ADVOCACY & POLICY ADVICE
Women and Health Reform Working Group Report
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PROGRAMS & SERVICES: ADVOCACY & POLICY ADVICE Women and Health Reform Working Group Report |
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Appendix 1: A Gender Analysis of Health Issues and Reform Documents Introduction 3 Introduction This is an overview of women's health issues and the impact of health care reform on women in Manitoba. It expands on some of the discussions coming out of the outreach activities of the Women and Health Reform Working Group (WHRWG) and their meetings with women, government representatives and other involved people. The current health care reforms in Manitoba have heightened concerns among the general public, and women in particular, about the quality of their health care. It is increasingly recognized that health is achieved and maintained through many interrelated factors and this has opened the door to a new perspective on health which moves beyond a medical focus. The current health care reforms, while driven by economic restraint, do reflect this changing perspective. Women's groups and organizations have been instrumental in pushing this new definition of health forward and promoting alternative methods of health care including: the use of alternative providers; preventing illness through education; and, including consumers as active participants in their health care. The recent recognition of midwifery as an acceptable and legislated birth alternative in Manitoba is one example of this. Women make up the largest proportion of those working in the health care sector and have long been recognized as the caregivers within their families and communities as a result of their nurturing role. Despite this involvement, women have had little formal voice into health care reform. As a result, the health care reform process may not fully reflect the self-identified needs of women. Women & Health What is Health? Women, and women's organizations, have been strong advocates for a model of health which includes social and economic impacts in addition to a medical or physiological basis for health and illness13. The Platform for Action developed at the Fourth World Conference on Women in September 1995, built on the World Health Organization's definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"18, p.56 and included, "Women's health as individuals and as a social grouping involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology."18, p.56. The Canadian Government has made a commitment to the following objectives for women's health identified at the Fourth World Conference which reflect a recognition that gender has an impact on health:
Other inquiries into women's health in Canada have resulted in similar recommendations13. The Determinants of Health Access to medical care is only one factor which affects the ability of people to attain and maintain health. Other factors such as social status, income, and support networks also affect health status. All these factors combined are called the determinants of health. The commonly identified determinants of health include: income and social status; social support networks; education; employment and working conditions; physical environment; biology and genetic endowment; personal health practices and coping skills; healthy child development; and health services7, 14. Health Canada has recently identified three additional determinants of health: social environment; gender; and culture. The idea of gender as a determinant of health is just beginning to develop and may change over time. Gender does seem to have an impact on different health risks. Behaviours that are a threat to health may be triggered or caused by different things in men and women, for example, young women may take up smoking as a way of controlling weight gain. As many women are particularly vulnerable to the other determinants of health (i.e. through low income or unstable employment), gender may eventually be seen as an integral part of all the determinants of health rather than as a separate element. Health status is affected by multiple health determinants and as a result cannot be evaluated using only one aspect of health. For example, in the 1996 Report on the Health of Canadians7, women's health was identified as better than that of men's as women had longer life spans. In the same document, it was also reported that: women had lower self-reported health ratings and spent more years living with chronic illness; the gap in life expectancy between women and men was decreasing; and there had been no decline in the rate of low birth weight deliveries. When all these health measures are included in overall health status, it seems women's health is not necessarily better than males and it is not improving at the same rate as the health of males. Women's Health Issues As Manitoba Health will soon be releasing a framework for action on women's health and numerous other resources exist outlining the impact of gender on health, the following will provide only a brief summary of some of the issues2,9,13,17,18,19. As a result of employment and systemic barriers, women are at a higher risk for poverty in Canada than men13. Women consistently rank lower than men in income and economic security even with equivalent education7. Women are less likely than men to be employed and more likely to be working for less money and on a contract or part-time basis13. Part-time and contract jobs are more vulnerable to lay-offs and have fewer benefits including access to pension plans13. Low income and social status have been linked to poor health. Aboriginal women, women of immigrant status, and female