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Technical consultation on the development of a strategy on women’s health in the WHO European Region Meeting report Copenhagen, Denmark 16–17 December 2015
Technical consultation on the
development of a strategy on women’s health
in the WHO European Region
Meeting report
Copenhagen, Denmark 16–17 December 2015
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Technical consultation on the development of a strategy on women’s health in the WHO
European Region Copenhagen, Denmark 16–17 December 2015
Meeting report
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ABSTRACT
From the 16th to the 17th of December, the Division of Policy and Governance for Health and Well-being and the Division for Noncommunicable Diseases and Promoting Health through the Life-course, gathered a group of experts and senior technical staff from the WHO Regional Office for Europe to discuss priorities for action on women’s health in Europe. The priorities were identified through the review of evidence collected in the report Beyond the mortality advantage: investigating women’s health in Europe. The outcomes of the meeting informed the first draft of the Strategy on Women’s Health in the WHO European Region that will be presented for consideration at the 66th Regional Committee of the Regional Office for Europe.
The Strategy will go beyond reproductive and maternal health and focus on what determines women’s health. It will aim at reducing health inequities for women throughout the life-course, including actions on strengthening governance for women’s health and well-being; on eliminating discriminatory values, norms, practices and behaviors; on tackling the impact of gender, social, economic, cultural and environmental determinants; and on
improving health system responses to women.
Keywords
WOMEN’S HEALTH GENDER EQUITY SOCIAL DETERMINANTS MEETING REPORTS
World Health Organization – Regional Office For EuropeUN City, Marmorvej 51, Dk-2100 Copenhagen Ø, DenmarkTelephone: +45 45 33 70 00 Fax: +45 45 33 70 01
© World Health Organization 2016All rights reserved. This information material is intended for a limited audience only. It may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form or by any means.
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Content
Acronyms ........................................................................................................................................... 5
Background and objectives ......................................................................................................... 6
Taking forward the Health 2020 vision: developing the women’s health strategy in Europe ............................................................................................................................................ 7
Evidence supporting the strategy: producing the women’s health report ................. 8
Ensuring coherence and avoiding duplication: global commitments and regional perspectives .................................................................................................................................... 10
Developing national strategies on women’s health .......................................................... 11
Addressing the recommendations of the review of social determinants and the health divide ................................................................................................................................... 12
Identifying priorities ................................................................................................................... 13 Eliminating discriminatory values, norms, practice behaviours and system responses on tackling differential exposure and vulnerability ................................................................... 13 Biases in the health system and biases in health research ....................................................... 14
Monitoring and evaluation: aligning frameworks and facilitating accountability 15
Planning and next steps .............................................................................................................. 16
Annexes ............................................................................................................................................ 18 Annex 1. Scope and purpose ................................................................................................................ 18 Annex 2 Programme ............................................................................................................................... 20 Annex 3. List of participants ................................................................................................................ 22 Annex 4. Proposed framework for the women’s health strategy (handout)...................... 26
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Acronyms EIGE European Institute for Gender Equality
EU European Union
HAPI Health Action Partnership International
ILO International Labour Organization
MDGs Millennium Development Goals
OECD Organisation for Economic Co-operation and Development
SCRC Standing Committee of the Regional Committee for Europe
SDGs Sustainable Development Goals
UN United Nations
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
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Background and objectives The first technical consultation with experts on the development of the strategy on women’s health took place in Copenhagen, 16–17 December 2015. The scope and purpose of the consultation is presented at Annex 1 and the programme at Annex 2.
The aim of the technical consultation was to bring together experts and policy-makers in women’s health and other related areas to discuss guiding principles and priority areas for action, and to identify gaps and monitoring tools to assess progress and commitments in line with Health 2020,1 the 2030 Agenda for Sustainable Development2 and its accompanying Sustainable Development Goals (SDGs) and other European and global monitoring frameworks. Meeting participants included representatives from national institutes and ministries, experts from the Health Action Partnership International (HAPI), European Institute for Gender Equality (EIGE), European Institute of Women’s Health, researchers and technical experts from WHO, the United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA) and the Organisation for Economic Co-operation and Development (OECD), along with invited consultants and keynote speakers. The participants are listed at Annex 3. The meeting provided:
the European and global context for strategy development, including a progress update on the development of the European action plan for sexual and reproductive health and rights;
up-to-date information on evidence on women’s health and the intersections with underlying social determinants;
an overview of global and regional commitments in relation to women’s health; an exchange of national experiences of developing strategies on the topic; and discussion on how the existing regional and global monitoring frameworks should be
framed within the European strategy.
Presentations from experts were followed by panel discussions and questions from participants. The sessions were designed to identify key priorities, challenges and gaps. Finally, the next steps for the drafting and consultation of the strategy were discussed and a timeline for the coming months was presented.
This report summarises the main points of the presentations and discussions around the content and the process of developing the strategy. The experts expressed their support for this process.
1 Health 2020: the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe; 2012 (http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being, accessed 21 January 2016). 2 United Nations General Assembly resolution A/RES/70/1 on transforming our world: the 2030 agenda for sustainable development. New York (NY): United Nations; 2015 (http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E, accessed 21 January 2016).
