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(Mabel Bianco)

Introduction

The economic approach to analyze the health care services system was used for many decades. Cost benefits studies were developed to evaluate the economic gain related to the expenditure for a specific treatment or health care method. The great challenge of those studies are how to quantify, for example, the life of a person, its health status or some morbidity condition, in order to compare the cost of a treatment to the benefit in terms of health, cure or death avoidance. How much is the cost of a woman’s life? Cost benefit studies face also the methodological problem to evaluate the intervention impact and to avoid the influence of other variables.

The relation between economic growth and development and health, education and other basic needs of people is well recognized and studied since the beginning of this century. Illness and illiteracy are often concentrated among poor people. From the 1950’s to the 1970’s, health and education expenditures were considered social investment by policy makers. In Latin American and the Caribbean, the improvements in development observed since the 1950’s started to decline later in the 1970’s. Principal factors were increased external debt and world trade imbalance.

During the last decade, the economic crisis deepened in developing countries. Since 1990, due to the globalization of the world economy, new patterns of consumption and production emerged. In developing countries, structural adjustment policies were established to recover the economic balance. Fiscal balance became a goal, though public revenues decreased. Health, education and other social expenditures were reduced suddenly in developing countries. Those reductions were not so clearly applied in other public expenses as military ones. Imbalances and inequities among poor and rich increase worldwide and particularly affected women and children.

Since 1990 individual and families income reductions and the privatization of basic services occurred. Although this is a global trend, it is more evident in developing countries than in industrialized ones. The economic "recipes" applied in developing countries by the international economic agencies were very radical. For example, developing countries were pushed to privatize strategic services such as communications and airlines as well as oil production, while in industrialized countries they remained under the state control.

As a result of the applications of that economic model and of globalization in developing countries we now observe:

An increase of unemployment and poverty: in Argentina, for example, 10 per cent of the poorest people received 1,5 per cent of the national product;

A concentration of richness in a small proportion of population: in Argentina, for example, 10 per cent of the richest population concentrate 37 per cent of the national product;

The widening of the gap between rich and poor people;

The privatization of social services such as retirement, health, education and others;

The deterioration of education and health services as well as other social basic services such as nutrition, employment, housing and others.

Women and Health

Gender was recognized as an important determinant in health as seen in differences in health outcome between women and men. Women’s social and economic role in society has a negative impact on their health.

The Platform for Action adopted at the Fourth World Conference on Women (Beijing, 1995) established five strategic objectives for women health. The first, "to increase women’s access throughout the life cycle to appropriate, affordable and quality health care, information and related services", is becoming a great challenge for many countries, especially developing countries.

Despite high per capita income and advances in medicine throughout this century, millions of people in many countries still die each year from avoidable and curable diseases. The application of free market concepts to health services, including the privatization of those services in countries of Latin America and the Caribbean and other developing countries, increased the gap in access to health care services between rich and poor. Poverty increased, especially among women, newly formed health policies meant that no health care – or only very insufficient care at best - was available to most women. Notions of individual responsibility replaced systems based on solidarity.

Women have unequal access to basic health services. To change this, specific policies are required to ensure the accessibility of health care services. Those policies should be based on solidarity criteria to avoid economic barriers to accessibility.

The study published by the World Health Organization (WHO) in 1996 stated: "While the industrialized countries are expected to grow richer still in coming decades, most developing regions are likely to see more modest income growth...". The study recognized: "Since most of the world’ s ill health is borne by the people of low and middle income countries...". So: in developing countries the burden of disease will increase while the economic resources will decrease, so how to meet citizenship health needs?

The WHO study recognized that traditional threats to maternal and child health are high in poorest countries and also in middle income ones. The burden of those old problems decreased drastically in recent decades in industrialized countries, while in low and middle-income countries they still are responsible of half the burden. Also the study recognized how difficult it will be for those countries to meet the rising demand of health care services.

