Introduction
The Beijing Platform for Action is a call for concrete action to make a difference:
- Action to protect and promote the human rights of women and the girl child as an integral part of universal human rights;
- Action to eradicate the persistent and increasing burden of poverty on women;
- Action to remove the obstacles to women's full participation in public life and decision-making, at all levels-including the family;
- Action to eliminate all forms of violence against women;
- Action to ensure equal access for girl children and women to education and health services;
- Action to promote economy autonomy for women, and ensure their access to productive resources; and
- Action to encourage an equitable sharing of family responsibilities.
What exactly has happened to these calls? Are we getting real responses from government reflected by holistic and integrated health programme approaches? Or are these calls just echoing in women whose bodies have been claimed ownership by the husband, boyfriend, parents, family, community, religious authorities, health professionals and the State!
The Platform addresses women and health issues under Section C which encompasses women's rights to enjoying the highest attainable standard of physical, mental and emotional health, throughout their whole life-cycle in equality with men, free of fear, discrimination, prejudice, coercion and violence. However, despite identifying key issues and obstacles faced by women in attaining their health rights, and despite identifying actions which governments can take, in partnership with NGOs, mass media, employers and workers' organisations, the private sector (including TNCs and MNCs), health professionals, research institutions, women and youth organisations, multilateral and bilateral donor organisations and other international agencies (including the relevant UN bodies), not much progress has been made.
Women's Rights to Health, including Women's Sexual and Reproductive Rights as Human Rights
Human rights are viewed narrowly by governments as primarily political and civil (and therefore seen as threatening) rather than as entitlements towards improving well-being in all aspects of human life-socially, culturally and economically. Women's reproductive and sexual health is still perceived only in the context of their reproductive roles and functions. Hence, certain groups of women are "omitted" from receiving comprehensive sexual and reproductive health services such as adolescent/young women, single women, older women and disabled women.
Women's reproductive and sexual rights seem to threaten men's control over women and women's bodies. Women's individual reproductive rights are wrongly perceived as a threat to the well-being and interests of the family, community and nation as a whole. Reproductive rights are wrongly perceived as promoting promiscuous sex, abortion and lesbianism. Sexual rights of women are not accepted as a separate issue, and so policies and laws promoting women's sexual rights have not been developed. Women's sexual rights are deemed necessary and only "proper" to be seen within the context of their reproductive roles and functions.
Policies, programmes and services in place to help women achieve their health rights (which are usually limited to married women) do not take into account the situation of women in gender-disempowered relations with men. Even when full information is provided to the women, how can they make choices about their own bodies and sexuality when those choices are not for them to make (e.g. fear of stigmatisation and shame that women experience arising out of cultural, religious, patriarchal and sexist prejudices)? The call for men to work for and support the empowerment of women has been translated into calls for male involvement and male participation in reproductive health-in some cases with any reference to women muted or even missing.
Recommendations:
Governments uphold their commitments to the Convention on the Elimination of All Forms of Discrimination Against Women, the Beijing Platform for Action and the Cairo Programme of Action.
Governments need to put in place parallel programmes which would address the promotion of men's reproductive and sexual responsibilities. Change is needed in men who are prone to being violent towards women, who give women no say over their bodies and sexuality and who override women's decisions on these aspects, who have no concerns on how many abortions women have to go through because they won't practise self-control or safer sex, who have no concern that they can and do transmit STDs and HIV to women, and who do not share in the household responsibilties and childcare. Women's health policies, programmes and services should therefore not be designed without addressing gender-disempowered relations that women face, either in their own homes or with the community. This is not to say that there should be more reproductive health services for men at a time when reproductive healthcare policies, programmes and services are either still not in place or need to be improved upon tremendously. A two-pronged approach in empowering women to exercise control over their bodies and sexuality needs to be adopted i.e. not just meeting the unmet need of ALL women in terms of health services but to also sensitise and raise awareness and bring about change in the irresponsible sexual, reproductive, sexist and patriarchal behaviour of men.
There is an urgent need to support national and regional activities aimed at strengthening government and NGO capacity to implement the new approaches of the BPFA. Information resources, pilot health service projects, orientation and training of health service providers, policy dialogues, and revision of curricula for health service providers, are some of the critical activities.
Impact of Globalisation and Implications for Women's Health: Accessibility and Affordability to Health Services
With the growing pressures of globalisation, supported by some international organisations (e.g. World Bank, IMF) as the better way of ensuring cost effectiveness and effiency of economies, we find that governments' responsibility for social welfare is in danger of dying, and with it, progressive ideas and models of national health services. By allowing globalisation through deregulation, privatisation and free trade under the guise of increasing cost effectiveness, governments are practising a more insidious form of colonisation which commodifies women and the poor into dispensable and cheap factors of production. Privatisation of health care commodifies and targets women's reproductive health needs, providing TNCs and MNCs a large opportunity for profit-making at the expense of burdening women with increased health costs.
