A POLICY FOR WOMEN'S HEALTH?

A document on a women's health policy is currently being circulated in New Zealand. It is reproduced below with my comments added in normal font in square brackets [ ].

From an economics perspective, if efficient allocation of resources requires equal marginal benefit from the last dollar spent in each area, will a policy such as the one proposed achieve an efficient allocation of resources in the health sector overall? In particular, can such an outcome be achieved from a policy which will focus more attention on women's health issues (as specified by lobby groups?) compared to other sectors of society and in the absence of society-wide criteria?

A STATEMENT IN SUPPORT OF A NATIONAL WOMEN'S HEALTH POLICY

THE MEMBERS of the Women's Health Committee of the Health Research Council believe that it is only possible to develop a coherent and appropriate policy on women' s health research within the context of a national policy on women's health.

[What about a national policy on everyone's health as a context for a coherent and appropriate policy on women's health research? What context do we have for a national policy on women's health?]

At present New Zealand does not have such a national policy. The committee has, therefore, developed a statement in support of a National Women's Health Policy for circulation to interested groups*. This statement represents our collective opinion and not necessarily that of the Health Research Council itself.

Sue Bagshaw

Ruth Bonita

Marilyn Brewin

Sandra Coney

Marilyn Duxson

Nan Kinross (chair)

Anna Pasikale

Reasons for the development of Women's Health as a priority area for policy

1 The health of women is essential to the health of society, because of their role as caregivers

[Is caregiving unique to women? Aren't partners the primary caregivers for each other? Don't fathers also care for their children? If we want a more equal sharing of responsibility for caregiving, is such a selective perspective counter-productive? If, as indicated elsewhere, political moves emphasise women's interests, can we really say that they care for men?]

* If the health of women is ensured then this has a flow on effect to the health of children, the extended family and society in general.

[This reasoning is invalid. We cannot argue for special treatment for one group in relation to others without also considering the position of other groups. If men have a role as providers, their health has a flow on effect to the health of children, the extended family and society in general.]

* The health of Maori women as whare tangata within the whanau, hapu and iwi must be ensured for the benefit of those in their care.

[As above, is it assumed that Maori men have no responsibility for others? What makes women special?]

* Women have a special role as voluntary workers in the community, and they form the major part of the health care workforce.

[Census data show that voluntary work is not performed solely by women. There are slightly fewer men undertaking voluntary work, but they contribute more hours on average. See here for data. We should also ask who's paid work efforts enable voluntary workers to spend time in these activities instead of earning to support themselves.]

* Women are the primary carers of the aged and infirm, a role which will increase as the population ages.

[Women are also the majority of the aged and infirm. The proportion of aged in full-time care is twice as high for women as for men (from a presentation by Joanna Broad to the 1994 PHA Conference in Palmerston North.]

2 Women experience health problems which arise from their status and position in society as well as from their biological differences

[What is meant by "status and position"? Men have suffered more from stress-related illnesses, have higher rates of workplace deaths and injuries, and have higher suicide rates. Unlike the approach here, Australia's Draft Men's Health Policy and North Health's Men's Health Issues and Strategy (November 1995) "explain" men's health problems in terms of men's own choice of inappropriate behaviours. Perhaps we should take consistent approaches when considering men's and women's health.]

* Women predominate in the oldest age groups; the specific problems of aging women need to be highlighted in policy and service planning.

[... and also men's shorter life expectancy? Men's health problems as they age appear to result in death. Is this less serious than survivable problems?]

* There are specific problems in maternal health, in particular, the relatively high infant mortality rate and high teenage pregnancy rate.

[What is "high" in relation to infant mortality?

The 1994 New Zealand Official Yearbook states on page 89 that the infant mortality rate has dropped steadily, "from 41.7 per 1000 in 1939 to 20.5 per 1000 in 1962, and further to 7.3 per 1000 in 1992, [but] it is still high compared with some European countries". It is perhaps debatable whether this is a women's or a children's health issue.

Do teenage girls get pregnant on their own, or is this a wider social problem? It may be more appropriate to address behaviour patterns of teenage boys as well as girls.

As for the size of the teenage pregnancy problem, here are some data:

The following quote is from: "Mr, Mrs, Myths" by Bruce Ansley, New Zealand Listener, 20 July 1996, pp.32-34, reporting on research by Professor Ian Pool, director of Waikato University's population studies centre.

"Adolescent fertility, says Pool, has declined greatly. Now, the Maori rate is 60 per cent of its peak in 1962; the non-Maori figure is a mere 42 per cent of its high point, in 1972. The teenage birth rate has fallen from 50 per 1000 adolescents in 1976 to 35, a drop that Pool stresses is not due to the rise in the abortion rate; known adolescent conceptions (births plus abortions) also fell in that period. ... The big difference between the eras: in 1976, 54 per cent of adolescent childbearing was within marriage; now the figure is only nine per cent."

For some more miscellaneous figures:

In 1994 2500 out of 12835 abortions, or about 20 per cent, were for teenagers (1996 New Zealand Official Yearbook page 168). According to the 1996 New Zealand Official Yearbook page 89, the average age of new (married) mothers dropped from about 26.5 in 1945 to under 24 in the late 1960s and has since risen to almost 29. According to page 86 of the 1996 New Zealand Official Yearbook, the number of live births to unmarried teenage women was about 4000 in both 1980 and 1992, this being about 20 per cent of live births to unmarried women in New Zealand in the latter year. The Yearbook also states that 93 percent of births to teenagers were ex-nuptial in 1992, compared to 42 per cent in 1971.]

* Women are vulnerable to violence such as sexual abuse, rape and incest.