In addition, many countries are pushed to reform their health care systems without knowing how to provide equitable, efficient and high quality services. They do not know how to evaluate or quantify the impact on health of others sectors as for example education and employment. The impact on women’s health was not particularly measured, but estimations consider them very high. In order to measure illness burden researchers use DALY (Disability Adjusted Life Years), an index that expresses the impact of long-term disability as well as premature death and how healthy life is affected by disease.

The evaluation of disease burden in demographically developing regions, for communicable, maternal and perinatal health problems in 1990 and its estimation for 2020 measured in DALY will decrease from 48,7 per cent in 1990 to 22,2 per cent in 2020. According to that study, old health problems such as communicable, maternal and perinatal problems remained considerable high in developing countries. The maternal, perinatal and childhood burden measured in DALY’s in 1990 is higher in Sub-Saharian African countries and India when considered separately.

Still today women’s health is highly affected by reproductive and sexual health problems. Nearly 600.000 women die of pregnancy–related causes each year, especially in developing countries. Many more women became ill during pregnancy or remain with consequences after delivery. Maternal mortality and morbidity are still a big burden for women’s health especially in developing countries, a burden which could be prevented in approximately 70 per cent by awareness of the problem and by appropriate interventions.

Maternal mortality rates (MMR) present great differences between industrialized and developing countries. Nowadays, MMR could be considered a good indicator of the development level of a country or community, as used to be the Infant Mortality Rate (IMR) in the decades of 1960-70, before cheap and simple tools were developed and applied worldwide, such as for example rehydration formulas.

Figure 3

1960 and 1995 MM Rates according to the development level of countries

 

MMR
1960	1995
Industrialized countries	31	7
Developing countries	138	67
Less developed countries	172	109
Whole World (mean)	123	61

Source: UNICEF, Global State of Childhood, 1997.

 

Since 1990 the gap of MMR between industrialized and developing countries widened and shows principal differences of health care services -accessibility and quality- and women’s socioeconomic status. Increasing income reductions and poverty are responsible for malnutrition, excessive work, low access to antenatal care and other risks for pregnant women in developing countries. The risks of dying from pregnancy-related causes is high in developing countries- one in 48 versus one in 1800 in developed ones.

Poverty is pointed out as the principal cause of the high maternal mortality rate in developing countries. Worldwide it is recognized that poverty is still increasing, especially in developing countries and will continue to increase due to the economic model. As a consequence, women’s health will continue to deteriorate especially reproductive health. It should become more difficult in low-income countries to meet the Beijing first objective related to women’s. In the near future it will require the development of special tools, a clear political commitment and special interventions to be accomplished.

Reproductive Health

According to the WHO definition "reproductive health is the ability to have a safe, responsible and fulfilling sex life, the freedom to decide if, when and how often to have children and to avoid to become ill or die due to a reproductive cause".

Reproductive health is based in principal on the right of women and men to know about and obtain safe, effective, affordable and acceptable methods of family planning and the right of women to have access to appropriate and good quality health services to enable them to have a safe pregnancy and birth. Still today, those rights are not respected worldwide due to ideological and political obstacles and also to accessibility problems due to lack of health services or of poor quality due to economic restrictions. Reproductive health is severely jeopardized in poor countries and women’s and their children’s lives are affected.

The burden of poor reproductive health in terms of disease or death is difficult to be measured and quantified similar to other effects that cannot be quantified or measured in economical values. Maternal deaths are often more easily measured than morbidity problems or other effects such as urine incontinence, painful sexual intercourse or psychological distress due to abortion. Jamison and others experienced difficulties and limits when evaluating some women’s health problems in DALY’S related to poor reproductive health.

When considering the reasons for the persistence of the burden of poor reproductive health, for example excess fertility, it was found that an important cause of maternal morbidity and mortality remained high principally due to inefficient use of existing tools. Unmet needs of contraceptive methods for so many women are a principal cause. Lack of information about how to avoid a pregnancy and the small variety of contraceptives available for poor women contribute to maintain the burden. So the existence of tools and the possibility to apply them efficiently are considered very important to decrease that burden. It was suggested to develop new tools or methods to more efficiently meet family planning needs.

