Access to healthcare and long-term care: equal for women and men?

ACCESS TO HEALTHCARE AND LONG-TERM CARE
Equal for women and men?
European Commission

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ACCESS TO HEALTHCARE
AND LONG-TERM CARE:
Equal for women and men?

Final Synthesis Report
EGGSI coordinating team
Chiara Crepaldi, Manuela Samek Lodovici, Marcella Corsi
In collaboration with:
Stefano Capri, Sandra Naaf, Sergio Pasquinelli
Expert Group on Gender Equality and Social Inclusion,
Health and Long-Term Care Issues (EGGSI)
(* indicates non-EU countries)
Bettina Haidinger (Austria)
Ilze Trapenciere (Latvia)
Nathalie Wuiame (Belgium)
Ulrike Papouschek (Liechtenstein)*
Maria Slaveva Prohaska (Bulgaria)
Ruta Braziene (Lithuania)
Susana Pavlou (Cyprus)
Frances Camil ieri-Cassar (Malta)
Alena Křížková (Czech Republic)
Hugo Swinnen (Netherlands)
Bent Greve (Denmark)
Ira Malmberg-Heimonen (Norway)*
Reelika Leetmaa and Marre Karu (Estonia)
Irena Topinska (Poland)
Anita Haataja (Finland)
Teresa Maria Sarmento Pereira (Portugal)
Anne Eydoux (France)
Marieta Radu (Romania)
Alexandra Scheele and Julia Lepperhoff (Germany)
Eva Havelková (Slovakia)
Maria Stratigaki (Greece)
Masa Filipović (Slovenia)
Beáta Nagy (Hungary)
Elvira González Gago (Spain)
Sigurbjörg Sigurgeirsdóttir (Iceland)*
Anita Nyberg (Sweden)
James Wickham (Ireland)
Claire Annesley (United Kingdom)
Flavia Pesce (Italy)
European Commission
Directorate-General for Employment, Social Affairs and Equal Opportunities
Unit G.1
Manuscript completed in October 2009

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This report was financed by and prepared for the use of the European Commission, Directorate-General for Employment, Social Affairs and Equal
Opportunities in the framework of a contract managed by the Istituto per la Ricerca Sociale and Fondazione Giacomo Brodolini. It does not necessarily
reflect the opinion or position of the European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities.






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Contents
Executive summary ..................................................................................................... 5
Zusammenfassung ....................................................................................................11
Résumé ..........................................................................................................................17
Introduction .................................................................................................................23
1.
Main characteristics and recent trends in the health status
of women and men ........................................................................................... 25
1.1. Gender differences in life expectancy and healthy life years .............................................................25
1.2. Self-perceived health and disability ............................................................................................................25
1.3. Gender differences in health risks and death by typology of diseases .........................................28
1.4. Gender differences in mortality rates .........................................................................................................32
1.5. The impact of income and social inequalities on gender differences in health status .............35
2.
Gender differences in access to healthcare .........................................41
2.1. Existing service provisions: an overview of gender differences .......................................................41
2.1.1. Health promotion ........................................................................................................................................................ 43
2.1.2. Health prevention ........................................................................................................................................................ 50
2.1.3. General treatment ........................................................................................................................................................ 67
2.1.4. Gender mainstreaming in healthcare: recent trends ............................................................................. 84
2.2. Barriers to accessing service provisions .....................................................................................................87
2.2.1. Financial barriers: insurance coverage and individual costs .............................................................. 89
2.2.2. Cultural barriers ...........................................................................................................................................................100
2.2.3. Geographical and physical barriers .................................................................................................................106
3.
Gender differences in access to long-term care (LTC) ................... 111
3.1. Overview of existing LTC service provisions ..........................................................................................111
3.2. Overview of existing service provisions for LTC from a gender perspective ..............................115
3.3. Gender barriers to access LTC ......................................................................................................................118
3.3.1. Gender and financial barriers ..............................................................................................................................118
3.3.2. Gender and geographical barriers ...................................................................................................................119
3.3.3. Gender and bureaucratic and administrative barriers ........................................................................120
3.3.4. Gender and cultural barriers ................................................................................................................................120
3.4. Programmes aimed at overcoming barriers to LTC ..............................................................................122
3.5. Overall conclusions about gender barriers to access LTC ..................................................................124
4.
Conclusions ................................................................................................... 125
5.
Annex – Statistical tables .......................................................................... 129
References .................................................................................................................. 133
3

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Executive summary
While healthcare systems have contributed to
diseases, such as for cardiovascular and many sexually
significant improvements in health in Europe, access to
transmitted diseases.
healthcare remains uneven across countries and social
groups, according to socioeconomic status, place of
Besides biological factors, social norms also affect the
residence, ethnic group, and gender.
health status of women and men differently: women
are less likely to engage in risky health behaviour and
Gender plays a specific role both in the incidence and
consequently face fewer of the related illnesses and
prevalence of specific pathologies and also in their
disabilities than men. However, they are more likely
treatment and impact in terms of well-being and
than men to present ‘invisible’ illnesses and disabilities
recovery. This is due to the interrelations between sex-
which are often not adequately recognised by the
related biological differences and socioeconomic and
healthcare system. Examples include depression,
cultural factors which affect the behaviour of women
eating disorders, disabilities related to home accidents
and men and their access to services.
and sexual violence, as well as diseases and disabilities
related to old age. Women, especially very young
This comparative report presents the main differences
women, are more vulnerable to sexually transmitted
in the health status of women and men in European
diseases compared to men, and the consequences
countries and examines how healthcare and long-term
are more serious for them. Sexual abuse and domestic
care systems respond to the specific needs of women
violence particularly affect women and girls in all
and men in ensuring equal access. It considers the
countries and in all social classes.
main financial, cultural and physical barriers to access
and provides good practice examples of healthcare
The comparison of the population’s health status in
promotion, prevention and general treatment
European countries also shows that eastern European
programmes, as well as of long-term care.
countries tend to present worse health conditions for
women and men than western countries.
The information in this report is mainly provided by
the national experts of the EGGSI network of experts in
Overall, it can be noted that women are more aware of
gender equality, social inclusion, healthcare and long-
their health status and are greater users of healthcare
term care and covers 30 European countries (EU-27 and
services then men. There are several reasons for this,
EEA/EFTA) (1). Available comparative statistical data from
such as their reproductive role, their role as caregivers
Eurostat and OECD sources have also been considered.
for dependants (children, the elderly, the disabled),
their higher share among the older population and also
gender stereotypes, since men usually do not consider
Gender differences in health status it normal to complain about their health and to visit
physicians.
Gender differences in health status and health needs
are largely explained by biological and genetic factors,
as well as by differences in social norms and health
Gender differences in healthcare
behaviour.
provisions
On the one hand, women and men are susceptible
Little is known about gender differences in accessing
to sex-specific diseases related to their reproductive
healthcare and long-term care, and if and how
health, such as breast cancer and cancer of the
healthcare and long-term care systems take these into
cervix for women and cancer of the prostate for men.
account in service delivery. For example, while it has
On the other hand, women and men also present
been suggested that women are more likely than men
different symptoms and consequences of common
to engage in health-seeking behaviour and thus to
practise health prevention and promotion, there also
seems to be evidence that especially poor women (2)
1
( ) EGGSI is the European Commission’s network of 30 national
may have more difficulties accessing healthcare
experts (EU and EEA countries) in the fields of gender equality and
social inclusion, health and long-term care issues. The network
services than men.
is coordinated by the Istituto Ricerca Sociale and Fondazione
Giacomo Brodolini, and undertakes an annual programme of
2
( ) European Institute of Women’s Health Report, Gender
policy-oriented research and reports to the Directorate-General
Equity Conference, Conference of September 2000.

for Employment, Social Affairs and Equal Opportunities.
http://www.eurohealth.ie/gender/index.htm
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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
In some European countries (like Austria, Bulgaria,
Member States to take common action to implement
Germany, Iceland, Ireland, Italy, Norway, Spain, the
national cancer screening programmes with a
Netherlands, the UK, Slovenia), there is increasing
population-based approach and with appropriate
awareness regarding the need to acknowledge
quality assurance at all levels. Although much progress
gender differences in access to healthcare among
has been made, more is still required to ensure that
governmental institutions, universities, and especially
programmes are available in all Member States.
NGOs, which have traditionally been very active
in providing specialist services to women, ethnic
Across Europe, many prevention programmes address
minorities and other disadvantaged groups. In these
maternity: prenatal tests, support for the mothers with
countries, gender-sensitive strategies have recently
newborn children and family development, support for
been introduced within healthcare and medical
groups of children and mothers with special needs. Other
research: resource-centres and research institutes
widespread prevention programmes across Europe
with special knowledge regarding women and health
concern sexual and reproductive health. The health
have been created, observatories on women’s health
sector can also play a vital role in preventing domestic
have been set up to support the development of sex-
violence against women, by helping to identify abuse
disaggregated data and gendered medical research. In
early, providing victims with the necessary treatment,
addition, these countries have implemented specific
and referring women to appropriate care. A general
training projects aimed at general practitioners and
lack of attention among the population and awareness
healthcare providers, as well as pilot programmes
among health professionals has been described in some
for the treatment of disadvantaged women, such as
EGGSI national reports, together with some examples
homeless women, immigrant women, disabled women
of good practice of support services for victims.
and single mothers.
On the other hand, few programmes presented in
The comparative analysis presented in this report
the EGGSI national reports aimed at children and
has, however, shown that in most countries, besides
adolescents are gender sensitive. The most widespread
reproductive care, there are still few gendered
programme across Europe (even if there are differences
healthcare strategies and services addressing the
in access) and targeted at young girls is the Human
specificities of gender-related behaviours and diseases
Papilloma Virus (HPV) vaccination programme.
in a more structured way.
Another area where young girls are the main targets of
preventive programmes is education regarding healthy
Health promotion strategies appear to be largely
sexual behaviour and abortion prevention. Abortion in
gender neutral except for reproductive health. The
adolescence is still a problem in Europe even though a
promotion of breastfeeding is the most widespread
clear trend of reduction is detectable all over Europe.
promotion programme across Europe. It is supported
by common guidelines and accompanied in many
Although gender-specific health-related risk behaviour
countries by more general programmes supporting
is starting to be documented and knowledge about
mothers and their newborn babies. Also, programmes
the necessity to provide gender-specific health
promoting healthy behaviour addressed to adults or
treatment is increasingly diffused, gender differences
adolescents are often gender oriented, being either
in most healthcare treatments are often neglected.
targeted at women or men. The report presents
The exceptions are reproductive care (basic service
programmes aiming at reducing the consumption of
provision for pregnant women and childbirth) and the
alcohol and smoking and promoting diet and physical
treatment of specifically female diseases, such as, for
activity, programmes promoting mental health and
example, breast and cervical cancer.
occupational health, health-promotion programmes
and campaigns specifically targeted at more vulnerable
Age, income, education and residency are important
groups. In those countries where national health
determinants of access to healthcare treatment
promotion activities are less developed, NGOs usually
for women and men. For similar levels of health
have a relevant role as substitutes for public action and needs, individuals with lower income and education
are a stimulus in raising awareness of certain issues.
are more likely to use primary healthcare more
intensively, whereas specialised assistance tends to
Screening programmes are important preventive
be underutilised. In most countries, immigrants and
measures, since many diseases can be avoided through
non-residents usually only have access to emergency
early detection. The EGGSI national reports have
care. As long as there are gender differences in income
evidenced that gendered prevention programmes
levels, these different patterns are also relevant in terms
are mainly targeted at women. The most important
of gender.
and widespread gendered prevention programme
implemented in Europe is cancer screening. This is
The physical, psychological and social barriers that
related to a Council recommendation which invites
prevent many women from making healthy decisions
6

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Executive summary
are often not visible or addressed by healthcare
include the lack of insurance coverage (especially
treatment programmes and regulations. There is
affecting those without residency or citizenship, the
usually little recognition of gender specificities in the
long-term unemployed and the homeless in countries
treatment of some pathologies such as heart diseases,
based on social security contribution systems), the
sexually transmitted diseases, mental disorders,
direct financial costs of care (affecting low-income
or work-related illnesses, and of the long-term
groups), the lack of mobility (affecting disabled and
consequences of violence and abuse on women’s
elderly persons), the lack of language competence
health. In many cases, as for example in heart diseases, (affecting migrants and ethnic minorities), the lack of
the knowledge utilised is based on studies conducted
information access (affecting the poorly educated and
on men, which results in treatment that may, in migrants/ethnic minorities), as well as time constraints
some cases, not address the needs of women. Other
(affecting especially single mothers). In all of these
examples are the repercussions on mental health
factors there are specific gender issues to consider.
of the role overload of working women with care
responsibilities, or of the anxiety and social isolation
Financial barriers are particularly relevant for low-
often experienced by female single parents and older
income groups and for women. Income inequalities
single women. Domestic abuse, in particular, results
are especially related to the lack of insurance coverage,
in high rates of depression and anxiety for women.
the cost of certain (specialised) types of care (such as
As for work-related health risks, regulations on health
dental, ophthalmic and ear care) which are often not
and safety at the workplace mainly cover the risks
covered by public insurance systems, and the incidence
that men are more commonly exposed to, while little
of private insurance systems. Out-of-pocket costs and
consideration is given to the health risks of women in
the persistence of informal payments in many eastern
female-intensive occupations and sectors.
and southern European countries are also significant.
It has also been noticed that sometimes women and
The increasing role of private health insurance and out-
men are treated differently, not because their specific of-pocket payments may increase gender inequalities,
needs are recognised, but because of prejudiced
since men are more likely to be covered by private
and stereotyped attitudes by health practitioners.
insurance than women, although women are greater
For example, therapeutic support aimed at return to
consumers of healthcare services and medicines.
work after work accidents is more frequent among
Women usually have a lower income and do not
men than women. This is also due to the attitudes of
benefit from the same kind of firm-based private
occupational health physicians and of employers, who
insurance coverage as men do. Women also present
feel that rehabilitation is more important for men than
lower employment rates in the regular economy (many
for women.
are either inactive or work at home or in the informal
sector) and, when employed, they are more likely
The issue of health service provisions targeted
to be employed in the public sector and small firms
specifically at men is less recognised, even if in some
(which are not likely to provide supplementary private
countries there is an increasing attention to these
insurance schemes) with part-time and/or temporary
issues. Some male-related diseases (such as prostate or contracts in low-paying jobs. In addition, private
testicular cancers or benign prostatic diseases among
insurance schemes are less attractive to women since
the elderly) are not paid special attention in many
they usually consider age and gender-specific risks in
European countries. Also, the health programmes
defining contributions. Women from ethnic minorities
and treatment of some diseases related to gendered
and poor households may be especially penalised by
behaviours, such as alcohol addiction and alcohol-
the privatisation of health services and the increase
related diseases, which present different patterns
in out-of-pocket spending on healthcare. There are
and consequences among women and men, do not no sex-differentiated comparative data on insurance
consider gender differences sufficiently.
coverage by type of insurance in European countries,
however it is likely that financial barriers are particularly
relevant for women living in those countries where the
Barriers to access and gender
incidence of cost-sharing is higher and the extension of
differences
public insurance coverage is lower.
Even if universal or nearly universal rights to care are
Cultural barriers are also particularly relevant for
basic principles in all the Member States and most of
women, especially for immigrant women and women
the European population is covered by public health
of ethnic origin. The distinct roles and behaviours
insurance, these basic principles do not always translate
of men and women in a given culture, resulting
into equal access to and use of healthcare. Residency,
from gender norms and values, give rise to gender
socioeconomic and geographical factors can affect the
differences and inequalities in access to healthcare as
accessibility to healthcare for specific groups. These
well as in risk behaviours and in health status. Cultural
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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
barriers can be expressed in terms of prejudices and
(incidence of informal care and support for carers). In
lack of knowledge among healthcare professionals
the last 15 years, European countries have experienced
concerning gender specificities in needs and types
reforms aimed at removing inequalities in access to LTC
of care to be provided. Language barriers, as well
and improving the quality of care.
as traditions and cultural practices also play a role,
as certain groups of immigrant women and women
The gender perspective is relevant when considering
of ethnic origin have more difficult access to health
access to LTC services, as women are the main providers
facilities and information on sexual health. On the
of LTC, especially informal care, and the main users of
other hand, men also have to face stereotypes in
LTC services, because they live longer than men and
accessing healthcare and prevention programmes.
are more likely to live alone in old age. Elderly women
Osteoporosis, for instance, is perceived as a female
are also likely to be more negatively affected than men
disease, and it might be less obvious that men should
by the forms of co-payment for access to LTC which
be treated for osteoporosis as well. Education and have been introduced in many countries, because their
health prevention programmes are also targeted
average income is lower than men’s.
mostly at women and only occasionally address men.
The report shows that it is important to take into
consideration a variety of elements while analysing
Addressing gender inequalities
cultural barriers in accessing healthcare. These are
in access to healthcare and long-
prejudices and gender stereotypes, social status
and level of education, cultural differences inherent
term care
in ethnicity and migration issues (that involve not
only language skills but also traditions and norms of
The comparative analysis presented in this report has
hygiene), religious practices, prejudices concerning
highlighted some important issues which have to be
sexual orientation, and working culture.
addressed in order to reduce gender inequalities in
access to healthcare and long-term care and provide
Geographical variations in coverage and provision are
cost-effective and high-quality care.
another relevant barrier to access healthcare. The supply
of healthcare services is typically greater in bigger cities
The most important is the need to adopt a gender
and more densely populated areas, whilst there is a lack
perspective in healthcare policies, considering the
of General Practitioners or family doctors and of certain
biological, economic, social and cultural factors which
basic specialist services in small, rural and remote areas.
affect the health condition of women and men and
Hospitals are also often unevenly distributed across the
their access to healthcare. A gender mainstreaming
countries, with the explanation in some cases coming
approach to healthcare policies, addressing gender-
from geographical features (due to the presence of
specific risk factors in medical research, in service
islands or mountains). In some countries, however,
delivery (considering promotion, prevention and
disparities are the result of decentralised decision-
treatment policies) and the design of financing systems
making processes, giving regional and local authorities
enhances the effectiveness of the care provided for
policy discretion and permitting regional differences
women and men and reduces inequalities in access,
in funding. The distance from hospitals and healthcare
as shown in some of the good practices presented in
centres and the lack of accessible transportation and
the report.
facilities particularly affect women (especially those
living in rural or mountainous areas, the disabled and
Gender-based health research increases knowledge
the elderly), as they are less autonomous concerning
regarding the complex ways in which biological,
mobility than men (they drive cars less frequently than
social, cultural and environmental factors interact to
men), and live more years in old age and ill health.
affect the health of women and men. Gender-based
medical research also improves the attention of health
practitioners regarding gender differences and supports
Gender differences in access to
the provision of gender-differentiated treatment when
long-term care
necessary. For example, it is important that research in
cardiovascular diseases considers gender differences in
All over Europe various provisions concerning long-
morbidity and mortality and in reaction to treatment;
term care (LTC) are present. The mix of benefit types —
occupational health and safety research and practices
formal/informal, in cash/in kind, institutional/at home
should take gender-specific factors into account, such
care — varies among European countries, reflecting
as the different health risks that women and men are
more the organisational features of each system
exposed to, due to occupational gender segregation
rather than population structure and demographic
and the health risks resulting from precarious
developments. In particular, the variations reflect the
employment, domestic work and informal care work
different national approaches to familial solidarity
performed by women.
8

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Executive summary
The implementation of gendered health information
rural or low-populated areas and reduced patient/staff
systems and analysis tools (such as Gender Impact
ratios may have negative consequences for women
Assessment), upgrading quality in data collection
more than for men, as women are the majority both
and analysis, is essential to support medical research among healthcare users and providers. These issues
and the systematic gender-specific monitoring and
are particularly relevant for LTC, where gender plays
evaluation of healthcare systems.
an even more relevant role, women being the main
care providers (formal and informal) and care users.
The promotion of capacity building for gender
sensitivity in healthcare systems and gender-specific
Measures supporting LTC systems have important
training for healthcare professionals is likely to improve gender impacts. Provisions to overcome barriers
the attention paid to gender differences in service
to accessing LTC can be found across European
delivery and the effectiveness of healthcare services.
countries and are presented in the report. They are
mainly related to: supporting low-income groups
Recognition of women’s role as healthcare users
(such as in the Netherlands); improving the quality
and providers both within the healthcare system
of care (such as in Germany, Romania and Norway);
and outside as informal and often unpaid carers,
and supporting informal care providers (such as in
is important when evaluating the gender impact
Finland and Sweden).
of recent trends in healthcare reforms, especially
in relation to healthcare financing and delivery.
To conclude, the evidence emerging from this
Healthcare reform trends, especially increasing the
comparative report underlines the need to adopt
incidence of cost-sharing through private insurance
a gender mainstreaming approach to healthcare
schemes and out-of-pocket payments, may adversely
policies in order to improve their effectiveness. This
affect women more than men, since women are the
is even more relevant as the current financial and
majority among healthcare users and low-income
economic crisis may reduce the available resources for
groups. Recent trends in cost containment and the improving the quality and coverage of healthcare and
limitation in the basic care provisions included within
LTC provisions, with pilot gender-based programmes
primary care are also likely to increase gender and
at great risk of budget cuts. Eastern European
income inequalities if not adequately addressed. The
countries, in the process of improving the quality
rationalisation of healthcare services which, in many
and extension of their healthcare systems, especially
countries, has reduced local clinics and services in
present such a risk.
9

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Zusammenfassung
Obwohl das Gesundheitssystem zu bedeutenden Ver-
Geschlechterunterschiede
besserungen der Gesundheit in Europa beigetragen
hinsichtlich des
hat, bleibt der Zugang zum Gesundheitswesen in den
Ländern und Bevölkerungsgruppen unterschiedlich, je
Gesundheitszustands
nach sozioökonomischem Status, Wohnort, ethnischer
Gruppe und Geschlecht.
Geschlechterunterschiede hinsichtlich des Gesund-
heitszustands und der Gesundheitsbedürfnisse wer-
Das Geschlecht spielt eine wesentliche Rolle sowohl
den größtenteils durch biologische und genetische
beim Auftreten und der Verbreitung spezifischer Krank-
Faktoren sowie durch Unterschiede in gesellschaftli-
heiten, als auch in ihrer Behandlung und ihren Auswir-
chen Normen und Gesundheitsverhalten erklärt.
kungen auf das Wohlbefinden und die Genesung. Dies
ist bedingt durch die Wechselbeziehungen zwischen
Einerseits sind Frauen und Männer anfällig für
geschlechtsspezifischen biologischen Unterschieden
geschlechtsspezifische Krankheiten, die in Zusam-
und sozioökonomischen sowie kulturellen Faktoren,
menhang mit ihrer Reproduktionsgesundheit stehen,
die sich auf das Verhalten von Frauen und Männern und
wie zum Beispiel Brust- und Gebärmutterhalskrebs
deren Zugang zu Gesundheitsdiensten auswirken.
bei Frauen und Prostatakrebs bei Männern. Anderer-
seits weisen Frauen und Männer auch unterschiedliche
Dieser vergleichende Bericht stellt die Hauptunter-
Symptome und Folgeerscheinungen bei allgemeinen
schiede des Gesundheitszustands von Frauen und
Krankheiten auf, wie zum Beispiel bei kardiovaskulären
Männern in den europäischen Ländern dar und unter-
und bei vielen sexuell übertragbaren Krankheiten.
sucht, wie Gesundheits- und Pflegeversicherungssys-
teme die speziellen Bedürfnisse von Frauen und Män-
Abgesehen von biologischen Faktoren wirken sich
nern bei der Gewährleistung eines gleichberechtigten
auch gesellschaftliche Normen unterschiedlich auf den
Zugangs berücksichtigen. Dabei werden die wesentli-
Gesundheitszustand von Frauen und Männern aus:
chen finanziellen, kulturellen und physischen Zugangs-
Frauen lassen sich seltener auf riskantes Gesundheits-
barrieren betrachtet und Beispiele bewährter Metho-
verhalten ein und sind demzufolge nicht so häufig von
den für die Förderung von Gesundheitsbehandlungen,
den damit verbundenen Krankheiten und Behinderun-
Präventions- und allgemeinen Behandlungsprogram-
gen betroffen wie Männer. Allerdings weisen sie eher
men sowie der Pflegeversicherung vorgestellt.
als Männer „unsichtbare“ Krankheiten und Behinderun-
gen auf, die oftmals nicht angemessen vom Gesund-
Die in dieser Studie verwendeten Informationen
heitssystem anerkannt werden. Beispiele hierfür sind
stammen von der Expertengruppe des EGGSI Netz­
Depressionen, Essstörungen und Behinderungen, die
werkes für Geschlechtergleichstellung, soziale Integra­
durch Haushaltsunfälle und durch sexuelle Gewalt ver-
tion, Gesundheitsversorgung und Langzeitpflege und
ursacht wurden, sowie altersbedingte Krankheiten und
beziehen sich auf die 30 europäischen Länder (EU-27
Behinderungen. Frauen, vor allem sehr junge Frauen,
und EEA/EFTA) (3). Verfügbare vergleichende statisti-
sind anfälliger als Männer für sexuell übertragbare
sche Daten von Eurostat- und OECD-Quellen wurden
Krankheiten, und die Folgen sind für sie schwerwie-
ebenfalls herangezogen.
gender. Sexuelle Misshandlung und häusliche Gewalt
treffen Frauen und Mädchen in allen Ländern und in
allen sozialen Klassen.
Der Vergleich des Gesundheitszustands der Bevölke-
rung in den europäischen Ländern zeigt auch, dass
Frauen und Männer osteuropäischer Länder tenden-
ziell schlechtere Gesundheitsbedingungen aufweisen
3
( ) EGGSI ist ein Netzwerk der Europäischen Kommission, das
als Frauen aus westlichen Ländern.
sich aus 30 nationalen Experten (EU und EEA-Länder) aus den
Bereichen Geschlechtergleichstellung, soziale Integration,
Gesundheit und Langzeitpflege zusammensetzt. Das Netzwerk
Insgesamt kann beobachtet werden, dass Frauen ihren
wird vom Istituto per la Ricerca Sociale und der Stiftung
Gesundheitszustand bewusster wahrnehmen und häu-
Giacomo Brodolini koordiniert. Es führt jährlich ein strategisch
figer Gesundheitsbehandlungen in Anspruch nehmen
ausgerichtetes Forschungsprogramm durch und untersteht der
als Männer. Dies ist durch ihre Reproduktionsrolle, ihre
Generaldirektion Beschäftigung, soziale Angelegenheiten und
Rolle als Pflegerinnen von Angehörigen (Kinder, Ältere,
Chancengleichheit.
11

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Behinderte), ihren größeren Anteil an der älteren
geschlechterspezifischem Verhalten und Krankheiten
Bevölkerung und auch durch Geschlechterstereotype
in strukturierter Weise ansprechen.
bedingt, da Männer es im Allgemeinen nicht als nor-
mal betrachten, sich über ihre Gesundheit zu beschwe-
Gesundheitsförderungsstrategien scheinen weitgehend
ren und einen Arzt aufzusuchen.
geschlechtsneutral zu sein, mit Ausnahme der Repro-
duktionsgesundheit. Die Förderung des Stillens ist das
in Europa am weitesten verbreitete Förderungspro-
Geschlechterunterschiede
gramm. Es wird durch gemeinsame Richtlinien unter-
bei Maßnahmen der
stützt und geht in vielen Ländern mit allgemeinen Pro-
grammen einher, die Mütter und ihre neugeborenen
Gesundheitspflege
Babys unterstützen. Auch Programme zur Förderung
von gesundheitsbewusstem Verhalten für Erwachsene
Man weiß nur wenig über Geschlechterunterschiede
oder Jugendliche sind oftmals geschlechtsbezogen
beim Zugang zur Gesundheits- und Langzeitpflege
und speziell auf Frauen oder Männer ausgerichtet. Der
und darüber, ob und wie Gesundheits- und Langzeit-
Bericht stellt Programme vor, die auf die Reduzierung
pflegesysteme diese Unterschiede bei den Versor-
des Alkoholkonsums und des Rauchens abzielen und
gungsdiensten berücksichtigen. Während Frauen zum
gesunde Ernährungsweisen sowie körperliche Bewe-
Beispiel ein in stärkerem Maße gesundheitsbewusstes
gung fördern, Programme zur Förderung der psychi-
Verhalten als Männer aufweisen und daher auch mehr
schen und beruflichen Gesundheit, Gesundheitsförde-
für Gesundheitsprävention und -förderung tun, scheint
rungsprogramme und Kampagnen, die besonders auf
es auch bewiesen zu sein, dass insbesondere arme
gefährdete Gruppen abzielen. In denjenigen Ländern,
Frauen (4) größere Schwierigkeiten haben, auf Gesund-
in denen nationale Gesundheitsförderungsmaßnah-
heitsdienste zuzugreifen, als Männer.
men weniger entwickelt sind, spielen NRO eine maß-
gebliche Rolle beim Ersatz öffentlicher Maßnahmen
In einigen europäischen Ländern (wie in Österreich,
und bieten einen Anreiz zur Steigerung des Bewusst-
Bulgarien, Deutschland, Island, Italien, Norwegen, Spa-
seins in bestimmten Bereichen.
nien, den Niederlanden, Großbritannien und Slowe-
nien) steigt das Bewusstsein in staatlichen Einrichtun-
Screening-Programme sind wichtige Präventionsmaß­
gen, Universitäten und vor allem bei NRO, die seit Lan-
nahmen, da viele Krankheiten durch Früherkennung
gem aktiv an der Bereitstellung von speziellen Diens-
vermieden werden können. Die nationalen EGGSI-
ten für Frauen, ethnische Minderheiten und andere
Berichte haben hervorgehoben, dass geschlechter-
benachteiligte Gruppen beteiligt sind, Geschlechter-
bezogene Präventionsprogramme hauptsächlich auf
unterschiede beim Zugang zu Gesundheitsdiensten
Frauen abzielen. Das wichtigste und am weitesten
anzuerkennen. In diesen Ländern wurden vor Kurzem
verbreitete geschlechterbezogene Präventionspro-
geschlechtsspezifische Strategien in die Gesundheits-
gramm, das in Europa implementiert wurde, ist das
behandlungen und in der medizinischen Forschung
Krebs-Screening. Dieses steht in Zusammenhang mit
eingeführt: Es wurden Zentren für Ressourcen und For-
einer Empfehlung des Rates, der alle Mitgliedstaaten
schungsinstitute mit speziellem Fachwissen in Bezug
dazu auffordert, gemeinsame Maßnahmen zu ergrei-
auf Frauen und Gesundheit geschaffen sowie Obser-
fen, um nationale Krebs-Screening Programme mit
vatorien für Frauengesundheit eingerichtet, um die
einem bevölkerungsbasierten Ansatz und mit geeig-
Erhebung geschlechtsspezifischer Daten und die Ent-
neter Qualitätssicherung auf allen Ebenen zu imple-
wicklung entsprechender medizinischer Forschung
mentieren. Obwohl viele Fortschritte gemacht wurden,
zu unterstützen. Überdies haben diese Länder spezi-
muss jedoch noch mehr getan werden, um sicherzu-
elle Schulungsprojekte für Allgemeinmediziner und
stellen, dass Programme in allen Mitgliedstaaten zur
Gesundheitsdienste eingeführt sowie Pilotprogramme
Verfügung stehen.
für die Behandlung von benachteiligten Frauen, wie
beispielsweise Obdachlose, Immigrantinnen, behin-
In Europa beziehen sich viele Präventionsprogramme
derte Frauen und alleinstehende Mütter.
auf die Mutterschaft: Pränatal-Tests, Unterstützung für
Mütter mit neugeborenen Kindern und Familienent-
Die in diesem Bericht dargestellte vergleichende Ana-
wicklung, Unterstützung von Kindergruppen und Müt-
lyse hat gezeigt, dass es in den meisten Ländern abge-
tern mit besonderen Bedürfnissen. Andere weitverbrei-
sehen von der Reproduktionsmedizin noch immer
tete Präventionsprogramme in Europa betreffen die
wenige geschlechtsspezifische Gesundheitsstrate-
sexuelle Gesundheit und die Reproduktionsgesundheit.
gien und -dienste gibt, die die Besonderheiten von
Der Gesundheitssektor kann auch eine entscheidende
Rolle dabei spielen, häuslicher Gewalt gegen Frauen vor­
4
( ) Bericht des Instituts für Frauengesundheit (European Institute
zubeugen, indem er dazu beiträgt, Missbrauch früh zu
of Women’s Health), Konferenz zur Geschlechtergleichheit,
erkennen, den Opfern die notwendige Behandlung
Konferenz vom September 2000,


zukommen zu lassen und den Frauen die geeignete
http://www.eurohealth.ie/gender/index.htm
12

