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Women’s Global Network for Reproductive Rights (WGNRR)
In 1987, during a member’s meeting of WGNRR in Costa Rica, May 28 was declared the International Day of Action for Women’s Health. The 28th May has since become widely known and celebrated around the world by women’s and health groups. In 1999, It was officially acknowledged by the government of South Africa. Every year, WGNRR publishes a Call for Action to raise awareness and promote solidarity and action on the International Day of Action for Women’s Health.
Women’s Access to Health Campaign (WAHC)
Women have a right to health, which includes physical and social access to health services as well as ‘enabling conditions’ that are essential for women to enjoy good health. International and national policies that result in greater poverty of populations and growing inequality between rich and poor, men and women, have a direct impact on women’s possibilities to stay healthy and enjoy their sexuality. Women’s right to health cannot be fulfilled if sexual and reproductive rights are not addressed. It is time for governments to assume their responsibility for women’s health.
On May 28th 2003 the Women’s Global Network for Reproductive Rights (WGNRR) launched the Women’s Access to Health Campaign (WAHC) in collaboration with the People’s Health Movement (PHM). This campaign aims to mobilize women’s groups, health groups, youth groups as well as other social movements concerned with the deteriorating situation of women’s health around the world. Join the Women’s Access to Health Campaign by sending a message to wahc@wgnrr.nl or take a look at www.wgnrr.org for more information. Join us in taking action on the 28th May for women’s health!
Health
Health is defined by the World Health Organization (WHO) as: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Health is a fundamental human right, recognized in international treaties, as well as in national laws and public policies. Human rights are universal, indivisible and interdependent and apply to all women regardless of religion, ethnicity, class, orientation, age or disability. Sexual and reproductive health, including access to safe, legal and affordable abortion and contraceptive services, are considered central components of health. This is of great importance, especially to women, because it affirms that without the fulfillment of sexual and reproductive rights, the right to health cannot be fulfilled.
In 1978, governments from around the world signed the Alma Ata Declaration, committing themselves to achieving Health for All by the year 2000 through the Primary Health Care (PHC) approach. PHC calls on (public) health systems to meet the needs of the poorest and challenges all actors to see health as a right. It seeks to address the root causes of poor health instead of the symptoms and stresses the need for community involvement and for an intersectoral approach. At the International Conference on Population and Development (ICPD) in Cairo in 1994, a strong recommendation was made to all governments to make reproductive health accessible to all people before the year 2015 through a Primary Health Care system. Its Programme of Action was the first and most comprehensive international policy document to promote the concept of sexual and reproductive health and rights. At the World Conference on Women in Beijing (1995), governments strengthened some of the language of ICPD and committed to providing accessible, affordable, comprehensive, culturally appropriate and high-quality health care for all women.
However, about 25 years after Alma Ata and a decade after the Cairo and Beijing Conferences, we see that health services in many countries are in terminal decline and that the underlying conditions that determine women’s health and their ability to make decisions about their childbearing and sexuality are deteriorating. Governments have failed to reach the basic health indicators set by the Health for All agenda and maintain a selective vision of health and health-care. While factors such as the rise of fundamentalisms opposing women’s sexual and reproductive rights and continued Malthusian thinking ingrained in development institutions and government departments have proved to be hurdles in attaining women’s sexual and reproductive rights, the major reason for the deterioration in health status and services have been health sector reforms. It is time for governments to assume their responsibility for access to health for women, access to health for all!
What are Health Sector Reforms?
Since the 1980s, health sector reforms have played a major role in national and international health policies in industrialized as well as developing countries. Health sector reforms are mainly the outcomes of neo-liberal policies of international development and financial institutions and governments, whereby over the last couple of decades many developing countries have carried out economic structural reforms, including those in the health structure and other social sectors. Overall, health sector reforms have increasingly introduced market mechanisms into health-care provision, giving the private sector a greater role as the provider of public services. Health sector reforms aim to make health systems more cost-effective and efficient by reorganizing and decentralizing services, resources and management. The strategies for health sector reforms vary from country to country, but usually include a combination of the following developments: a shift of health services from the public to the private sector; decentralization; the establishment of cost-recovery mechanisms such as user fees or community-based financing; the introduction of health insurance systems; and adjustments aimed at improving the efficiency of civil service in general and ministries of health in particular. Health sector reforms are usually accompanied by substantial cuts in health budgets or a concentration of funds into areas of international donor priority.