From a gender perspective we will confirm that facts as coverage of family planning needs varied between countries. This is not only due to economic reasons, principal religious, cultural and political reasons against family planning services still remained in developing countries. In low and middle-income countries, unmet family planning needs are still very high. Contraceptive methods are not affordable for many women and couples due to economical cost. Many governments are unable to offer those services to poor people that could not pay for them. The programme of action of the ICPD adopted in Cairo clearly recognized the need "to increase the commitment to and the stability of international financial assistance and recognize priority to complement national financial efforts". Also budget estimations were required to fulfill the needs until 2015.

From a gender perspective we recognized the necessity to increase the variety of existing contraceptives and research is necessary to develop them. We emphasized that the principal problem is how to make them accessible for all women. In poor or middle income countries women would remain with their family planning needs being not met if no special interventions were developed, principally in countries with persistence of high MMR and with abortion as a principal cause of MMR. New knowledge is not sufficient to improve accessibility for poor women and couples. Clear political commitments and programmes are necessary. In many countries there is also a need for a budget increase through additional funds or reallocation of national financial resources, more efficient health care services and external cooperation.

A majority of the maternal deaths cannot be averted simply by improving women’s nutritional status and women’s overall health. Improvement of basic delivery services and effective antenatal care and counseling could avoid many illness and deaths. These are not very expensive services but need to be available for all women to be effective.

Cost-benefits studies about family planning services versus abortion complication care in low and middle incomes countries should be developed in order to demonstrate the economical benefit of family planning.

Women’s Sexual Health

The increasing incidence of women’s HIV/AIDS infections and illness was persistent since the early 90’s . Approximately 90 per cent of those new infections and diseases occurred in developing countries. In 1990, the burden of disease attributed to HIV/AIDS was almost one per cent of the global, and almost three per cent in Sub-Saharan Africa, where other STDs accounted for another two per cent. Projections of the HIV pandemic indicate that the total burden of disease attributable to HIV/AIDS would increase worldwide by 2020. Women are now more affected in some developing countries and the numbers will increase by 2020.

Today other STDs such as clamydia, syphilis, gonorrhea and others account for 1.4 per cent of the global disease burden and in urban population in developing countries increased to 15 per cent. Women are disproportionately affected by STDs. Women’s sexual health needs had been neglected since decades by the health services. Sexual taboos and prejudices negatively impact health care services and orientations. Stigmatization and women’s social rejection due to STDs or other chronic sexual disease or problem still remain.

The HIV/AIDS epidemic and its condition of sexual transmitted disease contributed to renew the interest of policy makers and public health people in STDs. But services didn’t increase nor improve. Advances and knowledge about diagnosis, therapeutic and programmes were not sufficiently applied specially to women’s health care services.

Cost benefit studies about syndromic approach to STDs in developing countries and at primary health care were done but few of their benefits were used to adopt decisions and programs developed.

The development of STDs services for women as part of reproductive health has been a recommendation for many years but is still not adopted. Activists from the women’s health movement and specialists have been requesting it in all forums of women’s health.

Due to mother/child HIV transmission, interest in young women’s protection to prevent STDs and HIV/AIDS infection or illness emerged but actions were oriented to HIV/AIDS. This was more clearly since 1994 when the first mother/child prevention study demonstrated the decrease of risk transmission in 66 per cent with the treatment of AZT to pregnant HIV+ women starting in the fourteen week of pregnancy. This prevention method was very expensive to be applied in many low-income countries, especially in Africa with high HIV/AIDS incidence rates. So a shorter treatment model was developed and recently proved to be effective in Thailand to decrease by 50 per cent the incidence of transmission.

As result of that evidence, some middle income countries are encouraged to implement the prevention for a high proportion of pregnant women living with HIV/AIDS. But still low incomes countries with high incidences cannot afford it. Some cost-benefits estimations were done and clearly demonstrated that it is a potential highly cost-effective method, so the scientific and public health community is very enthusiastic, as well as international agencies.

