Who cares, who pays and who decides? Gendered Health and Care Responsibilities in the Lake Victoria Basin, Kenya

In many parts of the world, the work of keeping a family healthy happens quietly inside the home, long before a doctor is ever called. It involves noticing a fever, arranging a trip to a clinic, deciding which medicine to buy, and finding the money to pay for it. While this labor is essential for survival, it is rarely shared equally. Sociologists and health experts have long observed that women globally perform the vast majority of this unpaid care work, often at the expense of their own time, income, and well-being. A critical question in public health is whether taking on this heavy load of responsibility also means having the power to make decisions or the resources to protect the family from financial ruin. Often, these two things are confused: people assume that if a woman is the one managing the sick child, she is also the one controlling the household budget or the one who can decide to buy health insurance. However, new research suggests that responsibility and power are not the same thing. One can be the primary caregiver without having the authority to change the situation or the access to safety nets that prevent a medical emergency from becoming a financial disaster.

A team of researchers from Jaramogi Oginga Odinga University of Science and Technology set out to untangle these complex relationships in the Lake Victoria Basin of Kenya. They focused on nine counties, a region with diverse landscapes ranging from river basins to highlands, where families rely on farming, fishing, and local markets. The researchers surveyed 1,718 adults, nearly evenly split between men and women, asking detailed questions about who does what in the household. They wanted to know who is responsible for reproductive health, who decides when to see a doctor, who manages the money for medical bills, and who organizes the care for sick family members at home. Crucially, they also asked about health insurance, whether families paid for care out of their own pockets, and what desperate measures they took—like borrowing money, selling assets, or asking for donations—when they could not afford treatment.

The study revealed a stark reality: women carry the heaviest burden of responsibility, but this does not translate into greater control or protection. When asked about who handles reproductive health, makes healthcare decisions, manages medical finances, or governs home care, female respondents were far more likely to say "wife only" compared to their male counterparts. In fact, women were significantly more likely to report that these tasks fell solely on them rather than being shared with a partner. Yet, despite shouldering this extra weight, women were actually less likely to have medical insurance than men. The data showed that while women were the ones organizing the care, they were not necessarily the ones holding the keys to the resources needed to pay for it. This disconnect suggests that being the primary manager of health in a family does not automatically grant a woman the power to secure financial safety for that family.

To understand how these different patterns of responsibility and payment play out in real life, the researchers used a method that groups households into distinct "profiles" based on their answers, rather than just looking at averages. They identified five common ways families organize their health and care. One large group, representing about a third of the families, had a mix of shared duties and tasks that fell specifically to the wife. Another group, making up about a quarter of the sample, shared responsibilities more evenly without assigning specific tasks solely to the wife. A smaller but significant group, representing nearly 12 percent of families, was characterized by a "wife-centered" approach where the woman handled almost everything related to health and home care. Another profile, comprising over 18 percent of families, was intensive in home care but showed a stronger connection to health insurance. The final group had very limited decision-making power regarding health.

The study found that a woman's gender was a powerful predictor of which profile her household fell into. Women were nearly ten times more likely to belong to the "wife-centered" profile than to the profile where responsibilities were shared without a single person taking the lead. This confirms that the burden of care is not just a matter of individual choice but is deeply rooted in gender norms. Furthermore, the researchers looked at how these different household patterns affected actual health outcomes and financial coping. Families where the wife was the sole decision-maker for health and finance were less likely to have sought a preventive health check-up in the past year. They were also more likely to rely on borrowing money to pay for medical expenses. In contrast, the households that had a stronger link to health insurance and a broader selection of caregivers were less likely to resort to borrowing or fundraising when illness struck. This suggests that having a safety net like insurance changes how a family reacts to sickness, allowing them to avoid the stress of emergency fundraising.

The researchers also examined how these patterns varied across different parts of the region. The type of household profile was just as likely to depend on which county a family lived in as it was to depend on whether the respondent was a man or a woman. This indicates that local conditions, such as the availability of clinics, the cost of transport, and community norms, play a massive role in shaping how families manage health. The study did not find that one county was "better" than another; rather, it showed that the systems of care and finance are deeply local. The data also highlighted that even when families had insurance, they still often had to pay out of pocket, and many still faced the stress of selling assets or borrowing to cover costs. This means that having insurance is not a complete shield against financial hardship, but it does appear to reduce the need for the most desperate coping strategies.

Ultimately, the study challenges the idea that giving women more responsibility is the same as empowering them. The authors argue that when women are solely responsible for health and care without shared authority or access to financial resources, it can become a trap that limits their ability to seek timely care or protect the family from poverty. The findings suggest that policies aimed at improving health in this region need to look beyond just providing services. They must also address the invisible labor of care, ensure that women have direct access to insurance without relying on a male head of household, and encourage families to share decision-making and financial burdens. By recognizing that responsibility does not equal power, and that care work is a shared societal need rather than just a woman's duty, communities can begin to build systems that are not only more equitable but also more effective at protecting everyone's health and financial future.