Women's rights to health are being adversely impacted by globalisation. The liberalisation of national economies favour those who own capital. Mechanisms are not in place to ensure that poorer countries do not get dumped with poorly tested medical drugs and supplies, that adequate medicinal supplies is attainable at reasonable costs, that labour is allowed to move freely without fear of discrimination.
The continuing financial crisis of 1997 and reduction of government health budgets has further affected the cost and availability of services. Although contraceptive services and supplies have been affected in some countries like Indonesia, this remains the most affordable and accessible reproductive health service for women in most countries due to the priorities of donor funding. Although some countries have reported a trend of increased government spending on reproductive health, much more detailed analysis needs to be done. Much of the reproductive health budget for example, is allocated to family planning services.
More countries are reporting a growing trend of privatisation of public health services and the introduction of user-fee services for treatment and medicine (e.g. Cambodia, Lao, Philippines, India Indonesia, Thailand, Vietnam) despite the fact that most of the developing countries do not even have high quality primary healthcare services in place, with suitable and clean facilities, and with adequate medical supplies. For some countries like Indonesia, user-fees are even charged for childbirth services. In the Philippines, privatisation has led to the sale of government land and closure or scaling down of vital public hospital services in mental health, leprosy and TB. In Sri Lanka and Bangladesh, medical staff in public facilities invest more time in private practice to the detriment of quality of public health services. In New Zealand, government officials say that health rationing is now a fact of life. In 1997, there were 86,000 people on public hospital waiting lists, 20,000 more than when reforms began. The removal of price controls on pharmaceuticals and the opening of domestic markets to multinational corporations under globalisation have added to healthcare burdens. NGOs in China, India, the Philippines and Indonesia (due to the financial crisis) report that spiralling costs of medicines are a growing barrier to healthcare. In China, treatment for common ailments is prohibitively expensive: a typical prescription for Western drugs can cost US$60, or half a month's salary for an urban worker. In India, the increased cost of medical care is the second most common cause of rural indebtedness. Women place their health needs last when cost is an issue, seeking medical care too late or not at all.
Recommendation:
Governments should take a firm step to say "NO" to any form of privatisation of public healthcare services (as what the Malaysian government has done) and further ensure that adequate infrastructure is in place for women to reach these services.
Governments need to recognise that NGOs can only point to weaknesses and gaps of a public healthcare system, and even show on a micro-level how a gender-sensitive and women-centred healthcare model could be implemented well. Dismissing NGOs' findings as too small-scale and irrelevant cannot be seen as constructive actions. What governments could do is closely examine such good practices and models and provide support for upscaling or to pilot-test such models in other parts of the country concerned.
Women's access to affordable, quality reproductive health services needs to be evaluated more fully, as it would appear in a number of countries that their access is limited according to their income.
Addressing gender issues in health policies, programmes and services for women
Gender equality and equity has been mistaken for biological sameness. The argument that men and women can never be equal because of their sex is true only biologically. The human value of women, however, can be equal to that of men (and in matriarchal society even exceed that of men). Patriarchal and sexist views give women a lower human value, lower than the value of children and sometimes even, lower than the value given to animals. Women are kept in subordinate and disempowered positions, to be owned, commanded, and worse, violated.
Recommendation:
Gender concepts, including gender equality, are being introduced into legal documents in countries like Vietnam and the Philippines. The Philippines has developed and adopted the Philippine Plan for Gender-responsive development (1995-2025) which advocates for gender-sensitive health policies and services. These are at a pilot stage of implementation in the Department of Health. The concept of reproductive rights is included in Cambodia's Abortion Bill and Birth Spacing policy statement, which is a very progressive development. Governments need to share with each other on progressive documents such as the Philippine Plan for Gender-responsive development, and ensure that gender concepts are properly incorporated into national policies, programmes and services that affect women and their lives, to meet the health needs of women as women see them.
Design and implement, in co-operation with women and community-based organisations, gender-sensitive health programmes, including decentralised health services, that address the needs of women throughout their lives and take into account their multiple roles and responsibilities, the demands on their time, the special needs of rural women and women with disabilities and the diversity of women's needs arising from age and socio-economic and cultural differences [and sexual orientation], among others; include women, especially local and indigenous women, in the identification and planning of healthcare priorities and programmes; remove all barriers to women's health services and provide a broad range of healthcare services.
