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 2: Statement of Opportunities and Obstacles to Health Reform, A Letter to Ministers Hon. R. Vodrey and Hon. J. McCrae, October 1996 Women and Health Reform Working Group Honourable James McCrae Honourable Rosemary Vodrey October 23, 1996 Dear Ministers; The letter is in follow up to our meeting Tuesday, October 15, 1996. We felt that putting our comments in writing would be useful. Thank-you for putting time aside for meeting with us. We appreciate the time constraints you are under and see this meeting as a reflection of how seriously you take these issues. As we mentioned, the four organizations represented at our meeting are part of a broad based network of providers and consumers who have been meeting to educate ourselves on the various aspects of health reform in Manitoba. We have had presentations and discussions on Bill 49, the plans for the community needs assessments, the core services list, and the regional health boards. There are generally twenty to forty women in attendance at our meetings. The issues we bring forward, as well as the suggestions on how to address them, come from these meetings. Some of the issues outlined below were discussed during our meeting, others were not mentioned due to time constraints. The issues outlined below emphasize the perspective of women as consumers of health services. Women are also involved in the health system as health care providers and as employees, however, these perspectives have not been the primary focus of our Working Group. We are supportive of some of the goals which we believe underlie the Act such as the creation of mechanisms to increase coordination among health service providers and to increase local control over health services. We know our health system would benefit from consistent approaches in these areas. However, we do have concerns about particular measures proposed in the Act to achieve these goals and have some revisions to recommend. We have serious misgivings that, unless addressing women's needs and mechanisms for input from women are specifically required by Bill 49, women's health services will not receive the attention required through the re-structuring process. Women are key players relative to Canada's health system - as the majority of health care workers, as recipients of health services and as the segment of the population most likely to take on informal caregiver roles as services are moved out of institutions into the community and the home. * Almost all women visit a health care professional at least once a year and are more likely than men to be hospitalized * Women still bear most of the responsibility for looking after their families - whether employed outside the home, as unpaid volunteers in the community or as full-time homemakers * In the paid labour force, women are more likely than men to be absent from work because of personal or family responsibilities - and the number of days of work lost annually is rising. On average, female workers missed six days of work in 1994 because of these commitments, up from three days in 1980. This compares to less than a day in 1994 for male workers. * Women account for a large share of employment in nursing and health-related fields. In 1994, 86% of nurses and health-related therapists were women. Conversely, in 1994, women accounted for only 18% of dentists and 25% of doctors. " (excerpt "Women & Health Services", Health Canada 96) Since the 1960's, many women have been expressing dissatisfaction with the type of care which they have been receiving from the health system, finding it unresponsive to their social situation and health concerns, and finding that normal life changes were over-medicalized. The Women's Health Movement has been calling for greater consumer empowerment and involvement in health care and has been in the forefront of changes to the way health care is conceived and delivered. Women s critiques of health care have been a significant social force behind the principles which are purportedly driving the health reforms we are seeing today, such as an increasing emphasis on community- based service delivery and the importance of social and economic factors in creating good health, as well as a greater role for consumers and communities in the control of services delivered. This was recognised by Manitoba Health's own document, Quality Health for Manitobans: The Action Plan which acknowledged, for example, that the "dramatic and creative reforms [in childbirth]... have been driven not by health service professionals but by the consumers of health services." As a result our "system now provides better and, for the most part lower cost services." Our Concerns: 1. The lack of public awareness We are alarmed at the speed at which Bill 49 will become law. This legislation was made available to the public in June 1996 and is scheduled to move through second, third reading and proclamation by early November. Many critical aspects of legislation, such as a Core Service Agreement, have not been released for public discussion as late as September 30. This is an impossible time line for the community to educate itself about the issues and to review the legislation and comment. Considering the tremendous implications which the proposed new structure will have on our health system, this is not acceptable. While the issue of Regionalisation of health services was discussed extensively over the two year mandate of the Northern and Rural Health Advisory Council, the Bill itself deviates in some significant ways (eg. election of Board members) with the recommendations of this Council. Also, almost no public consultation about governance and regionalisation of health services has taken place in Winnipeg. Input to government decision-making to-date has been spear-headed by the Urban Health Planning Council which was composed of the CEOs of hospitals in Winnipeg. The various Strategy Teams, which were made up of health care providers were instructed not to concern themselves with governance and that there would be another process for this. These points lead us to conclude that public input to this legislation has not taken place. Recommendations: We urge the government to delay passing Bill 49 until:
2. The need for recognition of the unique role of women in relation to health services. Women face particular challenges in achieving good health. Some of these are outlined in the Beijing Platform for Action as "The prevalence among women of poverty and economic dependence, their experience of violence, negative attitudes towards women and girls, racial and other forms of discrimination, the limited power many women have over their sexual and reproductive lives and lack of influence in decision-making are social realities which have an adverse impact on their health." Through the Beijing Platform for Action, our government made a commitment to pursue the following strategic objectives:
