Women’s Health in Canada: Beijing and
Beyond
Prepared
by Olena Hankivsky, PhD
with The Canadian Women’s Health Network
February, 2005
Editor’s
Note: This document was prepared
as a Health Section for
With Special Thanks to Abby Lippman, Madeline
Boscoe, Kathleen O’Grady, Mona Dupré-Ollinik, Marilou McPhedran, and Women’s
Health in Women’s Hands.
This work would not have been possible
without the efforts of health advocates funded through the Health Canada Women’s
Health Contribution Program, Status of Women Canada, the Ontario Women’s Health
Council, and the ongoing vigilance and perseverance of those committed to
advancing the health of women and girls in
Overview
The
4th World Conference on Women in
·
to review and
appraise the advancement of women since 1985;
·
to mobilize women
and men at both the policy-making and grass roots levels;
·
to adopt a “Platform
for Action”(PFA); and
·
to determine the
priorities to be followed in 1996-2001 for implementation of the Strategies
within the United Nations system.
The
PFA was “inspired by Article 2 of the Convention on the Elimination of All
forms of Discrimination Against Women (CEDAW) which obligates States
parties to repeal or abolish all existing laws, regulations, penal provisions,
customs and practices that are discriminatory against women.”[1] Both CEDAW and the PFA contain specific sections on
women’s health that mutually reinforce the link between women’s health and
human rights, since CEDAW is a human rights treaty with the force of
international law and the PFA is a policy commitment of the highest order,
confirmed by the UN General Assembly in 1995 and again in 2000.Article 12 of
CEDAW imposes on states parties (Canada acceded to CEDAW in 1981) to “take all
appropriate measures to eliminate discrimination against women in the field of
health care in order to ensure , on a basis of equality of men and women,
access to health care services, including those related to family planning.“
The PFA has a section that prioritizes the right to the enjoyment of the
highest attainable standard of physical and mental health for women.
Significantly, it emphasizes a social determinants approach to understanding
women’s health by stating that:
“Health is a state of
complete physical, mental and social well-being and not merely the absence of
disease or infirmity. Women's health 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. …
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 reproductive and sexual lives, and lack of influence in
decision-making are social realities which have an adverse impact on their
health.”
The PFA also includes 5 strategic objectives
for women’s health including;
·
improving access
throughout the life cycle to appropriate affordable and quality health care
information and related services;
·
strengthening preventive
programmes;
·
undertaking
gender-sensitive initiatives that address sexually transmitted diseases,
HIV/AIDS, and sexual and reproductive health issues;
·
promoting
research and disseminating information; and
·
increasing
resources and monitoring.
In June 2000, the
General Assembly met in special session (
It was noted that
progress in member countries “has been constrained by the absence of a holistic
approach to health and health care for women and girls based on women's right
to the enjoyment of the highest attainable standard of physical and mental
health throughout the life cycle; ..the unequal power relationships between
women and men and a lack of communication and understanding between men and
women on women's health needs; and the lack of information on availability and
access to, inter alia,
appropriate, affordable, primary health-care services of high quality,
including sexual and reproductive health care.”
Also in 2000, the United Nations adopted the Millenium
Declaration, which set out the following eight Millenium Development Goals
(MDGS):
Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve
universal primary education
Goal 3: Promote gender equality and empower
women
Goal 4: Reduce child
mortality
Goal 5: Improve maternal
health
Goal 6: Combat HIV/AIDS,
malaria and other diseases
Goal 7: Ensure
environmental sustainability
Goal 8: Develop a global
partnership for development
While all the goals are relevant for women’s health, Goal 3
in particular, is thought to build
upon the
work of women's advocates at various UN conferences, in particular the 4th
World Conference on Women, and the five-year review of the Conference's
Platform for Action.
The Canadian Response
In 1995,
The Women's
Health Strategy (1999) is
an integrated framework for addressing major women's health issues and was
intended to address the principles of the Beijing Platform. The overarching
goal of the Strategy is to improve the health of women in
- Ensure that Health Canada
policies and programs are responsive to sex and gender differences and to
women's health needs;
- Increase knowledge and understanding of women's
health and women's health needs;
- Support the provision of effective health
services to women; and
- Promote good health through preventive
measures and the reduction of risk factors that most imperil the health of
women.
