There is a quiet assumption built into many modern healthcare systems, particularly when it comes to long-term conditions such as diabetes, cancer, cardiovascular disease, and other non-communicable diseases. That assumption is not written into policy documents, but it shapes how care is priced, delivered, and accessed. It assumes steady income, predictable work, and the ability to absorb ongoing costs without disruption.
For many people, especially women and communities of colour, that assumption does not reflect reality.
Across much of the Western world, women continue to earn less than men. In the United States, women earn roughly 80 cents for every dollar earned by a man. When race is added, the gap widens further. A Caucasian woman earns about 73 cents to a Caucasian man’s dollar. A Black woman earns closer to 64 cents, and a Latina woman around 51 cents. These differences are not about effort or ambition. They are structural gaps that compound over time.
In the UK, the picture is similar, though less extreme. Women working full time earn on average around 7 percent less per hour than men. That gap may seem modest on paper, but stretched across rent, food, childcare, and healthcare over decades, it shapes how much room someone has to cope when illness enters the picture.
In Southern Africa, the dynamics differ but the pattern remains. Women are more likely to be unemployed, underemployed, or working informally. In South Africa, women earn significantly less than men on a monthly basis, and that gap has widened in recent years. In Zambia, where informal work is common and employment benefits are not evenly available, income is often irregular. Money arrives in bursts rather than reliably each month.
Now place non-communicable diseases into this landscape.
NCDs are not short-term events. They require continuous management, whether that means insulin for diabetes, treatment cycles for cancer, medication for hypertension, or ongoing monitoring for heart disease. The costs are not only financial. They include time, transport, emotional energy, and consistency. Care does not pause when income does.
Healthcare systems, however, tend to price long-term care as if income itself is stable. Costs are often flat and recurring, regardless of whether someone’s earnings fluctuate. This matters because a fixed cost affects people very differently depending on what they earn.
If you earn a dollar and spend ten cents on healthcare, the impact is manageable. If you earn fifty cents and still have to spend the same ten cents, that cost cuts far deeper. This is how healthcare becomes regressive in practice. It takes up a larger share of income for those who already have less.
Women of colour often experience this pressure most acutely. Not necessarily because they have higher rates of every disease, but because they are more likely to earn less, have less job security, and carry a greater share of unpaid care. Managing households, children, and ageing relatives alongside paid work leaves little room for financial or emotional shocks.
Globally, men may have slightly higher prevalence rates for some non-communicable diseases, including diabetes. But prevalence alone does not tell the full story. The burden of managing chronic illness often lands more heavily on women. Appointments must be scheduled. Medication collected. Diets adjusted. Work rearranged. These demands collide with labour markets that already undervalue women’s time and earnings.
In Southern Africa, this mismatch is particularly visible. Public healthcare systems may provide essential treatment at low or no cost, but access is not always reliable. Clinics experience shortages. Travel is required. Waiting times are long. When the public system cannot deliver, people turn to private providers, where prices are set at market rates.
This creates a fragile balance. Care is affordable when it is available, and unaffordable when it is not. Payment is expected continuously, even when supply is inconsistent.
For someone earning a stable salary, this is frustrating. For someone earning irregularly, it can be devastating. Cancer treatment does not wait for cash flow to stabilise. Blood pressure does not adjust itself around informal work schedules. Illness does not respect pay cycles.
Studies across parts of Africa show that managing long-term conditions can cost several days’ wages each month. When income is unpredictable, this is not a budgeting challenge. It is a series of trade-offs between health, food, rent, and school fees.
Perhaps the more honest question is this. What would healthcare look like if it were designed for real lives rather than idealised ones?
It might include sliding-scale pricing based on income bands, not charity. Tiered pricing that recognises the difference between informal workers and salaried employees. Quarterly payment plans instead of punishing monthly ones. Care that travels to people, rather than expecting people to travel endlessly to care. Family-level coverage instead of isolating illness to one individual. Shared diagnostic tools within households, acknowledging that health in many cultures is managed collectively. None of these ideas are radical. They simply reflect how people actually live, earn, and care for one another.
This is not a story about personal failure or poor discipline. It is a story about design. Healthcare systems are often built around economic stability, while modern labour markets increasingly produce instability. When those two realities clash, illness becomes not only a medical condition, but a financial risk.
This is why conversations about non-communicable diseases cannot be separated from conversations about work, pay, and inequality. Awareness alone is not enough. Education alone is not enough. If systems continue to assume steady income while large segments of the population live without it, access will remain uneven.
This is not just about statistics. It is about our homes, our families, and the quiet calculations people make every day to stay well in systems that were not built for their realities.
Kaajal Vaghela is a sportswear designer and diabetes wellness consultant with over three decades of lived experience managing Type 1 diabetes. Having previously served as Chairperson of the Lusaka branch of the Diabetes Association of Zambia, she remains a passionate advocate for breaking down myths and building awareness about diabetes. For more personalised coaching or corporate wellness workshops, visit: www.kaajalvaghela.com and for any feedback: [email protected])