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Taking forward the Health 2020 vision: developing the women’s health strategy in Europe A strategy on women’s health will follow the commitments of Health 2020 and act against the social, economic and health inequalities that have been highlighted in the background report Beyond the mortality advantage: investigating women’s health in Europe. 3 The strategy will be closely connected to the forthcoming action plan on sexual and reproductive health and rights. The development of the strategy is a collaboration between the Division of Noncommunicable Diseases and Promoting Health through the Life-course and the Division of Policy and Governance for Health and Well-being of the WHO Regional Office for Europe. Promoting women’s health in the WHO European Region started more than 20 years ago with key milestones such as the Vienna Statement4 in 1994 and the Strategic action plan for the health of women in Europe5 and the Madrid statement,6 both in 2001. Currently, the European policy framework for health and well-being, Health 2020, the 2030 Agenda for Sustainable Development, Beijing + 207 and the Global strategy on women’s, children’s and adolescents’ health8 provide an enabling political environment for the Regional Office to improve women’s health. A European strategy on women’s health, together with the action plan for sexual and reproductive health and rights, presents a key opportunity to influence the health of women across Europe, particularly through key actions on social determinants. The relationship between the two documents was discussed and while there was a general understanding that the strategy and action plan would be mutually reinforcing, it was also agreed among participants that they each separately served specific, and not overlapping, functions. The Women’s health strategy and the report Beyond the mortality advantage are rooted in the values of Health 2020 that include gender mainstreaming as a mechanism to achieve gender 3 Beyond the mortality advantage: investigating women’s health in Europe. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_file/0008/287765/Beyond-the-mortalityadvantage.pdf?ua=1, accessed 21 January 2016). 4 Vienna statement on investing in women’s health in the countries of central and eastern Europe. Copenhagen: WHO Regional Office for Europe; 1994 (http://www.euro.who.int/__data/assets/pdf_file/0017/114236/E93952.pdf?ua=1, accessed 21 January 2016). 5 Strategic action plan for the health of women in Europe. Copenhagen: WHO Regional Office for Europe; 2001 (http://www.euro.who.int/en/publications/abstracts/strategic-action-plan-for-the-health-of-women-in-europe, accessed 21 January 2016). 6 Mainstreaming gender equity in health: the need to move forward. Madrid statement. Copenhagen: WHO Regional Office for Europe; 2001 (http://www.msssi.gob.es/ciudadanos/proteccionSalud/mujeres/docs/DeclaracionMadridIngles.pdf, accessed 21 January 2016). 7 Beijing+20. New York (NY): UN Women, 2016 (http://beijing20.unwomen.org/en/~/media/DFA04926C77F400E93A01048437FF503.ashx, accessed 21 January 2016). 8 Global strategy on women’s, children’s and adolescents’ health. Geneva: World Health Organization; 2015 (http://www.who.int/life-course/partners/ global-strategy/global-strategy-2016-2030/en/, accessed 21 January 2016).
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equity. Health 2020 acknowledges that gender is a determinant of women’s and men’s health that interacts with other social and environmental determinants. The Strategy focuses on what determines women’s health without necessarily comparing women with men. A gender approach also highlights and supports the need to strengthen the understanding of the determinants of men’s health and act on the causes of men dying young in the Region and this analysis will be taken forward. The proposed vision of the strategy is of a European Region in which: all girls and women are enabled and supported in achieving their full health potential and well-being; their human rights are respected, protected and fulfilled; and countries, individually and jointly, work towards reducing gender and socioeconomic inequities in health within the Region and beyond. The strategy will identify key areas for action to reduce health inequities for women throughout the life-course beyond reproductive and maternal health, including actions to: eliminate discriminatory values, norms, practices and behaviours; tackle differential exposure and vulnerability to disease, disability and injury; address biases in health systems and research; and governance. Furthermore, the strategy will be rooted in human rights treaties and commitments with the aim of progressively realizing the right to health for every girl and woman in the Region. It will be developed alongside the action plan for sexual and reproductive health and rights in the WHO European Region 2017–2021, which will also be submitted for consideration to the 66th session of the Regional Committee for Europe.
Evidence supporting the strategy: producing the women’s health report
The main findings of the report Beyond the mortality advantage: investigating women’s health in Europe9 were presented, including the scope, key messages and challenges to collecting evidence to support a women’s health strategy for Europe. The effort to analyse the existing evidence that informs the strategy is ongoing and a more complete version of the report will be published in 2016. It was clear during the discussion that monitoring and surveillance needs to be strengthened across the Region to better understand how inequities accumulate across the lifespan and affect women’s health.
The pattern of inequities varies from country to country and within countries. Inequities in health exist in relation to gender and to a number of socially stratifying factors including, but not limited to, ethnicity, place of residence and disability. These variables interact and can 9 Beyond the mortality advantage: investigating women’s health in Europe. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_file/0008/287765/Beyond-the-mortalityadvantage.pdf?ua=1, accessed 21 January 2016).
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sometimes compound one another. It is important to develop better frameworks for analysis, disseminate best practices and focus more on solutions than problems.
