and weak continuity after childbirth (Ross & Khuda, 2023; UN Women, 2023).

The literature also reveals a gap that this paper addresses directly. Many studies identify fragmentation and inequity, but fewer explain the mechanism through which financing systems and governance structures generate different policy trajectories. This paper contributes by connecting international financing incentives, domestic institutional design, and women’s practical ability to remain visible to the health system after reproductive contact ends.

5. Thematic Analysis

5.1 Reproductive-Centric Versus Life-Course Policy Paradigms

In much of the Global South, women’s health policy remains dominated by maternal and reproductive care. India’s National Health Mission, Ghana’s CHPS framework, Brazil’s Unified Health System, and Botswana’s sexual and reproductive health programming expanded institutional deliveries and antenatal coverage but often integrated mental health, cervical screening, or mid-life NCD care only weakly or unevenly (Ward et al., 2024; Pan American Health Organization [PAHO], 2025; Botswana Ministry of Health, 2011). Women frequently disengage from formal systems once pregnancy-related contact ends, creating what this paper terms a post-maternal policy exit.

By contrast, countries such as Norway, Finland, Germany, Japan, and Singapore increasingly institutionalize life-course frameworks that provide continuous health touchpoints independent of pregnancy status (European Commission, 2024; Government of Japan, 2023; Ministry of Health, Singapore, 2023). These systems are not perfect, but they illustrate what changes when women’s health is treated as an ongoing public-health responsibility rather than a short reproductive episode.

5.2 Health Financing and System Design

Health-financing models significantly shape women’s health outcomes. Tax-funded universal health coverage systems in Finland and France reduce out-of-pocket expenditure and enable preventive care across the life course (World Health Organization, 2024). By contrast, insurance-based and out-of-pocket-heavy systems disproportionately burden women in informal employment, women outside stable labour markets, and women requiring repeated care for chronic conditions (Witter et al., 2017).

Evidence from Thailand, Mexico, and Saudi Arabia demonstrates that UHC reforms improve equity but often retain maternal bias unless benefit packages explicitly include non-reproductive services and implementation pathways support uptake (Limwattananon et al., 2009; Gómez-Dantés et al., 2016; World Health Organization Eastern Mediterranean Region, 2023). This shows that financing matters not just through the amount spent, but through the incentives it creates for what services become routine.

5.3 Governance, Stability, and Policy Learning

The intersection of political stability and public-health efficacy is defined by the need for long-term institutional horizons, where stable governance enables a transition from vertical emergency interventions to horizontal life-course care (The Lancet, 2024; World Health Organization, 2025). Sri Lanka exemplifies this trajectory through a public-health system that integrated maternal care into a broader primary-care network capable of adding preventive screening and continuity over time (Rajapaksa et al., 2021; Ministry of Health, Sri Lanka, 2024).

In contrast, Myanmar’s post-2021 crisis, Afghanistan’s restrictions on women’s mobility and autonomy, and Venezuela’s prolonged institutional collapse demonstrate how instability pushes systems back into narrow emergency maternal modes (UN Women, 2021; Glass et al., 2023; BMJ Global Health, 2026). In such contexts, chronic disease management, psychosocial support, and violence-related services are often the first to become intermittent or disappear altogether.

6. Discussion

6.1 Life-Course Coverage and the Limits of Maternal-Centric Policy Frameworks

The findings suggest that while rhetorical commitment to comprehensive women’s health exists across most countries, policy operationalization remains overwhelmingly maternal-centric in many Global South settings. Across India, Bangladesh, Ghana, Nigeria, Ethiopia, Indonesia, Venezuela, Saudi Arabia, and Myanmar, health initiatives continue to prioritize pregnancy and childbirth, producing stronger maternal outcomes than broader life-course continuity.

In contrast, several Global North countries, including Finland, France, Norway, Germany, and Japan, have institutionalized stronger life-course frameworks that extend beyond reproductive services through preventive screening, mental health pathways, and age-specific primary-care routines. Yet even these systems show gaps, especially in postpartum mental health, migrant access, and unequal use by socially marginalized groups.

6.2 Moving Beyond Reproduction: Mental Health, NCDs, and Ageing

Women’s health policies vary significantly in their capacity to move beyond reproductive health and incorporate mental health, NCDs, and ageing-related care. In many Global South settings, these domains remain weakly integrated or fragmented outside women’s health frameworks. Mental health services are often underfunded or crisis-limited, while NCD prevention and management—despite being major sources of women’s morbidity and mortality—are rarely framed as women’s health priorities.

