Women in Politics and Public Health Spending: A Review of the Literature

The priorities of women differ because women still have a different role in society, although with respect to gender equality there have been positive changes over the years. Women do have different experiences in everyday life, especially with regard to family and children. In addition, the way women act (for example in conflict resolution) is different to men.

(Woman Member of the European Parliament)

 

I think that women are more concerned about issues such as home help for families and carers, equal pay and human rights. They also want to see women represented more equally in all areas of life, not least in politics.

(Male parliamentarian, United Kingdom)

 

Women’s perspectives and political priorities emphasize social matters such as education, culture, food security and health care.

(Woman parliamentarian, Lao People’s Democratic Republic)

 

Women and men are equal but different. Women are more family-oriented. They want running water, food and security. Men will focus more on transport, roads, communications, sports and war!

(Woman parliamentarian, Kenya. Source: A survey of Women and Men in Parliaments IPU 2008)

1. Introduction

Public health spending represents a cornerstone of modern welfare states and plays a crucial role in shaping population health, social equity, and long-term economic development. As governments allocate substantial resources to healthcare systems, understanding the political determinants of public health expenditure has become a central concern in political economy and public finance.

In recent years, a growing body of literature has examined whether the gender composition of political institutions influences government spending priorities. In particular, scholars have investigated whether women in political office, as legislators, cabinet members, or local executives, affect both the level and allocation of public expenditures, with particular attention to social sectors such as health, education, and family policies.

A key motivation for this line of inquiry lies in documented gender differences in policy preferences. Empirical studies consistently show that women tend to prioritize health and social spending more than men [1,2]. These differences may translate into policy outcomes when women hold political office, either through their own preferences or through their ability to better represent the interests of female constituents [3,4]. Consistent with this intuition, a growing empirical literature finds that higher female representation in legislative bodies is associated with increased allocation of public resources to health and other social policies [5,6].

Despite this progress, much of the existing literature has focused on women’s representation in legislatures, while comparatively less attention has been devoted to women in executive branches of government. This represents an important gap, as cabinets play a central role in shaping fiscal policy. Public spending decisions are typically formulated through cabinet negotiations during the budget process and subsequently approved by legislatures [7,8]. As a result, the gender composition of cabinets may have particularly strong implications for policy outcomes. Supporting this view, existing research shows that women in cabinet positions are associated with the adoption of female-friendly social policies [9].

Moreover, identifying the causal effect of women’s political representation remains challenging due to issues of endogeneity. Policy environments, including levels of public health spending, may themselves influence women’s political participation, while unobserved institutional and cultural factors may jointly determine both representation and policy outcomes. While some micro-level studies have addressed these concerns using electoral variation or quota policies [4,10], cross-country analyses often face more severe identification challenges.

An important contribution to this debate is provided by Mavisakalyan [11], who focuses on women’s representation in government cabinets and proposes an innovative instrumental variable strategy based on the gender composition of national leaders’ children. The study finds that higher female representation in the cabinet causally increases public health spending and contributes to improved health outcomes, including reductions in gender gaps in life expectancy. These findings highlight the importance of considering not only the presence of women in political institutions, but also their position within the hierarchy of decision-making power.

This article builds on and synthesizes this growing body of literature by reviewing the empirical evidence on the relationship between women in politics and public health expenditure. It integrates cross-national analyses [12,11], subnational and quasi-experimental studies [16,18], and research on contextual and conditional effects [19]. By combining insights from these different strands, the paper provides a comprehensive framework for understanding how gender representation shapes public health policy. Overall, the evidence reviewed suggests that women’s political representation is not only relevant for issues of equality and democratic inclusion, but also has important implications for fiscal policy and the allocation of public resources to health systems.

