PowerPoint Presentation

Mujeres, Salud y Desarrollo

Ana LangerWomen and Health InitiativeFUNSALUD6 de agosto, 2015

Today marks the culmination of a three year long collaboration with an amazing group of colleagues, leading thinkers, heads of programmes, and activists from around the world, who helped us articulate the women and health approach and principles, collect and analyze existing evidence and generate new one, and propose recommendations that we hope will influence dialogue, policies and programs and, ultimately, advance the women and health agenda in the places and among the populations that need it most.

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Langer A, Meleis A, Knaul FM, et al. Women and Health: The key for sustainable development. Lancet, June 2015.

Mujer y SaludWomen and Health is a novel concept that refers to the multifaceted pathways through which women and health interact.

W&H moves beyond the traditional focus on womens reproductive health to incorporate womens health along the life course and the roles of women as both users and providers of health care, and highlights the potential for synergy between them.

These elements are thoroughly reviewed and discussed in the Lancet report that we launch today.

As per womens health, in the paper we analyze the evolution of how it has been conceived over the last 50 years.

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Salud de las mujeresEnfermedades crnicas y no transmisiblesSalud a lo largo del ciclo de vidaSDSRSalud maternaSalud infantil y PF(FIFTH CIRCLE) The Women and Health Commission developed and advocates for a life course approach for womens health that includes health challenges that affect girls and women before, during and after their reproductive years, including conditions they share with men (like NCDs,) but with manifestations and effects that are especially severe for women due to biology, gender and other social determinants of health that affect women disproportionally.. We also recognize that risks and benefits accumulate throughout the life course and interact with crucial risk windows and prevention opportunities at different stages of the life cycle.

We also emphasize the social determinants of health and the impact of global and local demographic, economic, environmental and political transitions on womens burden of disease.

While sustained and committed attention to some aspects of womens health has paid off as, for instance, the global declines in maternal mortality, emphasized in Melinda Gates comment to the Women and Health Commission report, show, the challenges are far from over: unacceptable inequalities between countries and population groups persist in terms of maternal and broader sexual and reproductive health conditions, rights, and access to quality care, and health systems in many countries around the world are not ready to effectively address womens increasingly complex burden of disease.4

EL ENFOQUE DE CICLO DE VIDA

Nias y mujeres tienen necesidades de salud especiales y relacionadas

El estado de salud en todas las etapas refleja condiciones biolgicas y sociales

Las condiciones de salud y atencin en cada etapa influencian el estado de salud y bienestar en fases subsecuentes

Los efectos de factores positivos y negativos para la salud se acumulan en el tiempo

The life cycle approach recognizes that ..[READ SLIDE]5 Salud de las mujeres en transicin: 1990 2013

AumentoExpectativa de vida mujeres: 76 aos Muertes por NCDs: 30%

Disminucin Mortalidad infantil: 2/3Mortalidad materna: 3/5Muertes por enfermedades transmisibles: 17%

We also discuss the important health transition children and womens health have gone through in a short period of time.

In the last 20 plus years: Shift from MCH and communicable diseases to NCDs

We certainly need to keep the focus on the pre-epidemiologic transition unfinished agenda in the next era of global policy with the SDGs.

But we also need to recognize the tsunami of chronic and NCDs.6NCDs: proporcin de causa de muerte de mujeres, todas las edades

Specifically on chronic and non-communicable diseases, we highlight that they represent the largest proportion of womens deaths at all ages, at all ages except youngest (23 million deaths in 2013)7Tasa de mortalidad por NCDs entre mujeres de pases de distinto nivel socio-econmico Women in poorest countries have highest NCD death rates.

Very importantly, NCD during pregnancy (such as GDM, hypertension, PP depression, etc.) represent important risk factors for chornic NCDs later in life, perfectly illustrating the relevance of looking at womens health through a life cycle approach.8Aspectos desatendidos de salud de las mujeresSalud mentalImpacto de gnero sobre problemas mujeres comparten con hombresGrupos vulnerables: migrantes, mujeres con incapacidades; minoras sexualesInfertilidadMenopausiaSalud de mujeres en grandes ciudadesThe W&H Commission report also includes data and discussion on several neglected aspects of womens health and these are some examples:

Mental health: analysis of findings for GBD show that major depressive disorders are the top cause of disability adjusted life years among 10-19 girls and that self harm is the first cause of death in girls that age. Impact of gender on care women get for problems they share with me, e.g., lung cancer and cardiovascular disease.

Unseen groups, those who are left out, whose neglect is the main source of inequality.

Infertility: devastating effects everywhere, but especially where women are particularly valued because of their ability to reproduce.

Special challenges women face in cities and the factors that are contributiong to the eriosion of the urban advantage, i.e., better RH indicators among urban women.