heads of single-parent families are particularly at risk for living in poverty. A higher rate of poverty in women results in a higher rate of poverty for their children perpetuating a cycle which impacts on the health of communities for generations. In addition to disparities in the paid workforce, women shoulder more of the burden for unpaid labour even when both spouses are working outside of the home13. Women at the WHRWG outreach meetings echoed this concern. This creates additional stress in the lives of women. The increased stress in women as they juggle multiple roles may also contribute to an increase in risky lifestyle decisions for women such as smoking13. As would be expected, the increased rate of smoking in women has come with a corresponding increase in lung cancer7. As women, particularly young women, are smoking more, men are smoking less which may suggest gender differences in health delivery needs. Many women have not responded to the large scale health promotion efforts used to reduce smoking rates to the same extent men have, possibly indicating smoking may be motivated by different factors in women such as to control anger or for weight loss. A gender-specific focus may be required for prevention and health promotion activities. Women have often turned to alternative methods for managing illness. Health related support groups for women have evolved from the women's health movement and from women themselves to meet a wide range of needs including smoking cessation, and support for those with specific health problems such as breast cancer and endometriosis. Involvement with a support group for breast cancer has been found to increase the length of survival, reinforcing the value of these programs for women13. Programs such as these, while successful, are still unavailable for many women who may benefit, as they are often underfunded and depend on volunteer support. Within the health care system, there are barriers to women achieving their full health potential. The dynamic of the male physician/female patient relationship may inhibit some women from questioning their care and treatment options which can result in missed diagnoses or non-compliance with prescribed treatments. Access to female providers is particularly important to some women especially those who need to discuss sensitive issues such as present or past sexual or physical abuse. Violence against women, particularly within their own homes, continues to be a significant health risk for women. The National Forum on Health reported in their findings one half of Canadian women over 16 years of age have experienced violence at the hands of an intimate partner13. Even in a supportive physician patient relationship, the limited time available for each visit may inhibit some women from clearly expressing their concerns. Women from visible minorities, particularly recent immigrants, and older women may face barriers to accessing sensitive care. These barriers emphasize the need for women to have access to alternate physicians and/or alternative providers such as nurse practitioners, who generally have more time for each patient, in order to allow women to find someone with whom they are comfortable. Women at the WHRWG outreach meetings stressed the need for alternatives, even in rural areas. Female-specific diseases are under-represented in health research and the funding that is allocated to women's health issues tends to focus on women's reproductive health13. Medical research into disease has primarily used male subjects and assumed the findings would be the same for female populations. However, biological differences (ie. hormone levels) have been found to limit the usefulness of some of these findings for women13. As a result, medications which are safe for men may be ineffective and have harmful side-effects for women. Natural female processes such as childbirth and menopause have become over-medicalized although women have made great strides in promoting alternative options such as midwifery. The care of women experiencing other concerns such as psychiatric illness has also been over-medicalized and often does not touch on the underlying social and systemic barriers to health. Gender-Based Analysis Policy analysis involves looking at all the possible intended and unintended impacts of legislation and policy decisions. Gender-based analysis is a way of looking at the impact health care reform may have on women in Manitoba. Gender-based analysis should be part of good policy analysis and focuses on identifying the social and economic differences between men and women and the different impacts policy may have on men and women17,19,20. The term gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. This extends beyond the biological differences between the two sexes17. Gender-based analysis does not exclude men or women but includes the perspectives of both to determine potential differential impacts on women and men17. Through the Charter of Rights and Freedoms, the Government of Canada guarantees equality between men and women. Gender-sensitivity and gender-based analysis are ways of ensuring this equality19. Health Canada and the Department of Justice Canada are two departments currently indicating a commitment to integrate gender-analysis in all departmental programs and policy development work6. Gender-neutral policy, or policy that treats women and men identically might seem to provide equal opportunities for all people. However, men and women because of their differing circumstances, may not be able to take advantage of similar opportunities equally or may be affected by various aspects of a policy in different ways. Equity is not possible unless all people have equivalent