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Genderandequityinhealthsectorreform

programmes:areview

HILARYSTANDING

SectorReformProgramme,LiverpoolSchool

ofTropicalMedicine,Liverpool,UK countriesinthe inequalities ducers highlightingsixmain siveness.It

Thissuggests

Introduction

pact ofsuchreformsonthepoorestsectionsoftheir populations.

Ofparticularconcernhavebeentheim

plications ofcostrecoveryforthepoor.Other importantdimensions ofvulnerability,notably

Similarly,otherimportantaspects

ofhealthsector employment,havenotbeenconsideredfromthe viewpoint oftheirpossibleimpactonthegender composition oftheworkforce.

Thisdiscussionseeks

toaddresssomeoftheempirical andwomen'shealth.]Itspremise isthatgenderisa significantindicator ofinequalityanddisadvantage 2 etc.,it foundintheliteratureonhealthcare: •women'shealthneeds, •genderinequality. theimplicationsforwomen ofdifferencesinthe proachhighlightsthespecifichealthneeds ofwomen exclusively) ofthebiologyofreproduction.Two theimbalance

ofneed.Theotherstressesthecost-Downloaded from https://academic.oup.com/heapol/article/12/1/1/610536 by guest on 06 July 2023

2HilaryStanding

tions),both incomparisontoothertypesofinterven tionand asameanstoimprovethehealthofinfants inparticular.

Women'shealthandnutritionhavebecomeanin

creasingfocus ofinternationalconcern,whichiswell exemplified inarecentWorldBankpublication (1994).Thisstanceisthenpart ofthewidertheme of'investinginwomen'toreducetheburdenof seen asthemosteffectiveconduittoimproving of children.

Agenderinequalityapproach

tohealthisconcerned withtherole ofgenderrelationsintheproduction tiontoaccessandutilization ofservices.Itisthus theways inwhichhealthmayalsobeasiteofgender conflict. One ofthemostimportantfeaturesofagender approach isitsemphasisontheneedtoexamine resourceallocation withinhouseholds,ratherthan treatingthehousehold asthemostminimumfocus fecttheextent oftheinformalcareburdencarried predominantlybywomen.

Gender

isanimportantpointertovulnerabilityintwo resources,includinghealthcare,and tobemore

Interms

ofabsolutevulnerability,therefore,being femalecanbeone ofthemostimportantpredispos ingfactors.Vulnerability isalsorelative.Urban womenandgirlsgenerallyhavebetteraccess tohealth access ofwomenandgirlstohouseholdresourcesfor healthexpenditure inbothruralandurbanareashas beenfound inmanyinstancestobelessthanthatof ofhealthservices areimportantlyinfluenced byculturalandideological titioners,lack offreedomtoactwithoutpermission fromhusbandsorseniorkinandlowvaluation ofthe healthneeds ofwomenandgirlscomparedtothat

Segall1995).

Agenderapproachalsohighlightstheways

inwhich womenandmenarepositioneddifferently inrela criticalaspectstothis inthecontextofHSR.First, womengenerallycarrymore ofthecareburdenin adults.Thehouseholddivision oflabouralsotends treatment(Leslieetal.1988;Leslie1992). aregenderdifferentiated intermsoftheirdivisions importanthealthcareproducers aswellasconsumers, buttheytendtobeconcentrated inparticularsegments

Bloom1991;HoldenandLittlewood1991).

tions inrelationtoHSR.Fromawomen'shealth needspoint ofview,thequestionishowfarHSR

First,howfardoestheproposed

contentreflectthese needs?Second,whatisthelikelihood oftheiraccep tanceandimplementation inresourcepoorcountries? fromawomen'shealthpoint ofview.Doescost recoveryhaveamoreadverseimpactonwomen's capacitytoutilizeservicesthanonthat ofmen, leadingtoaneglect oftheirspecifichealthneeds? aboutboththeconsumptionandtheproduction of balances ingenderrelations?Forexample,interms itworsenorimprovethem, orcreatenochanges?

Inthecontext

ofwomen'srolesashealthcareDownloaded from https://academic.oup.com/heapol/article/12/1/1/610536 by guest on 06 July 2023

Genderandequityinhealthsectorreform3

forthose segments ofthehealthcaresystemtradi tionallystaffed bywomen?

Healthcare,genderandequity

Theconceptofequityisatroublesomeonetopin

down.Ananalysis ofitsuseinarangeofliterature points ofreferenceformeasurement(seee.g.Vogel

1988).Mooney(1987)hasreviewedthevarious

andshownhowtheyleadtosometimesprofoundly differentways ofconceptualizingit.Fromthepoint vantdistinction isbetweenmeasuresofequitywhich relate toaccess(whichtendtobealliedtoconcepts thegreatestneeds)andmeasureswhichrelate toout comes (suchashealthstatusorconsumptionofhealth goods).

Accessmeasures

ofequityappeartobeusedmore theWHOhaslongusedimprovedaccess bydisad vantagedgroups asitstouchstoneforequity(Kutzin

1995).Improvingaccessalsoimplies

anoutcomegoal of is alsoahelpfulmeasurefromthepointofviewofa problems ofaccessandunder-utilizationforwomen.

However,

inlinkingittogenderdisadvantage,italso begssomequestions. healthrisks,thenimprovedaccess isnotofitselfa sufficientconditionforachievingequity intermsof ofservicesonoffer,including possibleneedsto directlyadvantagewomen.

Second,thenotion

ofadisadvantagedgrouphas regionalindicators.Currently, inhealthsystems writing,there isalmostnodisaggregationofdataby orfordisadvantaged (andchildren)asformen.Giventheweight of referred toalready,therearegroundsforconcernthat thismaynotalwaysbeso.

Itispossiblethatmeasures

populationgroupsmayresulteither innoincrease aggregateimprovement inthelevelofaccesstohealth inequalities.Unfortunately, welacktheappropriate datawithwhichtotacklethesequestions. tion oftheburdenofcostanditsrelationshiptothe of servicesreceived(seee.g.Dave1991).Again, althoughmuchhasbeenwrittenonissuessuch asthe equityimplications ofdifferentformsoftaxationfor data isavailableonthegenderdimensionsofthe burden ofcost.

Clearly,equitycanmeananumber

ofthings.For sectorobjectives ofexpenditurecontrol,service definitions ofequityhaveatbesttobepragmatic.

Thus,Zambia'sapproachtoequitywithinanHSR

level or(morethan)amaximumcostlevelofhealth affordahigherlevel ofhealthcarefreetomakethat wouldnotsatisfyseveral ofthemorecommonsocial theories ofequity(notably,itlacksaredistributivequotesdbs_dbs17.pdfusesText_23