The report follows the life-course approach and there are several possibilities for framing the strategy by integrating this approach. Fig. 1 shows the link between the framework developed by the Knowledge Network for Gender and Women’s Health of the WHO Global Commission of Social Determinants of Health and its links with the life stages. The strategy will aim to make this framework, as well as the recommendations from the Review of social determinants and the health divide in the WHO European Region,10 more operational.
Fig 1. Draft framework for identifying priorities
The discussion around Fig. 1 pointed at the need to restructure the framework by:
merging “Biases in health systems” with “Biases in health research”; including considerations around governance for health equity; and embedding the framework in a narrative reflecting Health 2020 concepts and the
social determinants of health.
10 Review of social determinants and the health divide in the WHO European Region. Updated reprint 2014. Copenhagen: WHO Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0004/251878/Review-of-social-determinants-and-the-health-divide-in-the-WHO-European-Region-FINAL-REPORT.pdf, accessed 21 January 2016).
• Biases in health research
• Biases in health systems
• Differential exposure and vulnerability
• Discriminatory values, norms and practices
Girl child Adolescent
girl
Adult women
Older
women
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A substantial part of the discussion focused on the issue of implementation, the role and capacity of WHO to lead work on social determinants, and how to strengthen stakeholders’ ownership and control over the strategy. Some specific points summarizing the discussion follows.
The choice of key interventions should, as far as possible, reflect the competences, capacities and mandate of WHO as reflected in Health 2020.
In regards to key interventions that are not directly related to the mandate of WHO, it is crucial to identify key partners and sectors for intersectoral collaboration.
Intersectoral interventions should be identified at national level to underpin the strategy and for dissemination as good practice for policy learning.
“Using the right language” – it is necessary to acknowledge that health sector policy-makers are usually more responsive to biomedical concepts and epidemiological findings, and therefore it would be important to make clear the evidence-based connections between action on the determinants of health and concrete health outcomes. Continuous involvement and engagement of stakeholders to build up ownership and facilitate implementation will be necessary.
There is a need to move beyond the mortality/life expectancy measure and build up the well-being and morbidity measures, which are also supported by Health 2020.
In terms of evidence gaps, comments were made in relation to informal carers and the need to understand more about opportunity costs for carers. Although informal care services are not reflected in national health accounts, they are mostly provided by women and are rarely included in any calculation of the overall cost of long-term care. This type of evidence is needed if the strategy aims to be transformative and present options to reduce the burden on women. Linked to these evidence gaps, there were also suggestions to gather more data on health issues related to mental health.
Ensuring coherence and avoiding duplication: global commitments and regional perspectives The development of the Global strategy on women’s, children’s and adolescents’ health 2016–2030 is an important policy document that involved a broad consultation process. The accompanying operational framework of the global strategy is now being developed and it is important to anchor the European strategy within this framework. The SDGs highlight the intersections between health and social determinants and the key achievements of the Millennium Development Goals (MDGs) in health have been to a large extent succeeded by work in sectors outside of health. It is also important to ensure financial support and have a strong research infrastructure. Global goals, targets and indicators can help to reach objectives of regional agendas linked to women’s health. Another global initiative relevant for the strategy is the World Health Assembly resolution on strengthening the role of the health system in addressing violence, in particular against
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women, girls and children,that will be followed by a global action plan currently undergoing consultation. The global action plan acknowledges that countries are in very different stages of recognizing violence against women as a public health issue. Violence against women is a key cross-cutting area for the women’s health strategy and the action plan on sexual and reproductive health and rights. The European strategy on women’s health could be instrumental in accelerating work in implementing the Global strategy on women’s, children’s and adolescents’ health, the SDGs and the World Health Assembly resolution on violence. The strategy can serve as an enabler of United Nations (UN) partnership and interagency coordination in countries, where intersectoral collaboration can be a useful mechanism to “get your own house in order” and responsibilities around when to be a strategic leader and when to be a supporting partner in gender equality work can be shared. The European strategy should also have as an objective to engage other stakeholders from broader society, which is fruitful for implementation. Including and aligning global and regional targets will strengthen commitments from all. WHO is aware of the need to minimize the burden of reporting, and all efforts will be made to avoid overlap and duplication and facilitate the task as far as possible.
Developing national strategies on women’s health Countries in the European Region are addressing women’s health in different ways through policies and plans. Examples from two countries’ national policies on women’s health – Austria and France – illustrated the discussion on how a European strategy can inform national policies and how it can relate to national priorities. The Austrian national action plan for women’s health is based on the Health 2020 principles. It includes 40 actions across all age groups and strongly affirms the importance of addressing gender-based inequalities and the impact of social determinants and equity-oriented approaches. The draft of the strategy is well advanced and it will be discussed by the Austrian Parliament during the first half of 2016. Priorities focus on mental health, gender stereotypes, targeted intersectoral approaches, strong health system responses and awareness-raising about violence and health. The French national strategy on women’s health is at the stage of preparing a report that reviews existing evidence on women’s health and current programmes dealing with key areas. This report will serve to identify priority areas for the national strategy. The proposal is to move from a biological approach centred mostly on reproductive health to a more holistic approach that: a) coordinates policies at national, subnational and local levels; b) improves epidemiological and sociological knowledge; c) acts on the determinants of health; and d) improves the mental health path and professional practices in cardiovascular diseases. The European strategy may support the national strategy in the collection and dissemination of evidence and good practices, particularly in relation to work with other sectors.