The Strategy has seven main
features: it is balanced, respectful of diversity, egalitarian, evidence-based,
coherent, multi-sectoral and incremental. The departmental lead for the
Strategy is the Bureau of Women's Health and Gender Analysis.[4]
In 2000, the federal government re-affirmed
its commitment to gender equality by approving the Agenda for Gender
Equality (AGE), a five-year government-wide strategy. Its objectives
include accelerating the implementation of GBA, including civil society in the
policy process so that women’s experiences and perspectives can inform issues
on the policy agenda and to meet
Despite these responses and some
progress made in
When the Strategy was first
introduced, it was thought to have significant potential for making change.
First, it explicitly laid out the government’s commitment to improved health
through action on the social determinants of health. The framework provided a
clear rationale for why a specific women’s health strategy in
This Review
Our review in this document focuses
on four areas: Gender-Based Analysis, Health Services, Prevention Programs, and
Research and Evaluation, which reflect the key objectives of the Women’s
Health Strategy, to determine the progress that the Canadian government has
made in advancing women’s health. Even
though the report deals with a select number of women’s health issues, a number
of conclusions can be drawn. Almost 6 years after the Women’s Health Strategy
was introduced, some progress has been made. On balance, however, it is also
clear that much more work needs to be done to realize the federal government’s
commitments to
I. Gender-Based Analysis
The first
objective of the Women’s Health Strategy is to ensure that Health
Canada's policies and programs are responsive to sex and gender differences and
to women's health needs: “In keeping with the commitment in the Federal Plan
for Gender Equality, Health Canada will, as a matter of standard practice,
apply gender-based analysis (GBA) to programs and policies in the areas of
health system modernization, population health, risk management, direct
services and research.” (Health Canada, 1999: 21). Health
In 2000, Health
According
to Caron, “GBA implementation is ongoing, and development of GBA training
modules has generated particular tools for gender-sensitive research and
evaluation. Currently a GBA training program for Health
As well,
the Women’s Health Contribution program, an approximately two million dollar
per year initiative, funds four Centres of Excellence for Women’s Health;
research networks focusing on Health protection, Health Reform, Aboriginal
Women’s Health; and the Canadian Women’s Health Network. This in turns supports
GBA by producing and disseminating new and better knowledge of women’s health.
Recently,
in Health
"The fundamental planning
considerations for the Department that are specific to health are complemented
by the integration of ongoing government-wide priorities that have implications
for the health of Canadians. For example, sustainable development perspectives
and gender-based analysis are integrated into planning for the development,
implementation and review of policies, programs and operations."
In reality, however, GBA has not been
consistently incorporated into policy development, implementation, or
evaluation.
One stark example of a failure to implement
GBA into health planning and reform is evidenced in the Romanow Royal
Commission on the Future of Health Care, which published its report in
November 2002. While praised for its recommendation to re-enforce and expand
Medicare it was criticized for failing to incorporate a gender lens in its
analysis and proposals. As noted by the National Coordinating Group on Health
Care Reform and Women (NCGHCRW) in its Reading Romanow: The Implications of
the Final Report of the Commission on the Future of Health Care for Women, “…the
Report is fundamentally flawed. By not offering a gendered analysis, it fails
to consider women’s places in the health care system and the consequences of
health care reforms for women in different locations throughout the system”
(2003: 7).
Moreover, the Health Accord that was
derived from the Romanow Report and signed by the provinces and federal
government in February 2003 was also void of any kind of gender analysis. This
can be partly explained by the fact that although “almost all health care is
provided by women and women are most of those who receive care, women are a
minority of those making policy decisions about health care. They have few
means of influencing how major policy decisions are made, even though their
daily practices bring so many of them into direct contact with the health care
system” (NCGHCRW, 2003). A similar lack is also apparent in the recent report
of the Health Council of Canada: The Health of Canadians (2004).
While highlighting the importance of health disparities, the potential role of
GBA in furthering the understanding of such disparities is not recognized. The absence of gender from these initiatives
is an example of the isolated nature of women’s health policy and gender
analysis within the machinery of government.
As the
government of
First, the
integration of GBA is often hindered by a lack of political will and adequate
government financing and support. There is little coordination between levels
of government and the general public has not been educated around GBA.
