II. Gender and health sector reform
1. Women and health
1.1. Women's health needs
1.2. Gender inequality
2. Framework for health sector reforms
2.1. Intentions of a health sector reform
2.2. Health care systems around the world
2.3. Challenges facing health care systems
2.4. Health sector reforms as policy responses
3. Health sector reforms and gender equity
3.1. Decentralisation and promoting social participation
3.2. Reorganisation of health services, including the redefinition of care models and the formulation of basic packages of service
3.3. Restructuring of human resource management
3.4. Restructuring of financing systems, including participation of the private sector
Abbildung in dieser Leseprobe nicht enthalten
The health sector is facing cost explosions for various reasons. Facing limited resources contemporary politics tend to focus on the reduction of costs when talking about reforming the health sector. Reforming the health sector is a complex issue with implications on equity. Since women are particularly vulnerable in health issues, this paper deals with the effects of health sector reforms on gender and equity.
Therefore, it describes what kind of challenges the different health systems around the world have to face and how policy responds. The different components of health sector reforms are researched towards the effect on gender equity. Figures and examples are used to prove the evidence of the subject and the implications on gender issues.
This paper concludes that women are often disadvantaged in access to health care due to barriers in access to remuneration and cultural barriers within families. This affects women’s health status. A major challenge in this context is to promote the participation of women in order to adjust reforms and components of services to their needs.
In its constitution the WHO defines health as a state of complete physical, mental and social well-being, and not merely as the absence of disease or infirmity (Fathalla, 1997: 5). This WHO definition implies that social, economical, and cultural variables are influencing the health of every human being. Human beings themselves and their health needs differ for obvious biological reasons depending on the sex. A person‘s sex itself is again essential for the determination of a person‘s role in a social, cultural and economic context. These correlations show why sex - in this context appropriately labelled gender - is important when discussing economic and social consequences of a health sector reform. Such reforms aim particularly to reduce costs, to tighten services, and to improve the supply of services which affect different groups of the society differently, including men and women. Considering women‘s special health needs and social status there is a broad range of possible consequences and challenges. This paper is, therefore, going to focus on gender equity in relation to health sector reforms.
The first chapter it is going to deal with women and health in relation to equity. The second chapter is going to explore what challenges different health sectors around the world have to cope with and how policy faces the challenges. Afterwards, different components and approaches of health sector reforms will be researched towards their effects on gender and equity. Finally, the results are going to be discussed.
II. Gender and health sector reforms
1. Women and health
For centuries women and their health problems have been linked almost exclusively to their biological function as bearers of children (Bayne-Smith, 1996: 17). Thus, socially determined gender differences and their impact on physical and mental health have been broadly neglected (Verbrugge, 1989: 23, and Markides, 1989: 10). Beyond biological differences, contemporary research considers gender issues and their impact on health and health care (Cole, 2000: 1, Standing, 1997: 2, and PAHO, 1998: 7). According to Standing (1997: 1) literature distinguishes two main approaches in thinking about gender in relation to health care: One that focuses on women‘s specific health needs and a second one which considers gender issues as a key variable for inequality. These two approaches will be described in this chapter.
1.1 Women‘s health needs
The women‘s health needs approach stresses the specific needs of women and girls as consequence of (although not exclusively) the biological reproduction (Standing, 1997:1). As Doyal (2000: 993) describes, reproductive health care considers women‘s disadvantage in comparison with men due to obvious differences in reproduction. According to the researcher, this includes control of women‘s fertility as well as the provision of resources necessary to ensure healthy pregnancy and childbirth.
Therefore, reproductive health care is meant to offer a compensation for women‘s special vulnerability in order to guarantee equity among men and women, she states.
Simultaneously, women‘s health needs can be seen in relation to the cost-effectiveness of interventions which target reproductive health care (Standing, 1997: 2). While in a number of countries efforts are made to develop a more effective health system, the question raises whether cost-effectiveness could incorporate gender equity concerns (Cole, 2000: 1-2; see chapters II.3. - 3.4.).