Even in countries that have achieved substantial maternal health success, such as Rwanda, Sri Lanka, and Bangladesh, policy attention to menopause, cardiovascular disease, osteoporosis, and late-life mental health remains limited (UN Women, 2023; Pathirana & Herath, 2024). This is precisely the empirical shape of the maternal trap: women remain visible during pregnancy but become weakly visible afterwards.

6.3 Health System Design, Financing Models, and Life-Course Equity

The findings show that financing architecture plays a decisive role in determining whether women’s health policies remain vertically maternal-focused or evolve toward horizontal integration. Tax-funded systems support routine, non-event-based contact, while donor-supported and selectively subsidized systems often lower the cost of childbirth without extending protection to long-term NCD care, mental health, or menopause-related services.

This selective affordability reflects policy prioritization rather than fiscal incapacity alone. Financing choices shape what ministries count, what providers are trained to do, and what services women can reasonably expect beyond childbirth. In that sense, financing is a causal mechanism, not merely a background condition. For instance, Thailand’s universal coverage reforms substantially reduced catastrophic payments for childbirth but initially underfunded long-term diabetes and hypertension care, meaning that women could deliver in facilities without charge yet still forgo follow-up visits for chronic disease because of transport costs, lost wages, and medicine shortages.

6.4 Institutional Lock-In and the Persistence of Vertical Policy Architectures

The persistence of maternal-centric policies in many Global South settings is driven primarily by institutional and governance factors rather than by a simple lack of evidence or technical capacity. International development financing has reinforced this lock-in by privileging easily measurable indicators such as maternal mortality and skilled birth attendance (Doyal, 2018; UN Women, 2023). Health ministries organized around reproductive, maternal, or family health have further entrenched vertical service delivery, making integration of mental health, NCDs, and geriatric care institutionally difficult (Okonofua et al., 2022).

Importantly, similar lock-in can also appear in high-income contexts through pronatalist or exclusionary reproductive governance. Verticalization is therefore not exclusive to the Global South. The more important analytical divide is between systems that institutionalize women’s health across the life course and those that continue to define women primarily through reproduction.

6.5 Political Stability, Policy Continuity, and Long-Term Capacity

The findings strongly support the argument that stable governance enables long-term institutional investment in essential healthcare. Sri Lanka illustrates how policy continuity allowed the health system to evolve beyond maternal survival into integrated screening and chronic disease management, even across difficult political periods. Conversely, countries experiencing instability, such as Myanmar, Venezuela, and Afghanistan, show regression to emergency maternal-only provisioning, with institutional memory, supply chains, and workforce stability all weakening under crisis.

6.6 Women’s Agency as a Mediating Factor in Policy Effectiveness

The study finds that women’s agency and decision-making power mediate policy effectiveness across all contexts. In many Global South settings, socio-cultural norms, legal constraints, and household power relations limit women’s ability to access even nominally free services. Evidence from India, Nigeria, Bangladesh, and Afghanistan shows that weak decision-making power can turn formal coverage into what is effectively paper coverage.

Global North systems usually offer stronger legal protections for informed consent and reproductive autonomy, but these do not always translate into equal lived access, particularly for migrants, racialized minorities, and women in precarious employment. Agency therefore works as a causal filter through which accessibility, affordability, and quality either become real or remain abstract.

6.7 Policy Learning and Pathways Toward Life-Course Equity

The analysis suggests that effective policy learning must be selective rather than model-based. The most useful lesson from the Global North is not to copy expensive systems wholesale, but to adopt design principles such as preventive entry points, primary-care integration, sex disaggregated data, and explicit inclusion of non-reproductive services. At the same time, higher-performing Global South cases such as Sri Lanka, Rwanda, and selected Indian sub-national models demonstrate that life-course integration can be built incrementally within existing public-health and community-health platforms.

1. Global South: India, Bangladesh, Afghanistan, Bhutan, Ghana, Ethiopia, Kenya, Nigeria, Sierra Leone, Namibia, Rwanda, Indonesia, Venezuela, Mexico, Mauritius, Cuba, Saudi Arabia, Botswana, Myanmar, Sri Lanka, Vietnam, Brazil, Argentina, and South Africa illustrate a range from strongly maternal-centric systems to transitional mixed models. Across these cases, common gaps include weak integration of NCD care, mental health, menopause support, geriatric pathways, and violence-related services after childbirth.
2. Global North: Norway, the United States, Japan, Finland, France, and Germany illustrate more explicit life-course designs, though each still shows implementation gaps related to migrants, postpartum mental health, or unequal access. The comparison demonstrates that the most meaningful divide is not income level alone, but whether policy architecture creates repeated, non-pregnancy-based entry points into care.