Second,
even when GBA is integrated into some areas of policy, it is rarely applied in
a systematic fashion to all policy areas including for instance, economic and
technology policies that effect health (Rankin and Vickers, 2004). Indeed, the
current neo-liberal policy context,
characterized
by privatization and deregulation, is consistently at odds with gender equality
(Teghstsoonian, 2000).
Third,
women’s organizations and women who are both providers and users of the health
care system are rarely consulted (Hankivsky, 2005c). As well, the
infrastructure for women and equity seeking groups has been reduced significantly, thereby
decreasing the likelihood of the ongoing monitoring required to support change.
Fourth, the
distinctions between sex and gender as well as the relationship between the two
concepts are not well understood
(Hankivsky, 2005b). Finally, attention to diversity and difference
within GBA requires a better understanding of how gender interfaces with other
variables such as ethnicity, class, age, sexuality, and so on (Hankivsky,
2005a).
It is clear that a commitment to GBA within the federal
health sector is not by itself a guarantee of meaningful change. Most
importantly, although the Bureau of Women’s Health and Gender Analysis does provide progress reports on the process
and implementation of GBA across Health
Thus, it is not possible to determine with any certainty
whether GBA has been effective at the level of health policy, programs and
services, or indeed across other policy sectors that directly affect health.
Not surprisingly, activists and other health care professionals remain unsure
as to whether or not GBA has had any impact on the women’s health community or
for women’s health in
II. Health Services
Access to and improvement of a
range of health services is prioritized in Objective 3 of the Women’s Health
Strategy. Certainly, the recommendation by the Royal Commission on the
Future of Health
The finding that a publicly
insured and managed system was more cost effective and provided higher quality
care is important not only for Canadians, but internationally for those
countries which are being increasingly pressured to allow for profit services
to manage their health care.
There have also been a number of
improvements in some areas for both the users of the system and unpaid care
providers, the majority of whom are women.
For instance, in the Health Care Accord of 2003, the federal government
introduced a basket of services for short-term acute home care, including acute
mental community mental health, and end of life care. In 1998, the caregiver
tax credit for individuals that reside with and provide care to low-income
parent, grandparent or an infirm, dependant relative was established. In 2004, EI Compassionate Care benefits were
introduced allowing some workers temporary absence from work to provide care to
a closer family member with a serious medical condition with significant risk
of death within six months. Such benefits, however, only benefit a small
portion of the population, and exclude the great number of female caregivers
who are underemployed or unemployed.
Significant
shortcomings continue to exist in the areas of primary care, home care, and
pharmacare because of an absence of GBA. For example, comprehensive, innovative
and effective primary health care services for women, such as women-centred
health centres that provide effective gender-specific interventions and
preventions, comprehensive reproductive health services, and midwifery
programs, are lacking (Donner and Pederson 2004). There is no national home
care program that attends to long-term care, chronic care or care for people
with disabilities. This has clear gender implications. Women constitute 80% of
those who provide unpaid personal care in the home as well as the majority of
those who require care in their home (NCGHCRW 2003). Not surprisingly, caregiving primarily affects the
health of women rather than men and in particular immigrant, refugee and
visible minority women (Morris 2001a).
In terms of pharmacare - women continue to be over-prescribed a variety
of drugs that they often cannot afford or whose intended and unintended health
effects are not fully known.
Access to
abortion services varies widely across
The needs of other vulnerable groups of women
are especially not reflected in the majority of existing services. For example,
the ability of all women, and in particular Aboriginal women living in rural,
remote, northern communities to obtain essential health services in a timely
fashion, closer to home continues to be undermined (Ministerial Advisory
Council on Rural Health 2002, Centres of Excellence for Women’s Health 2004).
Aboriginal women consistently experience a lack of appropriate services,
such as reproductive and anti-violence services (Bent 2004). Immigrant and
refugee women, a group that is more likely to report poorer health than
Canadian-born women, have access to a paucity of services that respond to their
unique health care needs (Vissandjee et al. 2004). Many shelters and drop-in centres across the country are not
accessible to immigrants and refugees because of linguistic barriers and lack
of culture-appropriate services (SCPI
2003). There is a pressing
need for health care services that are “culturally appropriate, anti-racist,
and inclusive of all members of Canadian society regardless of race, gender,
socio-economic situation, immigration status or other suppressions”(WHIWH
2001). Women with disabilities are also not well understood within the health
care system, have few opportunities to engage in preventive healthcare
activities, do not have adequate access to primary healthcare (appropriates
screening for breast and cervical cancer, supports for making appropriate
reproductive health choices), hospital care, and long-term care services
(Morris 2001b,Wendell 2001, Gill 1997).