Besides reproduction, the PAHO (1998: 10) points out another issue which is relevant for women‘s health needs: women‘s longevity. As to be seen in most developed and developing countries, women‘s life expectancy is, on average, higher than men‘s (Fathalla, 1997: 9). Men usually die younger but women report more often illnesses and disability (Ory & Warner, 1990: xxii). Using data from the United States, Verbrugge (1989: 63) notes that women have in total and relatively more years of disability than men. Thus, women are sometimes excluded from services generally covered by insurances (PAHO, 1998: 17). This explains why special attention has to be paid to women‘s longevity as the organisation argues although it seems to be an advantage - at least at first sight.
1.2. Gender inequality
A gender inequality approach is concerned with the role of gender relations in the production of vulnerability to ill health or disadvantage within health care systems (Standing, 1997: 2, and Baden, 1997: 8). This includes particularly the conditions which promote inequality between the sexes in relation to access and utilisation of health care services. (Standing, 1997: 2; and PAHO, 1998: 10). The approach considers that, on the one hand, women‘s health status depends on their role within their families and is, on the other hand, determined by larger systems of culture and social structures (Cole, 2000: 1, and Bayne-Smith & McBarnette, 1996: 174).
Cultural and ideological factors can also interfere with access and utilisation of health services for women (Ojanuga & Gilbert, 1992: 615). In some countries, women are for example required to have their husbands consent to obtain medical treatment (Ojanuga & Gilbert, 1992: 615, and Hardee & Smith, 2000: 16). Moreover, embargos to consult male practitioners and the low valuation of health needs of women and girls compared to men and boys can have a strong impact on access and utilisation of health services (Yu & Sarri, 1997: 1888, Standing, 1997: 2, and Doyal, 2000: 934).
Another issue affects women‘s access to health care: Within their families women are the principal providers of health care and bear the greatest burden in this respect (PAHO, 1998: 16 and Cole, 2000: 1). The result is that women spend more time to take care of the children and other family members in case of illness or disability than men (Standing, 1997: 2). Duties at home keep women away from the labour market and create higher opportunity cost for women in seeking treatment (Schuler et al., 2002: 196 - 197).
In absolute terms of vulnerability, being female can be one of the most important predisposing factors since women are over represented among the poor and have lower access to remuneration and other health resources, including health and social security services (Standing, 1997: 2, and PAHO, 1998: 10).
2. Framework for health sector reforms
2.1 Intentions of a health sector reform
Health sector reform is not a new development: As Hardee and Smith (2000: 2) argue, for the last decade international organisations, such as the World Bank, have supported that countries undertake health sector reforms. The ILO (1998: 3) states that this trend is the result of a number of challenges due to structural, social and economic changes in many societies and the world as whole. It argues that many health care systems won‘t be able to fulfil their tasks if reforms would not be realised.
The purpose of health sector reforms is to address poorly functioning health systems by making improvements to each aspect of the system (Hardee & Smith, 2000: 2). In this context it is important that health care systems around the world differ in terms of institutional structures and mix of arrangements for financing, producing and distributing health care services (McPake et al., 2002: 188). Thus, a short overview over the conceptual background, the challenges in facing health sector reforms and components of a health sector reforms will be given in the following sections.
 Recently there has been a shift away from talking about ‚women‘ to talking about ‚gender‘, as Doyal (2000: 931) describes. She states that the emphasis is now on the social construction of gender identities and on the nature of the relationship between women and men.
 Hardee and Smith (2000: 6) provide the following way to interpret the ICPD definition of reproductive health. It includes the following reproductive health concerns and related information and services: prevention of unintended pregnancy through provision of family planning services; provision of safe pregnancy services to reduce maternal morbidity and mortality; provision of post abortion care services and safe abortion (where permitted by law); prevention and treatment of RTIs, STDs, and HIV/AIDS; provision of reproductive health services to adolescents; improvement of maternal and infant nutrition, including promotion of breastfeeding; screening and management of specific gynaecological problems such as reproductive tract cancers (including breast cancer) and infertility; and addressing social problems such as prevention and management of harmful practices, including female genital cutting and gender-based violence.
 Possible biological and genetic reasons for longevity will not be discussed here (for different aspects and biological and genetic reasons see e.g. Wingard and Cohn, Smith and Warner, Neel, Gartler, Hazzard, Wekser, McKinlay et al., and Thomas & Kelman, in: Ory and Warner, 1990: 25 - 156)
 The HDR 2003 shows that female work time is mainly spent for non-market activities while men spend most time for market activities. Moreover, it shows that women in selected developing countries work in total longer than men. (UNDP, 2003: 326)