Health sector reforms may seem gender-neutral, but they have significant impact specifically on women due to their reproductive capacity and their socio-cultural and economical responsibilities and status. As health budgets are decreased, much of the work is transferred from the formal health-care system to the informal care system which depends above all on women’s unpaid work. While some aspects of health sector reforms may contribute to the provision of health services for those paying, they are likely to widen the gaps between rich and poor, with particular detriment to women and children.
Why Health Sector Reforms?
Health sector reforms are based on the assumption that the public sector is either unable or should not be allowed to operate as an effective provider of health-care services. Indeed, after two decades of structural adjustment, most developing countries are incapacitated as effective providers of public services. Advocates of health sector reforms – like the World Bank, International Monetary Fund (IMF), regional development banks and most donor governments – tend to focus their arguments within the narrow confines of efficiency and effectiveness: privatization of the health sector will promote competition in health services according to the free market principle resulting in an enhancement of access to and quality of services. They argue that the State should undertake only minimal intervention in economics and social welfare and, by definition, should run only essential services. Public services are viewed as anachronistic and antagonistic to quality services and consumer choice.
The strong focus on the need to contain the escalating costs of health-care provision tends to obscure the nature of the services to be reorganized and the most appropriate means through which cost containment might be achieved. Although repeatedly ignored, such issues remain of critical significance to the questions of equity and the distribution of limited resources. Health sector reforms ignore the impact of factors such as poverty, inequality, social class, gender, and age divisions in society upon the process of development, and in particular the disproportionate dependence among the poor upon public provision of services.
While developing countries and countries in transition have been pressured to implement major changes to the organization and delivery of services based on free market mechanisms, the State has long played a crucial role in the organization and delivery of health-care in many industrialized countries. In other countries, including in many industrialized countries, similar health sector reforms have been pursued more or less voluntarily. Chile voluntarily privatized its health-care system, leading to a decreased access to services and lower quality of care for the poor. In France, there is a strong debate about increasing the share of private insurance schemes in the social security system, while in the Netherlands steps backwards have recently been taken by taking services such as the contraceptive pill out of the public health insurance. Women, especially poor and migrant women, are most affected.
Budget Cuts on Health Services: SAPs and PRSPs
“Health care services of most developing countries require urgent investment and international support” - World Health Report 2003, Shaping the Future
Health sector reforms have been implemented in many countries as part of Structural Adjustment Programs (SAPs). SAPs were introduced by the IMF and the World Bank in many poor and highly indebted countries of Latin America, Africa and Asia in the 1980s and 1990s to ‘generate economic growth’ and ‘create the climate for repayment’. As a result of the economic crisis of the late 1970s, and the preceding period of excessive lending by international banks, many developing countries entered a debt-crisis. Interest on loans to be repaid accumulated and often exceeded the total incomes of these countries from their export earnings. Brazil had one of the highest debts: its interest repayments were $30 million per day. The conditions for the loans offered by IMF and the World Bank differed per country, but focused on the adoption of neo-liberal economic policies and drastic budget cuts on social services.
By the mid-1980s, the Third World was already a net exporter of money, meaning that debt servicing was higher than the total inflow of loans, bilateral and multilateral aid and foreign direct investment. The impact has been felt most severely in the health, education, food and security sectors. In Tanzania, debt service payments are 9 times greater than expenditures on primary health care and 4 times greater than expenditures on education. The World Bank’s analysis of SAPs in Sub-Saharan Africa shows that the share of government budget allocated to the health sector fell in most countries during the adjustment period. Between 1975 and 1989 health expenditures in Somalia were cut by 78%. While donor countries are more than wil-ling to dictate the national budget priorities of developing countries, they are reluctant to enforce a transfer of funds from war to health.