In order to make this prevention method available to all countries, especially low-income countries, two proposals were developed. First: the Joint United Nations programme on HIV/AIDS (UNAIDS) and pharmaceutical enterprises initiated a negotiation process to reduce the price of AZT in those countries. Glaxo Welcome, the AZT producer accepted to reduce the prize of AZT by 25 per cent of the regular price for those programs in poor countries.

Second: the French government with NGOs from the South and UNAIDS developed a proposal presented last December, the creation of an International Solidarity Fund for HIV/AIDS. That fund will be an special fund to collect money from industrialized countries specifically oriented to help low income countries to buy drugs for HIV/AIDS care. France made it a priority to support prevention programs of M/C transmission in low-income countries.

From a gender perspective, it is necessary to reinforce the following needs in the prevention of mother to child transmission: First, to develop or increase prevention programs to HIV/AIDS infection for young women. These programmes are more urgent and important to be implemented than the M/C transmission, because still now it is a priority in HIV/AIDS to stop new infections especially for women independently if they are or will be pregnant.

Second, it is necessary to promote a better access of all women to antenatal care. In developing countries, antenatal care coverage is still very low and the quality of those services is very insufficient. In many Latin American countries, for example, the coverage of antenatal care decreased due to less services available, long waiting lists and the requirement to pay those services, among other factors. In Argentina, poor women attend the public hospital for antenatal care during the last month of the pregnancy only to ensure being accepted for the delivery, because institutional deliveries are eligible for all women. Primary health centers are insufficient to cover antenatal care, because they are not fully equipped nor organized to ensure a good quality and accessibility of services. In a situational analysis to integrate HIV/AIDS services at primary health care in a poor area of Greater Buenos Aires, women interviewed expressed that it was time consuming to obtain the appointment and the later problems they faced to fulfill the diagnostic in the hospitals. While no programmatic organization among health centers and hospitals was developed and primary health care centers are prepared to solve the whole range of needs, women will continue going straight on to hospitals. But they recognize that waiting lists and bureaucratic procedures were more complex at hospitals. These difficulties and obstacles to accessibility discouraged women’s to attend to their health needs.

Third, many ethical and human rights violations are still related to the HIV test of pregnant women. It is recognized worldwide that a HIV test is to be based on voluntary basis that is not always respected. Attempts to test newborns without their mothers ‘ consent is a violation of women’s rights to ensure the child’s rights. Pre- and post-test counseling is recommended but in developing countries counseling is often not conceded as part of the health services and neglected. Women’s groups and women living with HIV/AIDS consider counseling an important prevention method, and an educational tool to avoid discrimination and to learn how to live with HIV/AIDS.

Still today we find out that approaches to prevent mother to child HIV transmission are more oriented to prevent children from infection than to improve women status.

Studies to evaluate mothers’ long term risks due to AZT administration and resistance due to monotherapy are needed. More research about methods not requiring HIV test such as vitamin A supplement given to pregnant women and others is still needed.

From a gender perspective it is important to analyze M/C prevention interventions and to stimulate the development of strategies as those two forms of solidarity mention. It is also necessary to point other changes such as how decisions to improve women’s health could be implemented.

 

Human Development and Gender

Since 1990, is UNDP proposing a new method to evaluate human advances, the Human Development Index (HDI). This index explains how development is related to human well being, not only by economic growth. The HDI is based on a new concept of development centered in human kind.

In 1995, UNDP developed an special measure to evaluate gender differences, the Gender Development Index (GDI). The 1995 Human Development Report was a contribution to the Fourth International Women’s Conference. It presented the GDI and applied it to countries in the world. GDI evaluates indirectly health differences among men and women based on life expectancy. In 1996, no country had an GDI equal to 1, so the report concluded: "no country has an equal deal among men and women". The five countries with the highest GDI are: Sweden, Norway, Finland, Canada and USA. 43 of the 137 countries studied have a GDI low of 0.50 while only 37 countries have an index of 0.80 or up. This demonstrates the few advances made to improve women’s equity.