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Experts from Iceland, the Republic of Moldova and Slovenia highlighted priorities from their countries that were complemented by other experts during the general discussion. These priorities included:
looking at the impact of the wider determinants of health and of gender equality policies; using epidemiological data to trigger political agenda-setting; building skills and competences to negotiate with, and present solutions to, other sectors
to transform discriminatory practices; strengthening the health system infrastructure to respond to women’s health needs; analysing the role of the feminization of the health workforce; addressing barriers in the workforce due to lack of competences and skills and to
discriminatory norms and values; and focusing on multiple vulnerabilities and the severe exclusion faced by rural women,
women belonging to minorities, migrant women, older women and women discriminated against because of their sexual and gender identities (linking with the sexual and reproductive health and rights action plan).
Addressing the recommendations of the review of social determinants and the health divide The WHO Review of social determinants and the health divide in the European Region11 made a series of recommendations for actions on upstream determinants that can have a strong impact on improving women’s health. The European women’s health strategy can play an important role in assisting countries to implement these recommendations. The review recognises that gender inequities affect women’s health status and well-being, that women also face inequities in the social and economic determinants of health, and that addressing women’s health in the European Region means tackling social and economic inequities in society. It is important to accumulate knowledge and build on the existing policies, initiatives and experiences at country level. Some of the key recommendations were highlighted, such as promoting gender equity and adequate social protection measures, strengthening action at local level, targeting social exclusion and promoting sustainable development. Health and well-being is interconnected at every age and across generations and making social protection for health more efficient is an important recommendation for women’s health. The International Labour Organization (ILO)
11 Review of social determinants and the health divide in the WHO European Region. Updated reprint 2014. Copenhagen: WHO Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0004/251878/Review-of-social-determinants-and-the-health-divide-in-the-WHO-European-Region-FINAL-REPORT.pdf, accessed 21 January 2016).
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resolution on social protection floors (access to basic health and education services) could be a tool for WHO to strengthen social protection. The difficulty for WHO in driving social agendas and welfare redistribution was acknowledged as a key challenge and, the need for more strategic advocacy and intersectoral approaches, both at international and country levels, was highlighted. Some suggestions to make the recommendations more specific were brought into the discussion. It is important to link the broader determinants with universal health coverage, and then further drill down to more specific and concrete actions. Some actions could propose frameworks on how to collect disaggregated data on well-being and morbidity or toolkits and training for countries to look at issues such as gender bias in the workplace, education and employment. The importance of encouraging leadership on women’s health in the health system, promoting good policy models and health system practices between countries, and supporting policy dialogue and learning was recognized.
Identifying priorities
The presentations and discussions served to develop a framework that included a proposed vision of the strategy, guiding principles and main objectives. This was shared with participants in a handout to guide the discussion on priorities (see Annex 4).
Eliminating discriminatory values, norms, practice behaviours and system responses on tackling differential exposure and vulnerability
This session discussed how discriminatory values, norms, practices, behaviours and system responses increase vulnerability and limit access to services. Discriminatory values and norms are behind gender stereotypes in society and the combined work of the education and health sectors is crucial to promote positive body images among girls and adolescents and avoid negative health consequences. Gender-based violence against women in all its forms – sexual, physical and mental – is an example of discrimination present in all countries in the Region. Although general awareness has increased over the last 20 years, gender-based violence against women is not consistently recognized by everyone in the health system as a health problem. The importance of specifically addressing discriminatory values and practices produced by the system and embedded in professional attitudes was highlighted. Specific barriers to health care services experienced by migrant and Roma women was described as a consequence of discriminatory practices and biases in the health system.
Another example looked at how social determinants and gender stereotypes affect the prevalence of depression and dementia among women in Europe. This is not specifically recognized in the current WHO mental health action plan, and it would therefore be of
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essence to have it covered in a European women’s health strategy. The strategy on women’s health will strengthen the use of a gender approach to mental health that looks at and analyses sex-disaggregated data. A gender approach to mental health and well-being will translate in improvements for both women and men. Specific suggestions for the strategy to address included:
increasing awareness and capacity-building among health professionals that gender-based violence is a public health issue;
strengthening the links between mental health and gender-based violence; implementing specific actions on gender stereotyping in mental health and gender
bias in acute care and hospital management related to cardiovascular disease; specific actions on follow-up treatment for women in mental health (women may
have adverse side-effects from antidepressant drugs); and promoting health assets – what are the positive reinforcing factors that prevent
suicide, depression and anxiety, for example?