In the late 1990s, the World Bank and the IMF introduced the Poverty Reduction Strategy Papers (PRSP) in response to increasing criticisms that SAPs were leading to increased poverty, economic crises and a collapse of public service infrastructures, including health services. PRSPs were established in some of the least developed and highly indebted countries, with the intention of providing them with soft concessional loans to strategize for overcoming poverty. According to the IMF and World Bank, PRSPs reflect the priorities of the country in its fight against poverty, but in reality governments tend to focus on what the IMF and World Bank would like to see, without voicing the priorities of the people. Civil society organizations have found themselves used more like an alibi than being recognized as a true partner in the process. It has become clear that with PRSPs there has been no clear shift from the earlier SAPs approach and pressure for neoliberal reforms has not reduced. In fact, the scope of the loan conditions of the World Bank and IMF has increased, allowing an even greater intrusion into domestic policies.
Privatization of Health
Privatization, as part of health sector reforms, has transformed public health into a commodity to be purchased. It has been seen as a means to transfer government attention towards the provision of only basic services to the poorest people. This was clearly advocated in the World Bank’s 1997 World Development Report, which suggests that the State should undertake only what it can best afford. In many developing countries, this was interpreted to mean only ‘essential packages of basic care’ consisting of selec-ted interventions and services. Health-care in this perspective is not viewed as a need, much less as a right, but as a consumer demand.
Privatization of health services and other social services greatly increases health inequality. The international health-care industry is an emerging phenomenon in the developing world as prospects increase for private health-care insurance and hospital provision directed to those able to pay. Subsequently, the process of privatization leaves large sections of the population, particularly the rural poor and the majority women, dependent upon an inadequately equipped and shrinking public sector, while the private sector expands rapidly and becomes more costly and available only to those able to pay. In the UK, thousands of patients are denied access to treatment at National Health Service hospitals because priority is given to people who can afford to pay the high fees.
The Unregulated Health Market
Discussions of health sector reform tend to limit analysis to the bio-medical health-care system, which is explicitly targeted by policies on health sector reform, rather than looking at how best to achieve sustainable improvements in people’s health. Yet in many countries people move back and forth from biomedical health-care to traditional healers, birth attendants or spiritual assistance. In China traditional health treatments account for 40% of all health care delivered while in parts of Africa as much as 80% of the population uses traditional medicine for primary health care.
In many countries an increasingly unregulated health care market has emerged in which a wide range of providers, including public sector agencies, private sector players, NGOs and traditional healers are practicing. These practitioners may or may not be qualified or competent. This diversity has been largely ignored in health reforms, failing to address its impact on women’s health in different parts of the world.
Health Sector Reforms Jeopardizing Women’s Health
“The supposed benefits of privatizing social services are elusive with inconclusive evidence on efficiency and quality standards in the private relative to the public sector” - United Nations Development Program (UNDP) 2003 Human Development Report
Health sector reforms have not led to the positive outcomes, either in economic terms or in terms of access and quality of care, anticipated by the reformers. Rather, they reinforce the view that in situations of gross structural socio-economic inequalities, the application of market principles acts to reinforce poverty and inequality. Women and marginalized groups suffer the most.
Less Money, Less Health Centers
As a result of health sector reforms, many health centers and clinics have closed down or limited their services due to budget cuts or
lack of trained personnel. Many developing countries are facing a shortage of qualified medical staff as a result of migration, or ‘brain
drain’. In Ghana, 12.365 health professionals including 11.325 nurses left the country between 1993 and 2002. In Vietnam, during the
period of state subsidy, over 93% of the villages had their own clinics and maternity houses. This has now fallen to 75% since health
budget cuts were introduced. When clinics and health centers close down and services are available only at a distance, women are the most affected due to their work and home responsibilities, lower access to resources to travel and socio-cultural factors that prevent their mobility.