Indicators to assess women's health needs-availability and reliability of data
Efforts to obtain proper and accurate baseline data on the range of women's health needs is lacking. Attention has not been given to gender-based violence as a reliable and valid indicator of women's health status. Governments continue to rely on contraceptive prevalence rates, life expectancy of women and maternal mortality rates (when available) as sufficient health impact indicators to assess women's health needs within the framework of the Beijing PFA. Data available are primarily national data reflecting national averages. It is still difficult to obtain data which is already analysed and presented by age, geographical location (rural, urban), class/income, religion/culture, indigenous and ethnic groups. The lack of available and reliable data makes it impossible to have a more in-depth approach in improving women's health. For example, which women are more at risk for acquiring cervical cancer and less likely to seek screening or treatment in specific countries? Which women are dying in pregnancy and childbirth?-young women, older women, indigenous women, women of a particular religion or culture, or poor women?
This lack of available and reliable data on women's health needs (throughout their lives) reflects the past focus of health programmes for women on family planning and indicates the neglect of women's comprehensive health needs.
Recommendations:
It is essential that baseline data on the range of women's health concerns contained in the Beijing PFA is obtained so that women's health needs can be identified, prioritised and appropriate action taken. Furthermore, specific attention should be given to gender-based violence as a reliable and valid indicator of women's health status.
There is an urgent need to develop a monitoring framework of specific financial indicators which differentiates maternal health, family planning, screening for reproductive cancers, HIV/AIDS services etc. within the reproductive health budget. In addition, financial indicators need to be agreed on to monitor spending on women's comprehensive health services.
Inadequate basic infrastructure and availability services for women's health
Some countries such as Malaysia and Thailand, have been able (prior to the Beijing Conference) to provide women with adequate infrastructure and services for maternal health care. Other countries such as Indonesia, Cambodia, Laos, Vietnam, and the Philippines, have not yet achieved this and maternal mortality rates are still high.
Contraceptive services are widely available (although not necessary accessible due to cultural, religious, and political factors) in most countries, but not yet in Lao PDR and Cambodia who have only recently begun birth spacing programmes.
Availability of reproductive and sexual health services in most countries is poor. In Lao PDR, for example, cancer treatment is not available and women (and men) who can afford to go to Thailand. Vietnam's cancer treatment services are urban-based and this is the situation in most South-east Asian countries. Even cervical cancer screening services for women are not yet a core part of reproductive health services in most countries. Data on the number of women who have had a pap smear screening test according to guidelines is not known generally. For example, although pap smears are available in Malaysia through the public health services nationwide, only 25 per cent of women reported ever having had a smear in a recent health longitudinal survey. This shows that accessibility and quality of services is just as critical as availability.
The availability of services for women suffering from gender-based violence is either inadequate or non-existant. Malaysia and Philippines were the only two countries, which have set up multi-disciplinary integrated public health services for women. Most of the other countries have reported extensive gender-violence problems. However, barriers such as socio-cultural stigmatisation, under-reporting of cases and lack of national prevalence data have undermined the seriousness of the problem.
Recommendations:
Governments need to uphold their commitments to the Beijing Platform for Action in providing basic infrastructure to ensure women's access to high quality of healthcare. Healthcare services need to be decentralised particularly to rural areas. Governments need to also ensure the provision of adequate and timely medical supplies as well as clean and suitable facilities of a certain standard of quality, especially in the rural areas.
Monitoring and Implementation of the Beijing PFA-Insufficient National Mechanisms
Country studies report in most countries that the Beijing PFA's recommendations on women's health have as yet been given little serious attention by health policy makers. There are not yet agreed upon core indicators for monitoring the new broad concept of women's health and rights, nor national institutional mechanisms to develop such a framework. Women's Ministries and departments need to bring together health policy makers and women NGOs with a health and rights agenda through sustained mechanisms such as a National Committee to facilitate and monitor implementation of the National Action Plan post-Beijing on women's health.
Recommendation:
Adopt ARROW's framework of indicators of action on women's health needs and rights for monitoring the implementation of the Beijing Platform for Action. This has been piloted in seven countries (four Southeast Asian countries and three Indo-China countries) in the Asia-Pacific region. The framework contains both quantitative and qualitative measures which cover women's health status; health services provision, use and quality; and national laws, policies, plans and regulations, with cross-referencing to the Beijing PFA paragraphs and strategic actions. To develop this framework, ARROW reviewed what was available from UNFPA and WHO and other international and regional NGOs, and found especially useful the work of the Commonwealth Medical Association's project "Advocacy for Women's Health" and the work of women's health and rights advocates. The framework was developed as part of a seven-country project funded by the Canadian Southeast Asia Gender Equity Programme based in Singapore.