Biases in the health system and biases in health research Three examples of gender bias in the health system illustrated this discussion: responses to cardiovascular diseases; the role and needs of women in formal and informal care; and gender-blind medicine. While cardiovascular disease is the major cause of death for women in the European Region, it is still perceived as a men’s health issue. The risk to women is often underestimated because of the perception that women are “protected”. Women have a lower risk during fertile age, but protection fades away after menopause, when risk increases. Assessment and management of cardiovascular risk in women often ignores factors that are particularly important for women, such as diabetes, obesity, physical inactivity and smoking. There is a need to increase participation of women in clinical trials, to perform a gender analysis of data, increase women’s awareness of cardiovascular disease and build professionals’ capacity. The gender dimensions of formal and informal care are crucial and need to be addressed, particularly among the older population. The consequences of an ageing population causes challenges for long-term care strategies, as recognized in the WHO strategy and action plan for healthy ageing in Europe, 2012–2020.12 Women are overrepresented as care providers in the formal and informal sector but also as care recipients among those aged 65 and over, both in institutions and at home. Moreover, there has been an internationalization of long-term care with growing staff migration, involving mostly women. The strategy presents a unique
12 Strategy and action plan for healthy ageing in Europe, 2012–2020. Copenhagen: WHO Regional Office for Europe; 2012 (EUR/RC62/10; http://www.euro.who.int/__data/assets/pdf_file/0008/175544/RC62wd10Rev1-Eng.pdf?ua=1, accessed 21 January 2016).
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opportunity to address the gender dimension of care by addressing the role and needs of women across their lives. While some diseases affect men and women differently (such as lung cancer, diabetes, depression and cardiovascular disease), medicines resulting from clinical trials where men are overrepresented mask different side-effects for women and different efficiency of treatments. The relationship between sex and gender is not integrated in medical education.
Specific suggestions for the strategy to address included:
adding health financing in the section on “Biases in the health system and biases in health research”;
reflecting how the health system integrates women’s needs in practice, such as addressing gender gaps in high-quality acute care and hospital management related to cardiovascular diseases; and
recommending practices aligned with the health system’s capacity to respond (mammography, for example, does not improve women’s health if there is no capacity for diagnosis, treatment and follow-up).
Monitoring and evaluation: aligning frameworks and facilitating accountability Monitoring and evaluation are key interventions for guiding implementation and fostering commitment. This should be done within existing monitoring frameworks developed for Health 2020 implementation, the global strategy and the SDGs. The European strategy on women’s health will not develop specific targets but will promote the monitoring of women’s health within existing indicators, since there is a plea from countries not to create new indicators. One first step would be, however, to promote and ensure that key indicators are disaggregated by sex, age and socioeconomic variables. Another will be to use existing equality indexes to monitor women’s health and well-being across the Region. It is recommended that the SDG and global strategy accountability framework be used to help countries strengthen their monitoring and accountability processes, in particular around monitoring equity. Discussion was organized around existing monitoring frameworks developed by WHO (Health 2020), the OECD (well-being) and EIGE (the Gender Equality Index). Health 2020 has developed targets and indicators that are being used to monitor progress in countries. The framework presents opportunities to strengthen gender analysis, promote disaggregation of data and strengthen measurement of well-being.
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OECD’s work on measuring well-being and social progress looks at gender differences in well-being throughout the life-course in different settings, and social determinants of health. The strong correlation between health and other well-being outcomes can be seen in the reduced economic resources of single mothers and women over 65, the impact of gender stereotypes on health, the wage gap between women with children and women without children, and the health impact of unpaid work and subjective well-being of women. The composite index for equality among women for policy actions looks at income, health, employment, education, social support and life satisfaction. Another important actor in monitoring gender inequalities is the EIGE, which has a mandate limited to European Union (EU) countries. The health domain of the Gender Equality Index is currently based on limited data (life expectancy, healthy life years, self-perceived health and access to medical examination and dental examination). EIGE is working on including data on health behaviour to the index to reflect gender inequalities better. In doing so, EIGE would like to be in line with the objectives of the women’s health strategy so the index could be used to monitor some aspect of the strategy in EU countries. Another important monitoring tool is the series of regular reports monitoring the Beijing Platform for Action produced for the EU presidencies. The next one, prepared for the Slovakian Presidency, will cover women and poverty. In case any of the future presidency countries chooses to monitor the area of health in the Beijing Platform for Action, EIGE would be reviewing these areas. In this context, EIGE is developing indicators that provide an opportunity for EU-wide indicators to be in line with the women’s health strategy. Specific suggestions for the strategy to address included:
the need to look at quality, not only quantity (for instance, not only the quantity of jobs but also their quality);
strengthening knowledge of intra-household allocation of economic resources; recording and valuing unpaid care work; giving visibility to invisible women in statistics, such as homeless and Roma women; strengthening data quality and capacity for gender and equity analysis across the
Region; and using the monitoring framework to strengthen accountability.
Planning and next steps
Below is a series of key milestones in the development of the strategy on women’s health:
• mid-November 2015: feedback from the second session of the Twenty-third Standing Committee of the Regional Committee for Europe (SCRC);
• mid-December 2015: technical consultation with experts about priorities based on existing evidence;
• end of January 2016: full draft of the strategy submitted for consultation to the Twenty-third SCRC;
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• February 2016: consultations with civil society and technical focal points;
• March 2016: online consultation with Member States;
• May 2016: open discussion of the draft strategy at the fourth session of the Twenty-third SCRC; and
• September 2016: 66th session of the Regional Committee for Europe:
- launch of the European women’s health report 2016; and - discussion of the strategy on women’s health in the WHO European Region
2017–2021, presented in a draft resolution together with the action plan for sexual and reproductive health and rights in the WHO European Region 2017–2021.
