Sm. Sri. Med. Vol. 35, No. 4, pp. 619A26, 1992
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WOMEN AND ACCESS TO HEALTH CARE CRISTINAPUENTES-MARKIDES Pan American Health Organization, Health Policies Development Programme, 525 23rd Street NW, Washington, DC 20037, U.S.A. Abstract--This paper is concerned with access to health care for women in developing countries, with specific reference to Latin American and Caribbean countries. It reviews the available literature on the concept of access as it relates to other variables such as accountability, affordability and acceptability of health services, taking into consideration the effects of the generalized socio-economic crisis that has affected most countries during the last decade, as well as equity objectives. Various approaches to defining variables affecting access to health care appear in the literature reviewed. While some of them indicate that ability to pay for services act as a major determinant of access to health care, others point to behavioral issues related to motivation, health seeking behavior or perception of illness as a deterrent to women in the low socioeconomic strata, while others indicate that sociocultural issues, such as values, education, religion or demographic variables related to age, infiuence access to health care. The paper concludes with some comments on policies and strategies for securing access to health and healthcare, indicating the need to move away from traditional solutions including framing gender-based health differences in status and access adequately, promoting and strengthening social participation of women in policy making. Key
access, health services, healthcare, health policy
INTRODUCTION The situation of women in relation to the health care system, and therefore how they access it, appears
dependent upon variables such as women’s status in the specific culture and society to which they belong, that is questions related to gender and control of decision making, their socio-economic situation, the degree of social investment in women [l], their position in the labor force, and in some instances their ethnicity. It is recognized in the feminist literature that women’s world views and gender determines illness perception and health seeking behavior, issues that have been discussed elsewhere . Without fear of generalizing, for most developing countries these variables interact with others related particularly to the structure of the health services and the behavior of the providers, and influenced by economic policies, so as to result in a complicated web of restricted access to health care and limited solution to health problems . In this sense, any segmented view of the problem is unable to capture all its dimensions. For most countries traditional health indicators (i.e. infant mortality rate, maternal mortality, life expectancy and mortality for certain diseases) appear to have improved overall . However, inequalities are apparent when incorporating into the analysis sociocultural variables such as class, ethnicity for certain countries, as well as demographic and epidemiological information such as age, risk exposure and incidence of some illnesses, and conditions,
health status and risks of death, illness and injury, at least for the information available in Latin
American and Caribbean countries [S]. The social and economic crisis affecting most developing countries at present must be considered as perhaps the most influential element in the process of social change for better health, and not solely understood as an issue of external debt or economic adjustment. It is a great deal more complicated. The distribution pattern of economic benefits to the countries and within them have worsened, increasing inequality at all levels, and stagnation has characterized the context of the past years. Even in the last decades, in countries where the economy grew considerably, this was not reflected in a greater social dynamism, and struggles for women’s equality have yielded uneven results. The generalized crisis and the economic adjustment policies of the late eighties seem to have widened social and economic inequality among social groups. This reality bears directly on the availability and quality of goods and services, including health. The social cost that is and will be endured by societies in the next years will undoubtedly be high and its effects long-lasting, with serious repercussions on the organization and financing of health care systems affecting the availability, affordability and quality of health services for all, making it more difficult for the governments to formulate and implement policies directed at maintaining or increasing coverage and quality. Women as a socially disadvantaged group in society, and in particular poor women, bear a great proportion of the 619
burden. A perceived trend in most countries of the Latin American and Caribbean region is the increase of female headed households, a phenomenon that could be explained in terms of the instability that is created due to lack of work and economic pressures on the couples, or due to a tendency related to modifications in the traditional gender roles, which is more difficult to prove. This reality increases the woman’s responsibility in achieving and maintaining health for themselves and their families. Inadequate access to health services is an expression of inequity that is unjust and avoidable. Equity and access are two concepts that policy makers have a hard time defining , and even harder implementing through programL and policies, since equity has moral and ethical dimensions, values that are not shared by all members of society, and when they are, they are often not explicit. Equity objectives are directly related to those of access and availability of health services to all, and therefore, considering gender differences and women’s disadvantaged position in society, make their objectives a challenge to achieve. WOMEN’S