Further, there is a lack of consumer and
women’s NGO participation and control in service development and delivery, and
little attention paid to incorporating the perspectives and needs of health
care workers.
Despite increasing evidence demonstrating the
affects of poverty and social exclusion on the health of individuals and
populations, insufficient attention is
paid to social, political, and economic factors and related policies, services,
and programs that affect women’s health and health care needs. These include
for example, food and economic security, shelter and housing, social services
and assistance, education, the environment, and continuing gender
discrimination that horizontally cuts through all social structures and
institutions of society.
Calls for action to protecting Canadian
social programs, new or existing, go unheeded.
National day care, pharmacare, and homecare programs will need
protection if they are to become not for profit and publicly managed--- an
essential component for managing quality and cost effectiveness. The effects of
globalization and trade agreements and how they relate to all aspects of the
Canadian health care system also remain largely unexamined.
Finally, no effective gender-based analysis
of what is currently being delivered, and no long term planning among the
federal, provincial and territorial governments that prioritizes the diversity
of women’s unique health service needs have been put into place.
III. Preventative
programs that promote women’s health
According
to Objective 4 of the Strategy, Health
The
increasing focus on “pills for prevention” is a trend that is particularly
troubling for those advocating healthier and safer prevention options. Examples
include hormone “replacement” therapy for osteoporosis; certain hormonal drugs
(e.g. Tamoxifen) to prevent breast cancer in healthy women and statins to
prevent cardiovascular disease. These trends are being heavily influenced and
nourished by direct-to-consumer advertising of prescription drugs, despite the
fact that this practice is illegal in
Violence against Women
The partial
estimated costs of violence against women are over $4.2 billion annually (Greaves, Hankivsky, &
Kingston-Riechers, 1995). The effects of these experiences are manifest in
higher costs for the health care and social services systems (Yodanis, Godenzi, & Stanko, 2000). The physical and mental health implications of
violence include: acute physical injuries, unwanted pregnancies and
miscarriages, STDs including HIV/AIDS, (Gielen
et al., 2000; Martin et al., 1999; Zierler, 1997) and, psychological trauma and poorer mental health (Cascardi, O'Leary, & Schlee, 1999;
Herman, 1992; Mouton, Rovi, Furniss, & Lasser, 1999). Over their lives, abuse survivors experience more
surgical interventions, physician and pharmacy visits, hospital stays, and
mental health consultations than other women even when controlling for other
factors affecting health care utilization (Heise
& Ellsberg, 1999).
On behalf
of the federal government and 12 partner departments,
Health
Despite the
FVI and related initiatives, over the last decade, significant cuts have been
made to abused women’s community services and supports in many Canadian
provinces (Morrow, Hankivsky and Varcoe 2004). These have put all women at
increased risk for abuse and sexual assault, poverty and homelessness, made it
more difficult for women to leave abusive relationships, and led to decreased
access to justice for women who experience abuse. The changes have affected all
women, but especially those most vulnerable such as Aboriginal women, women of
colour, immigrant women, poor and low-income women, women with disabilities and
lesbian, bi-sexual and transgendered women.
Specifically, racialized and gender-based violence against Aboriginal
women continues to go largely unchecked. The stress and emotional burden placed
on women who are not able to leave an abusive relationship often manifest themselves
in an increase of physical/mental illness and disease (Campbell, Kub, Belknap, & Templin, 1997; Campbell &
Soeken, 1999; Day, 1995; Gerlock, 1999).