9Causas de muerte ms comunes en Amrica Latina, mujeres 1990 y 2010

1990 mean rank2010 mean rankBlue=non-communicable diseasesRed=communicable, maternal, neonatal, and nutritional disordersGreen=injuriesSource: Institute for Health Metrics and EvaluationPermalink to these data: http://ihmeuw.org/3f9b

1010 causas ms importantes de DALYs en ALC, 2010MaleSource: Institute for Health Metrics and EvaluationFemale1. Major depressive disorder2. Forces of nature3. Ischemic heart disease4. Low back pain5. Diabetes6. Stroke7. Lower respiratory infections8. Other musculoskeletal9. Preterm birth complications10. Anxiety disordersMale1. Interpersonal violence2. Forces of nature3. Ischemic heart disease4. Road injury5. Lower respiratory infections6. Low back pain7. Stroke8. Diabetes9. Preterm birth complications10. CirrhosisPermalink: Men: http://ihmeuw.org/3ft2Women: http://ihmeuw.org/3ft3

Note: causes unique to each sex are highlighted in yellow11Calidad de la atencin

12Poor Quality of Care (photo from the Dominican Republic) But reaching the health facility does not mean that the problems will be solved. In many clinics and hospitals in poor countries, the technical and interpersonal quality of care is very poor. There is a lack of supplies, even the most basic ones like sheets, as you can see in this picture from a large maternity hospital in the Dominican Republic; no institutional protocols; overwhelmed, poorly trained and underpaid providers. Sometimes, irresponsible providers.Let me use the example of the Dominican Republic. In that small island in the Caribbean more than 95% of women deliver in hospitals, but still their maternal mortality is very high. Why is that so? In this case, the problem is not lack of access but the poor quality of care women receive in clinics and hospitals. Lets imagine a woman who arrives to a clinic with severe headache, swollen legs and hands, and labored breathing. Her blood pressure is very high. She has eclampsia. But at the time she arrives there, there is only a young resident in charge, and he does not know how to treat her condition or does not have the safe and cheap drug that could save her life: magnesium sulfate or Epsom salts. So she ends up dying in the place where she thought her problems would be resolved. (That is why we are testing an innovative solution in the DR to improve the quality of obstetric care in the largest maternity hospital.)

More than 75% of maternal deaths could be prevented if women had timely access to good quality care.

Source: Barro & Lee, 2014 (http://www.barrolee.com/data/yrsch.htm).19502010Escolaridad de mujeres, 15 aos y ms, ALC13Participacin de mujeres en el mercado laboral en pases seleccionados, 1970-2013

MenWomenSource: ILO, 2013. ( http://www.ilo.org/ilostat/faces/home/statisticaldata/data_by_subject )AVERAGE has also increased substantially14Remesas desde EEUU a ALC, 2012Source: Centro de Estudios Monetarios LatinoamericanosRecreated from URL: http://www.cemla.org/PDF/remesas/documentos-remesas-01.pdf

Note: includes selection of countries with highest number of remittances 15

Contribuciones de las mujeres a la atencina la saludInstituciones de saludPoliticas y gobernanzaComunidadesHogaresIndeed, health systems heavily rely on women in the workforce. They are a majority among nurses, doctors and other health professions, but too often they do not reach their full potential. Due to gender differences and lack of policies that allow women to integrate their reproductive and productive roles, women earn less than their male counterparts and are less likely than men to reach leadership and decision-making positions at all levels of the health systems.

Dr. Afaf Meleis, co-chair of the Commission, will further elaborate on these challenges using the case of nurses as an illustration.

Furthermore, in most societies girls and women provide home health care for family members who are acutely or chronically ill or disabled, cannot access institutional health care, or are elderly or dying. These contributions are typically performed by women with no training, and who are not recognized, supported or compensated by health systems. Families and societies give their work for granted, viewing caregiving as a normal part of womens domestic roles.

Aware of the magnitude and importance of the subsidy women provide to health systems and societies through their paid and unpaid work as health care providers, we at the Commission decided to estimate the financial value of womens contributions. My friend, colleague and fellow commissioner Felicia Knaul led the Global Valuing the Invaluable groundbreaking study and will discuss it later today.

Girls and womens health and their experiences as caregivers are interlinked and affected by the same social determinants and contextual factors. In the report, we developed a conceptual framework that represents these complex connections.

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In fact, both girls and womens health and their experiences as caregivers are both affected by gender equality, human rights, social justice, human development, and culture. A central principle of the Women and Health approach is that, because of persistent social and gender inequality, violations to human rights (including the right to health care), and cultural backgrounds that perpetuate injustice and limit womens human development, women are at increased risk of ill heath and have a low status in the health system.

These interplays, rooted in the same social determinants, are also affected by the same global and local transitions. In the report, we analyze in detail the impact of economic, social, environmental and demographic transitions on the health of women, the health systems, and the dual roles women play as consumers and providers of health care.

Furthermore, these roles are closely linked, which we represented in the figure with the area of overlap between the two circles. Some health issues help illustrate these connections.

Lets use maternal health as an example: minimally trained and unsupported women working at the lowest levels of the health system typically care for women in the poorest sectors of the population, among whom maternal deaths are concentrated. In other words, the most vulnerable women receive care from the most disenfranchised members of the health care system CHW, TBAs, or untrained relatives---who are likely to be women.