[These are not solely a concern for women, although the issues for men are rarely considered. If abuse in general is considered, there are problems for girls and boys, women and men. This is apparent from the gender-reversed version of the Duluth Wheel and Heather McDowell's paper on psychological abuse, delivered to the 1995 Family Violence Conference in Wellington.]

* In the absence of an overall focus on women' s health the special health needs of women are often neglected and invisible.

[Do we know that there are "special needs"? Who is to identify them?]

* There are specific issues relating to Maori women's health that have been marginalised and excluded.

[Does this not also apply to Maori men's health? While Maori women's life expectancy is lower than that of New Zealand women as a whole, Maori men's life expectancy is similarly lower than that for New Zealand men as a whole. Why assume that the lower life expectancy is gender specific, rather than being related to ethnicity? If we look in the wrong place, we will not find the right answers.]

3 There are special issues relating to women and the delivery of health services

* A life span perspective is needed to ensure that there is not an undue emphasis on reproductive health, which in the past has defined women's health.

[What does this mean? Should less emphasis be placed on reproduction-related health issues? Do other issues merit a specifically woman-focused approach?]

* Gender and ethnic inequalities and bias in the delivery of health care services have the potential for adverse outcomes in women's health.

[What is being advocated, a women's health policy or an ethnic one? What are the gender-biases and inequalities? Documents on men's health state that men are not using health care services as much as they should.]

* There is a need to re-examine the appropriateness of medical treatments in the light of new research evidence (evidence based practice) because of the increase in medicalisation and intervention in well women.

[Is this need unique to medical treatments for women?]

4 Research needs to be designed and interpreted within the parameters of a National Women's Health Policy

The Women's Health Committee of the HRC therefore recommends the development and adoption of a National Women's Health Policy.

Rationale for a National Women's Health Policy

[Which of the following statements would be more applicable if they referred to a National Health Policy rather than a National Women's Health Policy?]

* Although there are currently some policy statements in specific areas of women's health (for example, cervical screening), policy discussion papers (such as breast cancer screening, hormone replacement therapy, and smoking), and advice to providers of services for women, there is, as yet, no overall women's health policy for New Zealand women.

* As a result, many policies are being instituted on an ad hoc single issue basis rather than within the framework of an overall policy. For example, the Government has decided to institute a breast cancer screening programme in the absence of any formulation of priorities in women's health.

* At a time where capped health funding and rationing decisions are being made, the lack of a policy means that there is no mechanism for establishing criteria against which decisions can be made.

Advantages of a National Women's Health Policy

* A policy would allow the establishment of goals and targets for improving women's health to ensure that the health needs of women are fully addressed. It would also establish measurable goals against which health promotion and disease prevention efforts can be assessed. This would allow the most cost effective approaches to prevention.

A national women's health policy would provide national targets which could be addressed regionally by RHAs. It would provide a guide to purchasing services so that resources can be used in the most appropriate and cost effective manner.

In the absence of a policy there is a danger that individual RHAs will develop policy in particular areas with little regard for national consistency and co-ordination of efforts.

Partially in response to lobbying from women's groups, an informal RHA women's health network has developed, with input from the Ministries of Health and Women's Affairs. However, this is not a substitute for the formal development of policy involving consultation with women consumers and other agencies with expertise to offer.

[If these are real problems, then there should be a National Health Policy, not just one for women.]

* Cost effective research is much more likely to take place if it is done within the framework of a National Policy, and research funders have some guidelines on research priorities. A policy would also help to identify underresearched areas as well as areas which are being over-researched and should assist practitioners to base their practice in women's health on sound evidence.

* Issues and health needs identified by Maori women will be addressed appropriately.

* The issues identified by research produced by the Ministry of Health on women's health status in New Zealand could be addressed appropriately within the framework of a national policy. The analysis of the women's health status information would be an important first step in the development of a national policy.

* Above all, an overall framework would establish priority areas in which action taken would materially improve the health of women and where the greatest health gains could be made.

[If this is missing for women, it is missing for everyone. Why tackle the problem for women only? That is not efficient.]

Other uses of a National Women's Health Policy

A National Women's Health Policy would also provide a framework for future activities including the following -

* The development of health and medical research priorities in women's health by identifying those priorities for research into women's health within the framework established by the national policy.

* The encouragement of national non-government women's health organisations to represent and co-ordinate community participation in the national policy.

* The encouragement of national women's health conferences on a more or less regular basis to provide women in the community with an opportunity to review national priorities, goals and objectives in women's health and to foster New Zealand-wide community commitment and involvement in women's health.

* The use of the principles of women's health as outlined in the national policy for incorporation into the policy, programme planning, and targeting and resource allocation of the different RHAs.

* The provision of guidelines in relation to the special needs of women in all illness prevention and health promotion programmes, as well as research aimed at reducing inequalities for disadvantaged groups.

* The adoption of principles of a women's health policy in the terms of reference of advisory bodies set up to implement national health goals and targets and other national programmes.

[There is a real danger that a Woman's Health Policy could divert resources away from other areas, such as children's, Maori and men's health simply because less attention is given to those areas and there is a less organised lobbying structure.]

Information - Emeritus Professor Nancy Kinross, Department of Management Systems, Massey University, Private Bag 11222, Palmerston North, phone 06 356 9099 or 025 497 231, fax 06 350 5661

This document took as its backgound papers The Past Informing the Future: Focusing on Women's Health, a report prepared by Auckland Women's Health Council and Women's Health Action for North Health, April 1995; and Women, Aging and Health: Achieving Health Across the Lifecourse, a report prepared by Ruth Bonita for the Global Commission on Women's Health, WHO, Geneva, 1996. It also drew on the National Women's Health Policy launched by the Australian Government in April 1989.

Stuart Birks

Last modified 26 July, 1996