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Annexes Annex 1. Scope and purpose While women’s health in the WHO European Region is generally better than elsewhere in the world, this is not necessarily true for all women. Health inequities among women both within and between countries in the Region are still large and unjustifiable. Women in Europe have unequal access to the resources they need to enjoy their right to health. Moreover, health inequities have both social and economic costs for society as a whole. It is also known that women in the WHO European Region live longer than men in all 53 Member States and this is referred to as women’s mortality advantage. However, this doesn’t necessarily translate to healthy years: the extra years may be offset by disability or activity restriction.1 Reflecting the objectives of the European policy framework for health and well-being, Health 2020, the WHO Regional Office for Europe is proposing that a strategy on women’s health in the WHO European Region be adopted at the 66th session of the Regional Committee for Europe in 2016. The strategy will go beyond reproductive and maternal health to identify key areas for action to reduce health inequities for women throughout the life-course, including actions to: eliminate discriminatory values, norms, practices and behaviours; tackle differential exposure and vulnerability to disease, disability and injury; address biases in health systems; and address biases in research. The strategy will not be an isolated document: it will strengthen the global efforts to advance women’s health, which Member States have endorsed through the adoption of the 2030 Agenda for Sustainable Development and its accompanying Sustainable Development Goals, in particular Goals 3, 5 and 10 on health and well-being, achieving gender equality and reducing inequalities. It will also support the Global strategy on women’s, children’s and adolescents’ health 2016–2030.2 Furthermore, the strategy will be rooted in human rights treaties and commitments with the aim of progressively realizing the right to health for every girl and woman in the Region.
1 Beyond the mortality advantage: investigating women’s health in Europe. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_file/0008/287765/Beyond-the-mortalityadvantage.pdf?ua=1, accessed 21 January 2016). 2 Global strategy on women’s, children’s and adolescents’ health. Geneva: World Health Organization; 2015 (http://www.who.int/life-course/partners/ global-strategy/global-strategy-2016-2030/en/, accessed 21 January 2016).
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The intention is that the strategy will provide a framework to guide and inform development of country-specific policy responses in improving women’s health and build upon existing initiatives driven by Member States. It will reflect the fact that women are not a homogenous group and take into account the different cultural and socioeconomic profiles of the countries of the Region. The strategy will be developed alongside the action plan for sexual and reproductive health and rights in the WHO European Region 2017–2021, which will also be submitted to the Regional Committee for consideration at its 66th session. In the process of developing the strategy, the WHO Regional Office for Europe is planning a two-day technical consultation with experts on 16–17 December 2015 in Copenhagen. Objectives of the consultation The consultation aims to bring together the key experts in women’s health and other related areas, such as health systems, nutrition and physical activity, mental health, tobacco and alcohol, and the life-course approach from different parts of the Region. The specific objectives of the meeting are to:
1. discuss the guiding principles and the key priority areas for action;
2. identify gaps that will strengthen the evidence supporting the strategy;
3. suggest policy actions and guide implementation following the recommendations of the Review of social determinants and the health divide in the WHO European Region;3 and
4. discuss monitoring and evaluation that can be aligned with Health 2020, the SDGs
and the global strategy monitoring frameworks. The expected outcome of the meeting is consensus on the principles, key priority actions and further involvement of Member States and other stakeholders in finalization of the strategy.
3 Review of social determinants and the health divide in the WHO European Region. Updated reprint 2014. Copenhagen: WHO Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0004/251878/Review-of-social-determinants-and-the-health-divide-in-the-WHO-European-Region-FINAL-REPORT.pdf, accessed 21 January 2016).