Limited Services for Women
Due to health sector reforms, we see a loss of preventive services (information, hygiene training, etc) as the aim for profit leads to a disinterest in the factors that make people ill. In China, for example, privatization of health services in the last two decades has eroded highly acclaimed health education activities. Sexual and reproductive health services – in particular abortion services, violence preven-tion programs and sexual health services for adolescents – suffer as a result of decentralization because local implementing agents may disapprove of a policy and therefore do not carry it out. Integrated reproductive health services are being reduced (again) to basic family planning or population control programs, greatly limiting women’s access to sexual and reproductive rights. Unsafe abortions remain a significant health risk, killing over 80.000 women every year. Hundreds of thousands of women need treatment in a health center as a result of complications after an unsafe abortion, health costs that could easily be prevented by offering safe and accessible abortion services. There may not be any alternative around for women when clinics offering sexual and reproductive health services shut down.
Investing in abortion services may even result in lower medical costs for governments, as it will prevent abortion complications that need hospital treatment.
User Fees
The introduction of user fees has led to a decrease in access to health services for women around the world. Already in the early 1990s a clear correlation was established between the introduction of user fees for health services and a marked fall in women’s attendance at antenatal clinics in Zimbabwe, one of the first African countries to experience reforms. In Harare General Hospital, mortality rate among children born to mothers who did not attend antenatal clinics was almost five times that of their registered counterparts. Also in other African (Nigeria, Tanzania) and Latin American countries (Argentina and Guatemala) pregnant women are unable to access pre-natal and emergency care because they cannot afford it. In several countries, the introduction of user fees has actually led to an increase in maternal mortality rates. Between 1983 and 1998, when user fees were introduced for most health services in Nigeria, maternal deaths in the Zaria region increased by 56% and there was a threefold increase in obstetric complications. User fees increase the risk of sexually transmitted diseases (STDs) while at the same time making it more difficult for women to access treatment. Reductions in the utilization of STD services were noted in Kenya and Zambia due to user fees being introduced. 60% of all new HIV infections in Sub-Saharan Africa are among women. In South Africa, women are infected at a rate triple that of men.
In some countries, like Tanzania, Zimbabwe and Ghana, systems of exemption have been established for specific services such as maternal and child health and family planning services and for the most indigent patients, but all too often women are not aware of these regulations. There is no system in place to inform women about these options and there are often complex administrative barriers involved. Infertility treatment and abortion are generally not included in the exemptions. Because they are not informed, they are denied their right to access free care.
Limits of Health Insurance
National health insurance schemes often cover people working in the formal sector only, and even then not in all sectors or all regions of the country. Women are more likely to be working in the informal sector, jobs which often pose greater health risks than formal jobs, and are therefore often not covered by national health insurance schemes. In India, the informal sector covers 96% of all working women and in Africa less than 10% of the labor force is employed in the formal sector. In Cameroon, the national Social Insurance Fund only serves a small part of the formal sector population. In addition, many health insurance schemes exclude important services such as deliveries or abortions or require higher payments for women, negatively impacting women’s health. In Chile, insurance premiums for women in their reproductive ages are more than double that of men.
The USA, more than any other country in the world, has turned health care into a business. Health care is the largest sector of the US economy, on which over 2 trillion USD is spent each year. The USA ranks number one with the world’s highest health expenditure as a percentage of its Gross National Product (GNP). But over 44 million US Americans – 1 in every 6 persons – is not insured for health care, and millions of others are underinsured. The proportion of women of reproductive age with no insurance coverage whatsoever increased from 17.5% in 1994 to 19.2% in 1999.
Less Access to Less Quality
Health sector reforms have led to less equitable and lower quality services for most women. Governments around the world have been pressured by international donors and multinational institutions to reform their health-care system without first being able to put in place mechanisms to ensure quality and standards of treatment. There is a widespread undocumented provision of health services, such as injections and abortions, by unlicensed persons. Also in industrialized countries quality of health services is poorly maintained. In UK hospitals hygiene levels dropped to unacceptable levels due to budget cuts and outsourcing of cleaning and catering.
