The Beijing Platform for Action recognizes that “the advancement of women and the achievement of quality between women and men are a matter of human rights1”.Gender equality and women’s empowerment is also a condition for social justice, and sustainable development with cultural and environmental security for all. The Agreed Conclusions adopted at the Fifty-eighth session of the UN Commission on the Status of Women further reaffirms that the social determinants of health as well as health services need policy implementation to guarantee women’s health rights. The
1. Recognizes the wide diversity of girls and women who face differing and/or multiple discriminations. Barriers to good health may exist due to differences in “race, age, language, ethnicity, culture, religion or disability, because they are indigenous women or because of other status”2. Single parents, rural, refugee and displaced women, immigrants and women migrant workers vary in their ability to participate equally in decision-making and access health services.
2. Asserts that the right of women to control all aspects of their health, in particular, their own fertility and exercising their reproductive rights is basic to their empowerment
3. Acknowledges the importance of women’s health to end poverty and advance economic and political sustainable development.
4. Establishes a life cycle or life course approach with an emphasis on protection, prevention, and maintenance of health as a state of complete mental and physical well being.
5. Calls for universal access to health care, including quality sexual andreproductive health services, and
6. Recommends that men and boys help ensure an equal sharing of responsibilities and play an active role in achieving women’s empowerment.
Twenty years after the Fourth World Conference on Women, this framework continues to serve as an excellent policy guide. In addition, the 188 countries that ratified the Convention on the Elimination of All Forms of Discrimination against Women have a legal instrument to advance women’s rights to health as a human right. Have these international agreements become a reality? What are the achievements, obstacles, and challenges ahead? The following review provides examples related to the BPfA critical area of concern on women and health in North America and Europe with reference to
the global situation.
Universal Health Care is a human rights issue-example of the US.
As Dr Margaret Chan stated in her address to the World Health Assembly in May 2012, “Universal health coverage is the single most powerful concept that public health has to offer. It is a powerful equalizer that abolishes distinctions between rich and poor, the privileged and the marginalized, the young and the old, ethnic groups, and men and women. This is the anchor for the work of WHO as we move forward.”
Twenty years after the FWCW, the United States is an example of a late comer (as an advanced industrial country) to address UHC. How is it progressing? The U.S. Affordable Healthcare Act provides health insurance to all. Its key components are a Health Insurance Marketplace, a new way for individuals, families, and small businesses to get health coverage; coverage for people with pre-existing health conditions; insurance companies accountable for rate increases; protection against an insurance company arbitrarily cancelling a policy because a person gets sick; protection in choice of doctors; young adults under 26 covered under their parents’ insurance if they are not employed
and are students ; free preventive care; ( screening programs such as mammograms ), ending of lifetime and yearly limits on coverage of essential health benefits; breastfeeding equipment and support; birth control and counseling; mental health and substance abuse service parity; and the right to appeal a health plan decision. Prior to the Affordable Healthcare Act there was a healthcare crisis in the U.S.:
• In 2011, 35% of adults aged 18–64 who were uninsured did not get, or delayed, needed medical care due to its cost, compared with 7% of adults with private coverage and 13% of adults on Medicaid.
• In 2011, 24% of adults aged 18–64 who were uninsured did not get needed prescription drugs due to cost, compared with 5% of those with private coverage and 14% of those with Medicaid Center for Disease Control.
• Between 2001 and 2011, the percentage of the population under age 65 with private health insurance obtained through the workplace declined from 67% to 56%.
• In 2011, 7% of children under age 18 and 21% of adults, aged 18–64, had no health insurance coverage (public or private).
• The number of adult women and men without health insurance has increased. People with insurance are much more likely to have a doctoror other medical professional who provides regular care; one out of seven women has no usual source of health care. (White House Council on Women and Girls).
Prior to the Affordable Healthcare Act, many people with mental illness or substance abuse issues did not have insurance that covered the necessary services or they had a finite number of visits and inpatient psychiatric hospital stays. The Affordable Healthcare Act health insurance plans are now required to cover mental health and substance abuse services even if the condition was pre-existing. There is are also no waiting period for coverage of these services and no lifetime or yearly dollar limits for mental health services with parity protection for mental health services. This means that
limits applied to mental health and substance abuse services cannot be more restrictive
than limits applied to medical and surgical services.
Although it is too early to know what effect the full Affordable Healthcare Act will have on the American people, to date there has been a significant increase in coverage for 19-25 year olds. Evaluation results are likely to also indicate that disadvantaged women, including female heads of households, and older women coverage may be essential.
HIV/AIDS– Differences Among the Disadvantaged
New HIV/AIDS infections continue to decline in most of North America and Europe and access to treatment has improved. For example, by 2010, 88% of pregnant women living with HIV in Eastern Europe received treatment to prevent transmission to their child. However, social and ethnic inequalities persist. According to the Center for Disease Control, in 2010 the rate of HIV infections among Black women in the U.S. was 20 times that of white women.4 Aboriginal women, who represent 4% of the Canadian female population accounted for 45% of positive HIV tests among women in 2007.