access to the intended outcomes or benefits of policy and equal protection from unintended outcomes17. For example, a free full-time program to provide high-school equivalency courses to adults on welfare would not be equally available to single parents, the majority of whom are women, who may need to find additional financial resources for child care in order to attend. The program still has value, but provisions may be needed to provide or subsidise child care. While this may increase the overall costs of the program (and particularly the cost of participants requiring child care), this would be outweighed by the future societal costs of not making the program accessible for single parents and maintaining them in low paying jobs or on welfare. The current health care reforms in Manitoba which have not undergone a gender-analysis and do not include any gender specific criteria (such as mandated representation by both men and women on the advisory boards) are an example of gender-neutral policy which may continue existing gender inequities. A gender-based analysis of health care reform in Manitoba will identify possible strengths and weaknesses and increase the chances of improved health for women and men resulting from the reforms. Women's Health and Health Care Reform Underlying the current health care reforms in Manitoba, and much of Canada, is a belief that shifting to regional control over health care will result in improved coordination between different health care sectors (such as hospitals and community providers) and increased citizen participation in health care10. It is expected this will result in decreased costs and improved health outcomes through:
an increased emphasis on health promotion and prevention of illness activities. These have many potential benefits for the health of women and communities as a whole. However, in other provinces where reforms are further ahead, such as Alberta, women have experienced negative impacts as a result of health care reform both as users of the system and as formal and informal providers of health care2,5. Health is increasingly viewed as a shared responsibility with individuals and communities caring for each other4,12. Increased social networks and a community sense of involvement can result in healthier communities. Unfortunately, this vision of shared responsibility often increases the burden on women. Early discharge and community-based services have increased the unpaid caregiver responsibilities of many women and limited their opportunities to work outside of the home13. This is occurring at a time when many women, particularly in rural communities, are losing their paid employment as a direct result of restructuring through hospital closures and downsizing, forcing them to seek other jobs. Women's Involvement in Health Care Reform and Barriers to Participation Women in Manitoba have told the WHRWG that they are interested in actively participating in the reform process but need opportunities and support to do this. From the initial legislation to the current board appointments, there have been limited opportunities for women and the community at large to participate in shaping and providing feedback. The exclusion of health care providers from Regional Health Authority (RHA) boards will help to ensure a fresh community voice without ties to the existing health care system and able to make decisions without bias. However, this discriminates against women as many of the women in rural areas, with the expertise and interest needed for board positions, are already employed in health care. A balance between these two important issues is needed. A women's health committee for each region would ensure women's issues are addressed at the RHA board level. It is important these committees are representative of women within each region and that they have a direct link to the RHA boards, by having a member of the RHA board act as chair. It is difficult to ensure that purely appointed or elected boards are a true reflection of the socio-demographic make-up of the general community10. A mix of elected and appointed positions may be necessary to ensure boards do represent their regions equitably in gender, culture and socio-economic status. Regardless of gender representation, gender-sensitivity training, including information about the impact of gender on health, should be required for all board members. Courses have been developed for this in other settings and could be adapted16. Many women have not been socialized to be assertive in group situations which may limit their active participation without gender-sensitivity on the part of all board members. Through the community health needs assessments, the community will have a voice in health planning3. It can also be assumed that, since board members must reside in their regions, they will have an understanding of the health needs and priorities of the communities they serve. Health planning also includes data collected by Manitoba Health such as rates of disease, accidents and health care utilization for each region. These initiatives are part of the community-based or population health model which is being used for health planning by the regions8. They provide an avenue for improving health care in the regions but they require a gender-sensitive perspective to ensure the needs of women are being met. Core Health Services The framework for the shift of services from Manitoba Health to the ten Rural Health Authorities is outlined in Core Health Services in Manitoba15. This document outlines the services to which people in the regions must have access. Services are divided into ten primary areas: health promotion/education; health protection; prevention and community health services; treatment, emergency and diagnostic services; developmental and rehabilitation support services; home based care services; long term care; mental health services; substance abuse/addictions; and palliative care. The document generally does not specify programs or specific focus groups for each service in order to allow RHA's to structure the system to meet the needs of each unique region and community. While flexibility is important for region specific planning, access to crucial health services for women in each region must be ensured. Particular areas of concern are:
Health promotion activities are the least defined of the ten key areas and are relatively unchanged from the system already in place. Health promotion is defined as an enabling process which allows increased control over and improvements in health for individuals and communities15. Health promotion extends beyond the health care delivery system to include social, economic, physical and other environmental factors although the mechanisms for inter-sectoral action are not outlined. The definition of health promotion/education utilized in the core services document identifies equity as achieved through providing "equal opportunities and resources". As has been discussed previously, simply providing the same opportunity does not result in equity as not all individuals have the same ability to take advantage of opportunities. Women are not identified as a specific focus group for services in several key areas. These include services to families, seniors, and nutritional services. Families in need are identified as a focus for family services, as is child abuse, however, no direct references are made to violence against women. Due to the prevalence of violence against women in the home and the far reaching implications for the health of women and their families, services for these women must be mandated in all regions. Care providers from health and social services require gender-sensitive training to identify and support women experiencing violence in the home. At the very least, each region must have an adequate referral process in place for women experiencing family violence preferably including safe houses accessible within rural Manitoba and able to meet specific cultural needs (i.e. for Aboriginal or Francophone women). Senior women are at risk due to their higher rates of poverty and higher rates of chronic disease. Prevention and community health services for seniors should identify the need to direct services towards high risk groups. The promotion of nutrition education should identify young women in particular due to their higher risk for eating disorders. Childbirth services are included in the core services document under prevention and community health services and under acute and chronic care services. Ideally, this will ensure low-risk deliveries are available to all women as close to their home environment as possible. Midwifery is identified as an initiative of Manitoba Health to be coordinated through a central region, which hopefully, will not limit the availability of midwives in northern and rural Manitoba. Meaningful change to the existing system will be challenging as boards can be caught between cuts to funding and an inability to contain the costs and practice of providers not within their control10. In order to make educated decisions, the boards will require support and access to information about the costs and benefits of alternative providers, such as midwives. The boards will require similar supports as they make difficult funding decisions, weighing the value and cost of prevention activities against technology based treatment or diagnostic resources. Core Health Services in Manitoba briefly discusses the process for implementation of the core services and evaluation of outcomes. These areas require further clarification either in this or another document to clearly guide the evaluation process. Improvements to health status will come from consistent and extensive evaluation of the reforms and using these findings to guide further changes or strengthen effective strategies. Evaluations must include more than the fiscal outcomes of reforms and evolve from a gender-sensitive framework allowing the community to provide feedback and become actively involved in the process of shaping health care. Evaluators need to collect information from multiple sources both quantitative and qualitative. Quantitative data from Manitoba Health or the regions can be enhanced through the addition of qualitative data from community members and health care providers to include impacts on all the determinants of health. To ensure that women do experience positive health benefits from health care restructuring in Manitoba, a formal commitment to gender-sensitive planning and including women at all levels of decision-making and evaluation in health care is essential. Community Health Needs Assessment The community health needs assessments required in all regions will be used to: determine directions for health care delivery; evaluate both existing and proposed care delivery; and, determine funding allocations3. The community health needs assessment guidelines outline the needs assessment process and highlight its importance3. Not only does a needs assessment help to direct health planning and evaluation, it provides a tool for involving and informing the community, both of which have the potential to improve the health of the community. It is unclear how the RHA's will move beyond the existing core services currently provided and integrate their community assessments into their final Regional Health Plan. Often communities see hospital downsizing and closures as their