The GDI has no direct relation to the economic income or growth, it depends principally to political will and the adoption of public policies and decisions to ensure equity among sexs. Uruguay, for example, occupied the 26^th place, 23 places up of Quatar, while Uruguay has an income per capita approximately a quarter (25 per cent) of Quatar’s income per capita. Many differences of equity among sexs between countries exist, and have no relation to economic growth. For example, Jamaica with a low increase of economical growth improved the level of equity among sexs significantly more than countries with bigger economical growth increase such as Korea and Syria.

The ranking of countries according to the Gender Development Index presented many variations to the HDI ranking. Many countries have better positions in HDI than GDI or viceversa. For example, Argentina and some Arab States presented the biggest difference among the HDI and the GDI, which could be due to low political will to women’s equity existing in both countries.

When considering the balance between progress and deprivation of human development by regions published in the Human Development Report in 1996, , maternal mortality and morbidity are mentioned as deprivation in all developing regions except in Arab States. In sub-Saharan Africa HIV/AIDS incidence also was mentioned.

UNDP estimations of the years required by developing countries to reach the HDI level of the industrialized countries increased in the last years due to the worsening of development and economic growth as well as the increasing gap among rich and poor. For example, if trends of last 15 years remained equal, countries with middle IDH will required 17 years to reach high IDH, while low IDH countries will required 200 years.

Gender equity especially in health and education improvements require political will but also economic resources allocations. Are low and middle incomes countries able to do that? Could this be solved only with a more efficient use of actual resources? If health and education are basic components of human development, improvements in both are necessary, in girls’ education as well as in women’s reproductive health care.

Some donors and international agencies proposals to low and middle incomes countries are principally oriented to improve the efficiency of the health care services. Only improving the efficiency of health care services health indicators will improved? Women’s health specialists consider this as not sufficient, an increase of finance resources and a clear priority to primary health care services to satisfy women’s needs are necessary in many countries.

Mr. James Wolfensohn, the president of the World Bank, clearly recognized last June in an Africa meeting that "more resources must be found for such efforts (to diminush women’s and children health vulnerability)". And added: "...public expenditures reviews must give proper attention to health and alternative ways of financing health care must be tested".

UNDP recognized that human development has an intrinsic value that justifies the governmental decisions to support it. Gender equity is an additional value to human development and needs specific policies specially related to health and education. A gender perspective implies to recognize unequal opportunities for women and to suggest different priorities to allocate resources, to priorize actions and programmes oriented to women’s health needs, and to develop and manage the services efficiently. In terms of financial resources allocations, specialists from the women’s health movement recommend a decrease of military budgets and a reallocation of these funds to basic education and health.

To achieve that change we consider it necessary to include women’s with gender perspective in the decision making process and to open the discussion in the society including women.

Health services are often not open to community participation in all the process from planning to monitoring. The incorporation of women’s groups or NGO’s with gender perspective is less acceptable. In Cairo and Beijing that participation was encouraged, but the monitoring of the implementation of Cairo and Beijing Program of Actions showed how progress was not achieved. An study of ICPD implementation in Latin America done in five countries by the Latin American and the Caribbean Women’s Health Network showed the persistence of difficulties and obstacles to reach that participation.

The Health Care Services system

As a consequence of globalization and structural adjustment policies (SAP), privatization trends and changes of health care services increase worldwide.

Privatization has different economic dimensions for users, especially women, varying from some a small fee to be paid when receiving a service to a full payment requirement. Political, cultural and social dimensions of privatization have also other negative impacts on women’s health services.

An important dimension to evaluate the health care services system is the population accessibility. Geographical, cultural and economic barriers are the principal factors influencing accessibility to health care services. Women’s health care is negatively affected by those three factors, especially in developing countries.

In the health care financing system, public and private sectors are traditionally recognized. Health insurance methods were developed as a need to finance the health care cost specially due to it’s growth because technological and scientifical advances. The concept of social welfare developed since 1930-40 especially in developed countries as a response to growing inequities, was later adopted by developing countries.