---

Zusammenfassung
Hilfe zur Verfügung zu stellen. Ein allgemeiner Mangel
den Langzeitauswirkungen von Gewalt und Misshand-
an Aufmerksamkeit unter der Bevölkerung und bei der lungen auf die Frauengesundheit. In vielen Fällen, wie
Wahrnehmung durch das Gesundheitspersonal wurde
zum Beispiel bei Herzkrankheiten, basieren die verwen-
in einigen nationalen EGGSI-Berichten beschrieben,
deten Kenntnisse auf Studien, die an Männern durchge-
zusammen mit einigen Musterbeispielen im Zusam-
führt wurden, woraus sich Behandlungen ergeben, die
menhang mit Unterstützungsdiensten für die Opfer.
in einigen Fällen nicht auf die Bedürfnisse der Frauen
zugeschnitten sind. Andere Beispiele betreffen die
Einerseits sind nur wenige der in den nationalen EGGSI-
Auswirkungen auf die psychische Gesundheit durch
Berichten vorgestellten Programme, die auf Kinder und
die Rollenüberlastung von arbeitenden Frauen mit
Jugendliche abzielen, geschlechterbezogen. Das in
Pflegeverantwortung, oder der oftmals von alleinste-
Europa am weitesten verbreitete auf junge Mädchen
henden Müttern und alleinstehenden älteren Frauen
abzielende Programm (wenn auch mit Zugangsunter-
erfahrenen Angst und sozialen Isolation. Insbeson-
schieden), ist das Impfprogramm gegen humane Papil­
dere häuslicher Missbrauch hat oftmals hohe Depres-
loviren (HPV). Ein anderer Bereich, in dem junge Mäd-
sions- und Angstquoten von Frauen zur Folge. Bezüg-
chen die Hauptzielgruppe bei Präventivprogrammen
lich der Gesundheitsrisiken am Arbeitsplatz decken die
sind, ist die Erziehung zum gesunden Sexualverhalten
Gesundheits- und Sicherheitsbestimmungen haupt-
und Abtreibungsprävention. Abtreibung bei Jugend-
sächlich die Risiken ab, denen Männer im Allgemeinen
lichen stellt noch immer ein Problem in Europa dar,
ausgesetzt sind, während den Gesundheitsrisiken von
obwohl sich ein deutlicher Rückgang abzeichnet.
Frauen in frauentypischen Anstellungen und Sektoren
nur wenig Beachtung geschenkt wird.
Obwohl begonnen wurde, geschlechtsspezifisches
gesundheitsbezogenes Risikoverhalten zu doku-
Es wurde außerdem bemerkt, dass Frauen und Män-
mentieren und das Wissen über die Notwendig-
ner manchmal unterschiedlich behandelt werden, und
keit geschlechtsspezifischer Gesundheitsbehandlung
dies nicht, weil ihre speziellen Bedürfnisse berücksich-
immer weiter verbreitet ist, werden die Geschlechter-
tigt werden, sondern durch Vorurteile und stereoty-
unterschiede bei den meisten Gesundheitsbehandlun­
pes Verhalten des Gesundheitspersonals. Zum Beispiel
gen noch immer vernachlässigt. Ausnahmen stellen die
bekommen Männer bei der Rückkehr an ihren Arbeits-
Behandlung im Bereich der Reproduktion (Versorgung
platz nach Arbeitsunfällen häufiger therapeutische
mit dem grundlegenden Diensten für schwangere
Unterstützung als Frauen. Dies ist auch bedingt durch
Frauen und für die Entbindung) sowie die Behandlung
das Verhalten von Arbeitsärzten und Arbeitgebern, die
von besonderen weiblichen Krankheiten, wie zum Bei-
die Rehabilitation von Männern für wichtiger erachten
spiel Brust- und Gebärmutterhalskrebs, dar.
als die von Frauen.
Alter, Einkommen, Bildung und Wohnsitz sind wich-
Der Bereich der auf Männer ausgerichteten Gesundheits-
tige Zugangsfaktoren für die Gesundheitsbehandlun-
behandlung ist weniger anerkannt, auch wenn die-
gen von Frauen und Männern. Bei ähnlichen Gesund-
sem in einigen Ländern zunehmend Aufmerksamkeit
heitsbedürfnissen machen Personen mit niedrige-
geschenkt wird. Einigen männerspezifischen Krankhei-
rem Einkommen und Bildungsstand öfter und inten-
ten (wie Prostata- oder Hodenkrebs oder gutartige Pro-
siver Gebrauch von den Diensten der medizinischen
stataerkrankungen bei älteren Männern) wird in vie-
Grundversorgung, wohingegen Fachbehandlungen
len europäischen Ländern hingegen keine besondere
nicht ausreichend genutzt werden. In den meisten
Beachtung geschenkt. Auch Gesundheitsprogramme
Ländern haben Immigranten und Personen ohne Auf-
und die Behandlung einiger Krankheiten, die in Bezug
enthaltsstatus im Allgemeinen nur Zugang zur medi-
zu geschlechterbezogenem Verhalten stehen, wie bei-
zinischen Notfallversorgung. Solange es Geschlech-
spielsweise Alkoholismus und alkoholbedingte Krank-
terunterschiede beim Einkommensniveau gibt, sind
heiten, und die unterschiedliche Muster und Folgen
diese unterschiedlichen Muster auch in Bezug auf das
bei Frauen und Männern aufweisen, gehen nicht aus-
Geschlechterverhältnis relevant.
reichend auf die Geschlechterunterschiede ein.
Die physischen, psychologischen und sozialen Barrie-
ren, die viele Frauen davon abhalten, gesundheitsbe-
Zugangsbarrieren und
wusste Entscheidungen zu treffen, sind oft nicht sicht-
Geschlechterunterschiede
bar oder werden durch Gesundheitsbehandlungs-
programme und -bestimmungen nicht angespro-
Auch wenn ein allgemeines oder fast allgemeines Recht
chen. Es besteht normalerweise wenig Anerkennung
auf Gesundheitsversorgung ein Grundprinzip in allen
der geschlechtsspezifischen Besonderheiten bei der
Mitgliedstaaten darstellt und der größte Teil der euro-
Behandlung einiger Krankheiten, wie zum Beispiel bei
päischen Bevölkerung durch die öffentlichen Kranken-
Herzkrankheiten, sexuell übertragbaren Krankheiten,
kassen abgesichert ist, hat dieses Grundprinzip nicht
psychischen oder arbeitsbedingten Krankheiten sowie
immer den gleichen Zugang und die gleiche Nutzung
13

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
der Gesundheitsdienste zur Folge. Wohnsitz, sozio-
zes nach Versicherungsart in den europäischen Län-
ökonomische und geografische Faktoren können den
dern. Allerdings ist es wahrscheinlich, dass finanzielle
Zugang bestimmter Gruppen zu Gesundheitsdiens-
Barrieren besonders für Frauen relevant sind, die in
ten beeinflussen. Dies umfasst die fehlende Versiche-
Ländern leben, wo die Zuzahlungen höher sind und
rung (was insbesondere diejenigen betrifft, die keine
die Absicherung durch öffentliche Krankenversiche-
Aufenthaltsgenehmigung oder Staatsangehörigkeit
rungen niedriger ist.
haben sowie Langzeitarbeitslose und Obdachlose in
Ländern mit beitragsbezogenen sozialen Sicherungs-
Kulturelle Barrieren sind ebenfalls besonders rele-
systemen), die direkten finanziellen Kosten der Behand-
vant für Frauen, insbesondere für Immigrantinnen
lungen (betrifft Gruppen mit niedrigem Einkommen),
und für Frauen bestimmter ethnischer Herkunft. Die
fehlende Mobilität (betrifft Behinderte und Ältere), feh-
unterschiedlichen Rollen und Verhaltensweisen von
lende Sprachkompetenz (betrifft MigrantInnen und
Männern und Frauen in einer bestimmten Kultur, die
ethnische Minderheiten), den Mangel an Zugang zu
durch Geschlechternormen und -werte bedingt sind,
Informationen (betrifft Personen mit geringer Bildung
erhöhen Geschlechterunterschiede und -ungleichhei-
und MigrantInnen/ethnische Minderheiten), sowie
ten beim Zugang zu Gesundheitsdiensten sowie das
Zeitmangel (betrifft insbesondere alleinstehende Müt-
Risikoverhalten und den Gesundheitszustand. Kultu-
ter). Bei all diesen Faktoren müssen geschlechtsspezifi-
relle Barrieren können durch Vorurteile und fehlende
sche Belange berücksichtigt werden.
Kenntnisse bezüglich geschlechtsspezifischer Bedürf-
nisse und Behandlungsweisen beim Gesundheitsper-
Finanzielle Barrieren sind besonders relevant für Grup-
sonal zum Ausdruck kommen. Sprachbarrieren sowie
pen mit geringem Einkommen und für Frauen. Unglei-
Traditionen und kulturelle Praktiken spielen eben-
che Einkommen stehen insbesondere im Zusammen-
falls eine Rolle, da einige Immigrantinnen und Frauen
hang mit fehlender Versicherung, den Kosten bestimm-
bestimmter ethnischer Herkunft größere Schwierig-
ter (fachlicher) Pflegearten (wie Zahn-, Augen- und
keiten beim Zugang zu Gesundheitsdiensten und
Ohrenbehandlungen), die oft nicht durch die öffent-
zu Informationen zur sexuellen Gesundheit haben.
lichen Versicherungssysteme abgedeckt werden, und
Andererseits sind auch Männer beim Zugang zu
dem Vorhandensein privater Versicherungssysteme.
Gesundheitsbehandlungen und Präventionsprogram-
Private Zusatzkosten sowie das Fortbestehen informel-
men mit Stereotypen konfrontiert. Osteoporose wird
ler Zahlungen in vielen ost- und südeuropäischen Län-
zum Beispiel als eine Frauenkrankheit wahrgenom-
dern sind ebenfalls wichtig.
men, obwohl es offensichtlich ist, dass auch Männer
gegen Osteoporose behandelt werden sollten. Auch
Die zunehmende Bedeutung privater Krankenver-
Bildungs- und Gesundheitspräventionsprogramme
sicherungen und privater Zusatzkosten könnte
sind meistens auf Frauen ausgerichtet und sprechen
Geschlechterungleichheiten erhöhen, da Männer
nur gelegentlich Männer an. Der Bericht zeigt auch
öfter durch private Krankenversicherungen abgesi-
auf, dass es wichtig ist, verschiedene Elemente bei der
chert sind als Frauen, obwohl Frauen mehr Gesund-
Analyse der kulturellen Hindernisse beim Zugang zu
heitsbehandlungen und Medizin in Anspruch neh-
Gesundheitsdiensten zu berücksichtigen.
men. Frauen haben gewöhnlich ein niedrigeres Ein-
kommen und profitieren nicht in derselben Weise von
Dies betrifft Vorurteile und Geschlechterstereotypen,
firmenbasierten privaten Absicherungen wie Män-
sozialen Status und Bildungsniveau, kulturelle Unter-
ner. Frauen weisen überdies niedrigere Anstellungs-
schiede je nach ethnischer Zugehörigkeit und Migra-
raten in der geregelten Wirtschaft auf (viele sind ent-
tionshintergrund (was nicht nur die Sprachfähigkeiten
weder unbeschäftigt oder arbeiten zu Hause oder im
einschließt, sondern auch Traditionen und Hygiene-
informellen Sektor), und wenn sie beschäftigt sind,
normen), religiöse Praktiken, Vorurteile bezüglich sexu-
sind sie häufiger im öffentlichen Sektor und in klei-
eller Orientierung und der Arbeitskultur.
nen Firmen (die keine zusätzlichen privaten Kran-
kenversicherungen anbieten) sowie in Teilzeit- und/
Geografische Unterschiede in der Versorgung und der
oder mit Zeitverträgen in Niedriglohnjobs beschäf-
Flächendeckung sind weitere relevante Barrieren
tigt. Überdies sind private Krankenversicherungen
beim Zugang zu Gesundheitsbehandlungen. Die Ver-
für Frauen weniger attraktiv, da diese im Allgemeinen
sorgung mit Gesundheitsdiensten ist üblicherweise
Alter und geschlechtsspezifische Risiken bei der Bei-
besser in größeren Städten und in dichter besiedelten
tragsberechnung mit einbeziehen. Frauen ethnischer
Gebieten, während ein Mangel an Allgemeinmedizi-
Minderheiten und aus ärmeren Haushalten könnten
nern oder Hausärzten sowie an bestimmten grund-
besonders durch die Privatisierung von Gesundheits-
legenden Facharztdienstleistungen in kleinen, länd-
diensten und die zunehmenden privaten Zuzahlun-
lichen und abgelegenen Gebieten besteht. Kranken-
gen bei der Gesundheitsbehandlung benachteiligt
häuser sind in den Ländern oft ungleich verteilt, was
werden. Es gibt keine geschlechterdifferenzierten
sich in einigen Fällen durch geografische Merkmale
und vergleichenden Daten des Versicherungsschut-
(wie auf Inseln oder in Berggebieten) erklären lässt. In
14

---

Zusammenfassung
einigen Ländern sind Unterschiede jedoch das Ergeb-
Das Wichtigste ist die Notwendigkeit, eine Geschlech-
nis eines dezentralisierten Entscheidungsfindungspro-
terperspektive in Gesundheitsfürsorgerichtlinien zu
zesses, bei dem regionale und lokale Behörden Richt-
übernehmen, unter Berücksichtigung der biologi-
linienbefugnis haben und regionale Unterschiede bei
schen, ökonomischen, sozialen und kulturellen Fak-
der Finanzierung entstehen. Die Entfernung zu Kran-
toren, die den Gesundheitszustand von Männern und
kenhäusern und Gesundheitszentren und der Man-
Frauen und deren Zugang zu Gesundheitsdiensten
gel an erreichbaren Transportmitteln und Einrichtun-
beeinflussen. Der Ansatz einer geschlechterorientier-
gen betreffen insbesondere Frauen in ländlichen oder
ten Gesundheitspolitik, der geschlechterspezifische
bergigen Gebieten, Behinderte und ältere Frauen, da
Risikofaktoren in der medizinischen Forschung, in der
diese hinsichtlich der Mobilität weniger unabhängig
Versorgung (unter Berücksichtigung der Förderung,
sind als Männer (sie fahren seltener Auto als Männer)
Prävention und der Behandlungsrichtlinien) sowie
und eine höhere Lebenserwartung haben und somit
der Entwicklung von Finanzierungssystemen berück-
mehr Krankheitsjahre aufweisen.
sichtigt, verbessert die Wirksamkeit der Pflege für
Frauen und Männer und verringert Ungleichheiten
beim Zugang, wie in einigen der Beispiele im Bericht
Geschlechterunterschiede beim
gezeigt wurde.
Zugang zur Langzeitpflege
Geschlechterbasierte Gesundheitsforschung erhöht das
In ganz Europa gibt es zahlreiche Vorschriften für die
Wissen in Bezug auf die komplexe Art, in der biologi-
Langzeitpflege. Die Mischung der Leistungsarten –
sche, soziale, kulturelle und Umweltfaktoren zusam-
formell/informell, in Barzahlungen/in Sachleistungen,
menwirken und auf die Gesundheit von Frauen und
institutionelle/häusliche Pflege – variiert in den ver-
Männern einwirken. Geschlechterbasierte medizini-
schiedenen europäischen Ländern und spiegelt stär-
sche Forschung verbessert auch die Aufmerksamkeit
ker die organisatorischen Merkmale jedes Systems
des Gesundheitspersonals in Bezug auf Geschlech-
wider als die Bevölkerungsstruktur und die demo-
terunterschiede und unterstützt, wenn notwendig,
grafischen Entwicklungen. Insbesondere spiegeln die
die Förderung geschlechterdifferenzierter Behand-
Unterschiede die verschiedenen nationalen Annä-
lung. Es ist zum Beispiel wichtig, dass bei der Erfor-
herungen an familiäre Solidarität wider (informelle
schung kardiovaskulärer Krankheiten Geschlechter-
Pflege und Unterstützung für Pfleger). In den vergan-
unterschiede bei der Krankheitsziffer und der Ster-
genen fünfzehn Jahren haben europäische Länder
bewahrscheinlichkeit sowie als Folge auch in der
Reformen erfahren, die darauf abzielten, Ungleich-
Behandlung berücksichtigt werden; die Erforschung
heiten beim Zugang zur Langzeitpflege zu beseitigen
der Gesundheit am Arbeitsplatz und der Arbeitssi-
und die Pflegequalität zu verbessern.
cherheit sowie die Praktiken sollten geschlechtsspe-
zifische Faktoren in Betracht ziehen, wie zum Beispiel
Die Geschlechterperspektive ist bei der Berücksich-
die unterschiedlichen Gesundheitsrisiken, denen
tigung des Zugangs zu Langzeitpflegediensten rele-
Frauen und Männer aufgrund beruflicher geschlech-
vant, da Frauen die hauptsächlichen Anbieter von
terspezifischer Segregation ausgesetzt sind, und die
Langzeitpflege sind, insbesondere der informel-
Gesundheitsrisiken, die sich aus prekären Anstellun-
len Pflegedienste, und die Hauptnutzer, da sie län-
gen, bei der Hausarbeit und bei informeller Pflege
ger als Männer leben und häufiger im Alter alleinste-
durch Frauen ergeben.
hend sind. Auch sind ältere Frauen häufiger als Män-
ner negativ von den in vielen Ländern eingeführten
Die Einführung geschlechtsspezifischer Gesundheitsin­
Zuzahlungen für den Zugang zu Langzeitpflegediens-
formationssysteme und Analyseinstrumente (wie zum
ten betroffen, da ihr durchschnittliches Einkommen
Beispiel Gender Impact Assessment), die die Qualität
niedriger ist als das der Männer.
bei der Erhebung und Analyse von Daten verbessern, ist
grundlegend für die Unterstützung der medizinischen
Forschung und für die systematische geschlechtsspe-
Geschlechterungleichheiten beim zifische Überwachung und Evaluierung von Gesund-
Zugang zu Gesundheitsfürsorge
heitspflegesystemen.
und Langzeitpflegediensten
Die Förderung von Handlungskapazitäten und Wissen
für eine geschlechterspezifische Sensibilität in den
Die in diesem Bericht vorgestellte vergleichende Ana-
Gesundheitspflegesystemen und die geschlechtsspe­
lyse hat einige wichtige Probleme herausgearbeitet,
zifische Schulung des Gesundheitspflegepersonals
die angegangen werden müssen, um Geschlechter-
werden voraussichtlich die Aufmerksamkeit gegen-
unterschiede beim Zugang zu Gesundheitspflege und
über Geschlechterunterschieden bei der Bereitstel-
Langzeitpflege zu verringern und kostenwirksame
lung und der Wirksamkeit von Gesundheitspflege-
sowie qualitativ hochwertige Pflege zu liefern.
diensten erhöhen.
15

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Die Anerkennung der Rolle der Frauen als Nutzer und
(formell und informell) und Nutzer von Pflegeleis-
Anbieter der Gesundheitspflegedienste, sowohl
tungen sind.
innerhalb des Gesundheitspflegesystems als auch
außerhalb in Form von informellen und oft auch
Maßnahmen, die Langzeitpflegesysteme unterstützen,
unbezahlten Pflegediensten, ist bei der Evaluierung
wirken sich auf das Geschlechterverhältnis aus. Vorkeh-
der Geschlechterauswirkung auf die derzeitigen Refor­
rungen zur Überwindung von Barrieren für Langzeit-
men des Gesundheitswesens wichtig, insbesondere in
pflegedienste gibt es in einigen Mitgliedstaaten; sie
Bezug auf die Finanzierung und Bereitstellung der
werden im Bericht vorgestellt. Sie beziehen sich haupt-
Gesundheitspflege. Die Reformen des Gesundheits-
sächlich auf die Unterstützung von niedrigen Einkom-
wesens können sich wegen der Erhöhung der Kos-
mensgruppen (wie in den Niederlanden), die Verbesse-
tenteilung durch private Versicherungssysteme und
rung der Pflegequalität (wie in Deutschland, Rumänien
private Zuzahlungen nachteiliger auf Frauen auswir-
und Norwegen) sowie die Unterstützung informeller
ken als auf Männer, da Frauen die Mehrheit unter
Pflegeanbieter (wie in Finnland und Schweden).
den Gesundheitspflegenutzern und den Niedrig-
lohngruppen bilden. Die jüngsten Entwicklungen
Abschließend zeigen die Ergebnisse aus diesem ver-
zur Kostenreduzierung tragen zur Erhöhung von
gleichenden Bericht, dass die Notwendigkeit besteht,
Geschlechter- und Einkommensungleichheiten bei,
einen gleichstellungsorientierten Ansatz bei den
wenn dies nicht angemessen berücksichtigt wird.
Gesundheitspflegerichtlinien anzuwenden, um deren
Die Rationalisierung der Gesundheitspflegedienste,
Wirksamkeit zu verbessern. Dies ist insofern bedeut-
welche in vielen Ländern die Zahl der Kliniken und
sam, da die derzeitige Finanz- und Wirtschaftskrise
Dienstleistungen in ländlichen oder niedrig bevöl-
die verfügbaren Ressourcen zur Verbesserung der
kerten Gebieten sowie den Patienten-/Personalanteil
Qualität und der Deckung der Gesundheitspflege-
verringert hat, könnte für Frauen negativere Folgen
und Langzeitpflegemaßnahmen verringern könnte
als für Männer mit sich bringen, da Frauen sowohl
und geschlechterbasierte Pilotprogramme unter
die Mehrheit unter den Nutzern als auch unter den
großem Budgetkürzungsrisiko stehen. Die osteu-
Anbietern der Gesundheitspflege bilden. Diese Pro-
ropäischen Länder, die dabei sind, die Qualität und
bleme sind besonders relevant bei der Langzeit-
Erweiterung ihrer Gesundheitspflegesysteme zu ver-
pflege, bei der das Geschlecht eine noch relevantere
bessern, sind einem solchen Risiko in besonderem
Rolle spielt, da Frauen die hauptsächlichen Anbieter
Maße ausgesetzt.
16

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Résumé
Alors que les systèmes de soins ont contribué à
Différences de l’état de santé
améliorer de manière significative le domaine de la
selon le sexe
santé en Europe, l’accès à ces derniers demeure inégal
dans les pays et les groupes sociaux, en fonction du
Les différences de l’état de santé et des besoins en
statut socio-économique, du lieu de résidence, du
matière de santé selon le sexe s’expliquent largement
groupe ethnique et du sexe de la personne concernée.
par des facteurs biologiques et génétiques ainsi que par
des différences de normes sociales et de comportement
Le sexe joue un rôle particulier dans l’incidence et dans
en matière de santé.
la prédominance de pathologies spécifiques, mais aussi
dans leur traitement et leur impact en termes de bien-
D’une part, les femmes et les hommes sont prédisposés à
être et de rétablissement. Cela en raison des corrélations
des maladies spécifiques liées à leur santé reproductive;
qui existent entre les différences biologiques liées au
par exemple les cancers du sein et de l’utérus chez les
sexe et les facteurs culturels et socio-économiques
femmes et le cancer de la prostate chez les hommes.
qui produisent des effets sur le comportement des
D’autre part, les femmes et les hommes présentent des
hommes et femmes et sur leur accès aux services.
symptômes et des effets différents lors de maladies
courantes, telles que les maladies cardiovasculaires et
Le présent rapport comparatif expose les principales
de nombreuses maladies sexuellement transmissibles.
différences au niveau de l’état de santé des femmes
et des hommes dans les pays européens et étudie la
Tout comme les facteurs biologiques, les normes
façon dont les systèmes de soins, et surtout ceux de
sociales produisent également des effets différents sur
longue durée, répondent aux besoins spécifiques des
l’état de santé des femmes et des hommes: les femmes
femmes et des hommes en leur assurant une égalité
sont moins confrontées que les hommes aux maladies
d’accès aux soins. Il tient compte des principales
et handicaps dus à des comportements à risque pour
barrières financières, culturelles et physiques à cet
la santé, mais elles sont plus susceptibles de présenter
accès et donne des exemples de bonnes pratiques de
des maladies et handicaps «invisibles» qui souvent ne
promotion des soins, de prévention et de programmes
sont pas reconnus de manière adéquate par le système
de traitement général, ainsi que de soins de longue
de soins (par exemple la dépression, les troubles du
durée (SLD).
comportement alimentaire, les actes de violence
sexuelle, les handicaps liés à des accidents domestiques
Les informations contenues dans le présent rapport
et au grand âge). Les femmes, et plus particulièrement
sont fournies essentiellement par les experts
les très jeunes femmes, sont plus vulnérables que les
nationaux du EGGSI (réseau d’experts en égalité
hommes aux maladies sexuellement transmissibles,
des sexes, insertion sociale, soins de santé et soins
et les conséquences en sont plus sérieuses pour elles.
de longue durée) et couvre trente pays européens
Les abus sexuels et les violences domestiques affectent
(EU-27 et Espace économique européen/Association
particulièrement le sexe féminin dans l’ensemble des
européenne de libre-échange) (5). Des données
pays et dans toutes les classes sociales.
statistiques
comparatives
disponibles
auprès
d’Eurostat et de l’Organisation de coopération et de
La comparaison de l’état de santé des populations des
développement économiques (OCDE) ont également
pays européens montre également que les pays d’Europe
été prises en compte.
de l’Est tendent à présenter des conditions de santé
moins bonnes en général que les pays occidentaux.
Les femmes, en général, sont plus conscientes de leur
état de santé et utilisent plus les services de soins que
les hommes. Et ce, pour plusieurs raisons: leur rôle
5
( ) EGGSI est le réseau de la Commission européenne réunissant
trente experts nationaux (pays de l’Union européenne et de
dans la reproduction, leur rôle d’aidantes vis-à-vis des
l’Espace économique européen) dans les domaines de l’égalité
personnes dépendantes (enfants, personnes âgées,
des sexes et de l’insertion sociale ainsi que des questions de
handicapées), leur plus grande proportion au sein de
santé et de soins de longue durée. Ce réseau est coordonné
la population âgée et aussi les stéréotypes liés à leur
par l’Istituto per la ricerca sociale et la Fondazione Giacomo
Brodolini; il met en œuvre un programme annuel de recherche à
sexe, puisqu’en général les hommes n’estiment pas
caractère stratégique et en rend compte à la direction générale
normal de se plaindre de leur santé et de consulter
de l’emploi, des affaires sociales et de l’égalité des chances.
un médecin.
17