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Annex 2 Programme Day 1, 16 December 2015
09:00–09:30
Introductions and welcome, Gauden Galea, Director, Division of Noncommunicable Diseases and Promoting Health through the Life-course
Welcome and Opening of consultation Introduction of participants Setting the scene: meeting objectives
09:30–10:15 Session 1: Taking forward the Health 2020 vision: developing the women’s health strategy in Europe Chair, Gauden Galea, Director, Division o Noncommunicable Diseases and Promoting Health through the Life-course
Guiding principles, cross-cutting priorities and milestones: Isabel Yordi Aguirre, WHO Regional Office for Europe
Action plan on sexual and reproductive health and rights: Gunta Lazdane, WHO Regional Office for Europe
Discussion
10:45–12:15
Session 2: Evidence supporting the Strategy: producing the women’s health report
Chair, Claudia Garcia Moreno, WHO headquarters
Beyond the mortality advantage: Sarah Simpson, Consultant Presenting the working framework for the European women’s health
strategy: Isabel Yordi Aguirre, WHO Regional Office for Europe Discussion
13:30–15:00
Session 3: Ensuring coherence and avoiding duplication: global commitments and regional perspectives Chair: Gunta Lazdane, WHO Regional Office for Europe
SDGs and the Global strategy on women's, children's and adolescent's health 2016–2030: Anshu Banerjee, WHO headquarters
Panel including UN agencies’ perspectives: Christoph Hamelmann, UNDP; Tamar Khomasuridze, UNFPA; and Claudia Garcia Moreno, WHO (global action plan on preventing violence against women)
Discussion
15:30–17:00 Session 4: Developing national strategies on women’s health Chair Bosse Pettersson, Independent Public Health Consultant
Country presentations: Beate Wimmer-Puchinger (Austria) and Bernard Faliu (France)
Panel including experts’ perspectives: Vilborg Ingólfsdottir (Iceland), Sonja Tomsic (Slovenia) and Valentina Bodrug (Republic of Moldova)
Discussion
17:00 Conclusions of Day 1 Isabel Yordi Aguirre
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Day 2, 17 December 2015 08:30–10:00 Session 5: Addressing the recommendations of the review of social
determinants and the health divide Chair Monika Kosinska, WHO Regional Office for Europe
How the strategy can support and strengthen implementation with a focus on improving women's health: Johanna Hanefeld, Consultant
Panel discussion including perspectives from Bosse Petersson, Maggie Davies (Health Action Partnership International), Barbara Rohregger (Consultant) and Martin Weber (WHO Regional Office for Europe)
Discussion
10:30–12:00
Session 6: Key priority areas for action 1: eliminating discriminatory values, norms, practices and behaviours and on tackling differential exposure and vulnerability Chair: Isabel Yordi Aguirre
Short interventions from experts on violence against women (Claudia Garcia Moreno and Carmen Vives), gender stereotypes (Beate Wimmer-Puchinger), mental health (Matt Muijen)
Discussion
13:00–14:00 Session 7: Key priority areas for action 2: biases in the health system and biases in health research Chair: Isabel Yordi Aguirre
Short interventions from experts on cardiovascular diseases (Marco Stramba-Badiale), healthy ageing, disability and care (Manfred Huber) and gender-based medicine (Peggy Maguire)
Discussion
14:00–15:30 Session 8: Monitoring and evaluation: aligning frameworks and facilitating accountability Chair: Anshu Banerjee
Short presentations on relevant existing monitoring processes: WHO, Regional Office for Europe (Ivo Rakovac), OECD (Carlotta Balestra), European Institute for Gender Equality (Marre Karu)
What would be the strategy recommendations?
15:30–16:00 Session 9: Next steps and conclusion of the meeting Milestones and consultation process: involving Member States and civil society
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Annex 3. List of participants Temporary advisers Ms Carlotta Balestra Policy Analyst Statistics Directorate, OECD Professor Valentina Bodrug-Lungu President Gender-Center Dr Lourdes Cantarero Assistant Professor Department of Pharmacy, University of Copenhagen Dr Maggie Davies Executive Director Health Action Partnership International (HAPI) Dr Bernard Faliu Head of Population Health Office General Health Directorate, France (DGS) Dr Paula Franklin Research Officer, Gender Mainstreaming European Institute for Gender Equality (EIGE) Ms Vilborg Ingólfsdóttir Director General Ministry of Welfare in Iceland Dr Marre Karu Researcher, Gender Equality, Operations Unit European Institute for Gender Equality (EIGE) Ms Peggy Maguire Director-General European Institute of Women’s Health Mr Alexander Mathieson Freelance Writer and Editor Ms Cecilie Fenger Michaelsen Head of Section Rights and Social Progress, Development, Policy and Global Cooperation Ministry of Foreign Affairs, Denmark Ms Rosaana Peiró-Pérez Responsible for Cancer and Public Health Research Area FISABIO-DGSP, Conselleria Sanitat, G. Valenciana
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Mr Bosse Pettersson Independent Public Health Consultant Dr Barbara Rohregger Consultant, University of Applied Science Rhein Bonn Sieg Dr Marco Stramba-Badiale Director, Geriatrics and Cardiovascular Medicine Istituto Auxologico Italiano Dr Sonja Tomšič Public Health Specialist National Institute of Public Health, Slovenia Dr Carmen Vives Cases Associate Professor Community Nursing, Preventive Medicine and Public Health and History of Science Alicante University Professor Dr Beate Wimmer-Puchinger Executive Director for Women’s Health Vienna Women’s Health Programme Consultants Ms Vivian Barnekow Consultant WHO Regional Office for Europe Ms Johanna Hanefeld Consultant WHO Regional Office for Europe Ms Susanna Kugelberg Consultant WHO Regional Office for Europe Ms Sarah Simpson Consultant WHO Regional Office for Europe Representatives of other United Nations organizations Dr Christoph Hamelmann Regional Team Leader for HIV, Health and Development UNDP Regional Centre for Europe and the Commonwealth of Independent States Dr Tamar Khomasuridze Sexual and Reproductive Health Adviser for Eastern Europe and Central Asia UNFPA Eastern Europe and Central Asia Regional Office, Istanbul
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World Health Organization Regional Office for Europe Dr Gauden Galea Director Division of Noncommunicable Diseases and Health Promotion Dr Manfred Huber Coordinator of Healthy Ageing, Disability and Long Term Care Division of Noncommunicable Diseases and Health Promotion Ms Monika Kosinska Programme Manager for Governance for Health Division of Policy and Governance for Health and Well-being Dr Gunta Lazdane Programme Manager for Sexual and Reproductive Health Division of Noncommunicable Diseases and Health Promotion Ms Porcia Maley Secretary Division of Policy and Governance for Health and Well-being Dr Matthijs Muijen Programme Manager for Mental Health Division of Noncommunicable Diseases and Health Promotion Ms Natalia Nemirova Programme Assistant Division of Policy and Governance for Health and Well-being Ms Åsa Nihlen Technical Officer Division of Policy and Governance for Health and Well-being Dr Govin Permanand Health Policy Analyst Division of Health Systems and Public Health Dr Ivo Rakovac Technical Officer Division of Information, Evidence, Research and Innovation Dr Aiga Rurane Head of Country Office Latvia Dr Dinesh Sethi Programme Manager for Violence and Injury Prevention
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Ms Isabel Yordi Aguirre Gender Adviser Division of Policy and Governance for Health and Well-being Dr Martin Weber Programme Manager for Child and Adolescent Health and Development Division of Noncommunicable Diseases and Health Promotion WHO headquarters Dr Anshu Banerjee Senior Advisor Reproductive Health and Research Dr Claudia Garcia Moreno Esteva Medical Officer Adolescents and at-risk Populations, Reproductive Health and Research
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Annex 4. Proposed framework for the women’s health strategy (handout) Vision: a WHO European Region in which all girls and women are enabled and supported in achieving their full health potential and well-being; their human rights respected, protected and fulfilled; and countries, individually and jointly, work towards reducing gender and socioeconomic inequities in health within the Region and beyond.
