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Socio-Economic
Aspects of Reproduction
Cost
Benefit and Economic Approach
Related to Health Care
Services System
By Mabel Bianco
http://www.klaever.nl/
In this
paper, Mabel Bianco, an Argentinian medical doctor with a Master in
Public Health and Epidemiology, analyses the different gender
aspects she suggests should be taken into account when performing
Cost Benefit Studies related to health care service systems.
She states
in her introduction that "The economic approach to analyse the
health care services system was used for many decades. Cost benefits
(CB) studies were developed to evaluate the economic gain related to
the expenditure for a specific treatment or health care method. The
great challenge of those studies are how to quantify, for example,
the life of a person, its health status or some morbidity condition,
in order to compare the cost of a treatment to the benefit in terms
of health, cure or death avoidance. How much is the cost of a womans
life?" After a short description of the development of ideas and
methodologies that influenced CB studies in the last decades, she
presents her ideas concerning "Women and Health", "Reproductive
Health", "Womens Sexual Health", "Human Development and Gender" and
"The Health Care Services system", all related to her
recommendations of adapting the current CB study methods. She
finalises her paper with useful "Implications and recommendations
for integrating a gender perspective".
In this
Our Sponsors , reproduce four chapters of the paper:
Reproductive
Health
According to the
WHO definition "reproductive
health is the ability to have a safe, responsible and fulfilling sex
life, the freedom to decide if, when and how often to have children
and to avoid to become ill or die due to a reproductive cause".
Reproductive
health is based in principal on the right of women and men to know
about and obtain safe, effective, affordable and acceptable methods
of family planning and the right of women to have access to
appropriate and good quality health services to enable them to have
a safe pregnancy and birth. Still today, those rights are not
respected worldwide due to ideological and political obstacles and
also to accessibility problems due to lack of health services or of
poor quality due to economic restrictions. Reproductive health is
severely jeopardized in poor countries and womens and their
childrens lives are affected.
The burden of
poor reproductive health in terms of disease or death is difficult
to be measured and quantified similar to other effects that cannot
be quantified or measured in economical values. Maternal deaths are
often more easily measured than morbidity problems or other effects
such as urine incontinence, painful sexual intercourse or
psychological distress due to abortion. Jamison and others
experienced difficulties and limits when evaluating some womens
health problems, related to poor reproductive health, in DALYS
(Disability Adjusted Life Years) (1).
When considering
the reasons for the persistence of the burden of poor reproductive
health, for example excess fertility, it was found that an important
cause of maternal morbidity and mortality remained high, principally
due to inefficient use of existing tools. Unmet needs of
contraceptive methods for so many women are a principal cause. Lack
of information about how to avoid a pregnancy and the small variety
of contraceptives available for poor women contribute to maintain
the burden. So the existence of tools and the possibility to apply
them efficiently are considered very important to decrease that
burden. It was suggested that new tools or methods be developed in
order to meet more efficiently family planning needs.
From a gender
perspective we will confirm that facts as coverage of family
planning needs varied between countries. This is not only due to
economic reasons. Principal religious, cultural and political
reasons against family planning services still remained in
developing countries. In low and middle-income countries, unmet
family planning needs are still very high. Contraceptive methods are
not affordable for many women and couples due to the economical
cost. Many governments are unable to offer those services to poor
people that could not pay for them. The programme of action of the
ICPD adopted in Cairo clearly recognized the need
"to increase the commitment to and
the stability of international financial assistance and recognize
priority to complement national financial efforts". Also
budget estimations were required to fulfill the needs until 2015.
From a gender
perspective we recognized the necessity to increase the variety of
existing contraceptives and to carry out more research which is
necessary to develop them. We emphasized that the principal problem
is how to make them accessible for all women. In poor or middle
income countries, women would remain with their unmet family
planning needs if no special interventions were developed,
principally in countries with persistence of high Maternal Mortality
Rates (MMR) and with abortion as a principal cause of MMR. New
knowledge is not sufficient to improve accessibility for poor women
and couples. Clear political commitments and programmes are
necessary. In many countries there is also a need for a budget
increase through additional funds or reallocation of national
financial resources, more efficient health care services and
external cooperation.
A majority of the
maternal deaths cannot be averted simply by improving womens
nutritional status and womens overall health. Improvement of basic
delivery services and effective antenatal care and counseling could
avoid many illness and deaths. These are not very expensive services
but need to be available for all women to be effective.
Cost-benefits
studies about family planning services versus abortion complication
care in low and middle incomes countries should be developed in
order to demonstrate the economical benefit of family planning.
Womens
Sexual Health
The increasing
incidence of womens HIV/AIDS infections and illness was persistent
since the early 90s. Approximately 90 per cent of those new
infections and diseases occurred in developing countries. In 1990,
the burden of disease attributed to HIV/AIDS was almost one per cent
of the global, and almost three per cent in Sub-Saharan Africa,
where other Sexually Transmitted Diseases (STDs) accounted for
another two per cent. Projections of the HIV pandemic indicate that
the total burden of disease attributable to HIV/AIDS would increase
worldwide by 2020. Women are now more affected in some developing
countries and the numbers will increase by 2020.