Table 2. Comparative Differences in Women’s Health Policies Between Global North and Global South Using the Four-Pillar Framework

Across accessibility, affordability, quality, and agency, Global North systems in this sample more often institutionalize routine life-course care, while many of the sampled Global South systems—particularly in South Asia and Sub-Saharan Africa—continue to concentrate access and subsidy around pregnancy and childbirth. However, the variation within the Global South is substantial: some systems have stronger primary care, some stronger social protection, and some stronger legal commitments, even when implementation remains uneven.

Table 3. Comparative Performance of Global North and Global South Countries on Selected SDG Indicators Relevant to Women’s Health

The SDG comparison underlines a central argument of the paper. Many Global South countries have made major gains on SDG 3.1 through maternal interventions, yet remain weaker on NCDs, mental health, gender-responsive policy, and violence-related integration. The issue is not progress versus failure in absolute terms, but the asymmetry between maternal improvement and broader life-course inclusion.

7. Policy Implications and Recommendations

The findings suggest that advancing women’s health equity across the life course requires specific institutional reforms rather than broad increases in health expenditure alone. Based on the comparative evidence, six interrelated policy directions emerge as both necessary and feasible, though they must be calibrated to national capacity, governance structure, and epidemiological transition.

Table 4. Policy Recommendations for Advancing Life-Course Women’s Health: Cross-Country Applicability

First, countries should adopt horizontal, life-course women’s health frameworks. For India, Ghana, and Bangladesh, this means integrating NCD, mental-health, and menopause screening into existing primary healthcare and community-health worker platforms rather than building wholly new institutions. Second, states should mandate sex disaggregated data and gender-responsive research so that women’s health beyond maternity becomes visible in planning and budgeting.

Third, systems should integrate gender-based violence screening into primary healthcare, especially through task-sharing models in lower-capacity settings. Fourth, postpartum mental-health screening should become a routine component of maternal care across income levels rather than an optional add-on. Fifth, international financing metrics should move beyond maternal mortality ratios alone and reward broader indicators of women’s health continuity. Sixth, South-South and cross-context policy learning networks should be strengthened so that countries can exchange institutionally realistic models rather than rely only on one-directional transfer from the Global North.

Taken together, these recommendations point to a central conclusion: improving women’s health equity is less about absolute resource availability than about institutional alignment, incentive structures, and political commitment. Different countries will move at different speeds, but all can build pathways beyond narrowly maternal-focused approaches.

8. Limitations

This study relies on English-language secondary sources and national-level policy documents, which may under-represent sub-national variation in policy design and implementation, especially in federal or decentralized systems. The evidence base is also uneven across countries, particularly in conflict-affected and resource-scarce settings where health-system data are fragmented.

The qualitative comparative method is well suited to identifying institutional mechanisms and patterned relationships, but it does not provide population-based causal estimates or effect sizes. Future mixed-method or longitudinal work could test whether specific financing and governance arrangements measurably improve continuity of care across women’s life stages.

Another limitation is that gender-responsive governance is defined and operationalized differently across countries. Proxy measures of gender responsiveness may therefore capture formal commitment more clearly than actual implementation. This is especially relevant in contexts where policy language is ambitious but budgetary and service commitments remain weak.

9. Conclusion

The central finding of this paper is that women’s health inequity is sustained less by absolute scarcity than by institutional arrangements that define women primarily through reproduction. Maternal health investments have saved lives, but where financing incentives, governance structures, and service design remain vertical, women often disappear from policy attention once pregnancy ends.

A life-course approach clarifies what more integrated systems do differently: they create routine entry points beyond childbirth, protect access to non-reproductive care, and institutionalize continuity through financing, primary care, and governance. The most important lesson from the 28-country comparison is not that the Global North has solved women’s health while the Global South has not. It is that women’s health policy becomes more equitable wherever institutions are designed to keep women visible across the whole of life.

Acknowledgements

Dr. Vedvati Degaonkar and Ms. Bhargabi Medhi are sincerely thanked for their assistance with this paper.

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