Recently public health budgets reductions linked to the still growing costs of health care services and the increase of the demand reopen a need to review the health care system worldwide. WHO, the WB and others emphasized the health care analysis and it’s reform as an answer to improve access to health care. That analysis based on financing approaches and health services organizations have two central goals: to improve the efficiency in management of the health care services and the financing through a significant adoption of privatization concepts.

In developing countries, the health care systems have relied mainly on general revenues. Social insurance was developed, was based on the social welfare concept and usually was associated to employment. In countries with a considerable development of social security services, the accessibility to health services improved specially for workers as well as the access to services of better quality.

Nowadays increased unemployment in developing countries diminished the coverage of social insurance. People not only loose their employment but also their social security services, so the demand to public health services increased. Some private insurance services were recently developed but only to cover high-income groups.

Today in Latin America, public health services are overcrowded and without sufficient budgets and resources to maintain the quality of the services, affecting specially women’s health. A significant decrease of the standards of public health services and lack of medical supplies for antenatal, labor, delivery and post delivery care were observed, which has an impact on maternal morbidity and mortality. These were aggravated because women delay or not seek treatment due to logistical, social or cultural barriers.

Nowadays quality of health services in private sectors increased while it tended to decrease in public services, so differences among private and public services increased and widen the gap between rich and poors access to health.

Women’s have unequal access to health services compared to men. Generally women have less access to social or private insurance because of their economic subordination status.

Social insurance based on employment benefit principally men because of their higher participation in the labour market. In many developing countries, social security considers only workers no their families, so women have no access to those services.

Since 1990, health reform processes were developed especially in developing countries. Those reforms are principally oriented to improve efficiency of health services. Coordination and/or integration of public health services and social security was promoted while in both improvement of efficiency is the principal goal. As women we looked at those reforms to evaluate the real and potential impact on women’s health.

As part of that health reform process some forms of direct payment by the population when using health services are implemented also in public services. Privatization trends include the concept of self-sufficiency applied to public health institutions. This means each health service has its own budget and manages it independently, adopting different levels of payment based on "fee for services", which means that everyone must pay the services they received. The models vary from country to country but the ideology behind is the same: health is an individual responsibility, solidarity is put aside. This is an example of what Galbraith calls "the culture of contentment" based on individual responsibility and reducing health to a free market product.

In social matters such as health and education, free market rules are incompatible with universal accessibility. If public health services include any form or level of payment women’s accessibility is deteriorating. Solidarity is to be maintained in order to ensure access and quality of health services, especially for women and children. The role of public health care services need to be oriented not only to bring services but also to regulate the functioning of private and social security or insurance services to reach universal access of good quality services.

Solidarity among and within countries needs to be reinstated. Donors and International agencies have an important role to play. The 20/20 initiatives is an answer to that need as are specific subsidies to guarantee special health care programs for women’s health: sexual education, reproductive health care services including Family Planning, STDs and HIV/AIDS.

In Cairo and Beijing, women’s health groups and NGO’s participation in all the process of health care services was recommended. That participation should be in all steps, from diagnostic to monitoring, of health care services. The implementation of that participation still presented many obstacles expressed by governments and also international agencies and donors. Still today in developing countries, women’s groups or NGO’s participation often means for government to have low cost personnel because they are allowed principally to participate in the implementation of the services without payment or a low one.

Few examples of women’s groups participation in the decision-making process are reported in other developing countries. Civil society participation in health institutions often is reduced to academic institutions or trade unions associations. But in those groups or associations, women with gender perspective are generally not included. Participation of women’s groups and organizations with gender perspective in all the process of health care services is necessary to be implemented at all governmental levels and also by International agencies and donors. Often external cooperation programmes in developing countries do not include women’s voice as a civil society group. Women’s groups or NGOs only bring services. And in many cases this was done not based on a real clear and equal opportunity based selection to all groups and NGO’s.