The status of women, their position in the labor force and gender roles in most societies, contribute to make women the largest proportion of the population within or below poverty lines, holding low paying jobs, and unable to either pay for better services or cover health costs. On the other hand, the economic crisis that has swept Latin American and Caribbean countries in the past decade has worsened the situation, forcing women not only to continue to be underemployed, but to work in the informal sector, being away from home for longer hours with fewer social and health benefits, making it even harder to maintain their health or seek help for themselves or for their families (71. The literature about the influence of socio-economic indicators on the health status of women, as well as the mortality and morbidity for several conditions dates back at least 40 years , and it is well known that stressors, such as economic instability influence not only health status, but health seeking behavior. On another level of analysis, health policies and American and Caribbean legislation in Latin countries generally grant equal rights to women and men, but in practice, these constitutional precepts are not effective. The corpus of rights for women embodied in civil, family and criminal codes have been formulated considering man as the subject of law, and consequently legislation reflects the patriarchal, androcentric predominant culture. On the other hand, not only is legislation discriminatory against women, but women may not be aware of their rights under the law, or the law is erroneously interpreted by men and institutions, particularly when sexual equality or family violence is involved. This has an
important bearing on any efforts directed at reducing socio-cultural and economic barriers in health care. Prevalent medical models of disease causation in which biological or genetics causes predominate over social, economic or behavioral, and which orient projects, programs and discourse directed at lowering the traditional health indicators play a key role in determining women’s satisfaction of health needs. They also determine the value women have in their own societies, how the society at large perceives them and the gender biases of the planners, reflected on how they perceive their needs, and therefore plan the services. In general, there is little negotiation between the women in a particular community and the planners, due to the centralized nature of the process. Often the needs of women are perceived as almost exclusively related to their reproductive roles or their needs are defined in male terms, without considering and integrating their own experiences of health and illness, so that the health system is able to respond in a culturally appropriate and gender sensitive manner. On the other hand, due to feelings of helplessness, previous victimization, lack of information, experiences of fear or oppression, women are unable to voice their needs in any effective manner to influence policy making. In some societies, women’s health complaints are not perceived as real, and therefore there is no service available to solve the problem, nor little space to make it understood and therefore identified as a health need. Access to family planning and contraception is denied to 500 million couples in the world, and utilization remains low. In Latin America and the Caribbean, for example, birth control utilization fluctuates between 2&30% for all methods in Bolivia and Guatemala and Haiti, to a maximum of between 50% and 65% of all the population surveyed in Colombia, Brazil and Trinidad and Tobago . Access to obstetrical care in rural areas constitute a major determinant in the health outcome of the mother and child, accounting for more complicated deliveries, higher rates of premature babies, as well as increased costs of neonatal care. In some countries, having a baby in another community may hinder inheritance rights to the land, which creates not only stress in the decision of having the baby where the mother lives, and if this is a high risk pregnancy, risking both lives 1101. Most of the health care takes place in the home which is for the most part the responsibility of women who take care of children and relatives. A healthy mother most certainly assures a healthy child, although not all women are mothers and in this sense, health services when available and affordable tend to respond most often to the needs of mothers or women of childbearing age, neglecting the health needs of the rest of the women (young/adolescent, older women, battered, disabled, homeless or alone). Many national and international efforts geared towards
Women and access to health care improving health status of mother and children and to reduce mortality rates have emphasized, among other components, the expansion of prenatal care, and have neglected the creation or strengthening of general gynecological care, abortion and family planning, which are direct contributors to reducing maternal and child mortality [l 11. Women of lower socioeconomic status in developing countries suffer mostly from complications of pregnancy and childbirth. According to the latest PAHO statistics  these causes in Latin American and Caribbean countries are among the first five causes of deaths for women 1544 years of age. There is, however, in some countries an increasing recognition of the seriousness of chronic and cardiovascular ailments, due to longer life expectancy, and cervico-uterine and breast cancer, which had been the ‘privilege’ of higher class women. According to the latest statistics available, the incidence rates for cervico/uterine cancers per 100,000 