from  PHA-Exchange> What evidence is there about the effects of health care
reforms on gender equity

What evidence is there about the effects of health care reforms on gender
equity, particularly in health?

Piroska Östlin,  Senior Lecturer, Division of International Health (IHCAR),
Department of Public Health Sciences, Karolinska Institutet
Stockholm, Sweden
Karen Facey, Health Evidence Network.
The peer reviewers of this synthesis are:
Hilary Standing, Institute of Development Studies at the University of
Sussex.
Mercedes Juarez, Gender Mainstreaming Programme, WHO Regional Office for
Europe
World Health Organization - WHO/Europe -November 2005
Health Evidence Network

Website: http://www.euro.who.int/HEN/Syntheses/genderEquity/20051027_1
<http://www.euro.who.int/HEN/Syntheses/genderEquity/20051027_1>

Summary <http://www.euro.who.int/HEN/Syntheses/genderEquity/20051027_2>

Introduction <http://www.euro.who.int/HEN/Syntheses/genderEquity/20051027_1
>

Findings <http://www.euro.who.int/HEN/Syntheses/genderEquity/20051025_5>

Discussion <http://www.euro.who.int/HEN/Syntheses/genderEquity/20051025_4>

Conclusions <http://www.euro.who.int/HEN/Syntheses/genderEquity/20051025_3>

References <http://www.euro.who.int/HEN/Syntheses/genderEquity/20051025_1>

.pdf version [pdf, 230KB]
<http://www.euro.who.int/HEN/Syntheses/genderEquity/20051027_3>



".......In most countries the pressure for health care reform is aimed at
improving the efficiency, equity and effectiveness of the health sector.
Emerging evidence shows that health care reforms can affect men and women
differently, as a consequence of their different positions as users and
producers of health care. This review assesses the impact of four key
health
care reforms - decentralization, financing, privatization and priority
setting -
 on gender equity in health.

Findings

Literature on health sector reform and gender equity is sparse and often
focused on low-income countries. Moreover, gender-related papers are
predominantly concerned with women's health issues and focus on adverse
health
effects. These limitations affect the generalizability of the findings.

Rapid decentralization of responsibilities without corresponding devolution
of
authority and requisite human, institutional and financial resources may
lead
to difficulties in providing affordable, accessible and equitable health
services, as has been the case in many low-income countries.
Decentralization
may also inadvertently support more conservative reproductive health
agenda,
particularly in services for adolescents.

There is substantial evidence from both high-income and low-income
countries
that taxes and social insurance schemes provide the most equitable basis
for
health care financing. Other schemes, such as private insurance or direct
out-
of-pocket payment, are likely to increase inequities, particularly in
access to
care and health-seeking behaviour and this may affect women more, as they
generally have fewer financial resources.

Privatization, accompanied by emphasis on reducing costs and maximizing
efficiency, may have an important impact on gender equity in health care
access
and financial protection. In some countries patient/staff ratios have been
raised, personnel have been shifted, duties have been reassigned to less
skilled workers and the use of casual workers has increased. The negative
consequences of these policies affect women more than men since women are
over-
represented among both patients and health care personnel.

A range of gender biases have been revealed in some priority setting
methodologies, such as DALYs, which lead to the underestimation of women's
burden of disease. These systematic gender biases are generated through
various
technical and conceptual limitations.

Policy considerations

Gender equity in health requires that men and women will be treated equally
where they have common needs, and that their differences will be addressed
in
an equitable manner. This should be a consideration particularly in the
planning and delivery of services at national, regional and local levels.

Decentralization of responsibilities in health care should be accompanied
by a
corresponding devolution of authority and adequate human, institutional and
financial resources.

Well functioning and wide-ranging public health services provide equitable
and
affordable services to the less privileged, many of whom are women.
Shifting
from taxes to direct user fees to finance health services may increase the
burden of payment among economically less privileged groups, reduces
access,
and may generate a serious poverty trap. When health insurance schemes are
introduced, assurances are needed that vulnerable and marginalized groups,
including poor men and women, will be adequately covered.

Efficiency and equity need to be assured when privatizing health services.
Incentives may encourage the commercial health care sector to invest in
public
health and preventive care. If private sector management practices are
adopted,
steps should be taken to ensure that the working conditions of health
personnel
do not deteriorate.

The priority-setting methodologies require good quality evidence and data
free
from systematic gender biases and investments in high quality, gender
sensitive, medical and social research.

Type of evidence

The report is a synthesis of systematic reviews, narrative reviews and
individual articles. As it focuses on the impact of health policies, the
quality of the evidence has not been judged formally, but reference is made
to
the quantity of evidence and its generalizability...."   [au] .






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