Tobacco Prevention:
According
to a recent survey, overall, 26% of women in
The
Canadian government maintains that the issue of women and tobacco is integral
to a wide range of health promotion and disease prevention programs. The
Tobacco Control Initiative (TCI) has four important components: legislation and
regulations, enforcement, research and public education. Current strategies
focused on cessation, reduction of tobacco use, and protection of non-smokers pay
very little attention to gender differences or the full socioeconomic context
of women’s lives. e. There are key factors, such as child care
responsibilities, time stress, income adequacy, body image, and the nature of
women's work that cause women to experience
the effects of broad tobacco policies differently. For Aboriginal women in
particular, cultural issues, socioeconomic disadvantages and discrimination
issues need to be explicitly considered (with their direct input) in the
process of developing community-based approaches to prevention and cessation
(ANAC 1999). Without consistent gender analysis of tobacco policies and
women-centered policy (Greaves, Barr 2000), smoking related disease will
continue to be the number one killer of Canadian women, and little progress
will be made in terms of understanding the unique effects of tobacco on women’s
health.
Mental Health
Evidence shows that certain health complaints
are diagnosed more frequently as mental illnesses in women, that women utilize
the mental health care system more frequently than men, and that women require
a wider range of treatment options than are currently available (Rhodes, 2002,
F/P/T Advisory Committee on Population Health 1996, Health Canada 1999). Links between social conditions and
women’s mental health have also been well documented. For
example, after the
onset of puberty, a woman's risk of developing depression increases to twice
that of men (CMHA 2003). Mood disorders and anxiety
disorders are more common for women (Statistics Canada 2002). Eating
disorders affect girls and women more than boys and men (Health Canada 2002). Poverty, which disproportionately
affects women and specifically women with disabilities, Aboriginal women, and
single mothers, is linked to poorer mental health (Wiebe and Keirstead 2004).
However, this evidence has not been translated
into policy and practice in the mental health system (Morrow 2004). Few
services are able to respond to important issues that influence mental health
such as violence, addictions, or effects of child sexual abuse (Morrow 1999). According to the Canadian Community Health Survey over 22% women reported they needed help for their
emotions, mental health, or use of alcohol or drugs but did not receive it
(Statistics Canada 2003). Services that are available, tend to
over-medicalize women while not providing them with appropriate counselling to
meet their specific needs. Moreover, women consumers experience mental health
care services and access to them differently. There is a current lack of
racially, culturally and linguistically appropriate mental health care to serve
the needs of different ethno-cultural
communities. In a recent study, Canadian mental health providers were
consistently unable to diagnose Post Traumatic Stress Disorder (PTSD) in
immigrant and refugee women who had experienced war, rape, torture,
persecution, natural disasters and other traumas, and it was also found that
very few programs existed to help the children of these women, many of whom
also suffer from PTSD (IRVMWS 2001).
Critical position papers, educational material on mental
illness and descriptions of ‘best Practices,’ in mental health still typically
fail to discuss gender in relation to other social determinants of mental
health. The most recent example of this is the Standing Senate Committee On Social Affairs, Science
And Technology three volume report on Mental Health, Mental Illness and
Addictions released in November, 2004, where gender is mentioned only briefly
in relation to suicide and women are not included as one of the priority
populations identified. There is no evidence in this report of any gender-based
strategy, one that is attentive to the range of social inequities that affect
women’s mental health. Such omissions
point to the critical importance of developing a national women’s mental health
strategy, utilizing and expanding the evidence base on women’s mental health
and applying a gender-based analysis to policy and program development (Morrow
2004).
HIV/AIDS:
According
to Health
For
the most part, HIV/AIDS is still not considered to be a women’s health issue
and few programs and initiatives have specifically targeted women, and
especially vulnerable groups of women. Many women simply do not receive the
diagnostic and treatment services that could benefit them in the early stages
of their infection. Social and community supports are rarely available to women
who are HIV positive because they have not been developed with their specific
needs in mind. Not surprisingly, girls and women are often less educated than
men about HIV/AIDS and do not have the support structures they require. Disease
manifestations attributable to HIV/AIDS are also often different in women which
have also led to delays in diagnosis and appropriate treatment (Canadian
HIV/AIDS Legal Network, 2004). The challenge of engaging civil society
organizations in setting policy priorities, translating policies into effective
practice, ensuring policies address gender and intersecting determinants, and
establishing the evidence base for gender sensitive policies and practice
remains. In sum, there is a pressing and urgent need to develop a clear vision
for a women and HIV/AIDS strategy.