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Différences selon le sexe
Les stratégies de promotion de la santé apparaissent
dans la prestation des soins
comme largement neutres en matière de sexe, sauf
en ce qui concerne la santé liée à la reproduction. La
On sait peu de chose sur les disparités entre les
promotion de l’allaitement maternel est le programme
sexes en ce qui concerne l’accès aux soins et plus
le plus répandu à travers l’Europe. Il est soutenu par les
particulièrement aux soins de longue durée, et on ne
lignes directrices classiques et s’accompagne, dans de
sait pas davantage si ni comment ces disparités sont
nombreux pays, de programmes plus généraux d’aide
prises en compte dans la prestation des services de
aux mères et aux nouveau-nés. De plus, certains
santé. Par exemple, il semble que les femmes ont plus
programmes de promotion de comportements sains
un comportement qui favorise leur santé et pratiquent
s’adressant aux adultes ou aux adolescents sont
donc plus la prévention et la promotion de la santé par
souvent orientés selon le sexe et ont pour cible soit les
rapport aux hommes, mais il est également prouvé
hommes, soit les femmes: programmes visant à réduire
que les femmes pauvres (6), en particulier, peuvent
la consommation d’alcool et de cigarettes, programmes
rencontrer plus de difficultés que les hommes à accéder
soutenant les régimes et l’activité physique, programmes
aux services de santé.
promouvant la santé mentale et la santé au travail,
programmes de promotion de la santé et campagnes
Dans certains pays d’Europe (comme l’Allemagne,
ciblées tout particulièrement sur les groupes les plus
l’Autriche, la Bulgarie, l’Espagne, l’Irlande, l’Islande,
vulnérables. Dans les pays où les activités de promotion
l’Italie, la Norvège, les Pays-Bas, le Royaume-Uni et
nationale de la santé sont moins développées, les ONG
la Slovénie), on assiste à une prise de conscience
jouent habituellement un rôle important en se substituant
croissante du besoin de reconnaissance des
aux pouvoirs publics et en lançant des campagnes de
différences entre les sexes pour l’accès aux soins
sensibilisation sur des questions spécifiques.
au sein des institutions gouvernementales, des
universités, et en particulier des organisations non
Les programmes de dépistage constituent d’impor-
gouvernementales (ONG), traditionnellement très
tantes mesures de prévention, puisque de nombreuses
actives dans la fourniture de services de spécialistes
maladies peuvent être évitées grâce à une détection
aux femmes, aux minorités ethniques et autres
précoce. Les rapports nationaux de l’EGGSI ont mis en
groupes défavorisés. Dans ces pays, des stratégies
évidence que les programmes de prévention intégrant
tenant compte des besoins spécifiques des hommes
le facteur sexe sont principalement ciblés sur les
et des femmes ont été récemment mises en œuvre
femmes. En Europe, le programme de prévention le
dans le domaine des soins et de la recherche
plus important et le plus répandu intégrant le facteur
médicale: des centres de ressources et des instituts
sexe est le dépistage du cancer. Cela est dû à une
de recherche spécialisés dans le domaine des femmes
recommandation du Conseil invitant les États membres
et de la santé ont été créés, des observatoires sur la
à engager une action de mise en œuvre de programmes
santé des femmes ont été mis en place pour aider
nationaux de dépistage du cancer selon une approche
au développement de données ventilées par sexe et
basée sur la population et avec l’assurance d’une qualité
la recherche médicale sexuée. De plus, ces pays ont
appropriée à tous les niveaux. En dépit des grands
mis en œuvre des projets de formation particuliers
progrès réalisés, il est nécessaire d’en faire davantage
pour les praticiens généralistes et les prestataires
pour s’assurer que les programmes sont disponibles
de santé, ainsi que des programmes pilotes pour le
dans l’ensemble des États membres.
traitement des femmes défavorisées, telles que les
sans domicile fixe, les immigrées, les handicapées et
En Europe, de nombreux programmes de prévention
les mères célibataires.
concernent la maternité: tests prénataux, aide aux
mères ayant des nouveau-nés et au développement de
L’analyse comparative exposée dans le présent
la famille, aide aux groupes d’enfants et de mères ayant
rapport montre toutefois que, dans la plupart des
des besoins spécifiques. Mais il existe aussi d’autres
pays, en dehors des soins en matière de reproduction,
programmes de prévention importants concernant la
il existe encore peu de stratégies de soins intégrant
santé sexuelle et reproductive. Le secteur de la santé peut
le facteur sexe et de services abordant les spécificités
également jouer un rôle essentiel dans la prévention
d’attitudes et de maladies liées au sexe d’une manière
de la violence domestique contre les femmes, en aidant
plus structurée.
à la détection précoce des abus, en fournissant aux
victimes les traitements nécessaires et en renvoyant
les femmes aux soins appropriés. Certains rapports
nationaux de l’EGGSI ont fait état d’un manque général
d’attention de la population et de conscience parmi les
professionnels de la santé, mais ont également mis en
6
( ) Rapport du European Institute of Women’s Health, conférence
sur l’égalité des sexes, septembre 2000,


avant des exemples de bonnes pratiques de services
http://www.eurohealth.ie/gender/index.htm
d’aide aux victimes.
18

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Résumé
En revanche, peu de programmes présentés dans les
par les mères célibataires et les femmes âgées
rapports nationaux de l’EGGSI destinés aux enfants
vivant seules. Les actes de violence domestique, en
et aux adolescents sont ciblés selon le sexe. Le
particulier, entraînent habituellement des taux élevés
programme le plus répandu à travers l’Europe (même
de dépression et d’anxiété chez les femmes. Quant aux
s’il existe des différences quant à son accès) et ciblé sur
risques pour la santé liés au travail, les réglementations
les jeunes filles est le programme de vaccination contre
sur la santé et la sécurité sur le lieu de travail couvrent
les papillomavirus humains (PVH). L’éducation sexuelle
principalement les risques auxquels les hommes sont
et la prévention de l’avortement constituent un autre plus généralement exposés, tandis qu’il est fait peu
domaine où les jeunes filles sont la cible principale de
de cas des risques pour la santé des femmes dans des
programmes de prévention. En Europe, l’avortement
domaines et des activités féminines intensives.
chez les adolescentes est encore un problème, même
si une tendance à la réduction transparaît clairement.
Il a également été relevé que les femmes et les hommes
sont parfois traités différemment, non parce que leurs
Bien que le comportement à risque pour la santé
besoins spécifiques sont reconnus, mais en raison des
en fonction du sexe commence à être documenté et
attitudes préconçues et stéréotypées des praticiens de
que les connaissances sur la nécessité de fournir un
la santé. Par exemple, une aide thérapeutique pour le
traitement adapté au sexe soient diffusées de façon
retour au travail après un accident du travail est plus
croissante, les disparités entre les sexes dans la plupart fréquente chez les hommes que chez les femmes, car
des traitements de soins sont souvent négligées. Les
médecins du travail et les employeurs estiment que la
seules exceptions concernent les soins en matière de
réintégration est plus importante pour un homme que
reproduction (prestation de services de base pour les
pour une femme.
femmes enceintes et la naissance) et le traitement de
maladies spécifiquement féminines telle que le cancer
La prestation de services de santé ciblée spécifiquement
du sein et le cancer du col de l’utérus.
sur les hommes est moins reconnue, même si, dans
certains pays, ces questions font l’objet d’une attention
L’âge, les revenus, l’éducation et le lieu de résidence croissante. Certaines maladies spécifiques aux hommes
constituent des critères d’accès importants aux
(cancers de la prostate ou des testicules ou maladies
traitements de soins pour les hommes et les femmes.
bénignes de la prostate chez les hommes d’un certain
À des niveaux similaires de besoins de soins, les
âge) ne font pas l’objet d’une attention particulière
individus ayant de plus faibles revenus et une moins
dans de nombreux pays d’Europe. Par ailleurs, les
bonne éducation utilisent majoritairement les soins
programmes de santé et le traitement de certaines
primaires et tendent à sous-utiliser une assistance
maladies liées aux comportements sexués, telles
spécialisée. Dans la plupart des pays, les immigrés et
l’addiction à l’alcool et les maladies liées à l’alcool, qui
les non-résidents n’ont habituellement accès qu’aux
présentent des formes et des effets différents chez les
soins d’urgence. Tant qu’il existera des différences dans
femmes et les hommes, ne prennent pas suffisamment
les niveaux de revenus selon le sexe, ces différents
en compte les différences liées au sexe.
modèles seront également applicables en termes
d’inégalité de genre.
Barrières à l’accès aux soins
Les barrières physiques, psychologiques et sociales
et différences selon le sexe
qui empêchent de nombreuses femmes de prendre
des décisions relatives à leur santé sont souvent
Même si les droits universels ou quasi universels aux
non visibles ou abordées par les programmes et les
soins sont des principes de base dans l’ensemble
réglementations de traitement de soins. Les spécificités
des États membres et si la majorité des populations
féminines sont peu reconnues dans le traitement
européennes sont couvertes par l’assurance de santé
de certaines pathologies telles que les maladies
publique, ces principes de base ne se traduisent pas
cardiaques, les maladies sexuellement transmissibles,
toujours en un accès et une utilisation identiques
les troubles mentaux ou les maladies liées au travail, et
des soins de santé. Le lieu de résidence et certains
dans celui des conséquences à long terme d’actes de
facteurs socio-économiques et géographiques peu-
violence ou d’abus sexuels. En effet, dans de nombreux
vent influencer l’accessibilité aux soins de certains
cas, par exemple celui des maladies cardiaques, le
groupes particuliers: l’absence de couverture par
savoir utilisé est fondé sur des études menées sur des
une assurance (touchant en particulier les personnes
hommes, ce qui aboutit à un traitement qui ne répond
sans résidence ou nationalité, les chômeurs de
pas toujours aux besoins d’une femme. Les autres
longue durée et les sans domicile fixe dans des
exemples sont les répercussions sur la santé mentale
pays fondés sur des systèmes de contribution de
de la surcharge de tâches pour des femmes actives
sécurité sociale), les coûts financiers directs des
et ayant des responsabilités de soins, mais aussi de
soins (touchant les personnes percevant de faibles
l’anxiété et de l’isolement social souvent rencontrés
revenus), l’absence de mobilité (touchant les
19

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
personnes âgées et les handicapés), l’absence de
Les barrières culturelles sont aussi particulièrement
compétence linguistique (touchant les migrants
significatives pour les femmes, spécialement pour les
et les minorités ethniques), l’absence d’accès à
immigrées et les femmes d’origine ethnique. Les rôles et
l’information (touchant les personnes ayant reçu peu
comportements distincts des hommes et des femmes
d’éducation et les migrants/minorités ethniques) et
dans une culture donnée, résultant des normes et des
les contraintes de temps (touchant en particulier les
valeurs liées au sexe, donnent lieu à des différences et à
mères célibataires). Tous ces facteurs contiennent
des inégalités entre les sexes dans l’accès aux soins ainsi
aussi des éléments spécifiques liés au sexe qui
qu’au niveau des comportements à risque et de l’état de
doivent être pris en considération.
santé. Les barrières culturelles peuvent être exprimées
en termes de préjugés et de manque de connaissance
Les barrières financières sont particulièrement
parmi les professionnels de la santé en ce qui concerne
significatives pour les groupes disposant de faibles
les spécificités liées au sexe pour les besoins et les types
revenus et pour les femmes. Les inégalités de revenus
de soins à fournir. Les questions de langue ainsi que les
sont principalement liées à l’absence de couverture
traditions et les pratiques culturelles jouent également
par une assurance, au coût de certains types de soins
un rôle. Certains groupes de femmes immigrées et
spécialisés (tels que ceux concernant la dentition, la
d’origine ethnique ont de grandes difficultés d’accès
vue et l’audition) qui souvent ne sont pas couverts
aux équipements de santé et à l’information sur la santé
par les systèmes d’assurance publics et à l’incidence
sexuelle. D’un autre côté, les hommes sont également
des systèmes d’assurance privés. Les coûts non
confrontés à des stéréotypes lors de l’accès aux soins
remboursés et la persistance de paiements informels
et aux programmes de prévention. L’ostéoporose, par
dans de nombreux pays d’Europe de l’Est et du Sud ont
exemple, est perçue comme une maladie féminine,
également un impact significatif.
et il ne semble pas évident que certains hommes
doivent eux aussi être traités pour l’ostéoporose.
Le rôle croissant de l’assurance maladie privée et
Les programmes d’éducation et de prévention de la
des dépenses non remboursées peut accroître les
santé sont également ciblés principalement sur les
inégalités entre les sexes, puisque les hommes sont
femmes et ne s’adressent aux hommes que de manière
plus susceptibles d’être couverts par une assurance
occasionnelle. Ce rapport montre à quel point il est
privée que les femmes, bien que celles-ci soient de
important de prendre en considération une variété
plus grandes consommatrices de services de soins
d’éléments dans l’analyse des barrières culturelles à
et de médicaments. Habituellement, les femmes ont
l’accès aux soins. Ces éléments sont notamment les
un revenu inférieur et ne profitent pas du même type
préjugés et les stéréotypes sexuels, le statut social
de couverture d’assurance privée reposant sur une
et le niveau d’éducation, les différences culturelles
base professionnelle que les hommes. Les femmes
inhérentes à l’ethnie et les questions de migration (qui
présentent également des taux d’emploi plus faibles
impliquent non seulement des aptitudes linguistiques,
dans l’économie régulière (de nombreuses femmes
mais également des traditions et des règles d’hygiène),
sont inactives ou travaillent à la maison ou dans
les pratiques religieuses, les préjugés concernant
le secteur informel) et, lorsqu’elles ont un emploi,
l’orientation sexuelle, la culture du travail.
elles sont plus susceptibles d’être employées dans
le secteur public et les petites entreprises (qui ne
Les variations géographiques dans la couverture
sont pas obligées de fournir un système d’assurance
du territoire et la fourniture de services sont une
privée complémentaire) avec des contrats de travail
autre barrière significative à l’accès aux soins. La
à temps partiel et/ou temporaire pour un emploi mal
prestation de services de soins est généralement
payé. En outre, les systèmes d’assurance privée sont plus importante dans les grandes villes et les zones
moins attrayants pour les femmes puisqu’ils prennent
à forte densité de population, alors qu’il manque des
habituellement en considération les risques liés à l’âge
praticiens généralistes ou des médecins de famille et
et au sexe de la personne concernée pour fixer les
certains services spécialisés de base dans des petites
cotisations. Les femmes issues de minorités ethniques
zones rurales et reculées. Par ailleurs, dans certains
et de ménages pauvres peuvent être particulièrement
cas, les hôpitaux sont souvent répartis de manière
pénalisées par la privatisation des services de santé
inégale à travers les pays à cause de caractéristiques
et l’augmentation des dépenses de santé non
géographiques (en raison de la présence d’îles ou de
remboursées. Il n’existe pas de données comparatives
montagnes). Toutefois, dans certains pays, les dispari-
selon le sexe relatives à la couverture d’assurance par
tés sont le résultat de la décentralisation du processus
type d’assurance dans les pays européens, cependant,
de prise de décision, permettant aux autorités
il est vraisemblable que les barrières financières sont
régionales et locales de mener une politique
particulièrement significatives pour les femmes vivant
discrétionnaire et autorisant des différences régionales
dans les pays où l’incidence du partage des coûts
dans le financement. La distance jusqu’aux hôpitaux
est plus forte et où l’extension de la couverture de
et aux centres de soins et l’absence de moyens de
l’assurance publique est plus faible.
transport et d’équipements accessibles touchent en
20

---

Résumé
particulier les femmes (surtout celles vivant dans des
des facteurs de risques liés au sexe dans la recherche
zones rurales ou montagneuses, les handicapées et
médicale, la fourniture de services (prenant en consi-
les femmes âgées), qui sont moins autonomes que
dération les politiques de promotion, de prévention
les hommes sur le plan de la mobilité (il est moins
et de traitement) et la conception de systèmes de
fréquent que les femmes conduisent) et vivent un
financement, accroît l’efficacité des soins fournis
plus grand nombre d’années à un âge avancé et en
aux femmes et aux hommes et réduit les inégalités
mauvaise santé.
d’accès, comme cela est montré dans certaines bonnes
pratiques présentées dans ce rapport.
Les différences selon le sexe pour La recherche en matière de santé basée sur le sexe
l’accès aux soins de longue durée
augmente les connaissances sur le fait que les facteurs
biologiques, sociaux, culturels et environnementaux
Partout en Europe, il existe différentes dispositions
interagissent pour affecter la santé des femmes et
relatives aux SLD. Le mélange des types de prestation —
des hommes. La recherche médicale basée sur le sexe
formelle/informelle, en espèces/en nature, soins en
accroît également l’attention des praticiens de la santé
institution/à domicile — varie selon les pays européens,
sur les différences entre les sexes et aide à la fourniture
reflétant davantage les caractéristiques de l’organisation
d’un traitement différencié selon le sexe, si nécessaire.
propres à chaque système plutôt qu’une structure de
Par exemple, il est important que la recherche dans
population et des développements démographiques.
le domaine des maladies cardiovasculaires prenne en
En particulier, ces variations reflètent les différentes
considération les différences en fonction du sexe dans
approches nationales en matière de solidarité familiale
la morbidité et la mortalité et au niveau des réactions au
(incidence des soins informels et aide aux soignants). Au
traitement. Les recherches et les pratiques en matière de
cours des quinze dernières années, les pays européens
santé et de sécurité professionnelle devraient prendre
ont connu des réformes visant à effacer les inégalités
en compte les facteurs spécifiques au sexe, tels que les
d’accès aux SLD et à améliorer la qualité des soins.
différents risques auxquels les femmes et les hommes
s’exposent en raison d’une ségrégation professionnelle
La question du sexe est significative si l’on considère
selon le sexe et les risques pour la santé résultant de
l’accès aux services de soins de longue durée, puisque
l’emploi précaire, du travail à domicile et des travaux de
les femmes sont les principales fournisseuses de SLD,
soins informels accomplis par les femmes.
en particulier des soins informels, et les principales
utilisatrices des services SLD, parce qu’elles vivent
La mise en œuvre de systèmes d’information sur la
plus longtemps que les hommes et sont donc plus
santé sexuée et d’instruments d’analyse (tels que l’étude
susceptibles de vivre seules à un âge avancé. Les
d’impact de genre), améliorant la qualité de la col ecte
femmes les plus âgées sont souvent plus touchées
et de l’analyse des données, est essentiel e pour le
négativement que les hommes par la cotisation pour
soutien de la recherche médicale et pour l’évaluation
l’accès aux SLD, introduite dans de nombreux pays, car
et le contrôle systématique lié au sexe des systèmes de
leur revenu moyen est inférieur à celui des hommes.
soins.
La promotion du renforcement des capacités pour tenir
Aborder les inégalités entre les
compte des besoins spécifiques des femmes et des
sexes au niveau de l’accès aux
hommes dans les systèmes de soins et de la formation
spécifique au sexe pour les professionnels de la santé
soins et aux soins de longue durée est susceptible d’accroître l’attention accordée aux
différences entre les sexes dans la fourniture des
L’analyse comparative exposée dans le présent rapport
services et l’efficacité des services de soins.
a mis en lumière des questions importantes qui doivent
être abordées pour réduire les inégalités entre les sexes
La reconnaissance du rôle des femmes en tant
au niveau de l’accès aux soins, et en particulier aux soins
qu’utilisatrices et fournisseuses de soins à la fois à
de longue durée, et pour fournir des soins rentables et
l’intérieur et à l’extérieur du système de soins, en tant
de haute qualité.
que soignantes informelles et souvent non payées,
est importante lors de l’évaluation de l’impact sur
Le plus important est la nécessité d’adopter une
le genre des tendances récentes dans les réformes de
perspective spécifique au sexe dans les politiques
soins, en particulier en rapport avec le financement
de soins, en prenant en considération les facteurs
et la fourniture de soins. Les tendances de la réforme
biologiques, économiques, sociaux et culturels qui
des soins, augmentant notamment l’incidence du
affectent l’état de santé des hommes et des femmes
partage des coûts par des systèmes d’assurance privée
et leur accès aux soins. Une approche des politiques
et de dépenses non remboursées, peuvent affecter
de soins fondée sur une analyse selon le sexe, abordant
défavorablement les femmes plus que les hommes,
21

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
puisqu’elles constituent la majorité des utilisateurs des
dépasser les barrières pour l’accès aux SLD peuvent être
soins et des groupes à faibles revenus. Les dernières
trouvés dans les États membres et sont présentés dans
tendances en matière de limitation des coûts et de
ce rapport. Ils visent principalement: l’aide aux groupes
limitation dans la fourniture des soins de base inclus
ayant de faibles revenus (aux Pays-Bas), l’amélioration
dans les soins primaires sont également susceptibles
de la qualité des soins (en Allemagne, en Norvège et en
d’augmenter les inégalités de revenus et celles entre
Roumanie) et l’aide aux fournisseurs informels de soins
les sexes si elles ne sont pas abordées de manière
(en Finlande et en Suède).
adéquate. La rationalisation des services de soins
de santé qui, dans de nombreux pays, a réduit les En conclusion, les éléments se dégageant de ce
cliniques et les services locaux dans les zones rurales rapport comparatif soulignent le besoin d’adopter
ou moins peuplées et a réduit les ratios patient/
une approche intégrant le facteur sexe dans les
personnel médical peut avoir des effets négatifs sur
politiques de soins en vue d’améliorer leur efficacité.
les femmes plus que sur les hommes, car les femmes Cela est d’autant plus important que la crise financière
constituent la majorité des utilisateurs et fournisseurs
et économique actuelle peut réduire les ressources
de soins de santé. Ces questions sont particulièrement
disponibles pour l’amélioration de la qualité et de
importantes en matière de soins de longue durée, où
la couverture dans la prestation des soins, et en
le sexe joue un rôle encore plus important, puisque
particulier des SLD, avec des programmes pilotes
les femmes sont les principales fournisseuses de soins
basés sur le sexe qui font face à de grands risques de
(formels et informels) et utilisatrices de ces soins.
coupes budgétaires. Les pays d’Europe de l’Est, qui
sont dans un processus d’amélioration de la qualité et
Les mesures soutenant les systèmes de SLD ont des
de l’extension de leurs systèmes de soins, présentent
effets importants sur le sexe. Des textes permettant de
ce genre de risque.
22

---

Introduction
The 2007 Joint Report on Social Protection and
needs of women and men in ensuring equal access,
Social Inclusion underlined that while universal or
by assessing the main financial, cultural and physical
near universal rights (7) giving access to care can be
barriers to access and providing good-practice
found in all Member States, this does not necessarily
examples of healthcare promotion, prevention and
translate into universal access and significant sources
general treatment programmes as well as of long-
of inequality remain (8). These include, amongst others,
term care. The information in this report has mainly
lack of insurance coverage, lack of coverage/provision
been provided by the national experts of the EGGSI
of certain types of care, as well as high individual
network of experts in gender equality, social inclusion,
financial care costs (9). The 2008 Joint Report stressed
healthcare and long-term care and covers 30 European
that important steps are to increase population
countries (EU and EEA/EFTA) (12). Available comparative
coverage, address financial barriers to care, emphasise
statistical data from Eurostat and OECD sources have
promotion and prevention regarding curative care, and
also been considered.
address cultural barriers to the use of services (10).
The report is organised into four chapters: the first
Little is known about gender differences in accessing
summarises the main characteristics and trends in
healthcare and long-term care, and if and how
the health status of women and men across Europe.
healthcare and long-term care systems take these into
The second chapter addresses gender differences
account in service delivery. For example, while it has
in access to healthcare, first considering service
been suggested that women are more likely than men
provisions in health promotion, prevention and
to engage in health-seeking behaviour and thus to
treatment, and, second analysing how financial,
practise health prevention and promotion, there also
cultural and geographical barriers may affect women
seems to be evidence that especially poor women (11)
and men. The third chapter gives an overview
may have more difficulties in accessing healthcare
of existing service provisions for long-term care
services than men.
and gender differences in access, together with a
discussion of the main barriers to access long-term
This comparative report examines how healthcare
care services. The final chapter presents some overall
and long-term care systems respond to the specific
conclusions.
7
( ) Universal rights ensure that access does not depend on one’s
ability to pay, income or wealth and that the need for care does
not lead to poverty and financial dependency.
8
( ) European Commission (2007), Joint Report on Social Protection
and Social Inclusion, Supporting document, SEC(2007) 329,
Brussels.





http://ec.europa.eu/employment_social/spsi/docs/social_
inclusion/2007/joint_report/sec_2007_329_en.pdf
9
( ) European Commission (2007), Joint Report on Social Protection
and Social Inclusion, Supporting document, SEC(2007) 329,
Brussels.





http://ec.europa.eu/employment_social/spsi/docs/social_
inclusion/2007/joint_report/sec_2007_329_en.pdf
10
( ) Council of the European Union (2008), Joint Report on Social
Protection and Social Inclusion, Directorate-General for
12
( ) EGGSI is the European Commission’s network of 30 national
Employment, Social Policy, Health and Consumer Affairs,
experts (EU and EEA countries) in the fields of gender equality
Brussels.




and social inclusion, health and long-term care issues. The
http://register.consilium.europa.eu/pdf/en/08/st07/st07274.
network is coordinated by the Istituto per la Ricerca Sociale
en08.pdf
and Fondazione Giacomo Brodolini, and undertakes an annual
11
( ) European Institute of Women’s Health Report, Gender Equity
programme of policy-oriented research and reports to the
Conference, Conference of September 2000.


Directorate-General for Employment, Social Affairs and Equal
http://www.eurohealth.ie/gender/index.htm
Opportunities. http://eggsi.irs-online.it/
23

---

---

1. Main characteristics and
recent trends in the health
status of women and men
This chapter presents the main country specificities
Austria and Iceland, while the lowest life expectancies
in relation to gender differences in the health
(about 2–4 years below the EU-27 average) are in
status of the population in 30 European countries.
Romania, Bulgaria, Hungary, Latvia and Lithuania.
The analysis is mainly based on gender-relevant
Eurostat indicators in the field of health and long-
Since women live longer than men, they are more
term care, and on national data provided by the
likely to experience more years of poor health: in all EU
EGGSI national reports.
countries, the percentage of healthy life years without
disability is lower for women than for men (Table 1-1).
1.1. G
ender differences in life
Regarding the elderly, more women than men suffer
expectancy and healthy life
from long-standing illnesses or health problems.
Women experience more chronic ill health, distress and
years
disability, especially in old age, also due to their longer
life expectancy (14).
In all European Member States, women live longer
than men. The longer life expectancy of women is
mainly explained by biological and genetic factors,
1.2. S
elf-perceived health
as well as by differences in health behaviour: men
and disability
take more health risks and are less conscious about
health than women (13).
In all EU-25 countries and Iceland and Norway, men’s
self-perceived health is generally better than women’s
Life expectancy at birth in the EU-27 has increased
(very good and good), while more women consider
over the past two decades with a gain in longevity
their health to be fair or in a bad/very bad condition
of about 4–5 years. According to Eurostat, in 2006
(Table 1-2).
the average life expectancy was 82 years for women
and 76 for men. The increase in longevity, however,
EU-SILC was first launched in 2006 for Bulgaria and
is not the same among the EU countries: the highest
Romania. However, data on self-perceived health for
life expectancies are in Italy, Spain, Sweden, Norway,
Bulgaria and Romania are not available for the year 2006.
13
( ) European Parliament (2007), Discrimination against women and
young girls in the health sector, Directorate-General Internal
14
( ) Eurostat (2008), The life of women and men in Europe —
Policies, by the European Institute of Women’s Health, Brussels.
A statistical portrait, Luxembourg.

http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
h t t p : / / e p p. e u r o s t a t . e c . e u r o p a . e u / p o r t a l / p a g e ? _
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
pageid=1073,46587259&_dad=portal&_schema=PORTAL&p_
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
product_code=KS-80-07-135
25

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Table 1‑1 — Life expectancy and healthy life years for EU‑27, and Iceland and Norway, 2006

Life expectancy
Healthy life years
% of healthy life years

female
male
female
male
female
male
Austria
82.8
77.2
60.8
58.4
73.4
75.6
Belgium
82.3
76.6
62.8
62.8
76.3
82.0
Bulgaria
76.3
69.2
:
:
:
:
Cyprus
82.4
78.8
63.2
64.3
76.7
81.6
Czech Republic
79.9
73.5
59.8
57.8
74.8
78.6
Denmark
80.7
76.1
67.1
67.7
83.1
89.0
Estonia
78.6
67.4
53.7
49.4
68.3
73.3
Finland
83.1
75.9
52.7
52.9
63.4
69.7
France
84.4
77.3
64.1
62.7
75.9
81.1
Germany
82.4
77.2
58.0
58.5
70.4
75.8
Greece
81.9
77.2
67.9
66.3
82.9
85.9
Hungary
77.8
69.2
57.0
54.2
73.3
78.3
Ireland
82.1
77.3
65.0
63.3
79.2
81.9
Italy (*)
83.8
77.9
70.2
67.9
83.8
87.2
Latvia
76.3
65.4
52.1
50.5
68.3
77.2
Lithuania
77.0
65.3
56.1
52.4
72.9
80.2
Luxembourg
81.9
76.8
61.8
61.0
75.5
79.4
Malta
81.9
77.0
69.2
68.1
84.5
88.4
Netherlands
82.0
77.7
63.2
65.0
77.1
83.7
Poland
79.7
70.9
62.5
58.2
78.4
82.1
Portugal
82.3
75.5
57.6
59.6
70.0
78.9
Romania
76.2
69.2
:
:
:
:
Slovakia
78.4
70.4
54.4
54.3
69.4
77.1
Slovenia
82.0
74.5
61.0
57.6
74.4
77.3
Spain
84.4
77.7
63.3
63.7
75.0
82.0
Sweden
83.1
78.8
67.0
67.1
80.6
85.2
United Kingdom (*)
81.1
77.1
65.0
63.2
80.1
82.0
Iceland
82.9
79.5
65.3
68.3
78.8
85.9
Norway
82.9
78.2
63.4
65.7
76.5
84.0
Note: ‘:’ data not available.
(*) Data for Italy: 2004; Data for UK: 2005.
Source: European Commission, New common indicators from 2006 for the Open Method of Coordination
http://epp.eurostat.ec.europa.eu/portal/page/portal/health/public_health/main_tables
Indicator HC-P4a on Life Expectancy and HC-P5a on Healthy Life years, based on Eurostat data (EU-SILC)
EU-SILC was first launched in 2006 for Bulgaria and Romania. However, data on healthy life years for Bulgaria and Romania are not available
for the year 2006.
Explanatory note: life expectancy: Eurostat data on the mean number of years that a newborn child can expect to live if subject throughout life
to the current mortality conditions (age-specific probability of death). Healthy life years (HLY) is a health-expectancy indicator which combines
information on mortality and morbidity. The data considered are the age-specific prevalence (proportions) of the population in healthy and
unhealthy conditions and age-specific mortality information. A healthy condition is defined by the absence of limitations in functioning/disability.
The indicator is also called disability-free life expectancy (DFLE).
26

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1. Main characteristics and recent trends in the health status of women and men
Table 1‑2 — Self‑perceived health status of men and women,
for EU‑25 and Iceland and Norway, 2006

