1. Gender inequality in health care Ana Fernandes Julian Perelman Céu Mateus Meeting of the Aachen Group Sintra, 9-10th April 2006 Universidade Nova de Lisboa Escola Nacional de Saúde Pública

2. General focus Health services achieving –Universality –Solidarity –Equity in access/outcomes Health policies –Promoting adequacy of health services –Sensitive to the changing health needs of citizens Common Values

3. Dimensions of inequality Health Morbidity Mortality Health care provision Access Funding Resources’ source Resources’ allocation Vectorsof analisysVectorsof analisys Geographic: - regions - counties - municipalities Use - Age - Gender Socio-economic: - income - education - profession

4. Research on gender inequalities in health care Inequalities in access / treatment for: Cardiovascular diseases Cerebro-vascular diseases (stroke) Diabetes Dialysis and kidney transplant Screening for lung cancer HIV/AIDS (access to antiretroviral therapy) Higher use of pharmaceuticals among women

5. Cardiovascular diseases: Gender inequalities in treatment In early stage (before AMI) women have lower access to: –non-invasive procedures (stress test) –diagnostic high-technology procedures (angiography) –revascularization (PCI or bypass) In admissions for acute myocardial infarction: –lower access to bypass, but equal or higher access to PCI higher mortality and harder recovery for women after bypass –several studies do not ascertain any gender inequality in access to high-tech treatment

6. Cardiovascular disease: causes for gender inequalities in treatment 1.Lower access related to women’s lower socio-economic status (lower access to private insurance, out-of-pocket payments, poorer information) 2.Physician’s discrimination Subjective Objective – due to higher difficulty in interpreting or targeting symptoms (male-oriented research and guidelines) 3.Higher reluctance by women to follow invasive treatments

7. Socio-economic inequality related to gender In all OECD countries, women have, on average, a lower socio-economic status than men –In 2002, in Portugal, the average monthly income was € 601 for women and € 747 for men

8. Women's average pay as % of men's - 2004 Notes: figures are for 2004 except * 2002, ** 2000, *** 2003, **** 1998, ***** 2001 ; Source: EIRO

9. Inequity in access to general practitioner Pro rich Pro poor

10. Inequity in access to general specialist Pro rich

11. Women’s health Main priorities when studying women’s health 1.Main causes of death 2.Diseases with a higher prevalence 3.Reproductive health 4.Violence against women 5.Health determinants Chesney and Ozer, 1995

12. Women’s health Main priorities when studying women’s health 1.Main causes of death 2.Diseases with a higher prevalence 3.Reproductive health 4.Violence against women 5.Health determinants Chesney and Ozer, 1995

13. Main causes of death Cardiovascular diseases Stroke Female cancers (breast, uterus & cervix, ovary) Cancer of colon and rectum Lung cancer Sources: http://www.euro.who.int/ P. Boyle* & J. Ferlay Annals of Oncology 16: 481–488, 2005

14. Age-standardized death rates from cardio- vascular disease, women aged 35-74, latest available year Source: World Health Organization (2004) http://www3.who.int/whosis/menu.cfm www.heartstats.org

15. Age-standardized death rates from stroke, women aged 35-74, latest available year Source: World Health Organization (2004) http://www3.who.int/whosis/menu.cfm www.heartstats.org

16. Source: Atlas of Health in Europe, 2003 http://www.euro.who.int

17. Source: Atlas of Health in Europe, 2003 http://www.euro.who.int

18. Source: The European Health Report, 2005 http://www.euro.who.int/ehr2005

19. Women’s health Main priorities when studying women’s health 1.Main causes of death 2.Diseases with a higher prevalence 3.Reproductive health 4.Violence against women 5.Health determinants Chesney and Ozer, 1995

20. Diseases with higher prevalence Chronic diseases and mental health diseases Chronic diseases in Portugal WomenMen Diabetes56%44% Epilepsy57%43% Asthma54%45% Hypertension63%37% Back pain61%39% Source: National Health Survey, 1998/99, ONSA

21. Women’s health Main priorities when studying women’s health 1.Main causes of death 2.Diseases with a higher prevalence 3.Reproductive health 4.Violence against women 5.Health determinants Chesney and Ozer, 1995

22. Source: Atlas of Health in Europe http://www.euro.who.it Source: Atlas of Health in Europe, 2003 http://www.euro.who.int

23. Source: Atlas of Health in Europe, 2003 http://www.euro.who.int

24. Source: Atlas of Health in Europe, 2003 http://www.euro.who.int

25. Women’s health Main priorities when studying women’s health 1.Main causes of death 2.Diseases with a higher prevalence 3.Reproductive health 4.Violence against women 5.Health determinants (tobacco and alcohol consumption, physical activity, etc.) Chesney and Ozer, 1995

26. Women’s health Women’s health is an issue that goes well beyond gender inequalities in access and treatment

27. European Health Report 2005 “Differences across countries and population groups indicate how much impact policies to prevent and control major risk factors could have”

28. Research Outline for Portugal Inpatient administrative data Waiting lists IMS Outpatient administrative data (GP, specialists care)

29. Waiting times in Portugal: gender bias?

30. Discussion To reduce gender inequality in health care, socio-economic inequalities have to be addressed To tackle gender-related inequalities, health policies will vary according to relevant inequalities – a strong effort should be put on ascertaining causes and relevance of differences Research on gender inequalities in health care related to access and to treatment is not conclusive Systematic comparison of women’s health conditions and assessment of health policies promoting gender equality should figure in the agenda of a European Institute for Gender Equality.

31. Gender inequality and socio-economic inequality Inequity in access to care + gender socio-economic inequalities = gender inequalities in access to care? Reducing gender inequality in access should start with reducing socio-economic inequality in access!