Reproductive health
Beyond, HIV/AIDS, other sexual and reproductive health
issues still require much more government attention and leadership. Despite the
recommendations of a Royal Commission that explored issues of reproductive
technologies, infertility and reproductive health, there is no coherent action
plan in place. In 1999, Health
These power imbalances are compounded by the
continuing paucity of effective and appropriate information regarding birth
control, STIs, pregnancy, fertility, reproduction, and childbirth. Despite the positive experience in
other countries, emergency contraception pills (ECP) are only available by
prescription. A federal consultation to make ECP non-prescription has been
going on for over two years. To increase access, several provinces have
delegated prescription authority to a pharmacist but in many cases, this change
has meant increased costs for women.
Media literacy training for adolescent sexuality
education programs is underdeveloped and not attentive to the specific needs of
girls. STIs remain high among young women. Reported rates of chlamydia in girls
between 15 and 19 years of age are nine times the national rate (Health Canada
2004). Pregnant teens, especially Aboriginal teens, are also at greater risk of
health problems, including, for example, anemia, hypertension, renal disease,
eclampsia and depressive disorders as well as increased poverty (Bent 2004,
Combes-Orme 1993, Turner et al. 1990). And while
More than 10 years after the Royal Commission on
Reproductive Technologies, the Assisted Human Reproduction Act (2004) was
finally passed in 2004 albeit with many delays. The regulation, licensing and
monitoring regimes are as yet years away as services, mostly provided in the
for- profit sector, continue. Far more
attention is also needed in the management of reproductive technologies.
Specific needs of women with disabilities and lesbians
continue to be marginalized in all areas of sexual and reproductive health:
Women with disabilities are often assumed to be asexual and therefore are not
asked questions about reproductive health or fertility (Morris 2001b). Lesbians receive fewer regular pap smears to
test for cervical cancer because doctors regularly assume that they are not at
risk for sexually transmitted diseases (Health
V. Research and Evaluation
Objective 2
of the Strategy focuses on increasing knowledge of women’s health.
Clearly there have been attempts at a number of important initiatives in this
regard. In 1996-1997, Health
Further the federal government seems hesitant
to act in areas where it does have authority—direct to consumer advertising for
drugs are proliferating—a direct contravention of existing regulations. Calls
for an improved transparent drug approval system with improved citizen engagement in drug reviews,
five year temporary licenses for new drugs,
registries for products such breast implants, depo provera; mandatory
adverse event reporting and of post marketing surveillance have been ignored.
In 2000, the federal government,
as part of new program of funding for health research in
From
2003 to 2004, for example, IGH
provided funding for over 50 grants and awards covering four CIHR pillars of
biomedical, clinical, health services, and population health across five
research priorities: Access and equity for vulnerable populations, Promoting
health in the context of chronic conditions, Gender and health across the
lifespan, Promoting positive health behaviours, and Gender and the environment.
The IGH
also has provided leadership in advancing the careers of women scientists. The IGH, however, has a small budget used for
strategic projects in comparison to the general operating grants. A gender and health peer review committee has
been put in place. However, there is no legislative direction to undertake GBA
within the CIHR as there is in the USA
Launched
in 2002, Health
The Women’s
Health Surveillance Report: A Multidimensional Look at the Health of Canadian
Women (2003), funded jointly by CIHI and Health Canada, reported on gaps in
women’s health surveillance and recommendations were made for developing a
system in which a broad range of data is used to “support the development of
gender-sensitive monitoring systems, policies and programmes aimed at improving
women’s health across Canada”. (Caron 2003: 55). This report highlighted the
health inequities between women and men and among women, the burden women carry
in chronic disease, and the increasing feminization of poverty especially for
sole support mothers and unattached older women. How this groundbreaking report
(available only on-line and receiving limited exposure) and the results from
the indicators projects will be used remains unclear.
Further, the Women’s Health Contribution program, an
approximately two million dollar per year initiative funds four Centres of
Excellence for Women’s Health; research networks focusing on Health protection,
Health Reform, Aboriginal Women’s Health; as well as the Canadian Women’s
Health Network. This unique program provides an infrastructure for innovative
projects that address community needs and provide critical responses to policy
initiatives. The program was renewed recently – until March 2008.
