Women are underrepresented throughout the health policy continuum from research to access and appropriate healthcare. How can this imbalance be addressed?
What is killing women in Europe today? The list includes cardiovascular disease, cancer and respiratory disease, which account for nearly four-fifths of women's (and men’s) deaths on the continent (Eurostat 2017a; WHO 2012). However, data and evidence overwhelmingly indicate that healthcare (health service delivery) and health systems (policies and organisation) are systemically failing women.
Sex and gender—which includes both biological and social influences—are critical to health. Many diseases affect men and women differently, including diabetes, depression and cardiovascular disease. In addition, women do not present with the same symptoms and respond differently to treatments than do men. Women also have higher rates of disease such as breast cancer, osteoporosis and auto-immune diseases (EIWH 2018a; Eurostat 2017b; ENGENDER 2011; EIWH 2017ab).
Many factors that lie outside the health sector—including socioeconomic status, education, culture and ethnicity differences—impact patterns of behaviour, access to resources, affecting both women and men’s vulnerability to illness and ability to access appropriate healthcare (EIWH 2018a; ENGENDER 2011; EIWH 2006; 2017b). Biological differences and social factors create inequities for women with regard to access to quality healthcare and better health outcomes.
Health promotion and healthcare delivery have large implications for women’s health. The current model predominately employs a “one-size fits all” approach. Equity must underpin healthcare delivery. This does not necessarily mean providing the same treatment, but treatments that result in better outcomes that improve the health of women and men and effectively utilise health resources. The case for sex and gender-based interventions is indisputable. Despite available evidence calling for change, the motivation to transform the fundamental workings of over-stretched healthcare systems is inconsistent and often lacking.
The European Institute of Women’s Health recently published the recommendations from its multidisciplinary expert conference held in Brussels in December 2017. The delegates called for urgent action to integrate sex and gender right from the start in health research, policy, programming and practice through to implementation by employing a life course approach (EIWH 2018b; 2018c).
Women: the frontline of health
Women are on the frontline of health—and disproportionately so. They comprise the majority of health professionals and caregivers (paid and unfortunately, far too often unpaid). They perform most domestic household chores, essential yet predominantly unpaid or low-paid duties.
As mothers, daughters, wives and friends, women are the managers of health and key health decision-makers, often at the expense of their own health and wellbeing. Women are also patients, particularly during their older years, in an increasingly ageing society where women outlive men but spend their older years disproportionately burdened by ill health (Eurostat 2017b).
Women in Europe have lower pay, often in less secure and informal occupations. They earn 16 percent less than men and receive pensions that are 40 percent lower than men (European Parliament 2017). These accumulated inequities have large repercussions for their health. Equity of opportunities for women and men must be ensured in all policies as enshrined in the European Pillar of Social Rights (European Commission 2018).
Top killers of women
Lack of investment in prevention: Prevention, treatment and care fail to adequately integrate sex and gender differences at a high cost to women and their families. Available evidence must be used to identify entry points for interventions specific to girls and women. Health messaging must be tailored to compete with advertising (such as alcohol and tobacco) that targets women. Vaccination, cancer screening and other vital health promotion require dedicated budgets, and an overall shift is needed in policy and programming from treatment to a focus on prevention and early intervention.
Healthcare and health system organisation: The utilisation of healthcare services varies across life, and there are differences between men and women in health behaviour and care provision. For example, the symptoms of cardiovascular disease in women can be different from those of men, and women are slower than men to react when these symptoms appear (EIWH 2017b). As women and men use healthcare in different ways, services must be adapted to better meet everyone’s needs (EIWH 2018c). Multilingual, understandable and accessible information that empowers patients, caregivers and their families is lacking, despite evidence that health-literate patients experience better health outcomes and lower health service usage.
Lack of sex and gender in research: Women are the heaviest medicine users, yet they remain under-represented in biomedical and health research and data. Consequently, the evidence base is weaker for women as well as for older people. Women have more than a 50 percent greater risk of developing adverse drug reactions compared to men (Rademaker 2001). Medicinal products are safer and more effective for everyone when clinical research studies include diverse population groups. In order to provide more individualised care (personalised medicine), sex and gender must be incorporated throughout the process from design of clinical trial protocols, data analysis, health technology assessment and access to care. The inclusion of sex and gender benefits both women and men’s health.