Jim Kim and Tim Evans, in the wonderful comment they wrote for the W&H Commission report, provide another example: the Ebola epidemic in West Africa, where womens roles as primary caregivers and nurses put them at increased risk of contracting the deadly disease, and where large numbers of pregnant women died from preventable causes when maternity services were interrupted

This vicious cycle is one of the ways by which inequities are perpetuated and it needs to be broken. The Lancet Commission on Women and Health articulates and provides evidence of these complex and interrelated dimensions and offers recommendations to transform the vicious cycle into a virtuous one.

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2014 by Jonathan Torgovnik/Reportage by Getty ImagesUn crculo virtuoso

Valuing, training, compensating and supporting women in their roles as caregivers would prepare them to offer adequate health care, protect their own health, and improve the health and wellbeing of families and communities.

The impact that enabled and empowered women can have goes well beyond health.19

2012 PWRDFRecomendaciones20VALORAR A LAS MUJERESAsegurar el acceso universal de las mujeres a atencin a la salud de calidad y con enfoque de gneroReconocer las contribuciones remuneradas y no remuneradas de las mujeres a la atencin a la saludDesarrollar, implementar, y reforzar polticas sensibles al gnero que apoyen a las mujeres en sus esfuerzos por integrar sus papeles sociales, biolgicos, y ocupacionales

VALUE WOMEN

First, UHC is a crucial goal of the SDG framework. Giving all women access to a high quality, acceptable and affordable integrated package of preventative and curative interventions for their complex health needs at all stages of the life cycle is a critical priority. Governments and the private sector should expand the service delivery platforms for women to address the unfinished SRHR agenda and the emerging epidemic of chronic and non-communicable diseases and their major risk factors. To ensure equity, supply and demand side incentives to improve quality and access to care for the most vulnerable and marginalized groups of girls and women should be implemented, as well as policies and programs for the elimination of all kinds of barriers to health care, financial and otherwise.

Second, to value the enormous contributions of women as members of the health care workforce and unpaid caregivers, it is imperative to design, implement and guarantee supportive policies and programs. For example, domestic caregiver supportive policies should be widely incorporated into social security institutions and health reform initiatives.

Third, gender responsive social, economic, environmental, educational and health policies and programs can help women integrate their diverse roles. Labor market policies are particularly important, including proven measures such as maternity and paternity leave, child care, and flexible work and career schedules. Other examples include gender-sensitive human resource policies in health and academic institutions that eliminate differences in mens and womens access to advanced training and leadership positions by removing barriers and establishing flexible professional trajectories to ensure that women are not penalized for balancing family and professional duties.

21COMPENSAR A LAS MUJERESEstimar el valor de las contribuciones no remuneradas de las mujeres a la atencin a la salud y compensar su subsidio invisibleAsegurar que mujeres y hombres reciban la misma compensacin por el mismo trabajo en el sector salud (y otros sectores)

COMPENSATE WOMEN

22CONTAR A LAS MUJERESAsegurar que se cuente a las mujeres en la fuerza de trabajo del sector saludGarantizar datos de registros vitales, estadsticas de salud y encuestas desagregados por sexoEstablecer que proyectos de investigacin recluten a mujeres y publiquen resultados desagregados por sexo

COUNT WOMEN

In general, information on the health workforce, one of the key building blocks of health systems, is limited. Whatever data are available, they are not disaggregated by sex. Sex-disaggregated data are essential to increase our understanding of gender differences and inequalities in the health workforce, and to design and evaluate policies and programs to support women and eliminate gender gaps.

Second, civil registration and vital statistics systems are weak in most LMIC. As part of the ongoing calls to strengthen them, sex disaggregation should be one of the most pressing priorities as it would allow us to better understand and act upon the gender-related differences in problems that women share with men. Population surveys and censuses also need to make sex-specific data available. Sex disaggregated data are essential to construct a comprehensive view of womens health across the life course and build capacity for evidence-based policy and programs.

Third, research funding agencies, scientific journals and development partners that support research should promote the generation of evidence to document the interactions between women and health and the impact of policies and programs aimed at addressing the factors that negatively affect women in their dual roles of consumers and providers of health care.

Basic, clinical, social science, and public health research projects should disaggregate study populations by sex and explicitly consider gender in their design, implementation, analysis and reporting.

23RENDIR CUENTASDesarrollar e implementar un marco de rendicin de cuentas e indicadores para el seguimiento de programas y polticas de Mujer y SaludEstablecer mecanismos independientes a niveles global y nacional para apoyar, catalizar y asegurar seguimiento y rendicin de cuentas para Mujer y Salud

BE ACCOUNTABLE TO WOMEN

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In fact, the Commission proposes that women and health is the key for sustainable development.

We discuss a comprehensive model of sustainable development that takes account of womens roles in production and reproduction and their dual roles as consumers and providers of health care, which affect all three domains of sustainable development: society, the environment and the economy.

Our premise is twofold: when women are valued, enabled and empowered in each of these domains, gender equality and health can be achieved; and when women are healthy and have equity in all aspects of life, sustainable development will be possible.25

THANK YOU!GRACIAS!alanger@hsph.harvard.edu26