The Tri-Council policy on ethical
conduct, developed by the former MRC, NSERC and SSHRC includes
two important sections for women’s health research. In the Introduction to
Section 5 justice and the fair distribution of benefits and burdens are
emphasized and in Section 5B – Research Involving Women, 3.2 of the policy
states “Women shall not
automatically be excluded from research solely on the basis of sex or
reproductive capacity." No
evaluations, formal or informal, have been made of this policy (Caron
2003). And finally, the Policy Research
Fund of Status of Women Canada, which support independent policy
research on gender equality issues has also been instrumental in funding research
that furthers the understanding of linkages between health and other
determinants of women’s health.
On
balance, the strides made in the area of women’s health research over the last
five years have been substantial. However, many challenges remain.
First,
as the importance of evidence-based research increases, for numerous reasons,
women’s needs continue to be marginalized.
Second,
there is no formal mechanism requiring GBA in health research.
Third,
there is an under-representation of women in science and health careers.
Fourth,
current health indicators are narrowly conceptualized and inadequate because
they “do not reflect women’s specific health concerns (outside of reproductive
health), nor their central place in the health care system as both recipients
and providers of care” (NCGHCRW).
Moreover,
as Colman (2003) correctly notes, indicators need to go “beyond a mere listing
of male-female differences in health determinants, health status and health
determination. Rather, understanding must be grounded in analysis of gender
roles, socio-cultural context, power and economic relationships, structural and
systemic biases, and diversity (including the particular circumstances of
Aboriginal, immigrant, visible minority and disabled women)” (xiv). For
example, the need to expand indicators of this is supported by lack of
responsiveness to the increase in feminization of poverty especially for sole
support mothers and unattached older women.
The
lack of equitable income supports and safe housing has significant associations
with health status and yet there are no public health initiatives to address
these problems. With the exception of the province of Quebec, which recently
passed Bill 112 – which commits the government reduce poverty and income
inequalities, no levers have been put in place to reduce income and health
inequities in as systematic way. And, although the concept of ‘Health Impact
Assessments’ of policy and programs has been discussed, no jurisdiction has put
these into place.
Fifth,
researchers continue to research in their disciplinary homes, with little
meaningful communication across perspectives taking place. The ongoing discriminatory effects of research
agendas (e.g. biological essentialism and gender blindness) persist. And most
importantly, those with the direct experience – NGOs, women activists, and
women themselves continue to be largely excluded from influencing the research
agenda, participating in developing research plans and priorities, and shaping
tools for monitoring and evaluation. Indeed, funding for voluntary sector
groups and organizations has been decreasingly steadily, despite the Voluntary Sector Initiative (VSI), which was intended
to increase the capacity of this sector and engage it more actively in health
decision-making.
Recommendations and Suggestions:
- Increase accountability
mechanisms for the implementation of international agreements across all
jurisdictions (ie. federal, provincial, territorial and municipal levels
of government).
- Enshrine into law a Women’s
Health Office at the federal level,[9] thereby solidifying the commitment to women’s health
and health research in
- Increase funding for the
Women’s Health Bureau and related divisions, branches and offices dealing
with women’s health and gender analysis
- Renew and enhance the capacity
of the Women’s Health Strategy. The process of renewal should build
upon regional consultations, including discussions with all relevant key
stakeholders. A renewed Strategy should include concrete health
goals/priorities. An enhanced contributions program which funds research,
communication, education, policy advice and outreach activities would be
essential - given the complex and distributed mechanisms for health care.
This program should also include national, population based and provincial
projects. Currently, funding the Women’s Health Contributions Program, a key component of the Strategy,
is approximately $2.2 million per year compared to, for example, funding for HIV/AIDS
which will increase from $42.2 million (2004) to $84.4 annually by
2008-2009.
- Continue to advance GBA in the
health sector, but with a view of how existing approaches and methods of
implementation and evaluation can be improved. Add a GBA requirement to
the First Ministers' Accord on Health Care Renewal (2003). Establish a FTP
committee to provide leadership in the implementation of GBA and models of
women centered care. GBA should be an explicit requirement of all
federal/provincial and territorial health departments. There must be
adequate resources and support for GBA. Capacity building among
policymakers needs to be improved. Better coordination between all levels
of government and with civil society is also required.
- Produce annually an annual report
on Women’s Health modeled on the
one prepared by the Human Resources and Services Administration’s Office
of Women’s Health in the U.S., which collects current and historic data on
health challenges facing women, their families and communities and is used
as a reference for policymakers at all levels of government.