Implications and recommendations for integrating a gender perspective

Summarizing women’s health needs and their burden especially in developing countries, have great implications to orient health policies and programmes in developing countries based on a gender perspective.

As the World Bank recommended for Africa in a recent report "to overcome these conditions (improvements in health care, education, food security housing, energy supplies and others) there must be greater emphasis on programs for the poor and most vulnerable, specially women and children, including:

Effective family planning and reproductive health services;

Better treatment of childhood illness (diarrhea, pneumonia);

Radical steps to control HIV/AIDS;

Improved control of malaria;

Community nutrition schemes.

The difference to the World Bank’s recommendations is that, coming from a gender perspective, we emphasize policies and actions based on women’s health rights. We propose:

Reproductive health services should have a broad goal and include family planning services among others. The reproductive health services are to be based on a comprehensive approach of women’s health care as a basic component of quality of life. Those services should include care for all ages and principally provide primary health care services without excluding or neglecting other levels. For example, control of uterine cervix cancer provided at primary health care should include a proposal of subsequently care if a cancer is detected.

Family planning services are to be included in reproductive health services and based on gender perspective with the goal "to ensure women’s reproductive rights". As defined in Cairo and Beijing, "all forms of coercion" have to be avoided. The main difference with traditional family planning is that demographic goals are rejected because they include coercion.

Reproductive health programmes are required to ensure "adequate basic motherhood care to all women", including good antenatal care till delivery and post delivery services, including food supplementary programs for pregnant women.

Adolescents’ reproductive care to ensure access to sexual education and health services especially for female adolescents; confidentiality and counseling are also requested to guarantee adolescents’ rights.

STDs and HIV/AIDS services to ensure sexual rights of women at all ages, including enjoyment of their sexual health; those services should include prevention, diagnostic and treatment and eliminate all forms of compulsory HIV testing.

Abortion and post-abortion care are to be included; where abortion is legal, there should be availability of services and skilled practitioners to reduce morbidity and mortality; where abortion is illegal, post abortion care is to be included.

Genital cancer control should be included as well as women awareness of cancer prevention.

Harmful practices such as genital female mutilation, excessive caesarians and others should be eliminated.

Care of domestic violence, rape or sexual abuses should to be included in those services.

In order to develop these women’s health care services from a gender perspective we make the following recommendations:

1. To analyze the health care system with the participation of women’s health groups or NGO’s, and decision-makers in order to establish and adopt specific policies to ensure women’s health care;

2. To review and define the national budget and the specific health budget and its allocation to women’s health programmes, ensuring the participation of women’s groups or NGO’s in the review process;

3. To increase the health budgets in low-income countries through reallocation of funds from military budgets and defining national priorities according to human development criteria; this requires a broad participation of civil society but specifically of women’s health groups and NGO’s;

4. To reform health care services to improve the care of communicable and women’s and children health problems, especially through primary health care services;

5. To improve the primary health care services by increasing the budget, improving the skills of personnel including through gender training and adopting methods to improve efficiency;

6. To include the participation of women’s health groups and NGO’s in all levels of the health care system and to allow them to participate in the planning, implementation and monitoring process;

7. To improve data collection and analysis about health status disaggregated by sex as well as other socio-economic data; to publish and distribute that information to women’s health groups, NGO’s and other groups of the civil society;

8. To promote and carry out research about cost-effective health care methods in the services and to compare them with others studies and research; those studies will be done with the participation of women’s health groups and organizations as well as scientific and health professionals;

9. To improve partnership among governments, donors, enterprises and women’s health groups and NGO’s to define health policies and negotiate responsibilities, specially for women’s health matters;

10. To increase external cooperation to develop women’s health programmes based on a gender perspective and to achieve the goals established in the International Conferences in Cairo, Copenhague and Beijing.

I realize that these recommendations may seem "utopian" but it is utopia that has enabled the world to grow and develop. Utopia never dies; it changes and is renewed. As women’s health experts we didn’t loose our activism. Our voice it’s necessary to express what millions of women cannot say. Their silence it’s our inspiration and commitment.