Most alarming, the number of persons living with HIV in Eastern Europe and Central Asia almost tripled between 2000 and 2009 with young women appearing to be the most
vulnerable. In Russia, the number of young women aged 15 to 24 years with HIV is twice the number of men of the same age. Similar trends are found among young women in the U.S.6 other high-risk groups include women who use drugs (caused by needle sharing), women in prostitution, replace with commercial sexual workers, prisoners and victims of sexual violence.
NCD – The Missing Target
The most outstanding change in the global health context is the rise in noncommunicable diseases (NCDs). Although the BPfA mentions cancers, comprehensive policy guidance for women and NCDs developed more recently in response to the global epidemic. According to the Global Status Report on NCDs (WHO), almost two thirds of the 57 million deaths that occurred in 2008 were due to NCDs, mainly cardiovascular diseases, cancers, diabetes and chronic lung diseases. NCDs are the leading cause of death in women, killing 18 million women each year, exceeding communicable, maternal, perinatal and nutritional conditions combined. Of all the regions covered by WHO, Europe has the highest burden of NCDs, accounting for 77% of all disease and 86% of mortality before the age of 60.
The four main NCD risk factors are unhealthy diets, physical inactivity, tobacco use and abuse of alcohol. Women are more likely to be obese than men, become ill or die of secondhand smoke (SHS)9 and are less knowledgeable about heart disease. Even in highincome countries, women belonging to lower social economic strata have higher risks of cancer death due to unequal access to health services that provide early detection and treatment of breast and cervical cancer.
Many women are unaware of the methods of preventing or the need for early diagnosis of NCDs. For example, most North American women believe that men are more likely to suffer from heart disease and lung cancer, not realizing that heart disease is the number one killer of American women10 and that an increasing number of women are dying from lung cancer in North America and in high-income European countries, largely due to tobacco use.
Women carry the heaviest burden of NCDs due to economic inequalities and their role as unpaid caregivers. Few governments take women’s unpaid work into account in public financing. Nor do social protection programs sufficiently offer support for homebased care that would improve women’s capacity to balance work, caregiving and family responsibilities. Unfortunately women tend to neglect their own health and often do not have access to health care services and this puts them at a higher risk.
NCDs also affect national economies by inflicting debt and pushing millions of people into poverty. A report of the UNDP notes that NCDs constitute a larger share of lost output in higher-income countries because labour and health care costs are more expensive. By 2020, two thirds of the expected 7.5 million deaths from tobacco will occur in Lower and Middle-Income Countries and half will be among those in their economically productive middle years.
Multisectoral coordination is needed to ensure that women and girls are protected from aggressive marketing by the tobacco industry. Progress in combatting NCDs include ratification and enforcement of the WHO Framework Convention in Tobacco Control that calls for gender-specific policies, raised taxes and women’s participation in decision-making. Improved data collection on NCD risk factors, efforts in primary care as well as universal health care coverage such as the U.S. Affordable Care Act and health prevention are advancing. However, the costs of health care in Canada are escalating
and services are being cut. Greater attention is needed to inequalities, including those related to gender, age, socio-economic and ethnic status.
a. Universal health coverage should include financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for girls and women of all ages. Special measures should be taken to ensure access by women who face
discrimination by age, gender identity, social and economic status.
b. UHC should have benchmarks with progressive realization and financial investments in women’s health using the life cycle approach as women’s health needs and challenges they face vary with age.
c. Women should have equal leadership roles in public health information and communications campaigns to address myths and misconceptions about women and girls’ health, including sexual and reproductive health, HIV/AIDs and NCDs. Stronger efforts should be made to disseminate gender-sensitive information about early detection and timely treatment of cancers and diabetes, physical
activity, enforcement of smoke-free public places and raising taxes on harmful products like tobacco and alcohol. Special attention should be given to reach women and girls throughout their life course.
d. Women’s health data, including indicators on sexual and reproductive health, maternal mortality and other indicators reflecting the wide diversity of women should be included in the sustainable development goals (SDGs)
e. Public and private foundation funding should increase support for research and data collection to incorporate gender design, analysis and interpretation of studies on women’s health; gender-specific monitoring and evaluation of health services delivery and effectiveness is also needed.
f. Innovative partnerships should be established to improve access to affordable, quality-assured, gender-sensitive essential medicines to provide prevention, early detection and treatment for women—particularly in rural communities as well as low and middle-income countries.
g. Public policies should take women’s unpaid care work, including that related to support for the disabled and chronically ill, into account in national budgeting and ensure that public funds are allocated for social protection services. h. Civil society advocates for women and health and governments should support the full implementation of the BPfA, CEDAW, Convention on the Rights of the Child and other human rights instruments that support women’s health rights, WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases (2013 – 2010), the WHO Framework Convention on Tobacco Control, the Global Strategy on Diet, Physical Activity and Health as well as the Global Strategy to Reduce the Harmful Use of Alcohol.