This paper contributes by providing a focused narrative review of the relationship between women’s political representation and public health spending. The reviewed studies were selected based on their relevance to the relationship between women’s political representation and public health spending, welfare expenditure, and health outcomes. The review includes cross-country analyses, subnational studies, and quasi-experimental contributions. Particular attention is devoted to studies addressing endogeneity and causal inference through instrumental variables, regression discontinuity designs, and electoral or quota-based variation.

3. Theoretical Framework: Gender Representation and Spending Priorities

The literature on gender and public policy is grounded in the theory of substantive representation, which posits that descriptive representation, the presence of women in political institutions, can translate into policy outcomes reflecting women’s preferences and interests [20]. Applied to public finance, this framework suggests that female politicians may prioritize sectors such as healthcare, preventive medicine, and social protection.

Within the framework of Equality in Politics: A Survey of Women in Parliament (IPU, 2008), the histogram shows a strong consensus that women bring different views, perspectives, and talents to politics. A clear majority of both men and women agree or strongly agree with the statement, with support being notably higher among women (72% strongly agree compared to 30% of men). Men are more likely to express moderate agreement, while levels of disagreement remain minimal across both groups. Overall, the data highlights a broad recognition, particularly among women, of the distinctive contributions women make to political life. The quotations and survey evidence reported by the IPU reflect perceptions expressed by parliamentarians and should not be interpreted as direct causal evidence of gender-specific policy behavior.

A central mechanism underlying this relationship is the existence of gender differences in policy preferences. A large body of empirical research shows that women tend to prioritize health and social spending more than men [1,2]. These differences may arise from both socio-economic roles and differences in risk perception, as well as from women’s greater exposure to caregiving responsibilities.

When women gain access to political office, these preference differences may translate into policy outcomes through two main channels. First, female politicians may exhibit direct preference effects, shaping policy decisions according to their own priorities [3,4]. Second, they may improve policy responsiveness, as they are better able to represent and respond to the preferences of female constituents. Consistent with this view, several studies find a positive relationship between women’s representation in legislatures and the allocation of public resources to health [5,6].

In addition to preference-based explanations, a care-oriented policy perspective highlights that health spending is closely linked to caregiving roles, which women bear [13]. This may lead female politicians to place greater emphasis on investments in maternal and child health, preventive care, and services for vulnerable populations.

A complementary line of argument emphasizes governance and efficiency effects. If women in political office are less prone to corruption or rent-seeking behavior [21], public resources may be allocated more effectively, increasing spending on productive sectors such as healthcare.

However, the literature also emphasizes that these effects are not automatic. Recent literature reviews also highlight the importance of institutional and contextual factors in shaping the substantive effects of women’s political representation. Hessami and da Fonseca, in a comprehensive review of the empirical literature [22], show that female political representation is often associated with greater attention to welfare, health, and redistributive policies, although these effects vary considerably depending on institutional settings and the strength of causal identification strategies. Institutional constraints, such as party discipline, fiscal rules, and centralized budget processes, may limit the ability of individual politicians to influence spending outcomes. Moreover, the extent of women’s impact may depend on their position within political hierarchies and their access to decision-making power [23,24,25]. Importantly, much of the early literature has focused on women’s representation in legislatures, while comparatively less attention has been paid to women in executive positions, such as government cabinets. This represents a significant gap, as cabinets play a central role in shaping fiscal policy. Public spending decisions are typically formulated through cabinet negotiations during the budget process and subsequently approved by legislatures. As a result, cabinet members exert substantial influence over both the initiation and design of public health policies. Furthermore, compared to legislators, cabinet members are often appointed rather than directly elected, which may reduce electoral constraints and allow them to act more freely according to their preferences. This suggests that the gender composition of cabinets may have particularly strong implications for policy outcomes. Supporting this intuition, existing research shows that women in cabinet positions are associated with the adoption of female-friendly social policies [9].