Worldwide, 1.3 billion people live on less than 1 USD per day and of these over 70% are women. These women simply have no money to pay for user fees or insurance and need better living conditions with clean water and food and access to quality and comprehensive health services free of costs. With health sector reforms, women lose the most. The private health sector focuses on healthier and wealthier patients, largely excluding poorer populations, the chronically ill, disabled, those living in rural areas and other minorities. Private provision of health care as we see it around the world is NOT an effective means to promote health for women, health for all. Without good public health, the health of every individual is endangered.
We demand that:
1) Governments take responsibility for women’s health. Health is a human right and must be guaranteed by the State. Women’s sexual and reproductive rights must be included in all health policies and women must be given the opportunity to participate in all levels of planning,implementation and monitoring.
2) Governments develop more gender sensitive policies. Governments must put in place gender assessment instruments to alert them on the impact of new policies on women’s right to health. Government officials must be trained on gender issues and gender sensitivity.
3) Health budgets be increased with specifically earmarked budgets for women’s sexual and reproductive health. To enable and support this increase, donor countries, the World Bank and the IMF must drop all debts of developing countries. Put people first, not profit!
4) Quality of health-care and services be improved and prioritized over targets. Governments must put in place a process - in which women should participate - to monitor the quality of health services and the extent to which the services and service providers comply with women’s needs.
5) Health is recognized in a holistic and integrated manner - taking into account socio-economical and political factors and determinants of health - by governments, international institutions, health-care providers, and others. Women’s needs must be addressed holistically and not limited to biomedical health-care services.
Actions: What you can do
Sign up as campaign supporter with WGNRR: wahc@wgnrr.nl or send us a postcard.
Get informed about health policies, budgets and services in your country.
Collect information and case studies of how health sector reforms (including privatization) impacts women’s health. Keep in mind diverse groups related to age, socio-economic status, caste, ethnicity, sexual orientation, (dis)ability, etc.
Lobby governments and research institutes for more gender disaggregated health data, or initiate the collection and publication of gender specific health data yourself.
Share and distribute information related to women’s access to health in your country or community.
Organize protests or rallies against health sector reforms that jeopardize women’s health and sexual and reproductive rights.
Organize a seminar or start a debate in your country about the health sector and women’s right to health.
Use this Call for Action and the People’s Charter for Health (available at www.phmovement.org) as a tool to mobilize and educate community members, health-care providers, policy makers and government representatives about women’s right to health.
Advocate at local, national or international levels for the demands in this Call for Action.
Research and share examples of how public health services can be made more efficient, more accessible and of higher quality for women (‘success stories’). For example, research by Ipas in Peru has shown that service reorganization and provider training for the provision of post-abortion care led to better quality of care and reduced costs, both for the hospital and for the women themselves.
Join forces with related organizations in your country to promote women’s health and organize an event together on the 28th May.
Build alliances with other actors in civil society at the national and international levels (like health professionals, pressure groups, youth groups, parliamentarians, journalists, traditionalauthorities, etc).
Demand that your government lives up to the promises it made regarding women’s health in the Alma Ata Declaration, ICPD and Beijing Conferences, as well as the Millennium Development Goals.
Copy and distribute this Call for Action as widely as you can. Feel free to make adjustments or translations, as long as you send a copy to WGNRR.
Announce and promote the International Day of Action and the global Women’s Access to Health Campaign in the mass media (radio, tv, newspapers, internet).
Support related campaigns at national and international levelsvlike: the Million-Signature-Campaign demanding Health for All (www.themillionsignaturecampaign.org); the Universal Access to Health campaign targeting the World Bank (www.agirici.org); and the Health NOW! Campaign (www.healthnow.org).
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reports on key issues. |
GATS - trade in services
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Cairo +10 - ICPD +10
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Beijing +10: Conference on Women review
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Sexual and reproductive rights
Women’s involvement in contributing to expand the scope of the concept of human rights.
Health and health services, goods for sale
Is privatization the answer to health care problems that affect the poor?
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