Today other STDs
such as clamydia, syphilis, gonorrhea and others account for 1.4 per
cent of the global disease burden and in the urban population of
developing countries this number increased to 15 per cent. Women are
disproportionately affected by STDs. Womens sexual health needs have
been neglected for decades by the health services. Sexual taboos and
prejudices negatively impact health care services and orientations.
Stigmatization and womens social rejection due to STDs or other
chronic sexual disease or problem still remain.
The HIV/AIDS
epidemic and its condition of being a sexually-transmitted disease
contributed to the renewal of the interest of policy makers and
public health people working in the field of STDs. But services
didnt increase nor improve. Advances and knowledge about diagnosis,
therapeutic and programmes were not sufficiently applied especially
to womens health care services.
Cost benefit
studies about a syndromic approach to STDs in developing countries
and at primary health care were done but few of their benefits were
used to adopt decisions and programs developed.
The development
of STD health services for women as part of reproductive health has
been a recommendation for many years but is still not adopted.
Activists from the womens health movement and specialists have been
requesting it in all forums of womens health.
Due to
mother/child HIV transmission, interest in young womens protection
to prevent STDs and HIV/AIDS infection or illness emerged but
actions were oriented to HIV/AIDS. This has been more evident since
1994 when the first mother/child prevention study demonstrated the
decrease of risk transmission in 66 per cent with the treatment of
AZT to pregnant HIV+ women starting in the fourteenth week of
pregnancy. This prevention method was very expensive to be adopted
in many low-income countries, especially in Africa with high
HIV/AIDS incidence rates. So a shorter treatment model was developed
and recently proved to be effective in Thailand to decrease the
incidence of transmission by 50 per cent.
As result of that
evidence, some middle income countries are encouraged to implement
the prevention for a high proportion of pregnant women living with
HIV/AIDS. But still low incomes countries with high incidences
cannot afford it. Some cost-benefits estimations were done and
clearly demonstrated that it is a potential highly cost-effective
method, so the scientific and public health community is very
enthusiastic, as well as international agencies.
In order to make
this prevention method available to all countries, especially
low-income countries, two proposals were developed. First: the Joint
United Nations programme on HIV/AIDS (UNAIDS) and pharmaceutical
enterprises initiated a negotiation process to reduce the price of
AZT in those countries. Glaxo Welcome, the AZT producer accepted to
reduce the prize of AZT by 25 per cent of the regular price for
those programs in poor countries.
Second: the
French government with NGOs from the South and UNAIDS developed a
proposal presented last December with the creation of an
International Solidarity Fund for HIV/AIDS. That fund will be a
special fund to collect money from industrialized countries
specifically oriented to help low income countries to buy drugs for
HIV/AIDS care. France made it a priority to support prevention
programs of M/C transmission in low-income countries.
From a gender
perspective, it is necessary to reinforce the following needs in the
prevention of mother to child transmission: First, to develop or
increase prevention programs to HIV/AIDS infection for young women.
These programmes are more urgent and important to be implemented
than the M/C transmission, because it is still now a priority in
HIV/AIDS to stop new infections especially for women independently
if they are or will be pregnant.
Second, it is
necessary to promote a better access to antenatal care for all
women. In developing countries, antenatal care coverage is still
very low and the quality of those services is very insufficient. In
many Latin American countries, for example, the coverage of
antenatal care decreased due to less services available, long
waiting lists and the requirement to pay those services, among other
factors. In Argentina, poor women attend the public hospital for
antenatal care during the last month of the pregnancy only to ensure
being accepted for the delivery, because institutional deliveries
are eligible for all women. Primary health centers are insufficient
to cover antenatal care, because they are neither fully equipped nor
organized to ensure a good quality and accessibility of services. In
a situational analysis to integrate HIV/AIDS services at primary
health care in a poor area of Greater Buenos Aires, women
interviewed expressed that it was time-consuming to obtain the
appointment and the problems which later they faced to fulfill the
diagnostic in the hospitals. While no programmatic organization
among health centers and hospitals is developed and primary health
care centers are prepared to solve the whole range of needs, women
will continue going straight on to hospitals. But they recognize
that waiting lists and bureaucratic procedures were more complex at
hospitals. These difficulties and obstacles to accessibility
discouraged women to attend to their health needs.
Third, many
ethical and human rights violations are still related to the HIV
test of pregnant women. It is recognized worldwide that a HIV test
is to be based on voluntary basis that is not always respected.
Attempts to test newborns without their mothers consent is a
violation of womens rights to ensure the childs rights. Pre- and
post-test counseling is recommended but in developing countries
counseling is often not conceded as part of the health services and
neglected. Womens groups and women living with HIV/AIDS consider
counseling an important prevention method, and an educational tool
to avoid discrimination and to learn how to live with HIV/AIDS.
Still today we
find out that approaches to prevent mother to child HIV transmission
are more oriented to prevent children from infection than to improve
womens status.
Studies to
evaluate mothers long term risks due to AZT administration and
resistance due to monotherapy are needed. More research about
methods not requiring HIV tests, such as vitamin A supplement, for
pregnant women and others is still needed.