A key empirical challenge in this literature is the issue of endogeneity. Public health spending and broader policy environments may themselves influence women’s political participation, creating reverse causality [26,27,28]. Additionally, unobserved country characteristics, such as cultural attitudes and institutional quality, may simultaneously affect both gender representation and policy outcomes. While micro-level studies have addressed these issues using electoral discontinuities or reservation policies [4,10], cross-country analyses have often struggled with identification. An innovative approach to this problem is proposed by Mavisakalyan [11], who instruments women’s representation in cabinet using the share of daughters among national leaders’ children. The underlying intuition is that parenting daughters may shift leaders’ attitudes toward gender equality and increase their propensity to appoint women to cabinet positions. Empirical evidence supports this mechanism, showing that having daughters influences political behavior and attitudes toward women’s issues [29]. Using this instrumental variable strategy, the study finds that higher female representation in cabinets causally increases public health spending across countries. Moreover, it shows that greater female cabinet participation contributes to improvements in health outcomes, including reductions in gender gaps in life expectancy.

Although the validity of this identification strategy relies on strong assumptions, it represents an important contribution to the literature by providing causal evidence on the role of women in executive decision-making. Overall, this line of research highlights the importance of considering not only the presence of women in political institutions but also their position within the hierarchy of power.

3. Evidence on Women and Public Health Spending

A substantial body of cross-national research examines the relationship between women’s political representation and public health expenditure, providing consistent evidence of a positive association across different institutional and economic contexts. Ennser-Jedenastik contributes to this literature by examining the composition of family-related expenditures in OECD countries [30]. The study finds that women’s political representation is associated with higher spending on in-kind benefits, such as childcare services, rather than cash transfers. This reflects a preference for policies that address the structural constraints faced by women in balancing work and family responsibilities. Moreover, the effect is stronger in countries with higher female labor force participation, suggesting that women politicians are particularly responsive to social demand. De Siano and Chiariello [12] show that women’s political empowerment is positively associated with welfare spending across European countries, including health expenditure. Their spatial econometric approach reveals that these effects are not confined within national borders but exhibit significant spillovers across neighboring countries, suggesting that gender-related policy changes may diffuse internationally. Complementing this evidence, global panel studies based on large country-year datasets [13,14,15] find that increases in the share of women in national parliaments are associated with higher public health expenditure as a share of GDP, particularly in low- and middle-income countries. These studies also highlight that public health spending acts as a key transmission channel linking women’s representation to improved health outcomes, such as reductions in infant and maternal mortality. A crucial extension of this literature focuses on the role of women in executive positions. Mavisakalyan [11] provides evidence that women’s representation in government cabinets has a causal effect on public health spending. Using an instrumental variable approach based on the gender composition of national leaders’ children, the study finds that countries with higher shares of women in cabinet allocate more resources to healthcare. Importantly, this research highlights that cabinet-level representation may be particularly influential, as cabinets play a central role in budget formulation and policy design. Unlike legislatures, where individual influence may be diluted, cabinet members participate directly in negotiations over budgetary allocations, making their preferences especially consequential for public spending outcomes. Overall, cross-national studies provide strong evidence that women’s political representation, both in legislative and executive branches, is associated with increased public health spending. At the same time, they highlight the importance of addressing identification challenges and considering institutional context when interpreting these relationships.