Men
Women
Very good/
Very bad/ Very good/
Very bad/

Fair
Fair
good
bad
good
bad
EU‑25
67.8
23.1
9.1
61.7
26.2
12.1
Austria
73.1
19.9
7.1
70.9
20.5
8.6
Belgium
77.9
15.2
6.9
70.9
19.4
9.7
Cyprus
79.1
13.0
7.8
73.3
15.8
10.8
Czech Republic
62.8
25.6
11.7
56.3
28.9
14.9
Denmark
77.6
15.9
6.5
72.6
18.4
9.0
Estonia
56.5
30.0
13.5
50.8
32.8
16.4
Finland
69.1
21.7
9.2
68.3
21.1
10.6
France
72.3
19.6
8.2
66.8
22.5
10.7
Germany
63.5
27.9
8.6
57.8
32.3
10.1
Greece
79.9
12.1
8.1
74.0
15.9
10.2
Hungary
52.2
30.8
17.1
44.9
32.0
23.1
Ireland
84.4
12.4
3.2
81.9
14.9
3.1
Italy
60.8
30.6
8.6
53.2
34.4
12.4
Latvia
47.5
37.2
15.4
36.1
41.1
22.8
Lithuania
48.8
36.9
14.3
38.9
39.7
21.4
Luxembourg
76.2
17.6
6.1
76.2
17.6
6.1
Malta
77.3
18.8
4.0
72.8
22.4
4.8
Netherlands
80.0
16.0
4.0
74.0
19.7
6.4
Poland
58.7
26.0
15.3
51.0
30.0
19.1
Portugal
53.3
30.8
15.8
43.4
32.8
23.8
Slovakia
56.8
28.8
14.3
48.2
30.6
21.2
Slovenia
59.6
26.3
14.1
53.3
29.4
17.3
Spain
71.3
18.5
10.2
64.8
21.1
14.2
Sweden
78.6
16.7
4.7
78.6
16.7
4.7
UK
78.1
16.2
5.8
75.3
17.5
7.2
Iceland
83.1
13.9
3.0
80.3
13.7
6.0
Norway
76.4
15.8
7.8
72.6
16.5
10.9
Source: Eurostat data on health status based on EU-SILC Survey, 2006.
EU-SILC was first launched in 2006 for Bulgaria and Romania. However, data on self-perceived health for Bulgaria and Romania are not available for
the year 2006.
27

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Slightly more women than men all over the EU-25
Explanatory note: The data on chronic (long-standing)
countries suffer from limitations in their everyday
illnesses or conditions refer to the self-declaration by
activities because of chronic (long-standing) illnesses
the respondents regarding whether they have a chronic
or health problems (15). This difference may be the result
(long-standing) illness or condition or not.
of different attitudes by women compared with men,
and is also influenced by a different self-perception
Differences among countries vary widely, but these data
on the health status between women and men.
may be also affected by social differences in the self-
Psychological (such as self-esteem, social isolation,
perception of one’s health and disability status. Notably,
and work overload due to family responsibilities)
the income of people who experience considerable
and social determinants (such as the educational or
limitations (e.g. long-standing illness) was 22 % lower
income level) are generally more important factors
than those of people without limitations. The wage
influencing the health status of women, while
gap between men and women is also apparent here:
behavioural determinants (such as nutrition, exercise
earnings of men who experience strong limitations
and substance abuse) are more important for men.
are 12 % lower, while of those women who experience
Higher rates of accidents (traffic accidents, work-
considerable limitations are 28 % lower than those of
related accidents) and violence-related mortality in
people (both sexes) with no limitations (16).
men seem to be due to differences in gender norms
regarding risk-taking.
1.3. G
ender differences in health
According to Eurostat data on long-standing illness or
risks and death by typology
health problems (EU-SILC survey, 2006), it is estimated
that about 29.7 % of men and 34.2 % of women in the
of diseases
EU-25 have a long-standing health problem or disability
(Figure 1-1).
Differences in health risks behaviour exist between men
and women, starting from childhood. The literature
Bulgaria and Romania launched SILC in 2006.
shows that in childhood and adolescence boys present
However, data on long-standing illness or health
a higher mortality rate due to behaviour-generated
problem for Bulgaria and Romania were not available
causes (suicide, drug abuse, traffic accidents, etc.) and
for the year 2006.
more physical and mental problems than girls (17).
Figure 1‑1 — Long‑standing illness or health problem by sex (%), 2006
50
Women
Men
40
30
20
10
0
.
e
ia
g
ia
k
e
y
y
ay
ep
UK
alta
eec
Italy
ium
w
tvia
onia
M
Spain
eland
vak
tugal
lands
eden
venia
La
man
Gr
Austr
Ic
Cyprus
Ireland
Poland
Franc
enmar
Belg
Slo
Nor
Por
Sw
er
Finland
Est
Slo
D
Hungar
embour
Lithuania
G
Czech R
Nether
Lux
Source: Eurostat data based on EU-SILC survey.
Explanatory note: Bulgaria and Romania launched SILC in 2006, and are not included in the table. The data on chronic (long-standing) il nesses or
conditions refer to the self-declaration by the respondents regarding whether they have a chronic (long-standing) il ness or condition or not.
16
( ) According to Eurostat data based on EU-SILC survey (2006).
17
( ) WHO (1999), Gender and Health in Adolescence, Health policy
for children and adolescents (HEPCA), series No 1. by Kolip, P.
15
( ) Based on Eurostat SILC survey.
and Schmidt, B., Copenhagen.
28

---

1. Main characteristics and recent trends in the health status of women and men
Overall, the main health problems of males are injuries
for 508 000 deaths each year: around one in 10 men
caused by traffic accidents (18). Young women suffer
and one in eight women die from this disease; many
especially from invisible health risks (such as excessive
more suffer from non-fatal events (23).
medication use and dieting), sexual violence and
socioeconomic deprivation (since their economic
In the 35–74 age group, CVD accounts for 34 % of total
situation is generally less favourable than that of men),
mortality and ischaemic heart disease (IHD) for 15 % in
with serious effects on their health status (19).
2000–05 (24). Mortality rates are higher for men than for
women, which increases in the older age groups. IHD
In the European countries, men tend to die earlier
patterns showed a clear East–West gradient with the
than women, yet women tend to report higher
highest mortality rates in the Baltic and eastern European
levels of ill health at all ages than men. The following
member countries. The rates vary from 42.7 deaths per
analysis will show the main differences in terms of
100 000 in France (72 male and 16 female) to 327 deaths
mortality, incidence, prevalence, and in some case
per 100 000 in Latvia (555 men and 167 women) (25).
severity among women and men for the major
diseases and conditions.
Cancer
Cardiovascular diseases
The most frequent types of cancer and causes of cancer-
related mortality for women are breast cancer, colon
Overall in the European Union Member States, more
and lung cancer, and for men prostate cancer (26). The
men than women die of cardiovascular diseases (CVD),
increase of the incidence of lung cancer and mortality
still the main natural cause of death for both women
in women, compared to the decrease in men, is due to
and men. Although Member States register declining
the growing number of smokers among women.
mortality rates due to CVD, there is an increasing
number of people who live with CVD. This paradox is
In 2006, 3.2 million new cases and 1.7 million deaths
due to increased life expectancy and improved CVD
were estimated for all types of cancer all around
patient survival. More people die from CVD than from
Europe. The highest incidence rates in 2006 were in
(all forms of) cancer, with a higher percentage of
western European countries for men (482 new cases
women (54 % of all causes of mortality during 2000–05)
per 100 000) and in northern European countries for
than men (43 % of all causes of mortality during
women (351 new cases per 100 000), while the highest
2000–05), and there is a higher mortality rate in lower
mortality rates were reported in the eastern European
socioeconomic income groups (20).
Member States for men (287 deaths per 100 000) and
in the northern European Member States for women
Among cardiovascular diseases, coronary heart disease
(155 deaths per 100 000) (27). The countries with the
(CHD) (21) is the leading cause of mortality in the EU,
highest mortality rates for men were Hungary (337.1
accounting for over 741 000 deaths every year (one in
deaths per 100 000), Estonia (302.1), Lithuania and
six men and over one in seven women) (22). A stroke is
Latvia (299.4 and 299.3), and for women Hungary (172.9
the second leading cause of death in the EU, accounting
deaths per 100 000), Czech Republic (163.1), Ireland
(15.89), Poland (154.8) and the Netherlands (145.3) (28).
18
( ) WHO (1999), Gender and Health in Adolescence, Health policy
for children and adolescents (HEPCA), series No 1. by Kolip, P.
and Schmidt, B., Copenhagen, p. 13.
19
( ) See for instance on health behaviour: European Parliament
(2007), Discrimination against women and young girls in
the health sector, Directorate-General Internal Policies, by
the European Institute of Women’s Health, Brussels.

23
( ) The main forms of CVD are coronary heart disease (CHD) and
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
stroke. Just under half of all deaths from CVD are from CHD and
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
nearly a third are from stroke. European Heart Network, European
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
cardiovascular disease statistics, 2008 edition, Brussels.
20
( ) Allender S., Scarborough, P., Peto, V., Rayner, M. (2008),
24
( ) Allender, S., Scarborough, P., Peto, V., Rayner, M. (2008), European
European cardiovascular disease statistics, British Heart
cardiovascular disease statistics, British Heart Foundation Health
Foundation Health Promotion Research Group. Oxford.

Promotion Research Group, Oxford.
http://www.ehnheart.org/files/statistics%202008%20web-
25
( ) Allender, S., Scarborough, P., Peto, V., Rayner, M. (2008), European
161229A.pdf
cardiovascular disease statistics, British Heart Foundation Health
21
( ) Coronary heart disease (CHD) is a narrowing of the small blood
Promotion Research Group, Oxford.
vessels that supply blood and oxygen to the heart. CHD is
26
( ) Curado, M.P. et al. (2008), Cancer Incidence in Five Continents,
also called coronary artery disease. Ischaemic heart disease is
Vol. IX, IARC Scientific Publications No 160, Lyon.
related to a reduced coronary blood flow, often related to artery
27
( ) Eugloreh (2009), The Status of Health in the European Union:
diseases, which causes a lack of oxygen. Risk factors are related
Towards a healthier Europe, 2009, EU Public Health Programme
to smoking, high cholesterol levels, or high blood pressure.
project, Global Report on the health status in the European Union.
22
( ) Allender, S., Scarborough, P., Peto, V., Rayner, M. (2008), European
http://www.intratext.com/ixt/_EXT-rep/_INDEX.HTM#-.1
cardiovascular disease statistics, British Heart Foundation Health
28
( ) Eurostat data based on national information derived from the
Promotion Research Group, Oxford.
medical certificate of cause of death.
29

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Incidence rates are increasing both in men and in
Mental diseases and disorders
women in all the European macro-areas (northern,
western, eastern and southern Europe). On the contrary,
The incidence of mental illness, depression and anxiety
mortality is decreasing for men (with the exception of
disorders is higher for women, while alcohol and
the eastern EU countries) and is decreasing or constant
addiction disorders are more common for men (32).
for women. The countries with the highest incidence
rates were Hungary for men (599 new cases per
There are gender-specific risk factors for some common
100 000) and Denmark for women (414 new cases per
mental disorders. Women are at much greater risk of
100 000) (29).
experiencing domestic abuse than men; this can lead
to high rates of anxiety and depression, symptoms
Women generally have a better survival rate than men.
of post-traumatic stress, and subsequent difficulty in
Countries with 5-year relative survival higher than
establishing and maintaining relationships. Women
40 % for men and 55 % for women were the northern
living in poverty and women from minority groups are
countries (Finland, Sweden, Iceland and Norway),
at a higher risk for victimisation by violence. Similarly,
Austria, France, Germany, the Netherlands, Italy and
women living on a low income for an extended period
Spain. Denmark and the UK have lower survival rates
can experience stress, difficulty in personal and family
than other EU countries with similar GDP, both for men
relationships and be left feeling isolated and depressed.
and women. Lower levels of survival were also reported
Individuals most at risk for social isolation and anxiety
in the eastern European Member States (30).
are single mothers and retired women living alone (33).
Women’s social roles as primary carers for children and/
The prognosis for breast cancer is relatively good,
or other dependants can result in ‘role overload’, where
with 5-year relative survival rate exceeding 75 %
women assume both professional and household/
in most countries of western Europe. In Finland,
child-bearing responsibilities. This contributes to so-
Sweden, France and Italy survival was ≥80 %. England,
cial isolation and further impacts on mental health.
Scotland, Wales, Denmark, Malta and Portugal had
Moreover, women are more likely to approach their
5-year age-standardised survival of just above 70 %.
primary care physician for help. Men are more likely
On the contrary, low breast cancer survival was seen
to seek specialist mental healthcare and are the main
in eastern Europe (Estonia, Poland, Slovakia and
users of inpatient care (34).
Slovenia), with 5-year relative survival rate between
60 and 67 % (31).
Women are also more likely to be prescribed mood-
altering psychotropic drugs than men (35). This is
Survival after breast cancer has improved steadily
probably because physicians are more likely to diagnose
in all European countries since the nineties, but at
depression in women than in men, even when they have
different rates. Improvements were more marked
similar scores on standardised measures of depression,
for western Europe than in the Nordic countries
or present identical symptoms (36). There may also be
(Denmark, Finland, Iceland, Norway and Sweden)
differences in accessing specific treatments such as
where survival rates were already high for patients
psychotherapy or anti-depressant (37).
diagnosed in the 1980s. As a result, the gap between
breast cancer survival rates in the Nordic countries
Only cardiovascular disease has a greater toll on
and western Europe has greatly narrowed. There
morbidity and mortality than depression.
is some evidence of a more rapid improvement in
survival in the UK, with a gradual reduction of the
The mortality rate for suicide and intentional self-harm
survival deficit relative to other western European
varies considerably between the EU Member States
countries. Conversely, improvements in survival were
(EU-25 average in 2006 is 16.3 for men and 4.6 for
less evident in eastern European countries; actually,
women per 100 000) (38). Eurostat data indicates that
the gap between eastern and western European
countries has increased.
32
( ) Eugloreh (2009), The Status of Health in the European Union:
Towards a healthier Europe, 2009.
33
( ) Eugloreh (2009), The Status of Health in the European Union:
Towards a healthier Europe, 2009.
34
( ) WHO website on Gender and women’s mental health.

http://www.who.int/mental_health/prevention/genderwomen/en/
35
( ) WHO (2000), Women’s Mental Health — an evidence based
review, Geneva.




http://whqlibdoc.who.int/hq/2000/WHO_MSD_MDP_00.1.pdf
29
( ) Eugloreh (2009), The Status of Health in the European Union:
36
( ) Eugloreh (2009), The Status of Health in the European Union:
Towards a healthier Europe, 2009.
Towards a healthier Europe, 2009.
30
( ) Eugloreh (2009), The Status of Health in the European Union:
37
( ) WHO website on Gender and women’s mental health.

Towards a healthier Europe, 2009.
http://www.who.int/mental_health/prevention/genderwomen/en
31
( ) Eugloreh (2009), The Status of Health in the European Union:
38
( ) Eurostat data based on information derived from the medical
Towards a healthier Europe, 2009.
certificate of cause of death of each country.
30

---

1. Main characteristics and recent trends in the health status of women and men
the highest mortality rates for suicide and intentional
status (45). Women are often more unaware of the risks
self-harm among the Member States is found in
of HIV infection, do not have information on the ways
Lithuania (men 52.7 and women 9.3), Hungary (men
to protect themselves (and methods of contraception),
36.5 and women 9.3), Latvia (men 36.6 and women 5.1),
and might lack access to methods of contraception,
Slovenia (men 38.2 and women 9.2) and Finland (29.4
prevention and care services. In Europe, over 41 % of
and 8.9). Respectively, the lowest rates were observed
the population still does not take precautions during
in Cyprus (3.1 and 1.8), Greece (5.1 and 1.1), Malta (10
sexual intercourse (46). The groups with the highest risk
and 2.2), Italy (8.3 and 2.3) and Spain (10 and 2.8), and
are people with limited social standing or economic
for women also in Slovakia (2.3) (39). As regards gender,
security, or those who are involved in coercive or
in both the 15–64 and 65+ age groups, women in all
abusive relationships (47).
countries have much lower suicide mortality rates
compared to men (40).
Smoking and alcohol consumption
Sexually transmitted diseases
Smoking and alcohol consumption are widely dispersed
and HIV infection
in European countries and are among the major
causes of death. Smoking is the single largest cause of
Women (especially very young women) are more
avoidable death, and every year about 650 000 people
vulnerable to sexually transmitted diseases compared
die from it. Nearly 25 % of cancer deaths and 15 % of all
to men and the consequences are more serious for
deaths are related to tobacco-related diseases, such as
them (41). Since many sexually transmitted diseases are
lung cancer and other specific diseases. Approximately
asymptomatic in women, they often go untreated and
one third of EU citizens smoke, and one fifth of people
the presence of untreated sexually transmitted diseases
aged 15–25 smoke every day (48).
is a risk factor for HIV.
The number of smokers has decreased over the last
In Europe every year there are about 25 000 newly
five years (by nearly 10 %), but gender differences
diagnosed cases of HIV and heterosexual transmission
persist: it has decreased among men, but increased
is responsible for 50 % of the cases (42). Over a third
among women; however, women still smoke less
of the cases (36 %) of HIV infection were registered
frequently than men, starting in adolescence.
in women (2005) (43). Some 13 % of the cases were in
young people between 15–24 years of age. Women
In some countries, prevalence rates among girls are
are more likely to be at risk of HIV infections due to
higher than for boys (Denmark, Germany, and Spain) (49).
biological reasons (44) than men, but in some countries
Girls are more likely than boys to start and continue
also due to their unequal economic, social or cultural
smoking because they think that it might control
weight gain. Smoking may have particularly adverse
effects on girls’ future health, as it may interact with oral
contraceptives and this is thought to increase the risk of
39
( ) Eurostat data based on national information derived from the
cardiovascular disease and affect reproductive health.
medical certificate of cause of death.
40
( ) Eugloreh (2009), The Status of Health in the European Union:
Towards a healthier Europe, 2009, EU Public Health Programme
project, Global Report on the health status in the European Union.
41
( ) European Parliament (2007), Discrimination against women and
young girls in the health sector, Directorate-General Internal
Policies, by the European Institute of Women’s Health, Brussels.
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
45
( ) European Parliament (2007), Discrimination against women and
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
young girls in the health sector, Directorate-General Internal
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
Policies, by the European Institute of Women’s Health, Brussels.
42
( ) European Commission (2007), Healthier together in the
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
European Union, Luxembourg.
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
43
( ) EuroHIV (2006), HIV/AIDS Surveillance in Europe, End-Year
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
report 2005, No 73, European Centre for the Epidemiological
46
( ) European Commission (2007), Healthier together in the
Monitoring of HIV/AIDS WHO and UN AIDS Collaborating Centre
European Union, Luxembourg.
on HIV/AIDS, Saint-Maurice.


47
( ) Eugloreh (2009), The Status of Health in the European Union:
http://www.eurohiv.org/reports/report_72/pdf/report_
Towards a healthier Europe, 2009, EU Public Health Programme
eurohiv_72.pdf
project, Global Report on the health status in the European Union.
44
( ) Women are more likely to get HIV during vaginal intercourse for
48
( ) European Commission (2007), Healthier together in the
several biological reasons: 1. the lining of the vagina provides
European Union, Luxembourg.
a large area, which can be exposed to HIV-infected semen; 2.
49
( ) European Parliament (2007), Discrimination against women and
semen has higher levels of HIV than vaginal fluids do; 3. more
young girls in the health sector, Directorate-General Internal
semen is exchanged during sexual intercourse than vaginal
Policies, by the European Institute of Women’s Health, Brussels.
fluids; 4. having untreated sexually transmitted infections (STIs)
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
makes it more likely for women to get HIV.

D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
http://www.womenshealth.gov
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
31

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
There is a strong association between educational level
Work-related diseases and work accidents
and rate of decline in the prevalence of smoking: smoking
is declining only among more highly educated women,
There is very little research and awareness of gender
and increasing among lower-educated women, who
differences in work-related diseases. The still strong
also tend to be more addicted (50). This trend is likely to
occupational gender segregation in the European
create (in southern Europe) or further widen (in northern
labour market, however, means that women and men
Europe) the gap in smoking between higher and lower-
are exposed to different work-related health risks, and
educated women. In the EU-10 countries, the number of
this is still little recognised in the European and national
regular smokers is higher than the EU-15 level (51) .
approaches to occupational safety and health.
Alcohol consumption is a more complex health-risk
Eurostat data indicates that serious accidents and
factor. It is estimated that more than 55 million adults
fatal accidents at work have decreased in most of
drink at harmful levels. Younger population groups
the European countries (54). In general, men are more
are at high risk, also due to social reasons (such as
exposed to work-related (serious) accidents and
acceptance by peers). Harmful consumption of alcohol
injuries than women, because men predominate in
is responsible for approximately 195 000 deaths in
sectors where job-related risks/hazards are higher and
the EU, related to liver damage, heart disease, mouth
do more full-time work. In addition, in all countries,
and throat cancer, as well as traffic accidents. This is
men are much more prone to fatal accidents than
especially the case in younger age groups, usually
women (55).
prevalent in (young) men: among men aged 15–29,
more than one death in four is caused by alcohol, while
Work-related diseases more common in women are
this figure is one in 10 for women (52). It is possible,
asthma and allergies. Women also suffer more skin
however, that women are under-represented in the
diseases and are more exposed to infectious diseases,
statistics on alcohol abuse, because they feel more
particularly in the care and education sectors (56). Given
stigmatised by alcohol-related problems and do not
the prevalence of women working at home, more
respond to survey questions.
women are affected by accidents at home than men.
The consumption pattern also shows differences
according to income groups. Eurobarometer data
1.4. G
ender differences in
suggests that in lower income groups, excessive alcohol
mortality rates
consumption is more frequent in men in al countries,
while for women it may vary according to the country. Differences in mortality rates exist between men and
Excessive alcohol consumption is also a problem in
women not only with respect to different diseases (as
some Nordic countries (such as Denmark and Finland)
it is shown in paragraph 1.3.), but also with respect to
and Ireland, the UK and Austria, and in several eastern
infant mortality, maternal mortality and deaths due to
European countries (such as Lithuania, Latvia) and
external causes and accidents.
Greece (53).
54
( ) This refers to accidents resulting in more than 3 days of absence
and fatal accidents at work. Available data from Eurostat
refers to 1994–2002. Source: Eurostat (2004), Serious and fatal
accidents at work decreasing in the EU.


http://epp.eurostat.ec.europa.eu/cache/ITY_PUBLIC/3-
50
( ) European Parliament (2007), Discrimination against women and
28042004-AP/EN/3-28042004-AP-EN.HTML
young girls in the health sector, Directorate-General Internal
55
( ) Eurostat data for 2005 on the incidence rate per 100 000
Policies, by the European Institute of Women’s Health, Brussels.
workers of occupational disease indicates that 59.4 women
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
and 94.2 men are affected (Data refer to the countries Belgium,
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
Denmark, Spain, Italy, Luxembourg, the Netherlands, Austria,
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
Portugal, Finland, Sweden and the United Kingdom, and
51
( ) Mackenbach, J.P., et al. (2008), Socioeconomic Inequalities
includes occupational diseases and occupational death related
in Health in 22 European Countries, Special Article for the
to occupational disease). Source: Eurostat data based on the
European Union Working Group on Socioeconomic Inequalities
European Occupational Diseases Statistics (EODS).
in Health, New England Journal of Medicine, June 5, 2008.
http://epp.eurostat.ec.europa.eu/portal/page/portal/product_
http://content.nejm.org/cgi/reprint/358/23/2468.pdf
details/dataset?p_product_code=HSW_OD_NDSA
52
( ) European Commission (2007), Healthier together in the
56
( ) European Agency for Safety and Health at Work (2003), Gender
European Union, Luxembourg European Commission (2007),
issues in safety and health at work, A review, Luxembourg,
Healthier together in the European Union, Luxembourg.
2003. Fagan, C., Burchell, B. (2002), Gender, jobs and working
53
( ) European Commission (2007), Health and long-term care in the
conditions in the European Union, European Foundation for the
European Union, Special Eurobarometer, 283.

Improvement of Living and Working Conditions, Dublin.

http://ec.europa.eu/public_opinion/archives/ebs/ebs_283_
http://www.eurofound.europa.eu/pubdocs/2002/49/en/1/
en.pdf
ef0249en.pdf
32

---

1. Main characteristics and recent trends in the health status of women and men
Infant and adolescent mortality
than anywhere else) and five times higher in Lithuania
(because of a higher rate for men) (59).
Gender differences in mortality rates occur from
childhood onwards. The infant mortality rate is higher
Maternal mortality
for boys in all EU countries apart from Ireland, Cyprus
and Luxembourg. The proportion of deaths in the
The average maternal mortality ratio in the EU has
EU-27 among babies in their first year was 4.8 per 1 000
declined from about 20 maternal deaths per 100 000 live
live births for boys and 3.9 per 1 000 live births for girls
births in the early 1980s to 7 deaths per 100 000 in 2004 (60).
(2004) (57).
The most significant decline has been observed in
Deaths among boys aged 5–14 are slightly more
Romania, which had the highest ratio in Europe,
frequent than among girls in most EU-27 Member
between 140 and 160 per 100 000 in the 1980s.
States, with 14 deaths per 100 000 for boys relative
According to the EGGSI national report, after the
to 11 per 100 000 for girls in the EU in 2005. Only in
liberalisation of abortion (61), the ratio declined to 26 per
Cyprus, Iceland, Malta and Slovenia are the mortality
100 000 in the 2002–04 period, still the highest among
rates for girls slightly higher than for boys. Apart from
the EU Member States. The three Baltic countries also
Bulgaria, Cyprus, Latvia, Lithuania and Romania, the
had relatively high ratios in the 1990s, but their ratios
mortality rate for boys was under 30 per 100 000 in the
have declined (especially in Latvia and Lithuania).
EU Member States (58).
Data reported in Table 1-3 show an increasing trend
Deaths among young men increase above the age of
towards higher rates of caesarean sections in EU-25 and
20: the mortality rate of young men in the 20–24 age
Norway. Caesarean delivery is associated with increased
group is at least 2.5 times higher than the rate for
morbidity among mothers and requires longer and more
women in all EU-25 countries, except the Netherlands
costly lengths of hospital stay (62). These data also il ustrate
and Sweden, and it is more than four times higher in
the large variation between EU countries in the use of
Poland and Malta (in Poland because of a higher rate
caesarean sections, which ranges from about 150 per
for men and in Malta because of a lower rate for women
1 000 live births to 300 per 1 000 live births.
59
( ) Eurostat (2009), Health statistics — Atlas on mortality in the
European Union, Luxembourg.


http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-30-08-
57
( ) Data presented in Euro-Peristat (2008), European Perinatal
357/EN/KS-30-08-357-EN.PDF
Health Report, Project coordinated by the Assistance Publique-
60
( ) Euro-Peristat (2008), European Perinatal Health Report, Project
Hôpitaux de Paris (AP-HP) and the Institut de la santé et de la
coordinated by the Assistance Publique-Hôpitaux de Paris (AP-HP)
recherche médicale (Inserm).



and the Institut de la santé et de la recherche médicale (Inserm).
http://www.europeristat.com/publications/european-
61
( ) European Observatory on Health Systems and Policies (2008),
perinatal-health-report.shtml
Healthcare systems in transition, Vol. 10, No 3, Romania Health
58
( ) Eurostat (2008), The life of women and men in Europe — A
System Review.
statistical portrait, Luxembourg. http://epp.eurostat.ec.europa.
62
( ) Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.-H., Bréart, G.
eu/portal/page?_pageid=1073,46587259&_dad=portal&_
(2006), Post partum mortality and Caesarean delivery, Obstet
schema=PORTAL&p_product_code=KS-80-07-135
Gynecol. No 108, pp. 541–548.
33

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Table 1‑3 — Distribution of maternal deaths according
to obstetric causes (in %) by country, in 2003–04
etric
olism
e
tion
t
t obst
ec
ths
or
ec
auses
oemb
ations of
hage
uptur
tension
wn
olism
etric c
omb
er
no
Country/Region
o of dea
mniotic fluid
ther
naesthetic
erine r
ther dir
ther indir
N
A
emb
O
thr
Complic
hyp
Haemorr
Sepsis chorioamnitis
Ectopic ab
A
Ut
O
causes
O
obst
Unk
Total
Belgium
Flanders
5
0.0
0.0
20.0
0.0
20.0
0.0
0.0
0.0
0.0
20.0
40.0
100
Brussels
2
50.0
0.0
0.0
50.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
100
Czech Republic
19
15.8
21.1
0.0
10.5
5.3
0.0
0.0
5.3
15.8
21.1
5.3
100
Denmark
Germany
43
4.7
7.0
2.3
7.0
0.0
0.0
0.0
0.0
16.3
16.3
46.5
100
Estonia
8
12.5
12.5
0.0
25.0
12.5
0.0
0.0
0.0
37.5
0.0
0.0
100
Ireland
Greece
Spain
Valencia
4
0.0
0.0
25.0
0.0
50.0
0.0
0.0
0.0
25.0
0.0
0.0
100
France
107
14.0
14.0
14.0
17.8
2.8
8.4
0.9
0.9
15.0
8.4
3.7
100
Italy
17
5.9
5.9
5.9
17.6
11.8
5.9
5.9
23.5
5.9
5.9
5.9
100
Cyprus
Latvia
5
20.0
20.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
60.0
0.0
100
Lithuania
6
0.0
16.7
16.7
0.0
0.0
0.0
0.0
16.7
50.0
0.0
0.0
100
Luxembourg
Hungary
14
0.0
14.3
0.0
14.3
35.7
0.0
0.0
0.0
0.0
28.6
7.1
100
Malta
0
Netherlands
32
0.0
12.5
12.5
9.4
9.4
0.0
0.0
0.0
3.1
34.4
18.8
100
Austria
10
10.0
10.0
20.0
0.0
0.0
0.0
0.0
0.0
10.0
50.0
0.0
100
Poland
31
12.9
3.2
6.5
38.7
9.7
12.9
0.0
0.0
16.1
NA
0.0
100
Portugal
Slovenia
4
0.0
25.0
0.0
50.0
0.0
0.0
0.0
0.0
0.0
25.0
0.0
100
Slovakia
Finland
9
11.1
0.0
11.1
11.1
0.0
0.0
11.1
11.1
22.2
22.2
0.0
100
Sweden
United Kingdom
108
13.9
8.3
9.3
5.6
5.6
9.3
0.9
0.0
25.0
22.2
0.0
100
Norway
Total of data provided 425
10.6
10.4
9.2
13.2
6.4
5.6
0.9
1.9
16.7
16.9
8.2
100
to Europeristat
Source: Euro-Peristat (2008), European Perinatal Health Report, Project coordinated by the Assistance Publique-Hôpitaux de Paris (AP-HP) and the
Institut de la santé et de la recherche médicale (Inserm), p. 101.
Explanatory note: Countries were asked to report the number of deaths that corresponded to the ICD-10 codes for the fol owing causes: amniotic
fluid embolism, other thromboembolic causes, hypertension, haemorrhage, chorioamnionitis/sepsis, abortion/ectopic pregnancy, anaesthesia,
uterine rupture, other direct causes, indirect causes, or unknown cause. The availability of the data general y depends on what information is
written on death certificates and how this is coded by the national statistics office responsible for processing data from death certificates.
A maternal death is usual y the consequence of a series of unexpected obstetric complications and possibly also adverse social circumstances
which in combination lead to the death of a woman who is general y young and in good health. As a result, the choice of the underlying cause
and therefore its coding (attribution of the appropriate digit code of the ICD) is not easy and differs from one country to another.
N.B.: Data for Ireland, Denmark, Greece, Cyprus, Portugal, Luxembourg, Sweden, Norway are not available.
34