women reach 83.2 in Recife, Brazil, which is seven times higher than that for Canadian women. Consumption of alcohol, drugs and tobacco have increased markedly in the region. Incidence of lung cancer for women has doubled in the past three decades, with detrimental effects related to low birth weight, spontaneous abortions, and sudden death syndrome [ 121. There are health risks for women associated with the lack of safe drinking water, since they usually carry water, wash in rivers or other contaminated sources, cook, and are therefore more exposed to infections than men. Working women are exposed to chemicals or physical contaminants in the work place, they are usually tired due to the double day of work, they often lack social security benefits because they hold low paying jobs, or jobs in the informal sector. Several studies have concluded that women’s work day is three or four times longer than that of men . In some cases, it appears that due to lack of women’s ownership and control of technologies, health care technologies are over used (e.g. fetal monitoring, cesareans). In the case of cesareans, Brazil reported in 1970 about 15% rate rising to over 30% in 1980 . However, other documents indicate that women’s access to some health care technologies such as prenatal genetic testing  is being denied [ 151. On the other hand, recent works in the United States indicate that clinical trials involve more male subjects than female for testing life-saving drugs and treatments, especially for cardiovascular diseases; women with heart trouble are less likely than men to receive coronary bypass surgery, or other type of appropriate treatment, are less likely to receive an organ transplant or to receive dialysis and physicians may fail to test for lung cancer. One would speculate that this differential access to health care technologies may also be prevalent in developing countries.
621 A DEFINITION
When considering access, one may perceive it as an encounter between client, in this case the woman, and the health system, be it through personal contact with a healthcare provider or through the appropriation of information, as a means to better health. An encounter that means interaction in some form but that could have little to do with quality, equality, satisfaction or resolution to the problem the client seeks. Several authors have explored in depth the relationship between access and quality of care received, and have challenged the notion that limited access to health care means inappropriate care . It is difficult to enumerate all the variables that determine access, since access occurs as the interaction of many factors related to three fundamental elements: the structure of the health system, the behavior of health professionals, and characteristics of the population seeking care. These three elements are in turn influenced in varying degrees by other factors at the more macro-social level which are related to the political orientation of the government, macroeconomic policies and health policies, or the status assigned women in society. Table 1 identifies broadly those levels and issues within each one of them that affect women’s access to health care. Upon reviewing the available public health literature on this topic, access appears a concept difficult to define precisely in operational terms, being related most often to utilization of health services, that is the possibility that people who actually need a particular service are unable to obtain it , and as a means to measure utilization for health planning purposes. However, recent literature suggests that the relationship between increased access and utilization is not at all clear. It is important to distinguish between demand and utilization, since the latter informs about the transaction between the client and the system, it is a point in time where demand and supply meet, while demand explains a set of behaviors. The study carried out in Peru, pointed at problems when dealing with utilization information, since “it does not consider effective and potential demand, it does not consider behavior of user with respect to the decision to utilize the service, does not account for levels of demand for those that request service outside the formal sector (the information is very limited), even if you could include this information, it would account only for utilization and not for demand” [IO]. Moreover, the most common indicators of access such as the number of uninsured individuals, utilization of health care services and health status are usually not completely available for most developing countries, a fact that jeopardizes the formulation of effective policies. Access on the other hand, is a concept almost indistinguishable from those of availability and
Table 1. Possible levels of analysis Societal macro level Style of development Macroeconomic policies Political orientation Status of women Work/employment conditions Health policies Self-help systems Social support networks Institutional Structure
of the health svstem
level Behavior of health orofessionals
Individual/family Characteristics clients
level Behavior of clients
Cost of services Prevalence of Western medical culture Referral patterns Professional recruitment Staff training Race and class structure of health system Fragmentation Inability to diagnose certain ailments Profit orientation of the medical system Provider-Consumer relationships Site of the service Hours of operation
Feelings towards poor women Beliefs about women’s status Discrimination on the basis of race or ethnicity Do not speak language of clients Physicians unwillingness to treat uninsured patients Little awareness of disparities in provision of health services Position on reproductive issues Position on expansion of sex roles