While cross-country studies provide valuable insights, they often face limitations related to endogeneity and identification. Subnational and quasi-experimental studies address these challenges by exploiting variation within countries and using research designs that allow for causal inference. One of the most influential studies in this literature is Brollo and Troiano [16], who use a regression discontinuity design based on close mayoral elections in Brazilian municipalities. Their analysis shows that municipalities governed by female mayors receive more federal transfers and allocate more resources to public goods, including healthcare infrastructure. These findings suggest that female political leadership can influence both the level and composition of public spending, shifting resources toward sectors that are closely linked to public health. Similarly, Svaleryd examines the impact of women’s representation in Swedish municipalities [17]. Using survey data, the study first documents that female politicians have different policy preferences than their male counterparts, particularly prioritizing childcare and education. It then uses panel data to show that these preferences translate into actual policy outcomes: municipalities with higher shares of women in local councils allocate more resources to childcare and education relative to elderly care. This provides evidence that gender differences in preferences can shape budgetary decisions. Evidence from developing countries further strengthens the causal argument. Bhalotra and Clots-Figueras [18] analyze the effects of female political representation in Indian state legislatures and find that an increase in the share of women politicians leads to improved access to antenatal and child health services and significant reductions in neonatal mortality. These results provide a direct link between political representation, public spending, and health outcomes. Additional evidence from Spanish municipalities [31,32] shows that female mayors tend to prioritize social and health-related expenditures, even when total spending levels remain unchanged. These findings suggest that gender effects may be more visible in the composition of public budgets rather than in aggregate spending levels.

Finally, several studies emphasize that the impact of women’s political representation depends on contextual factors, particularly the level of social need. Evidence from developing countries indicates that women’s political empowerment is particularly effective in contexts characterized by weak institutions and high levels of unmet health needs. In these settings, increased representation can lead to significant improvements in both public spending and health outcomes. Courtemanche and Green [19] show that a greater presence of women in politics leads to increased public spending on healthcare for vulnerable groups, including children, the elderly, and people with disabilities. However, this effect is conditional: it becomes significant only when there is substantial demand for intervention. This suggests that women legislators are more likely to influence policy outcomes when they can mobilize support around pressing social issues. Similarly, Tadadjeu et al. [33] analyze data from 48 African countries over the period 2000-2017 and find robust evidence that women’s political empowerment, measured through civil liberties, participation in civil society, and political representation, leads to higher public health expenditure. Their results confirm that strengthening women’s political participation can be an effective strategy for improving health investment and policy outcomes in developing contexts.

4. Mechanisms Linking Women in Politics to Public Health Spending

The literature identifies several mechanisms through which women’s political representation influences public health expenditure. These mechanisms operate both directly, through policy preferences and budget decisions, and indirectly, through institutional and political channels.

First, budgetary prioritization plays a key role. A substantial body of evidence shows that female politicians tend to assign greater importance to policies that directly affect household welfare, particularly preventive care, maternal and child health, and universal access to basic health services. This reflects both gendered policy preferences and differences in lived experiences, which may lead women to be more attentive to social sector needs. As a result, higher female representation is often associated with increased allocations to public health systems and a stronger emphasis on redistributive and social policies [4,15,13,34].

Second, improved allocation efficiency may enhance the impact of public spending. Beyond the overall level of expenditure, female leaders may influence how resources are allocated and implemented. Evidence from quasi-experimental and cross-country studies suggests that women in political office may be associated with lower levels of corruption, better targeting of public goods, and more effective service delivery. These improvements can translate into greater health outcomes even without large increases in total spending, as resources are used more efficiently and leakages are reduced [27,35,36,21].

Third, the concept of critical mass highlights the importance of representation thresholds. Recent contributions further emphasize that the policy influence of women depends not only on descriptive representation but also on their effective participation in decision-making processes. Baskaran and Hessami [37] argue that the substantive effects of women in political bodies vary according to institutional arrangements, representation thresholds, and the extent to which female politicians are able to shape policy agendas and budgetary decisions. The influence of women in political institutions is not necessarily linear; instead, it often depends on reaching a sufficient level of representation that allows women to move beyond symbolic presence and actively shape policy agendas. Early contributions argue that women are unlikely to significantly influence policy outcomes when they constitute only a small minority, but their impact increases once they reach a “considerable minority” that enables collective action and agenda-setting [38]. In this context, scholars often identify thresholds, commonly around 15-30 percent, at which women become more effective in promoting policies related to social welfare, health, and family issues. When women constitute a substantial share of decision-makers, they are better positioned to form coalitions, influence legislative priorities, and participate meaningfully in budget negotiations. This collective presence increases the likelihood that health-related issues receive sustained attention and are translated into concrete fiscal commitments. Empirical research further supports the relevance of critical mass dynamics, showing that higher shares of female legislators are associated with stronger effects on social and health-related spending, particularly when representation crosses specific thresholds [39,40].