---

1. Main characteristics and recent trends in the health status of women and men
Deaths due to external causes and accidents
Transport accidents, especially road traffic accidents,
are the major cause of death of young people and
In the EU-27 external causes of death are relevant for
especially young men. Young men in the 15–19 and
6.9 % of men and 3.5 % of women, of which two thirds
20–24 age groups have much higher mortality due to
are caused by unintentional injuries (63). Among deaths
external causes than women of the same age groups in
due to external causes versus illnesses/diseases, more
all European countries. This tendency also remains in
men than women die from accidents (such as road or
the older age groups (64). When compared to women,
transport accidents) or non-illness related causes (such
well over twice as many men among those aged 65–
as suicide or self-inflicted injuries). This incidence,
74 die from external causes — around 92 per 100 000
however, varies by country.
against 37. In both cases, some 18 % were killed in
road or other transport accidents. Although these
figures vary substantially between Member States, in
Table 1‑4 — Death due to accidents and
all of them men in all ages were much more likely to be
transport accidents by sex in some European involved in fatal accidents than women.
countries and Iceland and Norway, 2006 (*)

Accidents
Transport accidents
1.5. T
he impact of income and

men
women
men
women
Bulgaria
social inequalities on gender
48.5
13.0
19.7
6.6
Czech Republic
48.6
18.0
15.5
4.5
differences in health status
Germany
24.0
10.7
9.4
3.0
Estonia
130.8
28.8
28.2
7.1
Education and income levels are relevant factors in
Ireland
25.8
10.8
9.9
3.1
influencing a person’s health status and access to
Greece
43.2
10.1
24.4
5.1
healthcare. According to a study by Menvielle, men and
Spain
33.1
10.7
15.0
4.0
women with less education have higher death rates
Italy
32.0
12.3
15.8
3.8
from all types of cancer, except for breast cancer where
Cyprus
39.9
17.6
18.5
3.6
a higher mortality is generally observed among more-
Latvia
162.3
39.4
30
8.1
educated women (65).
Lithuania
169.6
41.5
40.1
12.6
Hungary
63.0
19.7
24.7
5.9
In all countries with available data, mortality due
Malta
22.5
13.0
4.4
0.6
to cardiovascular disease is higher among men and
Netherlands
20.2
10.9
6.7
2.5
women with lower socioeconomic positions (66). This
Austria
35.2
13.2
12.7
3.9
does not, however, apply to all specific diseases of the
Poland
60.9
17.1
21.9
5.8
cardiovascular system. Of these, ischaemic heart disease
Portugal
29.9
8.3
15.8
3.8
(myocardial infarction) and cerebro-vascular disease
Romania
64.4
18.9
23.8
7.1
(stroke) are the most important. Whereas mortality
Slovenia
57.1
18.5
23.0
4.4
from stroke is always higher in the lower socioeconomic
Slovakia
63.7
14.3
23.5
5.7
groups, this is not the case for ischaemic heart disease.
Finland
70.7
23.4
12.4
3.3
Sweden
30.2
12.1
8.1
2.6
Deaths caused by cancer also show inequalities among
Iceland
39.8
19.0
17.5
8.2
different socioeconomic groups, but the differences
Norway
39.7
18.2
8.7
2.7
are less marked than for cardiovascular disease. Among
(*) Standardised death rate by 100 000 inhabitants
men, lung, larynx, oropharyngeal, oesophageal, and
Source: Eurostat data based on EU-SILC survey
stomach cancers occur more frequently in lower
socioeconomic groups. Among women, this applies to
Explanatory note: The (age-) standardised death rate is a weighted
oesophageal, stomach and cervical cancer (67).
average of age-specific mortality rates. The weighting factor is the age
distribution of a standard reference population. The standard reference
population used is the European standard population as defined by
64
( ) Eurostat (2008), The life of women and men in Europe, A
the World Health Organisation (WHO). As method for standardisation,
statistical portrait, Luxembourg.
the direct method is applied. Standardised death rates are calculated
65
( ) See among others: Menvielle, G., et al. (2008), Educational
for the age group 0–64 (‘premature death’) and for the total of ages. As
differences in cancer mortality among women and men: a
most causes of death vary significantly with people’s age and sex, the
gender pattern that differs across Europe, British Journal of
use of standardised death rates improves comparability over time and
Cancer (2008) 98: 1012–1019.
between countries.
66
( ) Cfr. among others Mackenbach, J.P., et al. (2008), Socioeconomic
Inequalities in Health in 22 European Countries, Special Article for
the European Union Working Group on Socioeconomic Inequalities
in Health, New England Journal of Medicine, June 5, 2008.
63
( ) Eurostat (2009), Health statistics — Atlas on mortality in the
http://content.nejm.org/cgi/reprint/358/23/2468.pdf
European Union.



67
( ) Menvielle, G, et al. (2008), Educational differences in cancer
http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-30-08-
mortality among women and men: a gender pattern that differs
357/EN/KS-30-08-357-EN.PDF
across Europe, British Journal of Cancer, 98(5): 1012–1019.
35

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
On the other hand, some cancers have a higher
‘too expensive’ is more than twice as high compared to
incidence in higher socioeconomic groups: colon
the EU-27 (71).
and brain cancer and skin melanoma in men, and
colon, breast and ovary cancer and skin melanoma
Figure 1-2, taken from a recent comparative study,
in women (68). In terms of cancer prevalence, there
shows the relative inequalities in the death rate from all
are no differences among social classes. But lower
causes according to education level (which is strongly
socioeconomic classes present shorter survival rates.
correlated with income level) in a study carried out in
Actually there is extensive evidence for socioeconomic
22 Member States (72). The relative inequality index (73)
inequalities in cancer survival: most studies show
is greater than 1 for both men and women in all
a survival advantage in patients with a higher
countries, indicating that throughout Europe mortality
socioeconomic position.
is higher among those with less education. The
magnitude of these inequalities varies substantially
Risk groups for suicide are above all people with mental
among countries. For example, in Sweden, the relative
disorders, including substance use disorders. 90 % of
index of inequality for men is less than 2, indicating that
suicides are associated with mental disorders, mostly
mortality among those with a lower level of education
with mood disorders like depression (60 % of suicides)
is less than twice that among those with the highest
but also with alcohol-use disorders (69). Risk groups also
education; on the other hand, in Hungary, the Czech
include those persons with severe somatic illnesses,
Republic and Poland, the relative index of inequality
the socially disadvantaged, those suffering from recent
for men is 4 or higher, indicating that mortality differs
loss (i.e. persons who lost a family member, or a job), by a factor of more than 4 between the lower and
and immigrants (70).
upper ends of the education scale.
As a result of the higher frequency of physical and
Figure 1-3 shows the relative inequalities in the
mental health problems in lower socioeconomic
prevalence of poorer, self-assessed health (weighted on
groups, the prevalence of limitations in functioning
the basis of the burden of chronic disease (74)), according
(‘daily activities’) and various forms of disability also
to education and income levels. The relative index of
tend to be higher.
inequality is greater than 1 in al countries, indicating
worse perceived health in groups of lower socio-
Socioeconomic factors explain low-health status, with
economic status in the countries studied. The variation
some disadvantages for men (accidents, disability rates)
of this measure among countries is considerably less
or for women (self-perceived health status). In Greece,
than that of inequalities in the rate of death from all
Hungary, Lithuania, Poland and Cyprus, the probability
causes, and the international pattern also tends to be
of perceiving unmet medical needs because they are
different from that of death from any cause.
68
( ) Mackenbach, J. (2006), Health Inequalities: Europe in Profile,
71
( ) Eurostat (2009), Perception of health and access to healthcare
Rotterdam.





in the EU-25 in 2007, by Baert, K. and de Norre, B., Statistics in
http://ec.europa.eu/health/ph_determinants/socio_
Focus, No 24/2009, Luxembourg.


economics/documents/ev_060302_rd06_en.pdf
http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-
69
( ) Wahlbeck, K., Makinen, M. (eds.) (2008), Prevention of depression
SF-09-024/EN/KS-SF-09-024-EN.PDF
and suicide, Consensus paper, Luxembourg.


72
( ) Mackenbach, J.P., et al. (2008), Socioeconomic Inequalities
http://ec.europa.eu/health/ph_determinants/life_style/
in Health in 22 European Countries, Special Article for the
mental/docs/consensus_depression_en.pdf
European Union Working Group on Socioeconomic Inequalities
70
( ) Several studies have shown, that immigrants have a higher
in Health, New England Journal of Medicine, June 5, 2008.
risk in suicide relative to people of their countries of origin
73
( ) The relative index of inequality is the ratio between the value
and relative to the native population of the host country. See
(mortality, self-perceived health, obesity, etc.) among individuals
for instance Hjern, A., Allebeck, P. (2002), Suicide in first- and
at rank 1 (the lowest education or income level) and rank 0 (the
second-generation immigrants in Sweden — A comparative
highest level). Therefore an index equal to 1 means equality;
study, In: Soc Psychiatry Psychiatr Epidemiol (2002) 37: 423–429.
while an index higher than 1 means inequality.
http://www.springerlink.com/content/7w74l3xwtx7m3w8a/
74
( ) e.g all cancers, all cardiovascular, ischaemic heart and
fulltext.pdf?page=1
cerebrovascular diseases, chronic obstructive pulmonary disease.
36

---

1. Main characteristics and recent trends in the health status of women and men
Figure 1‑2 — Relative inequalities in the rate of death from
any cause for men and women, in 16 European countries (75)
A E
A duca
E
tion, M
ducation, Men
en
55
yy
44
x of inequalit 3
x of inequalit 3
e indee inde 22
tivtiv
RelaRela 11
k
e
y
ayay
k
e
y)
y
in)in)
id)id)
y)
w
ales
ium
land
trtr
ope
edeneden
w
ales
ium
venia
oniaonia
ope
W
land
W
er
Franc
TurTur
adradr
venia
FinlandFinland
er
Poland
Eur
SwSw
NorNor
enmarenmar
Franc
Belg
celona)celona)
ounoun
Slo
epublicepublic
Poland
EstEst
Eur
DD
Belg
Slo
HungarHungar
LithuaniaLithuania
SwitzSwitz
Italy (Italy (
Spain (MSpain (M
Czech RCzech R
Spain (BarSpain (Bar
England and England and
Spain (Basque cSpain (Basque c
B E
B duca
E
tion,
duca
W
tion, omen
Women
55
yy
44
x of inequalit 3
x of inequalit 3
e indee inde 22
tivtiv
RelaRela 11
k
e
y
ayay
k
e
y)
y
in)in)
id)id)
y)
w
ales
ium
land
trtr
ope
edeneden
w
ales
ium
venia
oniaonia
ope
W
land
W
er
Franc
TurTur
adradr
venia
FinlandFinland
er
Poland
Eur
SwSw
NorNor
enmarenmar
Franc
Belg
celona)celona)
ounoun
Slo
epublicepublic
Poland
EstEst
Eur
DD
Belg
Slo
HungarHungar
LithuaniaLithuania
SwitzSwitz
Italy (Italy (

Spain (M

Spain (M
Czech RCzech R
Spain (BarSpain (Bar
England and England and
Spain (Basque cSpain (Basque c
Source: Mackenbach, J.P., et al. (2008), Socioeconomic Inequalities in Health in 22 European Countries, Special Article for the European Union
Working Group on Socioeconomic Inequalities in Health, New England Journal of Medicine, June 5, 2008, p. 2473.
Explanatory note: Panel A shows inequalities between men with the lowest level of education and those with the highest, and Panel B shows
education-related inequalities for women. Economical y inactive men whose last occupation was unknown were excluded from the analysis.
Because exclusion of these men may lead to underestimation of mortality differences between occupational classes, an adjustment procedure
was applied that was developed and tested in a previous European comparative study of inequalities in mortality; the procedure is based
on national estimates of the proportion of economical y inactive men in each occupational class and of the mortality rate ratio of inactive as
compared with active men in each occupational class. ‘Europe’ refers to the 16 countries presented in the figure.
75
( ) The year of reference is different for the countries. See:
Mackenbach, J.P., et al. (2008), Socioeconomic Inequalities in
Health in 22 European Countries, Special Article for the European
Union Working Group on Socioeconomic Inequalities in Health,
New England Journal of Medicine, June 5, 2008, p. 247.
37

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Figure 1‑3 — Relative inequalities in the prevalence
of poorer self‑assessed health in 19 European countries (76)
A Educa
A E tion, M
duca
en
tion, Men
B Educa
B E tion,
duca Women
tion, Women
A EA 2.22.2
duca
E tion, M
duca
en
tion, Men
B EB 2.22.2
duca
E tion,
duca Women
tion, Women
2.2 2.2
2.2
y
2.2
2.0
y
2.0
y
2.0
y
2.0
y
2.0
y
y
2.0
2.0
y
2.0
1.81.8
1.81.8
1.8 1.8
1.8 1.8
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
e inde
1.4
e inde
1.4
e inde
1.4
e inde
1.4
tiv
tiv
tiv
tiv
e inde
1.4
e inde
1.4
e inde
1.4
e inde
1.4
Relativ
1.2
Rela
1.2
tiv
Relativ
1.2
Rela
1.2
tiv
Rela
1.2
Rela
1.2
Rela
1.2
Rela
1.2
1.01.0
1.0
k
k
y
ay
ye e
y
y
1.0
k
y
e
y
ay
ep
k
y
ay
e
y
ep
ay
ep
ep
1.0 1.0
edenw
w
ium
ium
k
k
y
Italy
Italy
tvia
tvia
1.0
w
ium
1.0
Italy
tvia
ope
lands
mane y
e
Spain
tugal
veniay
onia
onia ope
ope
eden
y
edenw
ium
k
k
y
Italy
tvia
onia ope
lands
ay
man
lands
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e
Spain
tugal
ay
Franc
Spain
tugal
venia
veniay
onia
Ireland
ep
La
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ay
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ep
ay
Franc
Spain
tugal
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y
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Finland
Finland
Sw
ep
w
Nor
enmarIreland
Ireland
La
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enmar
ep
w
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ium
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erFranc
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Italy
tvia
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Italy
tvia
Eur
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Eur
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w
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w
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Por
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eden
eden
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Spain
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Czech RLithuania
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Lithuania
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Por
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Spain venia tugal Hungar venia
Lithuania
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Franc
Czech R
La
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Czech RLithuania
Finland
La
Finland
La
Nor
enmar Nor enmar
er
Est
er
Est Eur
Eur
Ireland
Ireland
Franc
Czech R
Sw
Sw
England
England Belg
Belg
Por
Slo
Finland
Finland Nor
enmar Nor enmar
er
Est
er
Est Eur
Eur
D
D
G
Por Hungar Slo
G
Hungar Lithuania
Sw
Sw
England
England Belg
Belg
Por
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Lithuania
D
D
G
Por Hungar Slo
Czech R
G
Hungar Lithuania
Czech R
Czech R
Lithuania
Czech R
The Nether
The Nether
The Nether
The Nether
C Inc
C ome
Inc , Men
ome, Men
D Inc
D ome
Inc , Women
ome, Women
The Nether
The Nether
The Nether
The Nether
C I 2.22.2
nc
C ome
Inc , Men
ome, Men
D I 2.22.2
nc
D ome
Inc , Women
ome, Women
2.2 2.2
2.2
y
y
y
2.2
2.02.0
y
2.02.0
y
2.0
y
y
2.0
2.0
y
2.0
1.81.8
1.81.8
1.8 1.8
1.8 1.8
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
x of inequalit
1.6
e inde
1.4
e inde
1.4
e inde
1.4
e inde
1.4
tiv
tiv
tiv
tiv
e inde
1.4
e inde
1.4
e inde
1.4
e inde
1.4
Relativ
1.2
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1.2
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Relativ
1.2
Rela
1.2
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1.2
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1.2
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1.2
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1.2
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Czech R
Czech R
Lithuania
Czech R
The Nether
The Nether
The Nether
The Nether
The Nether
The Nether
The Nether
The Nether
Source: Mackenbach, J.P., et al. (2008), Socioeconomic Inequalities in Health in 22 European Countries, Special Article for the European Union
Working Group on Socioeconomic Inequalities in Health, New England Journal of Medicine, June 5.
Explanatory note: Panels A and B show inequalities between persons with the lowest and those with the highest level of education for men
and women, respectively. Panels C and D show inequalities between persons with the lowest and those with the highest level of income for
men and women, respectively. In order to make use of the ful range of levels of self-assessed health, the burden of disease associated with
each level was estimated on the basis of the number of chronic conditions reported by respondents to these surveys. Relative differences in
self-reported chronic conditions between answer categories of the self-assessed health question were remarkably similar between countries
and varied only marginal y around a multiplicative factor of 1.85 (i.e. each step down on the self-assessed health scale was found to be
associated with 1.85 times more chronic conditions). On the basis of this analysis, a weight for burden of disease was assigned to each category
of answer to the question, ‘How is your health in general?’ ‘Very good’ was assigned a weight of 1.850 = 1, ‘good’ a weight of 1.851 = 1.85, ‘fair’
a weight of 1.852 = 3.42, and ‘poor’ or ‘very poor’ a weight of 1.853 = 6.33. Sensitivity analyses showed that the ranking of countries according
to the magnitude of inequalities in self-assessed health did not change when these weights were varied within the range of observed values.
‘Europe’ refers to the 19 countries presented in the figure.
In Europe as a whole, both smoking and obesity are
countries; smal inequalities (among women even reverse
more common among people of lower education levels;
inequalities, in which smoking rates are higher in groups
education-related inequalities in smoking are greater
with more education) are seen in the southern countries.
among men, and education-related inequalities in
In the eastern European countries, the pattern is unclear.
obesity are greater among women (Figure 1-4). There are
Great education-related inequalities in obesity are seen
striking differences between countries in the magnitude
in the southern region, particularly among women, for
and even the direction of these inequalities, however.
whom the relative indexes of inequality are above 4,
Striking education-related inequalities in smoking are
indicating that the prevalence of obesity among those
seen in the northern, western, and continental European
with the least education is more than four times higher
76
( ) The year of reference is different for the countries.
38

---

1. Main characteristics and recent trends in the health status of women and men
A Current smoking
Men
Women
Figur
6.0
e 1‑4 — Relative inequalities in the prevalence of current smoking (Panel A)
and obesity (Panel B) between persons with the lowest and those with
y the highest le
5.0
vel of education, according to sex, in 18 EU countries and Norway (77)
4.0
A Current smoking
Men
Women
6.0
3.0
x of inequalit
5.0
e inde
2.0
tivy
Rela
4.0
1.0
3.0
x of inequalit
0.0
k
y
e
y
ay
ep
w
ium
Italy
tvia
ope
e inde
2.0
onia
eden
lands
man
Spain
tugal
venia
La
tiv
Finland
Ireland
Nor
enmar
er
Franc
Est
Eur
Sw
England
Belg
Por
D
G
Slo
Hungar
Lithuania
Czech R
Rela
1.0
Nether
0.0
k
y
e
y
ay
ep
w
ium
Italy
tvia
onia
ope
eden
lands
man
Spain
tugal
venia
La
Finland
Ireland
Nor
enmar
er
Franc
Est
Eur
Sw
England
Belg
Por
D
G
Slo
Hungar
Lithuania
Czech R
Nether
B Obesity
Men
Women
6.0

5.0
y
4.0
B Obesity
Men
Women
6.0
3.0

x of inequalit
5.0
e inde
2.0
tivy
Rela
4.0
1.0
3.0
x of inequalit
0.0
k
y
e
y
ay
ep
w
ium
Italy
tvia
onia
ope
e inde
2.0
eden
lands
man
Spain
tugal
venia
La
tiv
Finland
Ireland
Nor
enmar
er
Franc
Est
Eur
Sw
England
Belg
Por
D
G
Slo
Hungar
Lithuania
Czech R
Rela
1.0
Nether
Source: M 0.0
ackenbach, J.P., et al. (2008), Socioeconomic Inequalities in Health in 22 European Countries, Special Article for the European Union
k
y
Working Group on Socioeconomic Inequalities in Health, New England Jou e
y
ay
rnal of Medicine, June 5.
ep
w
ium
Italy
tvia
onia
ope
eden
lands
man
Spain
tugal
venia
La
Explanatory note: Rel Finlandative inequalities in the Ireland
Nor
enmar
prevalence of current s er
moking Franc (Panel A) and obesity (Panel B) between persons withEst the loEur
Sw
England
Belg
west
Por
D
G
Slo
Hungar
Lithuania
and those with the highest level of education, according to sex. ‘Europe’ refers to the 19 countries present
Czech R
ed in the figure.
Nether
than that among those with the most education. By
the EU-25 average and have been

worsening in the
contrast, education-related inequalities in obesity tend to
nineties (see Box 1.1), as they present lower levels of
be below average in the eastern European countries.
GDP and lower investments in the healthcare system.
To improve access to and quality of health services, it
The correlation between the health status of the
is essential to improve accountability in healthcare, in
population and economic and social conditions is
these countries, which inherited

a good network of
particularly evident when considering the eastern
health services, and where the erosion in access that
European countries. In general, living and health
had been observed during the 1990s has been only
conditions in eastern European countries are below
partially reversed (78).
77
( ) The year of reference is different for the countries. See:
Mackenbach, J.P., et al. (2008), Socioeconomic Inequalities
in Health in 22 European Countries, Special Article for the
78
( ) Asad, A., Murthi, M., Yemtsov, R, et al. (2005), Growth, poverty,
European Union Working Group on Socioeconomic Inequalities
and inequality: eastern Europe and the former Soviet Union,
in Health, New England Journal of Medicine, June 5, 2008.
The World Bank, Washington, DC.
39

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Box 1‑1 — Health status in eastern European countries
Eurostat data on health show that eastern Europe reports
in the EU-27) (82). Mortality is still higher among men (16.1 %)
lower levels of health and substantial gender differences.
than women (13.5 %), and is higher in rural areas (20.7 %)
than in towns (12.3 %). Maternal mortality at birth was
Indeed, the negative impact on life expectancy during the
four times higher than in the EU-15 in 2000 and has varied
economic transition from a planned to a market economy is
during the last 15 years. It is higher in villages (25.5 %) than
visible for some countries (e.g. Bulgaria, Estonia, Lithuania,
in towns (16.5 %) due to the ‘low level of care at pregnancy
Romania, and Latvia), where a temporary decline in life
and the lack of qualified help at birth for particular groups
expectancy was seen between 1986 and 1996. In general,
of women from ethnic minorities’ (83).
these countries now show important improvements with
the exception of Latvia and Lithuania for men, where life
According to the EGGSI national report, in Romania maternal
expectancy is still below the 1986 level (79).
mortality was very high in the 1970s and 1980s, mainly due
to the ban on abortions. Since abortion became legal, the
For instance, in Estonia, the life expectancy is far below the
maternal mortality rate has continuously decreased, but is
EU average, with a gender gap of over 11 years, and there
still very high (15.5 per 100 000 live births in 2006) (84). This
has been no improvement since 1990. In the 5–19 and
can be mainly attributed to abortions not performed in
20–44 age groups, men lose three times as many life years
medical facilities and for obstetrical reasons. However there
as women. As for the causes of death, the largest gender
are significant ethnic and social class differences in both
differences concern suicide, accidents and transport
maternal and infant/child mortality rates and households
accidents, as over four times more men die due to these
headed by women are often at greatest risk.
reasons as compared to women. Standardised death rates
are also three times higher for men in case of pneumonia,
Also, lifestyle appears to be less healthy in these countries.
alcohol abuse, AIDS and homicide compared to women (80).
For example:
Among eastern European countries, Poland is in the best
In Slovenia alcohol consumption is culturally accepted
position, with life expectancy very close to the EU average,
and very common: 87 % of people drank alcohol in the last
with similar patterns of mortality and morbidity and rather
12 months (data for 2004) (85). Again, the share is higher
low alcohol consumption and smoking rates.
among men (90 %) than among women (83 %). The share
also somewhat increases with education, while there are
Mortality rates are also high in these countries relative to
no significant differences between age groups (only the
the EU-27 average.
youngest age group stands out with a somewhat higher
Data on socioeconomic inequalities in relation to mortality
consumption).
by cause of death are much more available for western
In Romania, smoking increased among both men and
than for eastern Europe. The few data for eastern EU
women after 1990, especially among young people. A survey
countries that do exist, however, show that mortality due to
by the Ministry of Health and Family from 1997 showed that
cardiovascular disease is higher in the lower socioeconomic
46 % of people (13 % of women) above the age of 18 were
groups there as well. This has been shown for a range
regular smokers, which is high compared to the EU, but
of countries including the Czech Republic, Hungary and
similar to other central and east European countries (86).
Estonia. Cardiovascular disease is also one of the main
causes for the increasing inequalities in the total mortality
Source: EGGSI network national reports 2009 and Eurostat data.
rates in many eastern European countries.
In Hungary the mortality rate caused by lung cancer in men
82
( ) Ministry of Health (Bulgaria), Report on the Health Status
is the highest in the world (81).
of the Citizens — Priority Investment into the Future of the
In Bulgaria the mortality rate has increased over the
Nation (2005–07), Sofia.
83
last two decades (14.8 per 1 000, the highest value
( ) Ministry of Labour and Social Policy (2006), National
Demographic Strategy of the Republic of Bulgaria (2006–20),
Sofia, 2007, p. 14.




79
( ) European Commission (2007), Health and long-term care in the
http://www.un-bg.bg/documents/unfpa_population_
European Union, Special Eurobarometer, 283.

strategy06-20_en.pdf
http://ec.europa.eu/public_opinion/archives/ebs/ebs_283_
84
( ) European Observatory on Health Systems and Policies (2008),
en.pdf
Healthcare systems in transition, Vol. 10, No 3, Romania Health
80
( ) EuroHIV (2006), HIV/AIDS Surveillance in Europe, End-year
System Review, p. 12.
report 2005, No 73, European Centre for the Epidemiological
85
( ) European Commission (2007), Health and long-term care in the
Monitoring of HIV/AIDS WHO and UN AIDS Collaborating
European Union. Special Eurobarometer, 283.

Centre on HIV/AIDS, Saint-Maurice.

http://ec.europa.eu/public_opinion/archives/ebs/ebs_283_
http://www.eurohiv.org/reports/report_72/pdf/report_
en.pdf
eurohiv_72.pdf
86
( ) Ministry of Public Health and Family (1997), Romanian health
81
( ) Curado, M.P., et al. (2008), Cancer Incidence in Five Continents,
status survey, Bucharest, Computing Centre for Health
Vol. IX, IARC Scientific Publications No 160, Lyon.
Statistics and Medical Documentation.
40

---

2. Gender differences
in access to healthcare
‘Despite overall improvements in health there remain
to the interrelation of biological aspects, psychological
striking differences in health outcomes not only across
and cultural behaviour (due to ethnic, social, and
Member States but also within each country between
religious background), socioeconomic conditions and
different sections of the population according to
the features of the healthcare systems. Some factors
socioeconomic status, place of residence and ethnic
can exacerbate gender inequalities in health and well-
group, and gender’ (87).
being, such as the gender pay gap and the burden of
family and care responsibilities, poverty and isolation,
The Joint Report on Social Protection and Social
leaving women particularly vulnerable, especially in
Inclusion (2008) (88) considers that on average, people
financial terms, in accessing health services. Their longer
with lower levels of education, wealth or occupational
lifespan, compared to men, increases the amount of
status have shorter lives and suffer more often from
time that they live in illness, disability and solitude. As
disease and illness than more well-off groups and
clearly shown in the previous chapter (Table 1-1), the
these gaps are not declining. ‘Income inequality,
proportion of healthy life years for men is higher than
poverty, unemployment, stress, poor working
for women throughout Europe.
conditions and housing are important determinants
of health inequalities, as are lifestyle and willingness
This chapter considers gender differences in access
and ability to bear the costs. While healthcare systems
to healthcare. The analysis firstly considers service
have contributed to significant improvements in
provisions in health promotion, prevention and
health across the EU, access to healthcare remains
treatment, and secondly, how financial, cultural and
uneven across social groups.’ The Member States are
geographical barriers may affect women and men
implementing policies at national or local levels to
differently in accessing service provision.
reduce these inequalities and to overcome present
barriers to accessing healthcare in terms of financial,
cultural and geographical obstacles. ‘Virtually all
2.1. Existing ser

vice provisions:
Member States have implemented universal or almost
an overview of gender
universal rights to care and have adapted services to
reach those who have difficulty accessing conventional
differences
services due to physical or mental disability or to
linguistic or cultural differences. Few have begun
Before considering gender differences in the provision
to address health inequalities systematically and
of healthcare services, it is useful to present some
comprehensively by reducing social differences’ (89).
indicators regarding the relevance of healthcare
expenditure in European countries and its composition.
Gender plays a specific role in the incidence and
Figures 2-1 and 2-2 present total healthcare expenditure
prevalence of certain types of pathologies (as
as a percentage of the GDP and per capita. Differences
described in Chapter 1) but also in their treatment and
among European countries are clearly visible: eastern
their impact in terms of well-being and recovery, due
European countries spend a much lower percentage
of the GDP than western countries, with the lowest
incidence in Estonia (5 % of GDP) and the highest in
87
( ) Council of the European Union (2008), Joint Report on Social
Protection and Social Inclusion, Directorate-General for
France (11 % of GDP). Also, per capita expenditures
Employment, Social Policy, Health and Consumer Affairs,
are much lower in eastern European countries, with
Brussels.