Guiding principles • Girls and women’s health across the life-course: sex and gender interact with social
determinants of health showing how health risks and benefits accumulate through life. • Equity driven: the strategy recognizes that women are not a homogeneous group and
will focus on girls and women experiencing social exclusion, discrimination or living in underserved communities.
• Human-rights based: women’s rights and the right to health need to be addressed across priorities and actions.
• Gender responsive: it recognizes the need for policies that aim to achieve gender equality as a contributor to health and well-being.
• Intersectoral action: the strategy aims to strengthen the role of the health sector in improving women’s health while identifying key areas for interaction with other sectors such as education, social protection and environment.
• Participation of women and communities: women are powerful actors of change and the strategy supports women’s leadership and participation in decision-making.
Objectives
A. Eliminating gender-based discriminatory values, norms, practices and behaviours by:
1. building capacity among health service providers to promote the valuing of girls and eliminate practices that are damaging to women’s health and violate their human rights, such as gender-bias sex selection, female genital mutilation, early marriage, forced marriage and violence against women;
2. challenging gender stereotypes that start early in life and are reinforced across the life-course, driving women:
a. into educational and occupational choices underpinned by limited gender transformative policies; and
b. towards health-damaging behaviours and outcomes such as eating disorders, depression and suicide; and
3. identifying and addressing institutional bias that may perpetuate discriminatory values, norms and practices in areas such as health education, pension schemes, health insurance policies and media messages.
B. Tackling the differential exposure and vulnerability to ill health caused by the interaction between gender and other socioeconomic determinants of health with a focus on:
1. improving mental health and well-being of girls and women;
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2. reducing risk behaviours such as alcohol and tobacco consumption, drug abuse and reduced physical activity;
3. improving the conditions and environments to be healthy; and 4. addressing the impact of migration on women’s health.
C. Addressing biases in health systems and health research by: 1. collecting and analysing data disaggregated by sex and age: evidence shows that even
in the European Region, collection and analysis of sex-disaggregated data, and cross-sections with other variables, such as income, education, and urban/rural residence, are still lacking;
2. ensuring that health services respond to women’s needs throughout the life-course: health services have traditionally considered women’s health to mean maternal health, whereas a life-course approach means considering the health of women in their own right, not only as potential mothers; health services have also assumed that women experience conditions, such as cardiovascular diseases, cancers, diabetes and others, in the same way as men, an assumption that can result in misdiagnosis and inefficient treatment;
3. promoting gender-transformative policies that guarantee caring for the carers, recognizing the value of women’s time as formal and informal carers and ensuring that increases in poverty levels in older age do not limit women’s access to health;
4. addressing gender bias in the education of the health workforce; 5. ensuring a policy and service response that ends the acceptability and tolerance of all
forms of violence against women and girls and strengthens the role of the health system;
6. promoting research and innovation to eliminate bias in service delivery and health promotion: women have the right to the best possible health and limiting their participation in research limits their potential and damages their health; and
7. supporting gender-based medicine to improve detection, diagnosis and treatment of major chronic diseases in women.
D. Strengthening governance for women’s health by: 1. including women’s health in intersectoral mechanisms for gender equality; 2. including gender perspectives in intersectoral initiatives addressing the social
determinants of health and health equity; 3. promoting women’s leadership for change at policy and health system levels; 4. leading by example: adopting gender-transformative policies and laws in the health
sector and ensuring a life-course approach to women’s health across health programmes and policies;
5. gender-budgeting health policy and programmes; 6. strengthening links with the education sector to address gender stereotypes in
primary, secondary and tertiary education; and 7. ensuring accountability mechanisms at country level that are coherent with European
and global mechanisms, targets and indicators.