Ability to pay for services Etiological beliefs Levels of education Residential segregation Lack of health insurance Do not speak language of country or of providers Ability to identify health problems as problems Homeless, battered, imprisoned, specific diseases, AIDS, mentally ill, elderly women, adolescent, migrant workers, refugees, nomads
Limited participation in decision making Delayed help seeking behavior Perception of severity of situation Perception about the ability of the service to solve the problem Previous negative experience with the service Fear
Availability Affordability Quality
acceptability, constituting different dimensions of the same reality. In this context, one can assume that having access to a health facility, or to health information, presupposes the availability or the existence of such services, as well as the acceptability of the person to be treated there or to integrate the health information provided into her own daily life so as to improve her health and that of her family. Access has also been utilized as a measure of accountability, or even as a feature of the health facilities. According to a U.S. study [ll], “access is defined as a general concept which deals with the relationship of the attributes of service production (supply) and providers to the attributes of clients and their needs that determine the patterns in use, particularly entry into the health care system and client security”. Donabedian and Penchansky define access as the ‘degree of fit’ between the clients and the health system , and consider that the concept of access contains dimensions such as those related to availability, accessibility, accommodation, affordability and acceptability. Other authors have defined access as that relationship that results from ensuring equal use for equal need . G. Taylor et al. define access in terms of the passage of a patient through the health care system, including the outcome of this contact [141. In a recent AMA publication , besides the characteristics of accessibility and affordability, those of strength, freedom, security and quality were
indicated. The proposal aims at maintaining or increasing access, and maintaining and improving quality and efficiency of the health system; however, they do not mention specifically the problems of women and access to health care. They point to the need to maintain the strengths of the present health system, freedom to determine how health care benefits are delivered, to ensure that continuous care is provided to elderly patients, and that access to health care should be facilitated by physicians committed to high ethical standards. All these features refer to the characteristics of the system, and they have eliminated those related to the services themselves (such as accommodation or availability) and those referred to the patients, such as acceptability of the services. Research studies carried out by Thomas and Penchansky , show that the mean level of dissatisfaction with acceptability as a dimension of access is significant for the women in the sample, but not for men, while dissatisfaction with affordability and availability seem more significant for the men. However, when they carried out further tests, these results were not significant, indicating therefore that the patterns of utilization of services are influenced by the importance of the various dimensions of access defined (availability, accessibility, affordability, accommodation and acceptability). Attempts were made in the early seventies to construct a social indicator of access to medical care,
Women and access to health care based on the symptoms-response ratio that reflects “the difference between the number of visits in response to symptoms that actually occur and the number that a panel of physicians indicate is appropriate for these same symptoms” . Although this index allows for the identification of variations in access to health services, it is not a useful indicator for predicting if the level of access is medically appropriate. The number of articles written about access in the recent literature suggest a renewed interest in the topic, due in part to the recognition by the governments that previous efforts had limited success, and that a healthy society is a productive society, but perhaps most of all due to the increasing costs of health care, and the plight of the uninsured in some instances. CURRENT
Various approaches to defining variables affecting access to health care show up in the literature reviewed, either based on research conducted in various countries and populations of women and specific health problems, or conceptual works. Some of them indicate that economic status, employment status, and therefore, ability to pay for services  act as a major determinant of access to health care, others point to behavioral issues related to motivation, health seeking behavior or perception of illness as a deterrent to women in the low socioeconomic strata , while others indicate that sociocultural issues, such as values, education, religion or demographic variables related to age, influence access to health care . All these approaches are complementary in conforming a more holistic view of the problems that must be geared toward the formulation of appropriate and equitable health policies for each national and local reality. However, in reviewing the literature, evidence shows that although availability of services in the proximity where people live may influence the volume of visits, more than the rate of utilization , socio-economic factors, distance and belief in the type of services offered being equal, cultural factors related to the status of women act as determinants in the utilization of these services . Several studies indicate that women utilize health services more than men, claim more disability days, suffer more chronic illness and certain kinds of tumors and cancers perhaps due to a longer life expectancy or wrong diagnosis at least in information from Latin American and Caribbean countries. Although recent speculation about the topic  has inquired about the explanation for differences in women and men’s health status and utilization of health services, the results are inconclusive, leaving room for further research. When race is introduced as a variable conditioning health outcomes, recent research indicates that