Finally, electoral incentives may reinforce these effects. A growing political economy literature shows that gender differences in policy choices can emerge from the interaction between voter preferences and reelection concerns. In particular, voters’ gender bias and electoral incentives can induce female and male leaders to adopt different policy strategies [41]. Empirically, female politicians have been found to be more responsive to social policy demands, particularly in domains such as healthcare and public goods provision [18,4,42]. This responsiveness can translate into higher investments in healthcare systems, especially when such policies are salient and electorally rewarding.

Despite this substantial body of evidence supporting a positive relationship between women’s political representation and public health spending, the literature also identifies several limitations and mixed findings. In some high-income countries, institutional constraints such as centralized budgeting processes, strict fiscal rules, and strong party discipline may limit the ability of individual politicians to influence spending decisions. As a result, increases in women’s representation may not always translate into higher overall health expenditure. Moreover, several studies suggest that women’s influence may be more pronounced in the composition of spending rather than its total level. For example, female politicians may prioritize preventive care or services targeting vulnerable populations without significantly increasing aggregate health budgets. Finally, issues related to endogeneity and measurement remain important challenges. While quasi-experimental and panel data approaches have improved identification, further research is needed to fully understand the causal mechanisms linking gender representation to fiscal outcomes.

5. Conclusion

Despite the growing body of evidence, several limitations remain and suggest caution in interpreting the relationship between women’s political representation and public health spending as fully causal or universally consistent. A central issue concerns endogeneity and identification, particularly in cross-country analyses. Countries characterized by stronger welfare institutions, higher levels of development, or more progressive social norms may simultaneously exhibit both greater female political representation and higher public health expenditure, making it difficult to isolate the independent effect of women in politics. Although several studies attempt to address these concerns through instrumental variables, panel techniques, or quasi-experimental designs, identification challenges remain important and the validity of some causal strategies continues to be debated in the literature.

At the same time, the evidence reviewed in this article generally suggests that women’s political participation is associated with greater attention to health and social welfare policies. Across cross-country analyses, subnational studies, and evidence from developing countries, female political representation tends to be linked to higher public investment in healthcare, preventive services, maternal and child health, and other social sectors. However, these effects are not always uniform in magnitude or direction. In several contexts, women’s representation appears to influence primarily the composition of public expenditure rather than the aggregate level of spending, redirecting resources toward more socially oriented policies without necessarily increasing total public budgets.

Moreover, the impact of women’s representation appears to depend strongly on institutional and socio-economic conditions. Factors such as electoral systems, party discipline, fiscal constraints, decentralization, and the degree of access women have to executive decision-making power may significantly shape policy outcomes. The literature also suggests that women’s influence may become more visible once representation reaches a certain threshold, enabling female politicians to move beyond symbolic presence and exert more substantial influence on budgetary decisions and policy priorities. Similarly, evidence from developing countries indicates that the relationship between women’s representation and public health spending may be particularly strong where unmet social and health needs are greater.

Overall, the literature reviewed in this article points toward a generally positive relationship between women’s political representation and public health-related policy outcomes. Nevertheless, the evidence remains context-dependent and heterogeneous across institutional settings and empirical approaches. While a number of studies provide relatively robust causal evidence, others identify more limited or conditional effects. Consequently, the findings should not be interpreted as implying that greater female representation automatically leads to higher public health spending in all contexts. Rather, the existing evidence suggests that women’s political participation can constitute an important factor shaping governments’ responsiveness to health and social welfare priorities, particularly when institutional conditions allow female policymakers to exercise meaningful influence over budgetary and policy decisions.