From a gender
perspective it is important to analyze M/C prevention interventions
and to stimulate the development of strategies as those two forms of
solidarity suggest. It is also necessary to point out other changes
such as how decisions to improve womens health could be implemented.
Implications and
recommendations for integrating a gender perspective
Summarizing
womens health needs and their burden especially in developing
countries, have great implications to influence health policies and
programmes in developing countries which are based on a gender
perspective.
As the World Bank
recommended for Africa in a recent report "to overcome these
conditions (improvements in health care, education, food security,
housing, energy supplies and others), there must be greater emphasis
on programs for the poor and most vulnerable, especially women and
children, including:
o
Effective family planning and reproductive health services;
o
Better treatment of childhood illness (diarrhea, pneumonia);
o
Radical steps to control HIV/AIDS;
o
Improved control of malaria;
o
Community nutrition schemes.
The difference to
the World Banks recommendations is that, coming from a gender
perspective, we emphasize policies and actions based on womens
health rights. We propose:
o
Reproductive health services should have a broad goal and include
family planning services among others. The reproductive health
services are to be based on a comprehensive approach of womens
health care as a basic component of quality of life. Those services
should include care for all ages and principally provide primary
health care services without excluding or neglecting other levels.
For example, control of uterine cervix cancer provided at primary
health care should include a proposal of subsequent care if a cancer
is detected.
o
Family planning services are to be included in reproductive health
services and based on a gender perspective with the goal "to ensure
womens reproductive rights". As defined in Cairo and Beijing, "all
forms of coercion" have to be avoided. The main difference with
traditional family planning is that demographic goals are rejected
because they include coercion.
o
Reproductive health programmes are required to ensure "adequate
basic motherhood care to all women", including good antenatal care
until delivery and post delivery services, including food
supplementary programs for pregnant women.
o
Adolescents reproductive care to ensure access to sexual education
and health services especially for female adolescents;
confidentiality and counseling are also requested to guarantee
adolescents rights.
o
STDs and HIV/AIDS services to ensure sexual rights of women at all
ages, including enjoyment of their sexual health; those services
should include prevention, diagnostic and treatment, and eliminate
all forms of compulsory HIV testing.
o
Abortion and post-abortion care are to be included; where abortion
is legal, there should be availability of services and skilled
practitioners to reduce morbidity and mortality; where abortion is
illegal, post abortion care is to be included.
o
Genital cancer control should be included as well as womens
awareness of cancer prevention.
o
Harmful practices such as genital female mutilation, excessive
caesarians and others should be eliminated.
o
Care of domestic violence, rape or sexual abuses should to be
included in those services.
In order to
develop these womens health care services from a gender perspective
we make the following recommendations:
1. To analyze the
health care system with the participation of womens health groups or
NGOs, and decision-makers in order to establish and adopt specific
policies to ensure womens health care;
2. To review and
define the national budget and the specific health budget and its
allocation to womens health programmes, ensuring the participation
of womens groups or NGOs in the review process;
3. To increase
the health budgets in low-income countries through reallocation of
funds from military budgets and defining national priorities
according to human development criteria; this requires a broad
participation of civil society but specifically of womens health
groups and NGOs;
4. To reform
health care services to improve the care of communicable womens and
childrens health problems, especially through primary health care
services;
5. To improve the
primary health care services by increasing the budget, improving the
skills of personnel through gender training and adopting methods to
improve efficiency;
6. To include the
participation of womens health groups and NGOs in all levels of the
health care system and to allow them to participate in the planning,
implementation and monitoring process;
7. To improve
data collection and analysis about health status disaggregated by
sex as well as other socio-economic data; to publish and distribute
that information to womens health groups, NGOs and other groups of
the civil society;
8. To promote and
carry out research about cost-effective health care methods in the
services and to compare them with others studies and research; those
studies will be done with the participation of womens health groups
and organizations as well as scientific and health professionals;
9. To improve
partnership among governments, donors, enterprises and womens health
groups and NGOs to define health policies and negotiate
responsibilities, especially for womens health matters;
10. To increase
external cooperation to develop womens health programmes based on a
gender perspective and to achieve the goals established in the
International Conferences in Cairo, Copenhagen and Beijing.
I realize that
these recommendations may seem "utopian" but it is utopia that has
enabled the world to grow and develop. Utopia never dies; it changes
and is renewed. As womens health experts we didnt loose our
activism. Our voice is necessary to express what millions of women
cannot say. Their silence is our inspiration and commitment.
The paper was
presented during the Expert Panel on Women and Health, organised by
the United Nations Division for the Advancement of Women, in 1999.
Several panels were organised by DAW between 1996-2000 as part of
the Beijing +5 activities.
For a complete version of the report in English or
French, please download from this Web site or contact us.
1.
Note from the editor: for further reading, the following two
articles are recommended:
"DALYs as a Tool
for Public Health Policy: A Critical Assessment",
Ritu Priya, Medical
Friends Circle, India, January 2000
"DALYs and Reproductive Health: A Critical Analysis",
Carla AbouZahr,
Reproductive Health Matters, Vol.7, No. 14, November 2000.
Both articles (English) are available upon request.
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