even when controlling for variables such as different physician characteristics, health and hospital coverage, in the case of breast cancer treatment, for example, black women received therapies considered less appropriate . However, the group involved in this study had different socio-economic and health insurance characteristics. One example from the mental health literature suggests that when therapist and patient (both women) belong to different ethnic or racial groups, interpersonal trust and respect, as well as a genuine recognition of values, override the importance of race . Other studies in the U.S., looking at health care for Latin0 populations in the U.S.-Mexican border found no relation between ethnicity and access to health care, identifying health insurance coverage as the leading variable predicting utilization of services . Although vital for the formulation of healthy and equitable policy, research of this nature is rare in developing countries, due to the economic constraints that inhibit such sophistication. Other research results have indicated that employment status of the woman is a strong variable in the utilization of preventive services. Considering the characteristics of clients, it has been indicated that women who either share the financial burden of the home with the men, or those who do not work outside the home and are supported by their males tend to utilize these services more than women who are heads of households . Other factors are psychological and refer to the woman’s feelings about gynecological examinations, and may be related to cultural perceptions, or related to previous experiences with the service provided and the behavior of the health personnel. It appears in some cases that the utilization of family planning services among low income women is conditioned more by the lack of a regular source of care, inadequate or no medical coverage, lack of coordination between health and social services and inappropriate treatment of clients, than by the fact that these populations are poor . Some studies have indicated that women without health insurance as well as those covered by state aid programs seek help later in pregnancy and make fewer visits . Another study explored the women’s variables associated with consultation and help seeking behavior for minor illnesses. The study indicated that perhaps due to the fact that women had broader or stronger social networks and were able to talk about psychosocial problems, their consultation behavior was more predictive . At present, one recognizes two major forces taking place in the broad sociopolitical reality of Latin American and Caribbean countries that may have a relevant impact on the availability, affordability and accessibility of the health services. One is the wave of privitization of health services sweeping most countries, the impact of which is still unclear for women’s access to health
care, although public services have been unable to satisfy their needs. During the 1980’s it was thought that government, through deregulation and competitive markets, could solve the problem of access to health care to underserved populations. This is being promoted in Latin America and the Caribbean, but it has been seen in the rural areas of the U.S. that this only widens the health gap between groups, and concentrates the physicians in certain metropolitan areas . These observed tendencies towards privatization appear to respond to the weakening regulatory capacity of governments, problems with the health services supply, bureaucratization of health care delivery, absenteeism, low productivity of resources and the implementation of economic adjustment policies. Recent studies indicate that private services may increase efficiency, as well as treatment of patients, or even access, since once the private sector expands, there will be more resources available for the government to implement programs for the poor. However, cost considerations may negatively affect the poor, who may be denied the right to health. A trend related to the previous one, is the imposition of user fees as a cost recovery measure for curative services in public health facilities, a worldwide measure geared towards increasing the public sector’s resources, some argue that paying for service will increase attendance rates. This proposal, already being implemented in some countries, is perceived by some outside the economic community as deleterious to the health of the most disadvantaged groups, specifically women and the poor, since it may reduce access and utilization of needed services . That is, the inaccessibility of the services is directly related to capacity to pay for the service fees . Other important events are the North American Free Trade Agreement between Mexico and the United States; and MERCOSUR, a regional integration strategy which includes the southern cone countries, and regional integration attempts being promoted in Central America. It is unclear how these economic agreements will affect health and health coverage for women in Latin America, since these changes presuppose major reorientations in the health sector structure, the financing of health services, coverage as well as training and deployment of health personnel. POLICIES AND STRATEGIES