The Platform for Action can be seen to give direction to Canadian provincial and regional health authorities. It urges governments to "design and implement, in cooperation with women and community- based organizations, gender sensitive health programmes, including decentralized health services that address the needs of women throughout their lives…and include women, especially local and indigenous women in the identification and planning of health-care priorities and programmes" (106.9c)). The document emphasizes the need to hear from women at the margins in formulating policies and designing programs. There is strong recognition of the economic and environmental determinants of health. (See for example sections C.(90); (92) (102) (105); C.2. 107 (n)). It calls on governments and other appropriate bodies to "pursue social, human development, education and employment policies to eliminate poverty among women in order to reduce their susceptibility to ill health and to improve their health." The special role which women have in relation to the health system should be recognized throughout the legislation and in the policy development process in relation to regionalization. These measures must be sensitive to the fact that women come from a diversity of backgrounds. We are aware that Manitoba Health is preparing a Women's Health Framework Policy Paper which we urge the government to release for community consultation as soon as possible. Such a Framework Paper could be an excellent tool for education of the public and of RHA Board and Committee members. It should also provide direction for planning services for women in the regions. Recommendations
3. Lack of Democratic Process in Selection of Regional Health Authority (RHA) Board In the current Bill there is no commitment to the regional election of Board members to the RHA nor a timetable for transition to the selection of Regional Board members by election as opposed to a appointment by the Minister. In order to ensure accountability to people in the region, and to ensure that the governance of the health system is not dominated by a desire to please the Minister (due to the fact that members are appointed by him/her), it is very important that the selection of these Boards be by election from their communities. This ensures impartiality both in reality and appearance. Recommendation: That future boards be consumer-based, with the substantial majority of directors elected. We suggest that a small number of Board positions (about 25% of total Board numbers) be filled by appointment by the elected board members in order to ensure appropriate reflection of the demographic composition of a particular region, including parity of representation of women, as well as representation of people of different cultural backgrounds and socio-economic status living in the region. 4. Lack of Commitment to uphold Principles of Canada Health Act and Universal Access to Health Services The Act currently includes repeated references to the charging of fees for unnamed services. This is not balanced by any reference to the level of services which shall remain insured. We are concerned about the fact that this may allow for further insidious de-insuring of health services. We do not believe such an important issue - what services will be provided by the health regions - can be left to regulation. Recommendations:
5. Extensive Regulatory Powers and Powers of the Minister Bill 49 appears to concentrate a great deal of decision-making power at the ministerial level rather than delegating the authority for the management and delivery of health services to the regions. Our understanding is that the primary rationale for regionalization is to bring decision-making about health services closer to the communities affected. Leaving so much authority in the hands of the Minister could encourage the Government to micro-manage health services delivery. The role of government in this new regionalized system should be to set standards and desired outcomes and power over operational service delivery should be delegated to the RHA. We are also concerned that many very important matters are being left to Regulation rather than being outlined in the Act. This means that many changes could be implemented, for example, to currently provided programs, without having to go back to the legislature for review. Regulatory review is done before a sub-Committee made up of government members only with limited public review. Thus, the health system would be allowed to evolve without public input. This is of particular concern if the Board members are appointed. Because of the impact on the welfare of Manitobans, we implore Government to commit all regulations arising from Bill 49 to public scrutiny. Recommendations
6. Need for Commitment to Community-based Health Services and System There is no commitment to fund a range of health services in the Act. In particular, there is no commitment to encourage the development of more community-based services. Providing more services closer to the community has been a stated goal of the government's health reforms since the 1992 Action Plan was announced. In order to ensure that a sufficient range of primary health care services are developed, the principles of primary health should be added to the Act. These are identified in the government's Health Advisory Network Taskforce on Primary Health Care (1994). Including these principles will ensure that Regions are required to provide services from a community-based perspective and address determinants of health. The importance of an appropriate and adequate system of primary health services which acknowledges the unique social and economic situation of women is recognized in the Beijing Platform for Action. The principle of being community-based should be a primary driver of health service planning. At present there is insufficient consultation required by the Act to ensure that citizens are included in the development of regional health plans. As stated above, such activities should explicitly ensure that consultations take place with women from and in the community due to the key role which women play in the health of their families and communities. This consultation process should also provide communities with examples of community based service delivery options. Most Manitobans have not had experience with the innovative models developed here or in other jurisdictions. For example, nurse practitioners, midwives, health educators, community health centres should be discussed as part of this consultation. Recommendations:
Going Forward In particular, we strongly recommend that specific initiatives for women commence very quickly. This process should have a variety of components including:
We would be happy to work with your staff in implementing this project. Our members are participants in provincial organizations and networks which have considerable expertise in gender specific health planning and programming, needs assessments and outreach. Given the timelines for the time table for the development of the first business plan and for the community needs assessment, we feel a real urgency to begin. We are well aware of the fiscal challenges currently faced here in Manitoba but believe that outreach activities such as these would ensure that costly errors and conflicts could be avoided. We were encouraged to see that we share common goals; namely to increase women's participation in health reform processes and to ensure that women s issues and concerns are addressed in all aspects of health planning, research and service. We would like to acknowledge the efforts being made, for example, to increase gender parity in the appointments to the current RHA's. As well, we are very pleased to hear that women's health will be reinstated as a priority by Manitoba Health. By improving women's health, our other priorities, children, the elderly and aboriginal peoples will also be addressed. From our conversation we understand that your departments will work with us in:
We see our discussion as the beginning of a process that will ensure the implementation of these goals. Our group looks forward to further discussions with both of you and your respective staff and would like to set up a timetable for further meetings. We look forward to hearing from you. Sincerely, On behalf of:
(C)1997,1998 By The Women's Health Clinic Of Manitoba. |
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