Maternal mortality and morbidity: Every woman has a fundamental right to high-quality maternity care within the European Union; however, large variations exist within and across Member States. Central issues such as perinatal health; pregnancy, birth, post-partum support; and the safe use of medicines during pregnancy and lactation must be resolved. Standards for maternal healthcare need to be systematically implemented and monitored.
Unhealthy ageing: Given women’s essential role, healthcare systems should be highly responsive to women, yet research, programming, policy and practice continue to let them down. Consequently, although women outlive men by more than five years, their healthy life expectancy advantage is less than nine months (Eurostat 2017b). Ageing is a major risk factor for women’s ill health. Women are also at the forefront of ageing due to their greater longevity than men and their multiple carer and societal roles. One of the biggest challenges facing European society, which has the highest proportion of older women in the world, is retaining and maintaining health during old age.
Health is not in all policies: Women’s health and wellbeing includes biological, social, economic and political factors, which must be incorporated into all policies that influence health. Sex and gender inequities like violence against women, lack of decision-making power, and unfair work division impact health in the short and long term. Everyone has the right to timely access to affordable, preventive and curative health care of good quality. These principles are enshrined in Article 168 of the Treaty on the Functioning of the European Union, “a high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities” (Publications Office of the European Union 2010). This legislation must be enacted and actively enforced.
Lack of women’s involvement and understanding: There is a lack of understanding of the impact of sex and gender. Healthcare professionals, citizens and women must be educated on the importance of systematically mainstreaming sex and gender and demand access to good healthcare as a fundamental right. Women need to be involved in health from the very start from basic medical research through treatment and care. Women are generally under-represented in clinical trials. The new clinical trials regulation (Regulation EU No 536/2014) is a major step forward in increasing clinical trial data transparency. However, the continued under representation of women in clinical trials needs to be urgently tackled, and the regulation must be enforced. Women are also grossly under-represented in STEM (Science, Technology, Engineering, and Mathematics), with a European average of 17 percent (European Institute for Gender Equality 2018). Investing in women’s health makes medical sense as well as being economically prudent, as closing the gap would increase gross domestic product (GDP) in Europe from €610 to €820 billion by 2050 (EIGE 2018; WISE 2012).
Europe’s health policy—stuck in neutral?
In order to ensure equitable health for women, sex and social determinants must be systematically incorporated into healthcare and health policy from research through implementation. The incremental, slow-moving nature of the policymaking process and budgeting cycles are out of sync with rapid changes of healthcare needs. Transformative thinking must be employed by the political system to make healthcare responsive to women (52 percent of the population). Women’s health is a smart investment and should be a political priority in order to guarantee health for all. We must employ an approach to health that focuses on wellbeing and incorporates the impact of the social determinants of health.
Women have and will continue to be society’s carers, but women must also care for themselves. Together, women must step up and demand equity—equity in research, access, treatment and decision-making in order to better meet both women and men’s health needs.
“Everyone has the right to timely access to affordable, preventive and curative health care of good quality” according to Article 168 of the Treaty on the Functioning of the European Union (Publications Office of the European Union 2010). The European Institute of Women’s Health calls on the EU Council, European Commission and European Parliament to strengthen health in the Multiannual Financial Framework and fully implement the EU Treaty requirements to protect health in all policies and promote wellbeing and social equity.
Currently, healthcare systems are not sex- and gender-sensitive, which results in costly, ineffective and unjust healthcare for all. Policies need to be made not only for women but also by women themselves. Women need to be engaged and involved throughout the policy process. Women are not looking for special attention, but attention focused on their specific health needs. Society must invest in women’s health and wellbeing today in order to not only combat inequities, but also to lay strong foundations for future generations.
Healthcare systems are letting down the women of Europe—in fact, they are often failing them. Many policy mechanisms to address the top killers of women are available, but few are being implemented. We must work individually and collectively to advance women’s health now through improved (personalised) care and better policy design.