priority health concern as they have significant economic impacts on affected communities. Many Canadians told the National Forum on Health they did not support channelling money away from treatment towards health promotion activities or to other areas such as education14. The connection between health and social determinants, particularly gender, is not always immediately apparent. Including education about the determinants of health, one of these being gender, in community needs assessments can help to encourage active and informed community participation in the process. The needs assessment guidelines do not identify gender as a specific collection or analysis category10. Presentations about the needs assessment process currently being held for each RHA discuss the need to identify voices that may not be heard, such as those from weak or disenfranchised groups. This is a promising direction but it does not ensure the voices of women will be sought out or heard. The guidelines include the need to go back with findings and "reality check" data collection and intended plans with community members. This is a crucial step as it will help the community maintain control over the findings and help to ensure they do represent the community voice. The reality check stage should also include a gender-sensitive analysis to identify any unintended negative impacts of policy or program directions. Manitoba Health data will be specific to each region, but it is critical this information include sex and age categories. Manitoba Health is developing The Manitoba Population Health Assessment Template to assist with the assessment process. This does include sex specific categories for data collection in several crucial areas such as demographic, socioeconomic status, subjective health status, some personal health practices, and pharmaceutical usage11. Sex specific data has not been identified for several key areas: health services (such as provider sex); service utilization (utilization by sex); smoking and alcohol-related illnesses, and some specific or general categories of diseases or injuries11. Workplace-related illness and injuries specifies industrial, farming, and mining occupations. These should also include the occupational injuries common in fields traditionally dominated by women such as repetitive strain injuries seen in office workers, among others. In addition to gender-specific statistical data, women must be able to lend their voices to the needs assessment process. Opportunities for meaningful participation by women are vital to ensure women's health issues are identified and services to meet these needs are being appropriately evaluated. Even if women's issues are a specific focus, this may not produce valid information if only one social grouping is consulted, such as professional women working in health care. Providing a voice to all community members requires a commitment to minimizing serious barriers to participation felt by some people. Community members without experience in public speaking may not be comfortable enough to present their views to an open mike community hearing, or even a focus group1. Not all community members have the reading or writing skills needed to fill out questionnaires and respond to written documents, particularly if these are only available in English. Existing social norms may also make women reluctant to publicly express concerns about the health care system or any hidden burdens they may be facing as a result of health care restructuring, such as additional care giving for family members. Due to the disparate unpaid work load on women and the implications of this for women's health, initiatives which require additional unpaid volunteer hours should be carefully considered and limited in number. Those with care giving responsibilities, both for children or for other family members, may be unable to find or afford respite or childcare to allow them the time to attend a community meeting and/or time to prepare to present their views. Women with a lower educational level or those of lower socioeconomic status in particular, may find participation intimidating and respond better to other less formal feedback mechanisms. The needs assessment process must include the supportive mechanisms needed to allow women an opportunity to participate either through traditional means or alternate opportunities such as informal one-on-one sessions. Conclusion The Platform for Action emphasized the need for health programs to develop in cooperation with women and community-based organizations18. A large number of women are willing and able to make whatever efforts are necessary to attend meetings or community forums and provide their input. Women will cease to participate when their input is sought but is disregarded. Health care reform has the potential to change women's health status for the better. However, in order to improve the health of women, policies and programs must ensure that gender differences are factored in and women are actively included in health care decision making13. This requires gender equity on RHA boards, gender-sensitive training for board members, the inclusion of a diverse range of women in the community needs assessment process, and a recognition of the needs of women in health care planning. Resources such as women's health committees to support the RHA's in these efforts must be in place as soon as possible as the new health systems begin to take shape. Resources
Additional copies of this report available from (C)1997,1998 by The Women's Health Clinic Of Manitoba |
Women's Health Clinic * Women's Health Clinic * Women's Health Clinic * Women's Health Clinic * Women's Health Clinic * Women's Health Clinic
