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BOOK REVIEW
Year : 2012  |  Volume : 135  |  Issue : 6  |  Page : 925-927

Gender, women and primary health care renewal: A discussion paper


Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi 110 067, India

Date of Web Publication23-Jul-2012

Correspondence Address:
Ritu Priya
Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi 110 067
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Priya R. Gender, women and primary health care renewal: A discussion paper. Indian J Med Res 2012;135:925-7

How to cite this URL:
Priya R. Gender, women and primary health care renewal: A discussion paper. Indian J Med Res [serial online] 2012 [cited 2020 Feb 28];135:925-7. Available from: http://www.ijmr.org.in/text.asp?2012/135/6/925/98889

Gender, women and primary health care renewal: A discussion paper (World Health Organization, Geneva, Switzerland) 2010. 76 pages. Price: CHF/US$ 25.00; in developing countries: CHF/US$ 17.50

ISBN 978-92-4-156403-8

The concept of primary health care (PHC), missing in the international health lexicon in any meaningful way since the 1990s, was revived by the WHO's World Health Report 2008. Enunciated in 1978 by the Alma Ata resolution calling for 'Health for All by 2000 A.D', the PHC approach provided an affordable, locally contextualised, community-centred focus, where primary, secondary and tertiary institutional services were to be supportive to basic and inter-sectoral health action through community participation. An international political environment questioning the imperial powers of the 'first world' and the modern development model facilitated the process, with anti-Vietnam war campaigns, workers' and women's movements bringing focus to pro-people oriented development.

Since the 1990s there have been two significant trends in global health: one, promotion of the private sector and decreasing role of the state in provisioning, leading to commercialization of health services, increased emphasis on medical technological solutions and more verticalised disease control programmes. The second trend, enhancing salience of human rights, equity and the gender perspective for health, is often viewed as a corrective to the first one's anti-poor and pro-commercialisation thrust. However, several analyses show these as together representing the neo-liberal, market oriented perspective underlying the economic policies of the times since, without questioning the over-medicalisation and malpractices of the health sector, 'rights', 'equity' and 'gender' issues can serve to further enhance irrational markets for the health industry. On the positive side, women's health has received much-needed attention. Hence, this document, focussing on how to integrate gender equality into the new PHC framework, is a welcome addition.

The document is a systematic presentation outlining elements of gender-equitable PHC reforms. It summarises the well accepted learnings of the last two decades from a large volume of research studies, evaluation reports and programme designs. It points out that the PHC approach was curtailed in its early stages and left with little scope for addressing gender gaps. In the 1970s-1980s, highlighting the neglect of women's health resulted in formulation of a small number of women-only projects and programmes, while it was business as usual within the sector as a whole. Recognising this, the need to 'mainstream' gender was widely articulated.

The document uses the new WHO framework for reviving PHC, with reforms in four aspects universal coverage, service delivery, public policy and leadership-- within the six building blocks of health systems service delivery; health workforce; health information system; medical products, vaccines and technologies; health financing; leadership and governance. Measures for institutional and programmatic gender mainstreaming are recommended, drawing upon case examples from several countries. The first chapter describes the new PHC approach and gender concepts. The second and third chapters examine what it would mean to 'engender' the four reforms. The last chapter summarises the main findings and makes action-oriented recommendations for policies and programmes.

The authors attempt to "reconcile the two trends in the prevailing policy context, striking a balance between laissez-faire disengagement of the state from the health sector and a command and control approach that relies on exclusive state control over financing and provision of health care services". They conclude that universal coverage of women and men alike would require a combination of tax revenue and social health insurance, with government subsidizing premium payments for the poor. Conditional cash transfers have been presented as having potential but requiring research to ensure that these improve health outcomes and equity. Gender sensitive insurance schemes "would include sexual and reproductive health services, many of which are 'non-insurable', and drugs for chronic diseases, which can involve considerable costs".

It is clarified that engendering service delivery reforms is not about making health services women-centred, but about gender responsiveness, i.e., taking into account differences between women and men in health needs, health risks, health-seeking behaviour, and access to services. For example, gender differentials in mental health: depression is more common in women and substance use in men, so both have to be tackled. Malaria, although more prevalent among men, has serious and fatal health consequences for pregnant women, calling for the integration of malaria screening into maternal and child health services. Ten important measures for 'patient centred' and 'women-centred care' by service providers have been proposed.

Priority areas of reform identified for gender mainstreaming include health information and research; sex-disaggregated statistics; indicators of gender inequality; monitoring systems to evaluate changes in health of women and men; vital statistics and disease surveillance to include upstream determinants of health (WHO Commission on Social Determinants of Health). Also suggested are appropriate representation of women in biomedical and behavioural research studies; supporting research on women's health issues; and advancement of women in biomedical careers. The criteria for promotions, moving beyond research publications to reward excellence also in teaching and clinical activities, is another welcome recommendation.

The document finds that though initiatives to integrate a gender perspective into health research have been undertaken by several countries and international organizations, only a few have been evaluated for impact, and findings show limited progress. The usual pattern identified was of academics or civil society actors engaging in gender analysis, then undertaking advocacy with senior decision-makers for action to redress gender gaps, which the government has no obligation to heed. An official technical committee to propose and monitor measures for addressing gender issues as an integral part of the policy-making process, reforming gender-discriminatory laws and policies, and assessing impact of all public policies on health equity with special reference to gender are recommended measures. A number of macroeconomic policies such as in trade, development and employment impact health, hence it is suggested that proactive measures are needed to ensure that the impact is not negative. Better representation of women on policy-making committees and boards, as well as monitoring mechanisms involving communities, women's groups and civil society are recommended.

Bringing all this together into one document is a commendable task. However, certain issues central to women's health are missing, one being conflict of interest and unethical medical practices, such as the misuse of medical technologies, excessive resort to caesarean sections, and use of ultrasonography for foetal sex determination with sex-biased abortions. Promotion of rational self-care and validated traditional health knowledge are equally conspicuous by their absence, even though the WHO has initiated their active promotion in PHC reform, the women's movement has been one of the strongest proponents of self-care since the 1970s-1980s, and women tend to be the largest users of traditional medicine. Thus, while this document is limited to prevailing approaches, it does initiate readers into reflecting on a more comprehensive approach to gender related health issues rather than represented by women's health concerns alone. Its recommendation of creating knowledge, awareness, and responsibility for gender among all health professionals can go far in improving health care for women and men. Policy makers, planners and implementers of health care will certainly benefit from a reading.




 

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