- Some specific suggestions for
improving the Women’s Health Strategy:
·
There
is no recognition in the existing Women’s Health Strategy of the global
neoliberal context and its potential effects on the implementation of GBA
and other women’s health objectives. In particular, health care privatization,
other reforms (e.g. reduced public participation in health care decisions), and
deregulation through free trade agreements are undermining the autonomy and
role of countries in determining their health care systems. It is becoming more
difficult to sustain existing systems as international pressures to reduce
public service spending increases. These changes are having a particular impact
on various groups of women as providers and patients and need to be better
understood and responded to.
·
While
the Strategy acknowledges the importance of a applying a social determinants
approach more attention needs to be paid to developing an useful inter-sectoral
approach that links social, economic and health policies and addresses the
determinants of women’s lives in their communities. The increasing feminization
of poverty and the increasing time stress in the lives of women is a result of
the failure to take women’s needs into account in other policies and programs.
More effort is needed to reduce health inequities by addressing factors that
result in inequitable health outcomes (economic, social, political and
environmental) (Labonte 1997). This can be accomplished through the
establishment of innovative programs that mitigate health inequities by
reducing income inequities and social exclusion and by the establishment of
Health Impact Assessments as a critical component of governmental decision
making.
·
Although
the overall Strategy promotes gender equality in health, gender based analysis
(GBA) needs to be integrated into all the objectives and commitments made in
the Strategy. Moreover, the Strategy requires all departments
within Health
·
A more
comprehensive approach that sees health issues in their full social, spiritual
and cultural contexts is needed. Such an understanding can only come from
speaking to women themselves and finding out what their health care priorities
are. As the results from a national consultation held (RIWC 2005) recently
concluded, there is “the need for a further and fuller explanation of what many
women in the country consider to be their health priorities, e.g. poverty and
equity issues.” Women-centered care models can be helpful in this
regard. An excellent example of this, prepared by the Vancouver/Richmond Health Board (2000), a
women-centered care framework should have the following 12 elements: need for
respect and safety, the importance of empowering women, involvement and
participation of women, collaborative and inclusive work environments, women’s
patterns or preferences in obtaining health care, women’s forms of
communication and interaction, the need for information, women’s
decision-making processes, a gender-inclusive approach to data, gendered
research and evaluation, gender sensitive training, and social justice
concerns.
·
Despite stating
that it will be sensitive to issues of diversity, the current Women’s
Health Strategy does not adequately take into account the diversity and health inequities among women:
women who are poor, women with disabilities
both mental and physical,
Aboriginal women, older and elderly women, immigrant, refugees, other
racialized women. In general, more attention to the relationship of not only
sex and gender but also other intersecting forms of discrimination and
oppression. And, when arguments are made about the significance of gender,
these must transcend the essentialization associated with biomedical
explanations, which downplay diversity among women and fall trap to treating
all women as equivalent (Weisman 1997).
·
Communication
between researchers in all distinct areas of health research inquiry needs to
be improved to promote: inter and trans-disciplinary investigations, mixed
methods approaches, participation of NGOs, women’s organizations, and women
consumers in setting research priorities, and in the end, facilitate a
comprehensive understanding of women’s health and establish a valuable approach
to measuring, monitoring and ultimately, improving all Canadian women’s health.
More recognition needs to be made about the role of non-Western scientific
traditions and knowledge as well as traditional and indigenous health
approaches, techniques and beliefs (i.e. complementary medicine).
·
We need to ensure
that any strategy for women’s health is a living, flexible framework, one that
is able to identify, clarify, accommodate and prioritize new and emerging
issues. It must be properly resourced to span departments within Health
Clearly,
as Canada assesses its success in responding to its international commitments,
and in particular the Beijing Platform for Action and the Outcome of the Twenty-Third
Special Session on the General Assembly (2000), an ideal opportunity exists to
consider Canada’s track record in the area of women’s health. While some
improvements have been made, current obligations need to be solidified
politically and financially. In particular, the Women’s Health Strategy
needs to be renewed and revised so that it can better respond to the myriad of
outstanding issues highlighted in this report: the inadequacies of gender based
analysis, health care services, prevention programs, research and evaluation.
Accommodating and addressing the complexities of gender and sex differences as
well as other intersecting social health determinants is essential for
improving the health related quality of care and life for women and for promoting
any agenda for gender equality.
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