Romania presenting the lowest and Luxembourg over
http://register.consilium.europa.eu/pdf/en/08/st07/st07274.
eight times more. Most countries show a clear upward
en08.pdf
trend in expenditure between 2000 and 2006, except
88
( ) Council of the European Union (2008), Joint Report on Social
Protection and Social Inclusion, Directorate-General for
Estonia and Lithuania which show a decline. Differences
Employment, Social Policy, Health and Consumer Affairs,
are due to various factors, such as the country’s income
Brussels.




level, the structure and organisation of the healthcare
http://register.consilium.europa.eu/pdf/en/08/st07/st07274.
services and the share of the old-age population.
en08.pdf
89
( ) Council of the European Union (2008), Joint Report on Social
Protection and Social Inclusion, Directorate-General for
Employment, Social Policy, Health and Consumer Affairs,
Brussels.





http://register.consilium.europa.eu/pdf/en/08/st07/st07274.
en08.pdf
41

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Figure 2‑1 — Total healthcare expenditure as a % of GDP,
in the EU‑27 countries, 2000 and 2006 — ranking
12
2000
2006
10
EU average
8
for 2006
EU average
6
for 2000
4
2
0
e
e
y
ia
k
.
y
UK
ia
g
ia
ium
eec
Italy
alta
ep
tvia
onia
tugal
man
lands
eden
venia
Spain
M
vak
La
Franc
Austr
Gr
Ireland
Cyprus
Poland
Est
er
Belg
Por
enmar
Finland
Sw
Slo
Bulgar
G
D
Hungar
Slo
Romania
embour
Lithuania
Czech R
Nether
Lux
Source: European Commission, New common indicators from 2006 for the Open Method of Coordination.
http://ec.europa.eu/employment_social/spsi/common_indicators_en.htm, Indicator HC-P12,
based on OECD health data 2007 and WHO Health for al databases.
Explanatory note: Data refer to total public and private expenditure on health as % of GDP. Public healthcare expenditure includes government
spending (including central government, state/provincial government and local/municipal government) and social security funds. Private
healthcare expenditure includes private health insurance (private social insurance + private insurance other than social insurance), private
households out-of-pocket expenditure, non-profit institutions and private corporations other than health insurance such as private companies
funding occupational healthcare.
Figure 2‑2 — Total healthcare expenditure per capita,
in the EU‑27 countries, 2000 and 2006 — ranking
5000
2000
2006
4000
3000
EU average for 2006
2000
EU average for 2000
1000
0
.
g
ia
e
y
k
e
y
UK
ep
ia
ia
ium
alta
Italy
tvia
lands
man
eden
eec
onia
Spain
tugal
venia
M
vak
Austr
Franc
Ireland
er
enmar
Finland
Gr
Cyprus
Poland
La
Est
Belg
Sw
Por
Slo
G
D
Hungar
Slo
embour
Bulgar
Romania
Lithuania
Czech R
Lux
Nether
Source: European Commission, New common indicators from 2006 for the Open Method of Coordination

http://ec.europa.eu/employment_social/spsi/common_indicators_en.htm, Indicator HC-P11, based on OECD health data 2007 and WHO
Health for all database.
Explanatory note: Data refer to total health expenditure per capita in USD PPP.
42

---

2. Gender differences in access to healthcare
In all European countries, most healthcare
public health services are still a marginal component
expenditures are dedicated to curative and
of health expenditures, even if with relevant
rehabilitative care, followed by medical goods
differences across countries (from 6.6 % of Romanian
dispensed to outpatients (Table 2-1). Prevention and
health expenditures to 0.2 % in Cyprus).
Table 2‑1 — Total healthcare expenditure by function (% share
of current health expenditure), in some European countries, 2005
Services of
Services of
Ancillary
Medical goods Prevention
Health
Services of rehabilitative curative and
services to
dispensed to
and public
administration and
curative care
care
rehabilitative care
healthcare
outpatient
health services health insurance
Belgium
50.6
2.6
:
4.4
19.3
1.8
6.2
Czech Republic
45.2
3.7
48.9
12.5
29.7
1.8
3.3
Denmark
:
:
56.8
3.1
13.6
2.3
1.8
Germany
50.2
3.3
53.5
4.6
20.2
3.4
5.8
Estonia
52.8
3.1
55.9
8.4
26.9
2.3
3.4
Spain
57.6
:
57.6
5.0
25.9
1.3
3.5
France
:
:
56.8
3.7
21.5
2.2
7.1
Cyprus
52.4
9.5
61.9
9.5
20.7
0.2
5.9
Lithuania
45.8
4.2
50.0
4.4
37.6
1.7
2.0
Luxembourg
53.2
2.5
55.7
5.0
11.1
1.1
9.7
Netherlands
50.6
4.4
55.0
3.9
17.1
4.7
5.8
Poland
49.9
3.0
52.8
3.8
32.5
2.4
1.6
Portugal
:
:
61.9
9.1
24.6
1.9
1.3
Romania
45.2
0.6
45.8
3.8
30.8
6.6
4.0
Slovenia
53.5
2.3
55.8
3.0
24.5
4.0
4.3
Note: no data available.
Source: European Commission, New common indicators from 2006 for the Open Method of Coordination
http://ec.europa.eu/employment_social/spsi/common_indicators_en.htm, Indicator HC-C4, based on Eurostat and OECD, based on System
of Health accounts (SHA).
Explanatory note: Data refer to prevention and public health as a percentage of total current health expenditure.
Across Europe, the overarching aim of the national
2.1.1. Health promotion
healthcare systems is that good health and care should
be offered to the whole population on equal terms,
The WHO defines health promotion strategies as those
independent of gender, country, occupation and level
strategies that are not limited to a specific health
of education. However, apart from general statements,
problem, nor to a specific set of behaviours (90): they
access to medical care remains varied in many EU
apply to a variety of population groups, risk factors and
countries, in terms of waiting time and waiting lists,
diseases, in various settings. Health promotion efforts
distance, costs for patients (such as out-of-pocket
in particular involve information campaigns, education,
payment), accessibility for specific ethnic groups, etc.
community development and al those measures that
are aimed at the promotion of healthy choices and
As age is a relevant variable in influencing one’s health
behaviours in raising the awareness of the population.
status and access to healthcare, the following analysis
Information and education campaigns play a key role in
adopts a life-cycle approach in presenting a selection
improving health by helping people to make healthier
of existing service provisions for women and men. The
choices and encouraging healthier behaviours. The
analysis begins by presenting provisions offered during
2008–13 EU Public Health Programme (91) includes
childhood and adolescence, then continues with those
offered in the reproductive age, and finally presents
90
( ) WHO, Health Promotion.
provisions offered during old age.
http://www.who.int/healthpromotion/en/

and European Commission, Health EU, the Public Health Portal.
http://ec.europa.eu/health-eu/health_in_the_eu/prevention_
and_promotion/index_en.htm
91
( ) European Parliament and the Council of the European Union
(2007), Decision No 1350/2007/EC of the European Parliament
and of the Council of 23 October 2007 establishing a second
programme of the Community action in the field of Health
(2008–13). Official Journal of the European Union L 301/3.
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:20
07:301:0003:0013:EN:PDF
43

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
actions to promote good health by addressing the major
throughout Europe is to target the entire population or
determinants of il health associated with morbidity
particular age groups, focusing on specific issues. The
and early mortality. To this end, specific projects
programmes, however, usually do not develop a gender
and initiatives are aimed at increasing awareness,
dimension, except for the areas of maternity, childbirth
disseminating information and sharing best practices.
and reproductive health in general, where the target
The focus of this section is on existing health promotion
group of existing programmes are in the great majority
strategies (programmes or activities) specifical y
of the cases women. It is also interesting to note that
targeted at women or men or at groups of women and
in particular in those countries where national health
men affected by specific forms of disadvantage.
promotion activities are less developed, the role of
NGOs is to be regarded as a relevant contributor to
The first element to be considered is that the
awareness-raising on issues that otherwise risk being
general tendency for health promotion programmes
less emphasised by public action.
Box 2‑1 — The attention on the gender dimension
in some health promotion programmes
France
Norway
Public policies aimed at creating a healthy environment
The main goal of the health policy in Norway is to increase
essentially address the entire population rather than a
healthy life years, reduce inequalities in health between
specific category. If the youth are the target, as in the Plan for
various socioeconomic groups, ethnic groups and between
youth health launched in 2008 (92), women are not subject to
women and men (95). The strategy for reducing health
such attention and gender is hardly taken into account. Since
inequalities emphasises the need for gender mainstreaming
these policies are not gendered, their impact on gendered
within all health information.
health inequalities remains largely undocumented. Policies
Poland
have nevertheless been developed to promote a healthy
environment for women in the workplace. This is due to
The National health programme for 2007–15 sets six goals
the French traditional ‘familialist’ approach (93) that tends to
(called operational goals) with respect to health promotion
protect mothers’ health at work in order to preserve their
aimed, in principle, at the entire population (96). None
role within the family. Targeted actions to promote women’s
of them mentions gender openly, so they seem gender
health have essentially been initiated by nongovernmental
neutral.
organisations (NGOs), such as the French movement for
Romania
family planning (Mouvement français du planning familial,
MFPF) created in 1956 to ensure women’s rights to control
The national health promotion programme elaborates a
their fertility and to combat against sexist violence.
national strategy for health promotion, carries out studies
regarding tobacco consumption, and also develops
The Netherlands
information, education and communication campaigns.
The Dutch organisation ZonMw is a national organisation
These campaigns address women and men equally and
for health research and innovation in healthcare. It finances
target the health problems identified at national or local
several innovative programmes and activities regarding
levels such as: HIV/AIDS discrimination, the need to develop
health promotion, including gender specific programmes
healthy behaviours (such as healthy diet, sports and fitness,
which consider sex, ethnicity, age and income. Between
fight against obesity in children and adults, etc.), prevention
October 2004 and May 2006, a programme was implemented
methods for specific diseases (tuberculosis, heart diseases,
in order to promote gender-specific healthcare for general
cancer), drug prevention, health promotion for mother and
practitioners (94).
child. The lack of targeted data analysis and interpretation
(such as possible sex- and gender-based differences) and
the scarce availability of existing data are among the weak
points of the health information system.
92
( ) Ministre de la Santé et des Sports (2008), Présentation du
plan santé des jeunes, Paris.


95
( ) Helse og omsorgsdepertementet (2006), Nasjonal Helseplan,
http://www.sante-jeunesse-sports.gouv.fr/actualite-presse/
Særtrykk av St.prp. nr. 1 (2006–07).



presse-sante/communiques/presentation-du-plan-sante-
h t t p : / / w w w. r e g j e r i n g e n . n o / u p l o a d / k i l d e / h o d /
jeunes.html
prm/2006/0083/ddd/pdfv/292402-nasjonal_helseplan_
93
( ) Lanquetin, M.-T. (1998), L’égalité professionnelle à l’épreuve
saertrykk.pdf
des faits, in Maruani, M., Les nouvelles frontières de l’inégalité
96
( ) There are also five operational goals targeted at specific
hommes–femmes sur le marché du travail, Paris.
subpopulations. Two of them are relevant for the gender
94
( ) The programme was initiated by the University Medical
discussion (Improvement of the care regarding mother and
Centre St. Radboud (Nijmegen) and was financed by ZonMw.
babies, and Making conditions for active life of the elderly)
This promotion programme was called ‘Seksespecifieke zorg
and will be mentioned in the next sections. The others refer to
in de huisartspraktijk: drie vliegen in één klap’.
children and the disabled and will not be discussed.
44

---

2. Gender differences in access to healthcare
Spain
Sweden
In 2006, the Ministry launched an online Information System
A broad aim of the Swedish healthcare system is that good
for Health Promotion and Education (97) that aimed to collect
health and care should be offered to the whole population
programmes and publications by territorial administrations
on equal terms. It is the task of society to see to it that
and classify them by topic and target groups. According
everyone has the same possibility to receive the care they
to the database, 6 out the 64 registered initiatives (run on
need independently of sex, where they live, what their job
regional and local levels) exclusively addressed women’s
is, what level of education they have or their ability to speak
health. One of the most active public institutions on
Swedish (98). It should be pointed out that in certain areas,
gender issues, the Women’s Institute, signed an agreement
there are long-established structures for health promotion
in 1992 with the Ministry of Justice for the establishment
and health prevention. Prenatal, child and youth clinics are
of a long-term programme aimed at promoting health
examples of the systematic and programmed structures
among women at penitentiary institutions (Programme for
established to carry out these tasks. Other examples are
the promotion of healthy habits and prevention of HIV for
infectious disease control, screening, registered follow-ups
women deprived of their liberty).
and health talks with asylum seekers. In 2007, all county
councils had goals for gender equality for caretakers
included in general policy documents (99).
Source: EGGSI network national reports 2009.
97
( ) Ministerio de sanidad y consume, Sistema de Información de
Promoción y Educación para la Salud.

98
( ) Statistiska Centralbyrån, Stockholm. http://www.socialstyrelsen.se
http://sipes.msc.es/sipes/ciudadano/index.html
99
( ) Statistiska Centralbyrån, Stockholm. http://www.socialstyrelsen.se
As anticipated, the following analysis of the health
■ A similar programme is in effect in Slovenia,
promotion programmes realised in European
where there are several health promotion and
countries is articulated according to a life-cycle
educational campaigns targeted at children
approach: childhood and adolescence, reproductive
and promoted by the Institute for Public Health.
age and old age. For each phase, an analysis of the
Among them is the Slovenian network of healthy
main features and a presentation of specific examples
schools, and also more focused campaigns that
have been provided.
promote vaccinations as well as awareness raising
regarding the negative consequences of smoking
Childhood and adolescence
(for teachers and pupils).
Across Europe, promotion programmes targeted at

■
In Liechtenstein the health education programme
children and adolescents are quite rarely gendered. In
in schools addresses three main goals: (a) the first
general, health promotion programmes in this phase of
goal is the children’s personality development, i.e.
the life cycle are targeted according to age and not to
the promotion of the ability to deal with conflict, the
gender, and they are organised within school activities.
ability to work in teams and the strengthening of self-
They generally address issues such as the promotion of
esteem, as well as a project on violence prevention
healthy life styles, the prevention of smoking, addiction
called Social Work in Schools; (b) the second goal
(alcohol, drugs) and eating disorders (such as anorexia/
concentrates on the physical development of
bulimia), the promotion of physical activities, sexuality
children by focusing on raising health awareness
and reproductive health. Here are some examples:
with respect to healthy eating habits, exercise,
addictive behaviour and sexuality; (c) the third goal

■
In Portugal the Health Promoting Schools project (100)
is to ensure communication between government
is directed both to girls and boys, assuming that
offices, parents, physicians and teachers.
early information and health prevention are
important tools to promote equal opportunities: the

■
In Spain within the bilateral cooperation between
project supervises, amongst other things, medical
the Ministry of Education and the Ministry of
examinations, the National Vaccination Plan (PNV),
Health, a reinforcement process was put into effect
improvement in finding solutions for problems of
between 2006 and 2008 in order to enhance health
children with special health needs at school, the
promotion at school. Other promotion programmes
promotion of oral health and encouragement for
are targeted at students at the undergraduate and
healthy student lifestyles (101).
postgraduate levels.

■
In Lithuania the programme is aimed at
100
( ) Official Communication No 734/2000, 18 July, signed by the
Ministers of Health and Education — establishes regulations for
strengthening healthcare promotion in schools,
the extension of Health Promoting Schools project network.
paying particular attention to the healthcare of
101
( ) Official Communication No 734/2000, 18 July, signed by the
teenagers, the development of healthy life styles
Ministers of Health and Education — establishes regulations for
and habits for both children and parents.
the extension of Health Promoting Schools project network.
45

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?

■
In France a series of measures have been introduced
Reproductive age
to protect the health of young people, mainly
from 16 to 25, and to meet their needs regarding
The following section provides an overview of health
independence and responsibility. Faced with the
promotion programmes concerning aspects of healthy
worrying spread of high-risk behaviour and the
behaviour (such as alcohol consumption, smoking, diet
development of eating disorders, the measures
and physical activity), mental and occupational health,
aim to better protect France’s youth by focusing
or addressing specific population groups (such as the
on: fighting addictive behaviour, making current
most vulnerable or rural women), HIV/AIDS, as well
legislation consistent regarding the sale of alcohol
maternity/breastfeeding. Many promotion programmes
to minors; more balanced eating habits, promoting
are targeted at adults or adolescents already in the
a proper environment by advertising for choice of
reproductive age. Many of them are gender oriented:
healthy food at supermarket check-out counters
in some cases they are targeted at women, in others
and school cafeterias; fighting anorexia, with a
at men. Some examples across Europe have been
charter to be signed soon by professionals working
analysed according to their main focus.
in the fashion sector, strengthening protection for
models, and especially those under 18, through
1. Programmes
aimed
at
reducing
the
the presence of an occupational physician, and
consumption of alcohol: in most EU countries,
prohibiting the glorification of extreme thinness
programmes of this kind are present. In some
and anorexia in the media (102).
cases, such as in Denmark, Slovakia and Finland
they are gender specific. In Denmark, health-

■
Finland launched its first Action programme 2007–11
promotion activities try to consider the ways
regarding the promotion of sexual and reproductive
the different sexes react to information and to
health in 2007 (103). The programme aims to
possible symptoms of sickness. In Slovakia, the
promote sexual and reproductive health among the
Public health awareness programme is focused
population, focusing especial y on young people.
on reducing the consumption of alcohol among
The programme is focused on health and social
men and in particular male smokers, with
welfare professionals, health teachers in secondary
a higher consumption of beer, wine and spirits.
schools and vocational schools, key partners and
In Finland the accidental deaths of young men
organisations. One of the major objectives is to
are considered such a relevant problem that
improve sexual counsel ing, which should be
decreasing these deaths is one of the main
integrated into basic and district level services: that
aims of the national health programme (Health
means that each health centre should have employees
2015). For this purpose, the 2004–07 Alcohol
who have completed training in sexual counselling.
Programme and the Armed Forces launched an
information campaign for men in the military

■
In the Netherlands the project Girls’ Talk — Healthy
and in civil service in 2006 with a leaflet entitled
sexual behaviour for young girls, promoted by
Test your knowledge on ways to control life!
Rutgers Nisso Groep (RNG), the Dutch expert centre
(Elämänhallinta-aineisto, testaa tietosi!) (105).
on sexuality (104), is targeted at young girls/women
between 12 and 25 years old with a Dutch or another
2. Programmes aimed at reducing smoking: most
ethnic background (Surinamese, Turkish, Moroccan),
EU countries have developed programmes of this
and a relatively low level of education. The key priorities
kind. In some cases they aim at different targets
of this programme are to provide young girls with sex-
and scopes: in Iceland for example, the focus
specific, culture sensitive group counsel ing in order
is mainly on men, being heavier smokers than
to provide information on healthy sexual behaviour;
women; in Norway and in Denmark measures
increase awareness among young girls of the possible
to decrease smoking among pregnant women
risks of unhealthy sexual behaviour; develop an
and women with small children have been
evaluation method in order to measure the effect of
mentioned by the EGGSI experts (106); in Cyprus
sex-specific counsel ing on healthy sexual behaviour.
the Ministry of Education has introduced, on
a trial basis, a group psychotherapy-based
102
( ) Ministère de la santé et des sports (2008), Présentation du plan
smoking cessation programme in one high
santé des jeunes.



school and one technical school in Nicosia.
http://www.sante-jeunesse-sports.gouv.fr/actualite-presse/presse-
sante/communiques/presentation-du-plan-sante-jeunes.html
103
( ) Ministry of Social Affairs and Health — MSAH (2007), Seksuaali-
105
( ) Finnish Ministry of Social Affairs and Health.

ja lisääntymisterveyden edistäminen. Toimintaohjelma
http://w w w.stm.fi/julk aisut/esitteita-sarja/nayta/_
2007–11 [Promotion of sexual and reproductive health. Action
julkaisu/1058533
Programme 2007–11, English abstract], Helsinki.
106
( ) Helse og Omdepartementet (2006), Najonal strategi for det
104
( ) Source: Databank effectieve jeugdinterventies — Nederlands
tobakksforebyglende ajrbeidet (2006–10), Oslo.

Jeugd Instituut (Dutch Youth Institute).

h t t p : / / w w w. h e l s e d i re k t o r a t e t . n o / v p / m u l t i m e d i a /
http://www.nji.nl/eCache/DEF/1/03/055.html
archive/00009/Nasjonal_strategi_for_9900a.pdf
46

---

2. Gender differences in access to healthcare
3. Programmes promoting diet and physical
from pregnancy through childbirth, infancy,
activity: examples are reported in several
childhood and adolescence to adulthood and
countries. In Hungary they are gender specific
old age. Mental health promotion implies
as, according to the data published in the
the creation of individual, social, societal and
National Public Health Programme (107), 2/3
environmental conditions that enable optimal
of male adults and 1/2 of female adults in
psychological
and
psycho-physiological
the population are overweight. The goal is to
development as well as a reduction in mental
decrease the frequency of health problems
health problems. Mental health promotion can
connected to nutrition, and to improve the
enhance emotional resilience, give rise to greater
health condition of the population by healthier
social inclusion and societal participation,
nutrition (108); in Slovenia the National Nutrition
improve the person–environment fit, as well as
Policy Programme 2005–10 emphasises the
increase the productivity of individuals (111). In
importance of healthy nutrition and lists men
Norway for example, the National strategy for
as the more vulnerable group: women are
employment and mental health 2007–12 aims
mentioned as more inclined to malnutrition
at preventing exclusion from the labour market
and diseases such as bulimia and anorexia; and
and enhancing employment participation
the Ministry of Labour, Family and Social Affairs
among people with psychological symptoms/
finances programmes to help women with
problems (112). As women have more problems
eating disorders (109). In Sweden the National
related to mental health than men, the strategy
Food Administration (NFA) has demonstrated
is important from a gender perspective, even
that women eat more fruit and vegetables
though it does not have a direct gender
than men, as do people with higher incomes
orientation. A similar programme is promoted
and higher education than those with lower
in Finland: the nationwide MASTO project,
incomes and education, hence indicating
launched in 2007, aimed at tackling depression
that the NFA should focus more on men
as a cause of work incapacitation (113). It also
than on women, as well as on people with
aims at developing a range of best practices
low incomes and education (110). In Iceland
concerning people on sick leave due to
the programme ‘Men and cancer — lifestyle,
depression. It does not have any gender-
health and nutrition’ is an awareness-raising
specific targets, in spite of recognising gender
campaign aimed at drawing men’s attention to
segregation as part of the problem, as women’s
the fact that the number of cancer cases can
and men’s symptoms and health behaviour
be reduced by 1/3 by doing physical exercise,
regarding mental health differ. In Spain
improving diet, refraining from smoking and
there are programmes promoting mental
reducing alcohol consumption: men over 40
health among young people, mainly through
are specifically targeted. Similar campaigns are
participatory workshops for parents and
promoted in Latvia. In many other countries,
adolescents aged 12–16 years old. The gender
programmes of this kind are not gendered.
perspective has been particularly addressed
In Austria the majority of the projects can
with a view to the dismantling of prejudices
be found in the area of prevention of eating
and obsolete gender roles.
disorders, and few of them focus on female-
specific prevention of addiction.
5. Programmes
promoting
occupational
health: in Sweden there are programmes on
4. Programmes promoting mental health
the improvement of working conditions for
and support for people with psychological
women employed as assistant nurses and male
symptoms/problems:
mental
health
hospital attendants employed within the care
promotion is viewed as an interdisciplinary
sector (114).
and socio-cultural endeavour aimed at
enhancing the wellbeing of individuals, groups
and communities. The process is life-long,
111
( ) European Commission (2003), Mental Health Promotion and
Prevention Strategies for Coping with Anxiety, Depression
and Stress Related Disorders in Europe (2001–03).
107
( ) National Public Health Programme, Budapest.
http://ec.europa.eu/health/ph_projects/2001/promotion/fp_
http://color.oefi.hu/program.htm
promotion_2001_frep_02_en.pdf
108
( ) Az Egészség Évtizedének Johan Béla Nemzeti Programja
112
( ) Helse
og
omsorgsdepartementet
(2007),
Nasjonal
(National Public Health Programme) 2003, Budapest.
strategiplan for arbeid og psykisk helse (2007–12), Oslo.

http://color.oefi.hu/program.htm
http://w w w.regjer ingen.no/upload/HOD/Vedlegg/
109
( ) NGO Women’s Counselling Service, Projects in the field of eating
Planer/I-1127%20B.pdf
disorders and body image, Zenska svetovalnica, Lubjana.
113
( ) Finnish Ministry of Social Affairs and Health.

http://www.drustvo-zenska-svetovalnica.si/a_pred.php
http://www.stm.fi/Resource.phx/eng/strag/masto/index.htx
110
( ) Socialstyrelsen (2005), Statistiska Centralbyrån.
114
( ) Parmsund, M. (2002), Hälsa – Arbetsliv – Kvinnoliv (projekt),
http://www.socialstyrelsen.se
Statens Folkhälsoinstitut, Stockholm.
47

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
6. Health
promotion
programmes
and
general advice about health issues. In Austria, the
campaigns specifically targeted at more
New medical check-up (Vorsorgeuntersuchung
vulnerable groups: in Spain this line of
neu) programme offers basic health check-ups,
action has particularly focused on the Roma
such as for cancer or cardiovascular diseases.
community and their specific disadvantages
Women are offered a gynaecological check-
to accessing health services: the gender
up, and for women above 40, every two years
perspective has been explicitly addressed, not
a mammography is paid. Also women-specific
only as a general principle, but also regarding
health centres have been established in Vienna,
the problem of domestic violence, as one of
Graz, Salzburg, Linz and Carinthia as well as
the main priorities. In Cyprus a specialised
an outpatient healthcare centre in Innsbruck
educational programme has targeted female
particularly for women.
third-country nationals who come to Cyprus
under the status of ‘artists’. Women entering
In the field of reproductive health, some programmes
the country under this status are often
address in particular HIV/AIDS. As a part of the effort
employed in establishments considered ‘high
to reduce HIV/AIDS, an increased focus on women is
risk’ for trafficking in women for the purpose
detectable in these promotion programmes, since
of sexual exploitation, thus the programme
women have an increased risk of HIV/AIDS. The focus
targets a particularly vulnerable group that
is often on ethnic minorities. Also, the World Health
suffers various forms of exclusion, particularly
Organisation has specific programmes concerning
in relation to health (115). In Slovenia some
gender inequalities and HIV, considering women much
health promotion programmes and campaigns
more vulnerable than men: ‘Gender norms related to
are specifically targeted at more vulnerable
masculinity can encourage men to have more sexual
groups (prisoners, refugees), and encourage
partners and older men to have sexual relations
the education of health workers regarding
with much younger women. In some settings, this
health promotion for vulnerable groups.
contributes to higher infection rates among young
These programmes are not gender oriented.
women (15–24 years) compared to young men. Norms
In Austria marginalised target groups such as
related to femininity can prevent women — especially
homeless women, sex workers, women living
young women — from accessing HIV information and
in women’s shelters, etc. are addressed by
services. Violence against women (physical, sexual and
female-specific health promotion projects,
emotional), which is experienced by 10 % to 60 % of
usually lasting for 1–2 years: there are very few
women (ages 15–49 years) worldwide, increases their
long-term projects.
vulnerability to HIV’ (117). Many European countries have
implemented programmes for sexual education and
7. Programmes on health promotion addressed the promotion of safer sex for preventing HIV/AIDS.
to rural women: in Cyprus two programmes In Austria, a gender-specific HIV/AIDS programme of
funded by EU programmes (Interreg and
the Aids Hilfe Wien aims at the sexual empowerment
Socrates) address rural women’s sexual and
of women, including also migrant women, young
reproductive health (116).
women, women in prison and partners of HIV-positive
men. In Spain, the National Plan on AIDS includes a
8. General programmes to check health status: an gender perspective in its campaigns, research and
interesting example comes from the UK: many
statistical data gathering, and addresses also pregnant
GP surgeries offer a ‘well woman’ clinic where
mothers or prostitutes, with a special approach. In
female patients may be seen by a female doctor
Sweden, pregnant women are offered HIV-testing,
or a female practice nurse to check their current
while in Germany educational programmes address in
health status and be provided with advice on
particular HIV homosexual men. Also in Norway, there
health promotion. Many also offer ‘well man’
is an increased focus on homosexual men, as well as
clinics which are specialised healthcare clinics
on women, especially ethnic minorities, which show a
for men. They offer men health check-ups and a
higher incidence of infections.
115
( ) Mediterranean Institute of Gender Studies (2007), Mapping the
Realities of Trafficking in Women for Sexual Exploitation in Cyprus.
116
( ) DELOA: Itinerant workshops for assessment, help, orientation
and information on sexual education, equal opportunities and
gender equality aimed at rural women, EC Socrates Grundtvig
1. Coordinating organisation: Fundación Paideia Galiza, Spain.
http://www.gender-equality.webinfo.lt/cd/content/theory/
117
( ) WHO (2009), Gender inequalities and HIV, Geneva.
theory13/fcontent.html
http://www.who.int/gender/hiv_aids/en/
48

---

2. Gender differences in access to healthcare
Box 2‑2 — Good practices: gender‑specific programmes/projects
on reproductive health and HIV/AIDS
Cyprus
Days for 12 to 13-year-old boys offers information on body
An interesting example of a gender-specific programme is
knowledge and changes in puberty, aggression, male-
‘Evaluation of the Sexual and Reproductive Health Needs of
role images and sexuality, as well as contraception and
Migrant Domestic Workers in Cyprus’: it was recently carried
protection in relationships. During the Girl Power Days girls
out by the Family Planning Association (CFPA) and funded by
between 11 and 13 are presented topics such as friendship,
the Cyprus University of Technology. Within the framework
‘My Body’, menstruation, etc. The goals of this project are to
of this programme the CFPA undertook Sunday workshops
promote awareness, improve communication abilities, and
on sexual health, with particular emphasis on contraception
expand behavioural competence (119).
and screening (Pap test, breast self-examination) for female
Romania
domestic workers. The workshops were followed-up by
clinical screening and testing services for participants,
The National programme for maternal and child health
which were provided by a female gynaecologist, as a
aims at improving access to reproductive health services.
means to meet the cultural sensitivities of many of these
The objectives are to maintain and increase the number
women, who tend to be from diverse ethnic and religious
of people using contraceptive methods and to reduce
backgrounds.
the number of abortions. In this respect, family doctors,
family planning offices, obstetrics-gynaecology sections
Hungary
in hospitals and clinics provide information/educational
Since 2003, starting on the first Sunday of May (Mother’s day
materials and free-of-charge contraceptives for certain
in Hungary), a national, non-profit series of programmes
disadvantaged categories of the population (unemployed
address issues about childbirth. Priority is given to
women, students, disadvantaged women, beneficiaries
information about planned pregnancy, delivery and
of minimum income/state benefits, women living in rural
nursing. Although the programme lasts just one week, its
areas, poor or low-income women). Moreover, a network
regional outreach is a basic feature. Moreover, the project’s
of community nurses and health mediators working with
homepage is very informative, offering information on
poorer categories of the population (rural residents, the
pregnancy (problems, expectations, etc.), preparation for
uninsured, Roma) has been developed. The community
delivery, mental and physical status, fatherhood, newborn
nurses and health mediators’ role is to identify people
babies, nursing, home delivery, etc. The target group is
who are not registered in family doctors’ lists (especially
mainly women, but also young fathers. It gives young
pregnant women and children) and to provide information
parents comprehensive information about pregnancy and
and counselling to these families. The programme’s
motherhood (118).
objective is to improve access to health and social services,
contribute to a change in mentality in relation to one’s own
Liechtenstein
health status, and to increase the responsibility of local
The Bureau for Sexual Matters and HIV Prevention provides
communities concerning the needs of women and men
gender-specific counselling on sex-education topics in
belonging to marginalised groups.
schools and youth centres, such as the project ‘Girl Power
Days’ and ‘Boy Power Days’ for girls and boys aged 11–13,
Source: EGGSI network national reports 2009.
developed in cooperation with the youth information
office ‘aha — Tips and Info for Young People’. The Boy Power
119
( ) Commission for Equal Opportunities (2007), Third report under
Article 18 of the Convention on the Elimination of All Forms of
118
( ) See http://www.szuleteshete.hu
Discrimination against Women of 18 December 1979, Vaduz.
The greatest concentration of health promotion World Health Assembly in May 2002 provides a basis
programmes targeted at women is in the area of for public health initiatives to protect, promote and
maternity. The promotion of breastfeeding is without a support breastfeeding. Indeed, ‘low rates and early
doubt the most widespread programme across Europe cessation of breastfeeding have important adverse
and has been supported by evidence and common health and social implications for women, children,
guidelines (120). The protection, promotion and support the community and the environment, result in greater
for breastfeeding are a public health priority throughout expenditure on national healthcare provision, and
Europe. The Global strategy on infant and young child increase inequalities in health’ (121). The promotion of
feeding adopted by all WHO member states at the 55th breastfeeding is usually accompanied by more general
120
( ) European Commission (2004), Protection, promotion and
121
( ) European Commission (2004), Protection, promotion and
support of breastfeeding in Europe: a blueprint for action, EU
support of breastfeeding in Europe: a blueprint for action, EU
Project on Promotion of Breastfeeding in Europe, Directorate
Project on Promotion of Breastfeeding in Europe, Directorate
Public Health and Risk Assessment, Luxembourg.
Public Health and Risk Assessment, Luxembourg.
http://ec.europa.eu/health/ph_projects/2002/promotion/fp_
http://ec.europa.eu/health/ph_projects/2002/promotion/fp_
promotion_2002_frep_18_en.pdf
promotion_2002_frep_18_en.pdf
49

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
programmes that support the health and well-being of
breastfeeding breaks has been introduced and is
mothers and their newly born babies, and the following
expected to have positive effects on employed
provide some examples.
women with infants.