Traditional solutions to the problem of access has been tackled almost always from the perspective of the health planners or policy makers utilizing a framework where needs are determined by the health care system’s most powerful stakeholders. Furthermore, planners frame gender-based health differences in status and access in non-gender terms. This in turn, has produced an array of health policies that are
insensitive to the needs of the less advantaged and to women in particular. This view has not only not taken into consideration the research results in relevant areas that could be fed into the formulation process, but in general has not considered the perspective of the people themselves, in order to tailor policies and programs in a negotiated process of restructuring the health system. Health policy proposals should emanate from the countries and communities themselves, and in this sense, we can only suggest some areas of possible work which could promote a more gender based policy formulation process. On the other hand, Latin America and Caribbean countries are receiving funds from international financing agencies to support the formulation of health development projects. Some cooperation agencies and academic research groups are working on developing tools for the formulation of gender sensitive investment projects. Evidently, any policy attempting to modify the status of women in society encounters resistance, because by giving women more independence and freedom of choice, the status and power of other groups in society are challenged. However, given the particular socio-cultural economic context affecting women’s health and well-being, it is essential that the policy analysts (or planners) gain insight and awareness about these factors, so as to be able to formulate equitable and effective policies. A clear and sincere recognition and inclusion of women’s perspectives in formulation health policy is needed. When dealing with most developing countries, even if information is available, its sytematization and feeding into a more or less rational process of decision making is a delicate task. Since most societies are just awakening to social changes that include actual equality for women, the task is even more difficult to achieve. On the other hand, a great number of research projects have yielded very useful information which is not readily available to those that could formulate or implement programs or projects due for the most part to institutional weaknesses and feeble links between research and policy formulation. In terms of the structure and financing of the health sector, there must be a reorientation of the health sector so as to secure access (a concept that must be clearly defined) to the population, by a safe mix of public and private providers, an expansion of rural infrastructures, and an increase in the coverage of primary and preventive health care services. Medical and public health training in local institutions should be geared towards the formulation and implementation of programs and projects that are just to women, that incorporate their views and allow for participation in decision-making processes regarding their own health, and therefore their futures. Gender-sensitive health information should be made available for scientists and policy makers in developing countries to facilitate the exchange of useful
and access to health
to the formulation
In this regard, international agencies play a key leadership role as visionaries of healthy futures, such as primary health care for all or health promotion in an equitable world. In terms of research, information and training in qualitative methods of research in health must be disseminated among researchers in developing countries, since they provide enriching insights that incorporate the perspectives of those involved. There is a need for a multi-disciplinary approach, a political legislation focus, and less biased efforts to educate the population. Participatory planning appears as the preferred method to ensure that all segments of society participate. It is based on decentralized administrative systems and allows for the local control and assignment of resources to specific health activities. It is a process fed with conventional and unconventional information about the socio-political, cultural and economic context of the community. The information gathered can be utilized to assess the needs and negotiate the demands of the community regarding health risks posed by poor health measures, since participatory planning should allow for the clear identification of demands and needs that must be satisfied. This modality of planning facilitates the process of decision-making vis ri uis cultural values as well as social and economic resources available. It can help interaction of individuals within a particular social structure so as to convey concepts and ideas and it makes it possible to analyze the available skills in cultural and ethical terms. Participatory planning should include a social feasibility component that is useful to determine the desired social effects of a particular strategy, policy, plan or program. The process of participatory planning is not an easy one, since it requires that professionals (from the public and private sectors, national or international agencies) working with the community modify their view of the community in order to consider it the most interested, active and responsible agent in their own development. It also requires attitudes of respect for ways of life and world views that may be different from their own, and it requires the ability to be able to share power through information, decisionmaking and actions that may not coincide with pre-conceived plans, but which constitute the chosen negotiated path towards a desired future. of well-formed
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