■
In France past legislation and collective agreements
Old age
were developed to protect women (night-work
prohibition, except in the health sector), pregnant
The first important element to be considered is that
women (maternity leave, right of absence to visit a
the proportion of elderly women is much higher than
doctor, etc.) or mothers (right to breastfeed at the
the proportion of elderly men (due to the higher
workplace, or to leave earlier for breastfeeding).
mortality rate of middle-aged men). This means that
Some of these regulations are still in effect
many elderly women live alone. Health promotion
(such as the maternity leave), but others have
programmes targeted at the elderly often provide a mix
recently been removed in the name of the fight
of activities concerning social and mental problems.
against discrimination (such as the night-work
An interesting example is a programme developed in
prohibition) (122).
the Netherlands, which deals with obesity and other
diseases linked to a lack of movement — it is addressed

■
In Hungary several initiatives have been launched
to socioeconomically disadvantaged older people and
with the aim of re-evaluating women’s roles as
older people from ethnic minority groups.
mothers. They are mainly connected to childbirth
and nursing. Childbirth Week, Nursing Day or
the national strategy ‘The Child is Our Common
Box 2‑3 — Good practice:
Treasure’, are part of the European strategy for child
Big! Move: health promotion
and adolescent health and development and aim
for older people
to raise the prestige of social roles connected to
children and the family. Moreover the health visitors’
In 2003, Big! Move, a project to promote health among
network focuses on infants’ and young mothers’
older people, was implemented by the local health
health promotion (
centre in the suburbs of Amsterdam (GAZO). The central
123).
aim of the project was to motivate people to fight against
obesity and other diseases linked to a lack of movement.

■
In Romania one of the few programmes specifically
The specific target groups of this programme were
targeting women is the National programme for
socioeconomically disadvantaged older people and
maternal and child health. The programme is
older people from ethnic minority groups. Within these
focused on improving reproductive health and
groups, women were more likely to suffer from obesity
childcare and one of the interventions targeting
than men (124).
women is breastfeeding promotion. This measure
aims at increasing the number of breast-fed babies
Source: EGGSI network national report 2009, the Netherlands.
and introducing alternative food for children after
the sixth month of life. Trained personnel guarantee
124
( ) Overgoor, L., Aalders, M., Reitsma, S. (2007), Big!Move 2 —
counselling for young/pregnant women regarding
Evaluatieverslag verspreiding Big!Move in opdracht van
the advantages of breastfeeding in centres for
Agis op drie locaties, Amsterdam.
promoting breastfeeding.
2.1.2. Health prevention

■
In Slovenia targeted health promotion activities
include the promotion of breastfeeding and
Many costly and disabling conditions — such as
health education for pregnant women and fathers
cardiovascular diseases, cancer, diabetes, chronic
and mothers, increasing pregnant women’s
respiratory diseases — are linked to common
physical activity. Some of the Institute for Public
preventable risk factors, related to hereditary factors,
Health’s health promotion campaigns specifically
individual health behaviour, living conditions or
target women, especially those concerned with
socioeconomic and working conditions. Screening
childbearing (they publish a leaflet for pregnant
programmes are important preventive measures,
women on their rights, others on how to deal with
since many diseases can be cured through early
psychological stress after the birth of a child, as well
detection. Gender specificities addressed by the
as on healthy lifestyles for future parents).
main health prevention/screening programmes,
promoted at the national and/or regional level, as

■
In Norway, to increase the time and number
well as their main features and the key challenges
of women who breastfeed, a measure for paid
are presented below.
122
( ) Cornet, A., Laufer, J., Belghiti-Mahut, S. (2008), GRH et genre, les
défis de l’égalité hommes-femmes, Vuibert, AGRH, Paris.
123
( ) For more information on this programme, see Box 2-11.
50

---

2. Gender differences in access to healthcare
Childhood and adolescence
refusal. As a result, the vaccination campaign was
interrupted and the Ministry of Public Health is
Policies and programmes of health prevention
planning to develop an information and education
targeted at children and adolescents generally concern
campaign in 2009. Depending on the results, the
immunisation and screening programmes provided to
vaccination campaign is to be re-launched.
the entire youth population or to specific targets among
them. Only few of these programmes presented in the

■
In Italy the Minister of Health promoted an
EGGSI national reports take specifically into account
informative campaign on the free of charge
gender issues: the most widespread across Europe
public inoculation against HPV. In March 2008, a
targeted at young girls is the vaccination programme
compulsory vaccination programme (the first in
for the human papilloma virus (HPV): what is particularly
Europe) against HPV was launched. The vaccination
interesting to note is that across Europe, the access and
programme is widespread throughout the national
the target for such a programme is different, as shown
territory for all girls between the ages of 11 and 12;
by the following five examples.
it is supposed to produce, in the following years,
a progressive immunisation of the young female

■
In Belgium, since November 2007, two vaccines
population throughout the country.
against this virus have been offered free of charge
for girls aged 12 to 15 years, and recently up to
In many countries, important abortion prevention
18 years.
campaigns have been promoted, targeted mainly at
adolescents and youths. Abortion in adolescence in

■
HPV vaccination was recently made available in
fact is still a problem in Europe, with many thousands
Cyprus, and the public health services publicised
of cases per year, even though a clear reduction is
recommendation for this vaccination, for girls and
detectable all over Europe (Table 2-2).
women under the age of 26 (although additional
research may indicate that vaccination at older ages
may also be appropriate). However, the state does
Table 2‑2 — Declared legal abortions
not subsidise the HPV vaccination, and the cost may
by age, 1996 and 2006 in 19 EU countries
be too high for many young women and girls (the
and Iceland and Norway
total cost for a three-phase shot is EUR 500–600).
Between


Less than 15 years
■
In Germany the vaccination against cervical
15 and 19 years
carcinoma for girls was included in the catalogue

1996
2006
1996
2006
of health insurance benefit schemes in the 2007
health reform. The target group was girls between
Bulgaria
319
166
11
349
12 and 17 years old prior to their first experience
Czech Republic
33
46
5
2
with sexual intercourse. Just 1.5 years after this
Denmark
58
0
2 281
2 518
vaccination was officially recommended, more than
Estonia
12
20
169
1 298
a half of girls (59 %) between 15 and 17 years had
Finland
20
65
2
2
been vaccinated (125).
Germany
365
542
11 131
15 209
Greece
17
:
468
:

■
In Romania in November 2008, the Ministry of Public
France
:
:
25 638
:
Health started an HPV vaccination campaign in
Hungary
256
175
11
5
schools, targeted at 9–12-year-old girls. An average
Iceland
8
:
207
:
of 110 000 girls was estimated to be vaccinated.
Italy
216
:
11
:
The campaign created a huge controversy among
Latvia
25
10
3
1
parents (in the first week, 70 % of parents refused
Lithuania
9
6
2
890
the vaccine for their daughters). The main reasons
leading to the failure of the campaign were identified
Norway
:
37
:
2
as: lack of information and education among parents
Poland
:
0
:
24
and the general public regarding the advantages
Romania
862
616
36
17
and risks of the vaccine, lack of a methodological
Slovakia
19
12
2
1
letter sent to the physicians involved in the
Slovenia
3
5
780
430
campaign and the use of the concept of informed
Spain
100
:
7 211
:
Sweden
137
0
4
7
125
( ) Deutsche Krebsgesellschaft (2008), Aktuelle Impfraten,
United Kingdom
1
:
36
:
Hohe Akzeptanz der HPV-Impfungen bei jungen Mädchen,
Source: European Commission, Directorate-General for Health and
20.11.2008.




Consumers on the basis of Eurostat data.
http://w w w.lifepr.de/pressemeldungen/deutsche -
http://ec.europa.eu/health/ph_information/dissemination/diseases/
krebsgesellschaft-ev/boxid-75751.html
docs/reproductive3_en.pdf
51

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
An example of an overall campaign was promoted
have unanimously adopted a recommendation on
in Norway: the campaign offered free hormonal
cancer screening in 2003 (129), based on the positive
contraception for women in the 20- to 24-year-old age
experience of the Europe Against Cancer programme
group (126) as a measure to reduce the abortion rate (127).
and its key achievements. The European Union Council’s
As a consequence, the abortion rate for the age group
recommendation on cancer screening acknowledges
20–24 declined by 24 % from 1992 to 2000 (128). The main
both the significance of the incidence of cancer in
focus of the campaign was on youths, young adults,
the European population and the evidence for the
ethnic minority youths, groups with special needs,
effectiveness of breast, cervical and colorectal cancer
i.e. the disabled, and on women/couples planning an
screening in reducing the incidence of disease. The
abortion. As a consequence, measures easily accessible
Council Recommendation spells out the fundamental
by young people have been established, such as
principles of best practice in early cancer detection
information on the Internet, specific youth health
and invites Member States to take common action to
centres and increased information given at schools. In
implement national cancer screening programmes with
addition, al hormonal y based prevention is subsidised
a population-based approach and with appropriate
for women in the 16–19 age group. A government-
quality assurance at all levels, taking into account
supported private foundation offers nationwide, free
European quality assurance guidelines for cancer
counselling to women who have found themselves
screening, where they exist.
pregnant, targeting more vulnerable groups of women
in particular, such as ethnic minority women and lone
Figure 2-3 presents the distribution of cervical cancer
women with weak social networks.
screening programmes in the European Union in 2007,
by programme type and country implementation
Reproductive age
status. Programmes shown use the screening test (Pap
smear) recommended by the Council of the European
Health prevention in reproductive age mostly
Union since 2003 (130). Cytology-based cervical cancer
involves programmes concerning cancer screenings,
screening is widely accepted as a public health policy
programmes on maternity and sexual/reproductive
in the EU. Programmes are currently running or being
health, programmes concerning domestic violence
established in 25 of the 27 Member States. ‘Population-
and the prevention of depression. Most of them
based (131) programmes are currently running or being
are addressed to women but some of them are also
established in 15 Member States (Denmark, Estonia,
specifically targeted at men.
Finland, France, Hungary, Ireland, Italy, the Netherlands,
Poland, Portugal, Romania, Slovenia, Spain, Sweden, and
Cancer screenings
the United Kingdom). Non-population-based screening
programmes are running in 12 Member States (Austria,
The most important and widespread gendered
Belgium, Bulgaria, Czech Republic, France, Germany,
preventive programmes implemented in Europe are
Greece, Latvia, Lithuania, Luxembourg, Slovakia, and
cancer screenings. The European Union health ministers
Spain)’. (132)
129
( ) Council of the European Union (2003), Council Recommendation
of 2 December 2003 on cancer screening (2003/878/EC). Official
Journal of the European Union 16.12.2003.


http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:20
03:327:0034:0038:EN:PDF
130
( ) Council of the European Union (2003), Council Recommendation
of 2 December 2003 on cancer screening (2003/878/EC). Official
126
( ) Norvegian Directorate of Health.


Journal of the European Union, 16.12.2003,


http://www.helsedirektoratet.no/helseogomsorg
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:20
127
( ) Helse og omsorgsdepartementet, St.prp.nr. 1 (2006–07), For
03:327:0034:0038:EN:PDF
budsjettåret 2007.




131
( ) Population-based screening means that in each round of
http://www.regjeringen.no/Rpub/STP/20062007/001HOD/
screening the persons in the eligible target population in the
PDFS/STP200620070001HODDDDPDFS.pdf
area served by a programme are individually identified and
128
( ) http://www.helsedirektoratet.no/seksuellhelse/sex_og_
personally invited to attend screening.
samliv/reproductive_health___preventing_unwanted_
132
( ) http://ec.europa.eu/health/ph_determinants/genetics/
pregnancies__5500
documents/cancer_screening.pdf
52

---

2. Gender differences in access to healthcare
Figure 2‑3 — Distribution of cervical screening programmes based
on cervical cytology in the EU, 2007
Population-based, Nationwide

Rollout complete

Rollout ongoing

Piloting

Planning
Population-based, Regional
R
Rollout complete
R
Rollout ongoing
R
Piloting
R
Non-population-based,
Nationwide
R
Non-population-based,
Regional
R
Population-based and
Non-population-based

No programme
R
R
R
R
Source: European Commission (2008), Report from the Commission to the Council, the European Parliament, the European Economic and
Social Committee and the Committee of the Region Implementation of the Council Recommendation of 2 December 2003 on cancer screening
(2003/878/EC), COM(2008) 882 final 22.12.2008.
http://ec.europa.eu/health/ph_determinants/genetics/documents/com_2008_882.en.pdf
Figure 2-4 presents the distribution of the breast
based programmes were running or being established
screening programme across Europe in 2007, by
in 22 Member States (Austria, Belgium, Cyprus, Czech
programme type and country implementation
Republic, Denmark, Estonia, Finland, France, Germany,
status. Programmes shown use the screening test
Hungary, Ireland, Italy, Luxembourg, Malta, the
(mammography) recommended by the Council of the
Netherlands, Poland, Portugal, Romania, Slovenia, Spain,
European Union since 2003 (133). As reported by the study
Sweden, and the United Kingdom). Of the five Member
in 2007 ‘programmes were running or being established
States operating non-population-based breast screening
in at least 26 of the 27 Member States. Population-
programmes based on mammography in 2007 (Austria,
Greece, Latvia, Lithuania, and the Slovakia), one (Austria)
133
( ) Council of the European Union (2003), Council Recommendation
was also piloting or planning implementation of a
of 2 December 2003 on cancer screening (2003/878/EC). Official
nationwide population-based programme’ (134).
Journal of the European Union, 16.12.2003.

http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:20
134
( ) http://ec.europa.eu/health/ph_determinants/genetics/
03:327:0034:0038:EN:PDF
documents/cancer_screening.pdf
53

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Figure 2‑4 — Distribution of breast cancer screening programmes
based on mammography in the EU, 2007
Population-based, Nationwide

Rollout complete

Rollout ongoing

Piloting

Planning
Non-population-based,
Nationwide
Population-based and
Non-population-based

No programme
Source: European Commission (2008), Report from the Commission to the Council, the European Parliament, the European Economic and Social
Committee and the Committee of the Regions, Implementation of the Council Recommendation of 2 December 2003 on cancer screening
(2003/878/EC), COM(2008) 882 final 22.12.2008, Brussels.
http://ec.europa.eu/health/ph_determinants/genetics/documents/com_2008_882.en.pdf
Figure 2-5 presents the distribution of colorectal
new cases of colorectal cancer were estimated at
cancer screening programmes (135) based on
140 000 in women and 170 000 in men. Colorectal
FOBT (faecal occult blood test) in the European
cancer deaths were estimated at 68 000 for women
Union in 2007, by programme type and country
and 78 000 for men in the EU’ (136). Colorectal cancer
implementation status. While the first two types
screening is also widely accepted as a public health
of cancer are typically feminine, this third one has
policy in the EU. Programmes are currently running
a much higher incidence among men: ‘In 2006
or being established in 19 of the 27 Member
136
( ) Council of the European Union (2003), Council Recommendation
of 2 December 2003 on cancer screening (2003/878/EC). Official
Journal of the European Union, 16.12.2003,

135
( ) Programmes shown use the screening test recommended by
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:20
the Council of the European Union in 2003.
03:327:0034:0038:EN:PDF
54

---

2. Gender differences in access to healthcare
States. Twelve of the Member States have adopted
Republic, Germany, Greece, Latvia, and the Slovakia).
the population-based approach to programme
‘Compared to the situation with breast and cervical
implementation recommended by the Council
cancer screening in 2007, colorectal cancer screening
of the European Union (Cyprus, Finland, France,
programmes were running or being established in a
Hungary, Italy, Poland, Portugal, Romania, Slovenia,
smaller number of the Member States, programme
Spain, Sweden and the United Kingdom). Seven
implementation was less advanced, and a smaller
Member States have established non-population-
proportion of the population specified in the Council
based programmes (Austria, Bulgaria, the Czech
Recommendation was targeted’ (137).
Figure 2‑5 — Distribution of colorectal cancer screening programmes
based on the faecal occult blood test in the EU, 2007
Population-based, Nationwide

Rollout ongoing

Piloting

Planning
Population-based, Regional
R
Piloting

Planning
Non-population-based,
R
Nationwide
R
Population-based and
Non-population-based

No programme
R
Source: European Commission (2008), Report from the Commission to the Council, the European Parliament, the European Economic and
Social Committee and the Committee of the Region Implementation of the Council Recommendation of 2 December 2003 on cancer screening
(2003/878/EC), COM(2008) 882 final 22.12.2008, Brussels.
http://ec.europa.eu/health/ph_determinants/genetics/documents/com_2008_882.en.pdf
137
( ) http://ec.europa.eu/health/ph_determinants/genetics/
documents/cancer_screening.pdf
55

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
As the three maps above indicate, although much
providing some examples of the situation across
progress has been made, more is still required: ‘The
Europe from the EGGSI national reports. Box 2-4
current annual volume of screening examinations in
shows that in most EU countries, the cervical cancer
the EU is considerable; however, this volume is less
screening programme is free of charge and, in those
than one half of the minimum annual number of
best organised, women are invited, with a personal
examinations that would be expected if the screening
reminder, to do the test. It is also interesting to note
tests specified in the Council Recommendation on
that, where the figure is available, there is a consistent
cancer screening were available to all EU citizens
differentiation in the take-up rate: it ranges from
of appropriate age (approximately 125 million
59 % in Belgium to 79.2 % in the UK. Some EGGSI
examinations per year). Furthermore, less than one
reports evidence that income (as in Belgium) and
half of the current volume of examinations (41 %)
geographical barriers (in rural areas in Hungary) play
is performed in population-based programmes
a consistent role in accessing the programme. In Italy,
which provide the organisational framework for
the screening programme is not homogeneously
implementing comprehensive quality assurance as
spread across the country. Another element to note is
required by the Council Recommendation’ (138).
that the target of the programme is generally people
between the ages of 25–64, but in some cases, such
The following two boxes show in greater detail the
as in Poland, it is offered to women aged 25–59, and
first two screening programmes described above,
in Slovenia 20–75.
Box 2‑4 — Cervical cancer prevention programmes in some European countries
Belgium
Estonia
Even though a regular Pap smear, according to scientific The cervical cancer screening programme has been carried
literature (139), can detect 1 400 cases of cervical cancer, per out yearly since 2003 among women aged 20–59. The
year, only 59 % of women aged 25 to 64 go to their doctor participation rate of cervical cancer screening is lower than
or gynaecologist for a Pap smear systematically. There is an that of breast cancer and the effectiveness of the programme
important social component, as women from lower income has not been assessed yet.
groups are 13 % less likely to perform such test (21 % less Finland
when compared with the highest income group) (140).
Cyprus
The oldest nationwide mass screening programme for
cancer typical for females is the Pap test, in effect since 1963
There is currently no running population or non-population (national programme 1967). Women aged 30–60 are called in
based public screening programme for cervical cancer for the screening every five years. In 2005, 71.4 % of women
in Cyprus. However, according to the 2003 Health Survey participated in the screening. In recent years, however, only
published by the Cyprus Statistical Service, 80.9 % of women about half of young women aged 30–35 participated (142).
aged 25–64 stated that they had a cervical cancer test at Some municipalities organise screening for 65 year olds,
least once in their lifetime (141).
and so in total about 15 % of this age group is screened
on a voluntary basis. Of the approximately 176 500 women
screened, 1 356 (0.8 %) were sent for further investigations
in 2005 (143).
139
( ) Health Care Knowledge Centre (KCE) (2006), Dépistage du
cancer du col de l’utérus et du Papillomavirus humain, Brussels.
http://www.kce.fgov.be
140
( ) Mutualité chrétienne (2008), Inégalités sociales de santé:
observations à l’aide de données mutualistes, MC Informations
233, septembre.




142
( ) Ministry of Social Affairs and Health — MSAH (2007),
h t t p : / / w w w. m c. b e / f r / 1 0 9 / i n fo _ e t _ a c t u a l i t e / m c _
Seulontaohjelmat [Screening programmes, A handbook for
informations/index.jsp
municipal authorities], Helsinki.
141
( ) Statistical services of the Republic of Cyprus.

143
( ) Finnish Cancer Organisation, Finnish mass screening registry
http://www.pio.gov.cy/mof/cystat/statistics.nsf/All/D4C9C72
40 years old.




CE63047EAC2257000002B2646?OpenDocument
http://www.cancer.fi/english/?x22567552=27328166
138
( ) European Commission (2008), Report from the Commission to
the Council, the European Parliament, the European Economic
and Social Committee and the Committee of the Region
Implementation of the Council Recommendation of 2 December
2003 on cancer screening (2003/878/EC), COM(2008) 882 final
22.12.2008, Brussels.




http://ec.europa.eu/health/ph_determinants/genetics/
documents/com_2008_882.en.pdf
56

---

2. Gender differences in access to healthcare
Hungary
The Netherlands
Cervical cancer screening is an important issue in Hungary.
Dutch female residents, between the ages of 30 and 60,
In Hungary, female mortality caused by cervical cancer
receive a personal reminder via regular mail regarding
was the third worst in the European Union in 2003, despite
cervical cancer screening every five years. This health
the increase in screening between 1980 and 2003. The
prevention programme was initiated at a national level
mortality rate caused by cervix cancer is still twice as high
by the Dutch Ministry of Health, Welfare and Sport in
in Hungary than in the EU (144). According to the Eurostat
collaboration with the National Institute for Public Health
data (145), 84.8 % of the female population between 25 and
and Environment (RIVM). Every year, 800 000 women are
74 had a cervical cancer screening in 2004. In order to reach
invited to participate in this screening; approximately
endangered women in the remote countryside, where
66 % of them actually participate (147). All women between
access to this service is difficult, the Hungarian Post (Magyar
30 and 60 years old are invited to make an appointment
Posta) started a mobile screening programme in 2006. The
with their regular general practitioner in order to undergo
mobile screening station drives across the country following
examination to prevent cervical cancer. This national health
a strict timetable and mobilises women of all endangered
prevention programme gives women the opportunity to
age groups.
determine their chances of developing cervical cancer at
Iceland
an early stage. Therefore, if they show symptoms which
indicate potential cervical cancer they can be treated in
Cervical cancer screening began in 1964 and consists of a
time. Women are examined by their general practitioner and
gynaecological examination and a Pap-smear. Before 1988,
results of the examination are sent to a medical lab where a
women were invited to a screening at two- to three-year
cytologist or pathologist further studies the cervical smear.
intervals and since 1 January 1988, at two-year intervals.
If the swab shows no anomaly during examination, women
From 1969 to 1987, screening was limited to women aged
do not have to return for a screening for another five years.
25–69, but as of 1 January 1988, the age limit was lowered
If the swab does show an anomaly, further examination
to 20. Women are invited to the screening by a personal
will be initiated by the general practitioner. The visit to
letter, reminding them to make an appointment. However,
the general practitioner, the analysis itself, the results and
they may also come of their own accord, without invitation,
even the further examination after six weeks if there is any
if it has been more than 18 months since the last screening,
indication for it, are free of charge. The cost is paid for by the
or whenever they have new symptoms.
national government.
Italy
Norway
Since 1996, Italian national guidelines have recommended
Every three years, women in the 25–69 age group are
regions to implement organised, free of charge screening
requested to be examined in order to prevent cervix
programmes for cervical cancer. These recommendations,
cancer (148).
largely based on European guidelines, include personal
invitations to women aged 25 to 64 for a Pap test every
Poland
three years (not applied uniformly across the country), a
The programme for the prevention and early diagnosis of
monitoring system, and quality assurance for each phase
cervical cancer is included in a widespread longitudinal
of the programme. The implementation of the regional
national programme for fighting malignant neoplasms set
plans has been constantly monitored. Two out of three
up in 2005, spanning the period 2006–15. It offers a free
Italian women between 25 and 64 years of age live in an
conventional Pap smear test and — if needed — further
area where an organised cervical screening programme is
medical consultations and treatment every three years
active (146).
(except in suspected cases) for women aged 25–59. The
Latvia
programme includes an educational component: patients
receive information on breast/cervical cancer, on possible
The health prevention programme on the prevention of
risk factors, prevention and treatment methods.
cervical cancer was introduced in 2009. The programme
includes primary and secondary prevention of cancer:
Romania
screening and vaccination. Screening is going to be free
Despite the fact that breast cancer and cervical cancer
of charge, and every woman of a certain age (between
are the primary causes of cancer-related deaths affecting
the ages of 25 and 67) will receive invitation letters to the
women, Romania is one of the few Member States that does
screening examination every three years.
not have a complete screening programme for identifying
and preventing these types of cancers in the early stages.
However, in 2009, the Romanian Ministry of Public Health
144
( ) National Strategy Report on Social Protection and Social
Inclusion 2006–08, Hungary, Budapest, 2006, Annex 1-1
announced the launching of two screening programmes
http://ec.europa.eu/employment_social/spsi/docs/social_
for breast cancer and cervical cancer. The screening
inclusion/2006/nap/hungary_annex1_1_en.pdf
programme is to be developed in three stages at the local,
145
( ) Eurostat data on population and social conditions based on
health interview surveys (HIS).


http://epp.eurostat.ec.europa.eu/portal/page/portal/product_
147
( ) Westert, G.P., Berg, M.J. van den et al. (eds.) (2008), Dutch
results/search_results?mo=containsall&ms=cervical+&saa=&
Healthcare Performance Report 2008, RIVM, Bilthoven.
p_action=SUBMIT&l=us&co=equal&ci=,&po=equal&pi=
148
( ) Helse og Omsorgsdepertementet (n.y.), Najonal strategj for
146
( ) Ministero della Salute (2007), Libro bianco: La salute della
kreftomraded, 2006–09, Oslo.


donna, Stato di salute e di Assistenza nelle regioni italiane,
http://www.regjeringen.no/upload/HOD/Sykehus/
Rome.
kreftstrategi%202006-2009.pdf
57

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
regional and national level. In the first stage, women at high 23 and 50 years of age are called every three years. Between
risk for this disease are tested, on recommendation of the 50 and 60, the screening is every five years. After the age of
family doctor. During the third stage, developed at national 50 it is very uncommon to develop cervix cancer (149).
level, all women between 25 and 65 years old are tested free UK
of charge. The programme is planned to be developed over
a three-year period.
All women between the ages of 25 and 64 are eligible for a
Slovenia
free cervical screening test every three to five years. Cervical
screening began in Britain in the mid-1960s and the NHS
The prevention programme for the early detection of Cervical Screening Programme was set up in 1988 to ensure
precancerous changes of the cervix (Zora programme) is that those at greatest risk were being tested, and those who
intended for women aged 20 to 75. Women in this age group had positive results were being followed up and treated
have the right to receive an examination every three years effectively. The programme screens almost four million
after two negative smears taken at 12-month intervals. The women in England each year. In 2006/7, the coverage of
programme has been under way since 2003, and operates eligible women was 79.2 % (150).
nationwide.
Sweden
Source: EGGSI network national reports 2009.
Screening programmes concerning cervix cancer are
widespread: all county councils offer Pap tests at a cost for
149
( ) http://www.sjukvardsradgivning.se
the patient or free of charge. The Pap test to prevent cervix
150
( ) NHS Cervical Screening Programme.

cancer has been offered since the 1970s. All women between
http://www.cancerscreening.nhs.uk/cervical/index.html
Table 2‑3 — Percentage of women
Table 2-3 provides information on the take-up rate of
reporting specific preventive examinations breast cancer screening programmes in 1996 and 2002
(derived from Eurobarometer) in 15 EU countries. It
1996 and 2002 — EU‑15
shows a great variation among EU-15 countries with
Breast examination
a wider diffusion of breast cancer examinations by
Breast examination
by X-ray
mammography in Austria, Portugal and Luxembourg
by hand
(mammography)
and by hand in Luxembourg, Germany and Austria.
1996
2002
1996
2002
Breast cancer prevention programmes as implemented
EU‑15
18.8
21.0
36.8
27.7
across Europe generally apply the European guidelines
Belgium
16.5
18.8
41.2
33.6
concerning the target group (50–69 years old). As
Denmark
30.6
11.3
52.8
15.1
shown in the box below (Box 2-5), women on lower
Germany
20.8
17.2
56.3
49.0
income tend to use these services less often and the
Greece
11.9
13.0
21.4
17.0
overall take-up rate is varied among countries.
Spain
18.7
20.5
29.9
18.8
France
18.2
23.4
46.8
26.9
Ireland
4.5
9.7
15.6
24.9
Italy
15.0
25.7
28.0
25.3
Luxembourg
27.1
30.4
51.6
54.4
Netherlands
18.2
25.8
27.9
11.4
Austria
28.4
37.1
52.7
45.8
Portugal
17.9
33.0
24.8
27.7
Finland
17.5
22.9
37.2
25.9
Sweden
27.5
24.2
33.1
11.2
United Kingdom
12.3
12.7
23.2
17.7
Source: Eurobarometer 43.0 and 59.0 in European Commission,
health information. Percentage of women reporting specific
preventive examinations — 1996 and 2002.
http://ec.europa.eu/health/ph_information/dissemination/echi/
echi_15_en.pdf
58

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2. Gender differences in access to healthcare
Box 2‑5 — Breast cancer prevention programmes
Austria
Finland
83 % of all women above the age of 40 years have undergone
Nationwide mammography tests were started in 1987.
a mammography for the early detection of breast cancer in
The tests first covered women aged 50–59, but many
2006 (151).
municipalities also included women aged 60–69. In the
Belgium
early 2000s, a systematic review of the effectiveness of
screening for 60–69 year olds was carried out. The new
Since 2001 (2002 in Wallonia) a campaign for breast
regulation (Act 1339/2006) introduced in 2007 included the
screening (mamotest) has targeted women aged between
60–69 age group in the screening programme, and the law
50 and 69. The main results of the evaluation of the
will be implemented gradually (155).
programme (152) show that the current coverage is 59 % of
the eligible population, but there are important disparities
France
between regions (higher proportion in Flanders). In terms
The Cancer plan launched in 2003 had five targets regarding
of accessibility for lower-income groups, women benefiting
cancer detection, among which the implementation at
from BIM (153) have less coverage (14 % less than other
national level of a programme of breast cancer detection
women). However, they constitute 30 % of the programme’s
and the improvement of individual detection for cervix
participants against 23 % of other women, but they also
cancer. If the objectives to implement at national level
leave the programme more frequently (26 % against 23 %).
breast cancer detection have been met (results need to be
The percentage of breast screening outside the mamotest
improved for cervix cancer detection), a major problem in
programme is still very high, at 83 %.
the field of cancer prevention remains the socioeconomic
Cyprus
inequalities in access to prevention. Among women aged
40 and more living in a modest household, 34 % have never
The Breast cancer screening programme began as a pilot
had a mammography (versus 19 % for other women) and
programme in July 2003 in one health centre in the capital
among women aged 20 to 70 living in a modest household,
Nicosia. The programme is now implemented in all major
12 % have never had a Pap smear test (double the number
areas of Cyprus. The programme is population based and
compared to other women) (156). In the same way, among
targets women aged 50–69 years. The programme is offered
women aged 25 to 65 years who do not benefit from
free of charge to all women, regardless of whether they are
complementary medical insurance, 56 % declare that they
eligible or not for free public healthcare.
have undergone cervix cancer detection in the last three
Estonia
years (versus 81 % for others), and among women aged
50 to 74 years who do not benefit from complementary
Breast cancer is one of the most common malignant
insurance, 48 % declare that they have had a mammography
tumours among Estonian women. The mammography
in the last two years (versus 80 % for others) (157).
screening pilot projects were first activated in Tallinn in 1996
and in Tartu in 1998, and the early breast cancer detection
Germany
project for 2002–06 was financed by the Estonian Health
Mammography screening is only for women between 50 and
Insurance Fund. The target group was women aged 45–59
69 free of charge and part of the statutory health scheme.
and up to 10 000 women are screened yearly with a mobile
The entitlement for services regarding the early detection
mammography. In May 2009 a one-year campaign, ‘don’t
of cancer from the age of 20 onwards (for women) and
be late’ for breast screening, started, targeted at women
from the age of 45 onwards (for men) only refers to general
between the ages of 50 to 65. It is financed by the Health
cancer prevention: mammography screening is only done
Insurance Fund (i.e. free for women). Until now only 50 % of
when the patient is suspected of having cancer.
the women who have received the invitation have come to
the screening (154).
Greece
A national screening strategy does not exist. This important
gap is fil ed by associations, such as the ‘Greek Association
of Women with Breast Cancer’, or the Municipality of Athens
(that offers free mammography to women residing in Athens)
but actions like this have only a limited impact, as they are
localised and do not apply to the whole national territory.
151
( ) Federal Ministry of Health, Youth and Family (2007), Austrian
Health Survey 2006/2007, Vienna. p. 43.

http://www.statistik.at/web_de/dynamic/statistiken/
gesundheit/publdetail?id=4&listid=4&detail=457
155
( ) Ministry of Social Affairs and Health — MSAH (2007),
152
( ) Fabri, V., Remacle, A. (2009), Programme de Dépistage
Seulontaohjelmat [Screening programmes. A handbook for
du Cancer du Sein Comparaison des trois premiers tours
municipal authorities], Helsinki.
2001–02, 2003–04 et 2005–06, Rapport numéro 6, Agence
156
( ) Saint Paul de, T. (2007), La santé des plus pauvres, Insee
Intermutualiste, Janvier.
première, No 1161, October.
153
( ) BIM stands for ‘Bénéficier d’Intervention Majorée’ (Beneficiary of
157
( ) Danet, S., Moisy, M. (2009), La santé des femmes en France,
increased intervention): it is an incremented reimbursement of
Communication on the work done for the book: ‘La santé des
healthcare expenses for specific cathegories of beneficiaries.
femmes en France’ (to be published), Drees–French Ministry of
154
( ) Eesti Vähiliit. http://www.cancer.ee/?op=body&id=162&cid=
Health and Sports, 8 April 2009, Paris.
59

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Iceland
2006–15 (161). The programme offers free mammography
In November 1987, two nationwide mammography
examinations and — if needed — further medical
screening programmes for breast cancer were set up: one
consultations and treatment for women aged 50–69 who
for women who were 35 years old and one for the 40–69 age
had no such examination during the last 24 months or need
group: the first screening round was completed in December
to repeat a mammography within 12 months because they
1989 and Iceland was the first country to complete a breast
belong to a group at risk for specific pathologies. Women
cancer screening of the whole female population in an age
diagnosed with a breast cancer are not covered by the
group, the age group from 40–69 years. In the following
programme (they receive a regular treatment, under health
years, the target age was reduced.
insurance).
Italy
Slovenia
Since 2001, mammography has been recommended by the
The prevention programme for the early detection of breast
Ministry of Health to be provided free of charge to people
cancer (Dora screening programme (162)) promoted by the
in selected age groups: women between 50 and 69. Three
Ministry of Health, Oncological Institute and the Institute
out of four Italian women between 50 and 69 years of
for Public Health Community health centres, is intended
age live in an area with an active breast cancer screening
for all women aged 50 to 69. Women from this age group
programme (
are personally invited in writing for mammographic
158).
screening every two years. However, the programme was
Latvia
only launched in 2008 and just in one region, but coverage
The screening examination of the breast cancer is going to
is planned for the entire country within three years. The
be introduced in 2009: an invitation is going to be sent to all
previous screening programme for the early detection of
women every two years from the age of 50 years onwards.
breast cancer, which has been under way for several years,
It is going to be free of charge.
entitled women aged 50 to 69 to undergo a preventive
mammogram every two years. However, women were not
The Netherlands
invited to these examinations. In 2007, 64 % of women who
The breast cancer screening programme is targeted at
underwent preventive examinations for breast cancer were
women between 50 and 75 years old. This health prevention
aged 40 or over (163).
programme was initiated at the national level by the Dutch
Sweden
Ministry of Health, Welfare and Sport in collaboration with
the National Institute for Public Health and Environment
All county councils offer mammography: the National
(RIVM). Every two years, all women above 50 years old
Board of Health and Welfare (NBHW) recommendation is
receive a breast cancer screening reminder: each year
that all women aged between 40 and 74 are called to be
approximately one million women are invited to undergo
screened, with the strongest recommendation for the 50–
breast cancer screening, and approximately 80 % of these
69 age bracket. Mammography is recommended every 18
women actually do participate (159). The examination usually
months, while every two years is sufficient for older women.
takes place in a mobile truck and is carried out by a female
The examination is voluntary (164).
healthcare professional. Participation in the breast cancer
UK
screening programme is free, paid by the Ministry of Health,
Welfare and Sport, and not mandatory. In the Netherlands,
The National Health Service (NHS) Breast Screening
the number of breast cancer cases is very high; more than
Programme provides free screening for breast cancer every
11 000 women are diagnosed with this disease annually.
three years to all women in the UK aged 50 and over. Set
up in 1988, it was the first screening programme of its kind
Norway
in the world. National coverage was reached by the mid-
The action programme regarding the prevention, diagnosis
1990s. Today, around one and a half million women aged
and treatment of breast cancer involves mammography
50–70 are screened in the UK per year. In September 2000,
screening for all women between 50–69, every two years. In
research demonstrated that the screening programme had
addition, women with a hereditary risk for breast cancer are
lowered mortality rates for breast cancer in the 55–69 age
followed up more intensively (160).
group (165).
Poland
Source: EGGSI network national reports 2009.
Programmes for the early diagnosis of breast cancer are
included in a widespread, longitudinal national programme
for fighting malignant neoplasms set up in 2005 for
161
( ) Dz.U. 08.54.325 and regulated by Resolution 47/2006 of the
Council Minister of 4 April 2006.
158
( ) Ministero della salute (2007), Libro bianco: La salute della
162
( ) Ministerstvo zdravotníctva SR, Dora cancer screening
donna, Stato di salute e di Assistenza nelle regioni italiane,
programme. See also http://dora.onko-i.si/
Rome.
163
( ) Institute of Public Health of the Republic of Slovenia (2007),
159
( ) Westert, G. P., Berg, M. J. van den et al. (eds.) (2008), Dutch
Statistical yearbook on health 2007, Slovenia.
Healthcare Performance Report 2008, Bilthoven.
164
( ) http://www.sjukvardsradgivning.se/allakapitel.asp?
160
( ) Social OS helsedirektoratet (2007), Najonalt handings med
CategoryID=28278&AllChap=True&PreView=artikel.
retningslinjer for diagnostikk, behandling og oppfolging av
asp?CategoryID=28279
pasienter med brystkreft.



165
( ) National Health Service — Cancer Screening Programmes,
http://w w w.helsedirektoratet.no/vp/multimedia/
Sheffield, United Kingdom.


archive/00021/Nasjonalt_handlingsp_21559a.pdf
http://www.cancerscreening.nhs.uk/breastscreen
60

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2. Gender differences in access to healthcare
Maternity and sexual/reproductive health
because of pregnancy or delivery’ (169). Maternal
deaths occur today in relatively small numbers, but
Across Europe many prevention programmes address
an analysis of the causes is essential for developing
maternity. Promoting healthy pregnancy and safe
strategies to prevent them. EGGSI national reports
childbirth is a goal of all European healthcare systems.
have described several prevention programmes
Despite significant improvements in recent decades,
addressing maternity. In almost all EU countries,
mothers and their babies are still often at risk during prenatal screening tests for the most common
the perinatal period, which covers pregnancy,
risks for foetuses and pregnant women are widely
delivery, and the postpartum period: ‘Perinatal
available and free of charge.
health problems affect young people — babies and
adults starting families — and, as such, have long-
Many EGGSI national reports have described prevention
term consequences. Impairments associated with
projects offering support for mothers with newborn
perinatal events represent a long-term burden for
children or for mothers with special needs: all over
children and their families as well as for health and
Europe women are offered medical support during
social services. It is increasingly understood that a
and after pregnancy, while in some countries there
healthy pregnancy and infancy reduce the risk of
are specific programmes which include other kinds of
common adult illnesses, such as hypertension and
support, such as psychological help, antenatal exercises
diabetes’ (166). In order to better monitor such factors, in
and birth preparation courses for couples featuring
2000 the European Commission launched the project
activities in nursing care.
Peristat — Indicators for monitoring and evaluating
perinatal health in Europe (167) coordinated by Inserm
Other widespread prevention programmes across
(France). Building on the work of the Peristat projects,
Europe concern sexual and reproductive health. The
in 2007 the Commission funded a project for a Better European Union actively promotes sexual health and
statistics for better health for pregnant women and
encourages the development of a healthy lifestyle
their babies (168) coordinated by Assistance Publique-
regarding sexual behaviours (170). This objective, with
Hôpitaux de Paris (France). The European Perinatal
a focus on young people, is included in the EU Health
Health Report, published in 2008 as a result of this
Programme for 2008–13. As reported by the EU-Health
project, was the first to collect data from 2004 in
website (171), the EU wants to develop ways to improve
all EU countries, including policy-relevant analyses
the sexual health status of all citizens and to promote
of maternal and child health outcomes, care
the exchange of good practices and information to
provision, inequalities and migrant health in order
address major concerns such as teenage pregnancy or
to develop an Action plan for sustainable perinatal
the prevention of sexually transmitted diseases. The
health reporting. Part of the study is dedicated to
EU has taken steps towards a European partnership
mothers’ health: mortality and morbidity associated
promoting sexual and reproductive health among
with childbearing. ‘Each year more than five million
young people and vulnerable groups in Europe.
women give birth in the EU. Another two million
Guiding principles for the improvement of health
women have failed pregnancies — spontaneous and
in general, and sexual and reproductive health
induced abortions as well as ectopic pregnancies.
in particular, have been adopted or reconfirmed
Maternal mortality is considered a major marker of
at international assemblies and conferences and
health system performance, and overall each year
set out in international documents (172). A specific
from 335 to 1 000 women die in Europe during and
case of difficult access to birth control options is
169
( ) Euro-Peristat (2008), European Perinatal Health Report,
Project coordinated by the Assistance Publique-Hôpitaux de
Paris (AP-HP) and the Institut de la santé et de la recherche
médicale (Inserm).




166
( ) Euro-Peristat (2008), European Perinatal Health Report,
http://www.europeristat.com/publications/european-
Project coordinated by the Assistance Publique-Hôpitaux de
perinatal-health-report.shtml
Paris (AP-HP) and the Institut de la santé et de la recherche
170
( ) See also http://ec.europa.eu/health-eu/my_lifestyle/sex/index_en.htm
médicale (Inserm).




171
( ) European Commission, Health EU, the Public Health Portal.
http://www.europeristat.com/publications/european-
http://ec.europa.eu/health-eu/my_lifestyle/sex/index_en.htm
perinatal-health-report.shtml
172
( ) See for example several documents concerning Policy and
167
( ) European Commission, Directorate-General for Health and
programmatic issues published on WHO website: http://www.
Consumer Protection, Public Health.


who.int/reproductivehealth/publications/policy/en/index.
http://ec.europa.eu/health/ph_projects/2000/monitoring/
html. Among others: Eliminating female genital mutilation:
monitoring_project_2000_full_en.htm#7
an interagency statement — OHCHR, Unaids, UNDP, UNECA,
168
( ) Euro-Peristat (2008), European Perinatal Health Report, Project
Unesco, UNFPA, UNHCR, Unicef, Unifem, WHO — 31 December
coordinated by the Assistance Publique-Hôpitaux de Paris (AP-HP)
2008; The WHO Strategic Approach to strengthening sexual and
and the Institut de la santé et de la recherche médicale (Inserm).
reproductive health policies and programmes — 31 December
http://www.europeristat.com/publications/european-
2007; Introducing WHO’s reproductive health guidelines and
perinatal-health-report.shtml
tools into national programmes — 31 December 2007.
61

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
worth mentioning: it is presented in the Cyprus
reasons for the scarcity of birth control options in
EGGSI national report. Here contraceptive options,
Cyprus are, on the one hand, physical barriers (the
such as the male condom, brands of combined oral
small population of the island, which means a small
contraceptives, the intrauterine device (IUD), and
market that would not be sufficiently responsive to
hormonal intrauterine systems (IUS) are available only
render such technologies profitable for importers)
through private clinics, pharmacies at market price,
and on the other hand cultural barriers (conscience
and at reduced price or for free only by the Cyprus
issues) as well as economic barriers (family planning
Family Planning Association (CFPA). Frequently cited
is left almost entirely to the free market).
Box 2‑6 — Maternal and children health prevention
In Norway for example, maternal health centres offer general Programme, has the main objective of creating conditions
medical services for pregnant women and pre-school children for healthy and harmonic family development (175). This
in a prevention perspective. The focus is on groups/individuals programme is a reaction to the recent decreasing birth rate,
with special needs, to identify early signals of malaise, the increase of the age of primiparous women (176) and the
abnormal development and antisocial behaviour. Maternal increase in the number of children raised in mono-parental
and child health centres cooperate with kindergartens and families. The focus is on information about matrimony,
schools, educational psychological services and child welfare parenthood, contraception, and the risk of drug addiction.
authorities (173). Special attention is paid to addicted pregnant
women: according to the national health plan, there is an In Italy the current concern is to reduce regional disparities
increased need for knowledge and information on the part regarding the care of mothers and their newborn babies
of women that become pregnant within LAR (drug-based by guaranteeing uniform obstetric and paediatric care
rehabilitation), and their children (
throughout the country. Regarding this, the Healthcare
174).
Plan 2008–09 identified specific priorities through a project
Furthermore, there is an ongoing self-help campaign to on motherhood and infancy (Progetto Obiettivo Materno
support pregnant women to quit smoking. In some countries Infantile), which paid specific attention to a particular female
families are also supported in their development: the case target group, namely women in prison. The Healthcare
of Slovakia is interesting, where a special health programme Plan 2008–09 invites the regions to carry out specific, direct
focused on women and young girls, cal ed Healthy Family programmes/projects to enhance female health issues for
female convicts and their children.
173
( ) Norwegian Ministry of health and care services, National
Source: EGGSI network national reports 2009.
strategy to reduce social inequalities in health.
Report No 20 (2006–07) to the Storting.

http://www.regjeringen.no/pages/1975150/PDFS/
STM200620070020000EN_PDFS.pdf
175
( ) Ministry of Health of the Slovak Republic (2007), Koncepcia
174
( ) Helse og omsorgsdepartementet (2006), For budsjettåret
Štátnej politiiky zdravia Slovenskej repubiky, Basic principles
2007, St.prp.nr. 1 (2006–07).


and structure of the healthcare system in the Slovak Republic.
http://www.regjeringen.no/Rpub/STP/20062007/001HOD/
http://www.uvzsr.sk/index.html
PDFS/STP200620070001HODDDDPDFS.pdf
176
( ) Refers to women who have given birth only once.
Domestic violence prevention programmes
in screening for domestic violence and abuse in order
to prevent the escalation of violence and its short- and
An issue specifically affecting women’s health is long-term health consequences. From EGGSI national
domestic violence. The health sector can play a reports, there emerges a general lack of awareness
vital role in preventing violence against women, by among health professionals with regard to existing
helping to identify abuse early, providing victims support services for victims and thus they are not
with the necessary treatment, and referring women always in a position to refer victims to the appropriate
to appropriate care. Particularly important for the services (177), but some good practices have also been
purposes of this report is the role of healthcare services described (see Box 2-7).
177
( ) Apostolidou, M., Apostolidou, Z., Payiatsou, M., Mavrikiou, P.
(2007), Evaluation of Services offered to Victims of Domestic
Violence by the National Health Service, Advisory Committee
for the Prevention and Compacting of Violence in the Family.
http://www.familyviolence.gov.cy
62

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2. Gender differences in access to healthcare
Box 2‑7 — Good practices to combat domestic violence
In Norway gender-based violence and violence within families detection of early signs of the consequences of violence. Over
are not considered private matters, but a political and public the last decade the Municipal Department — Promotion and
issue. The first National action plan to combat domestic Coordination of Women’s Issues has initiated a number of
violence was launched in 2000, the second in 2004 and the research projects, publications, conferences and model projects
third in 2007. The third includes also the need to combat on issues like sexual, physical and psychological violence
honour-based violence, forced marriages and female genital against women and children (e.g. a model project against
mutilation. According to the action plans, domestic violence stalking) and subsidises several counselling centres which
can be prevented by factors such as: women participating in support women in these situations, e.g. the 24-hour women’s
the formal economy at a rate of 80 %, having their own income emergency helpline and women’s shelters. The concepts and
and economic power, owning assets. It is considered essential measures of the Municipal Department for Women’s Issues aim
to make the problem emerge from the private sphere. Other at removing the taboo associated with these issues and try to
important measures are: educating the police force and the show that violence is a problem of society in order to bring
public at large, a strong cooperation between the NGOs and about structural changes (182).
public authorities and involving men in combating violence (178).
Particular attention has been paid to preventing domestic In the Czech Republic the project ‘Let’s discuss domestic
violence in families of ethnic minority back grounds (179). violence together’ (‘Mluvme spolu o domácím násilí’) (183) was
Female genital mutilation is prohibited and punishable by law a joint project supported by AVON cosmetics and the civic
in Norway, hence the prevention of female genital mutilation is association Accorus. It was an information campaign targeted
an important issue, and the government emphasised at the entire population regarding women and domestic
41 measures to combat female genital mutilation in its action violence. The main objective was to offer information about the
plan. As forced marriages may cause individual trauma, health various forms of domestic violence other than physical violence,
personnel are in a key position to identify and treat victims such as types of behaviour that are often not considered
of forced marriages. Within the action plan against forced violent (financial restrictions, interference with privacy, e.g.
marriages, emphasis was placed on strengthening existing searching through another’s personal possessions). A non-stop
regional resource centres expertise, including the development helpline was set up as part of this campaign. The impact of this
of mental healthcare for victims of forced marriages. One project has been evaluated positively, as the number of cal s
programme directed towards ethnic minorities was the project to the helpline and contacts at the counselling centre against
‘Ethnicity and domestic violence 2005–07’. The programme domestic violence increased notably since its implementation.
offered therapy for battered women and battering men, Sexual violence has been on the gender and health agenda
delivered in a culturally sensitive way, to which both the women since the first nationwide studies in Finland in the late 1990s.
and men participating in the programme responded (180).
There are currently many examples of how violence issues have
In Sweden a project called okejsex.nu launched by Operation become increasingly part of general health treatment. Two
Kvinnofrid (The National Authority Cooperation Project for good examples are the monitoring of possible interpersonal
Women’s Peace) in November 2007, together with a number of violence against young women and the standardised assault
youth organisations, magazines and municipalities was intended form for victims of violence. In the first case, maternity and
to address the low awareness regarding sexual violence (
child health clinics, midwives and public health nurses are the
181). The
two main objectives of the project were to increase awareness target groups for developing suitable methods for identifying,
about sexual violence and its extent (including definitions of addressing and discussing domestic violence (184). Another
sexual violence, when and where it happens according to statistics, example of how the issue of violence is being dealt with in
etc.). The target group was the young population in Stockholm. general healthcare is a tool for improving the legal protection
Special emphasis was given to school pupils, young members for assault victims: the assault form is an intervention tool
active in Internet communities and youth athletic groups.
which can assist healthcare professionals in going over
essential matters with patients at the initial stage. The southern
In Austria the Vienna Women’s Health programme has provincial state office of Finland has already put the assault
developed training measures for hospital staff for the form and the emergency care protocol into use (185).
178
( ) Hole, A. (2007), Lifting Domestic Violence from the Private
Source: EGGSI network national reports 2009.
to the Public Sphere, Ministry of children and equality.
http://www.regjeringen.no/en/dep/bld/BLD-arbeider-for-at/
182
( ) City of Vienna (2006), Women’s Health Report 2006, Vienna.
Organisation/Departments/Department-of-Family-Affairs-
w w w. o e b i g . o r g / u p l o a d / f i l e s / C M S E d i t o r / W I E N _
and-Gender-Equality/Director-General-Arni-Hole/Lifting-
Frauengesundheitsbericht2006.pdf
Domestic-Violence-from-the-Priva.html?id=481305
183
( ) Acorus, Avon proti domacimu nasili.

179
( ) Kjell, Erik Øie (2007), Domestic violence in families with a
http://www.acorus.cz/cz/novinky/29_acorus-je-partnerem-
minority ethnic background, Ministry of children and equality.
projektu-„avon-proti-domacimu-nasili“.html
http://www.regjeringen.no/en/dep/bld/BLD-arbeider-for-at/
184
( ) Ministry of Social Affairs and Health — MSAH (2008),
Other-political-staff/State-Secretary-Kjell-Erik-Oie-Social-De/
Recommendations for the prevention of interpersonal and
Speeches-and-articles-by-the-State-Sectr/2007/Domestic-
domestic violence, Recognise, protect and act, How to guide
violence-in-families-with-a-min.html?id=488410
and lead local and regional activities in social and healthcare
180
( ) Familievold og Etnisitie (2005), Rapport fra prosjectet.

services (English Abstract), Helsinki.
http://www.atv-stiftelsen.no/filer/Fagrapport%20familievold%20
185
( ) For details see website of Etelä-Suomen lääninhallitus.
og%20etnisitet%20-%20Alternativ%20til%20Vold.pdf
http://www.laaninhallitus.fi/lh%5Cetela%5Csto%5Chome.
181
( ) http://www.okejsex.nu/om/tack
nsf/Pages/1498EDC9E1753383C22570A80027DF38
63

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Prevention of depression
with by implementing prevention programmes at the
primary and secondary level: ‘primary prevention is
Anxiety, depression and stress-related disorders
directed at reducing the incidence of depression in the
rank high among the common mental disorders in
community by reducing risk factors and strengthening
the general population in Europe. They are likely to
protective factors. Primary prevention is achieved also
be the major cause in the increase in the burden of
by enhancing the coping abilities of people who are
disability in years to come: according to the most
currently without a mental disorder but are believed to
recent available data (2002) (186), ‘neuropsychiatric
be at risk of developing a particular disorder. Secondary
disorders are the first-ranked cause of years lived with
prevention involves efforts to reduce the prevalence of
disability (YLD) in Europe, accounting for 39.7 % of
a disorder by reducing duration of its effect. Secondary
those attributable to all causes. Unipolar depressive
prevention programmes are usually directed at people
disorder alone is responsible for 13.7 % of YLD, making
who show early signs and symptoms of a disorder and
it by far the leading cause of chronic conditions in
the goal is to shorten the duration of the disorder by
Europe’ (187). Specific forms of depression, like post-
early detection and prompt treatment intervention’ (188).
natal or post-partum depression, affect mostly women
EGGSI national reports cite some national experiences
while others affect mostly men. They can be dealt
in this regard.
Box 2‑8 — Good practices to combat depression
In Greece there is a specific national campaign for the based survey 18 % showed indications of depression in the
prevention of depression, but it is not specifically targeted at early stages of pregnancy (up to the 30th week), and 13 %
women (in fact the campaign’s ‘motto’ is ‘depression concerns two weeks before birth. During the period of the Austrian
everyone’), while significant help is offered by the ‘Fainareti’ survey, 28 % showed risky depression values in one of the
Non-Governmental Organisation (funded by the Ministry of four stages that were surveyed. During the project various
Health), which organises a day centre for the psychological prevention and support measures were also tested and
care of women who suffer from postnatal mental disorders. evaluated (189).
Its key priorities and aims are the following: the early
identification (pregnancy and early postpartum period) A specific programme regarding depression and mental
of mental disorders and early intervention for women and health targeted at men has been reported in Slovenia. It
their families in order to prevent postnatal mental disorders. concerns the reduction of suicide rates, a problem that
The targets are pregnant women, couples, mothers and affects men in particular. In 2003 a prevention programme
newborns.
was launched locally (in the two regions of Celje and
Ravne, where suicide rates are particularly high) to educate
In Austria the prevention of postnatal depression was family doctors and general practitioners aimed at the early
addressed by a pilot-project carried out as a part of the identification of people with suicidal tendencies (190).
Vienna Women’s Health programme in 2001 and 2002
and aimed at reducing the risk of postnatal depression
for pregnant women run by the Vienna programme for
189
( ) City of Vienna , Vienna Programme for Women’s Health.

women’s health. A network of all institutions and contact
http://www.diesie.at/projekte/abgeschlossene_projekte/
points dealing with potential cases of postnatal depression
nach_themen/schwangerschaft/senkung_ppd.html
190
has been established and many data on the incidence of ( ) Institute for Public Health of the Republic of Slovenia (2005),
postnatal depression have been collected. Of the 3 000
Cost efficiency of educational programmes for general
practitioners in early detection of risk factors for suicide in
women who took part in the questionnaire (2001–02)
region Ravne and Celje.
186
( ) WHO (2008), New WHO report: Policies and practices for mental
health in Europe, Factsheet, 10 October 2008. http://www.euro.
188
( ) Mental Health Promotion and Prevention Strategies for Coping
who.int/document/mediacentre/fs_mh_10oct2008e.pdf
with Anxiety, Depression and Stress-Related Disorders in Europe
187
( ) WHO (2004), Global burden of disease estimates, Geneva. http://
(2001–03).
http://ec.europa.eu/health/ph_projects/2001/
www.who.int/healthinfo/bodestimates/en/index.html
promotion/fp_promotion_2001_frep_02_en.pdf
64

---

2. Gender differences in access to healthcare
Programmes targeted at men
though men can suffer from it as well, but prevention
programmes rarely include men within the target
The EGGSI national reports have evidenced that
groups of prevention campaigns.
gendered prevention programmes implemented in
Europe are mainly targeted at women, while specific
Old age
male pathologies, where prevention could be useful,
are cited less frequently. This is the case, for example,
In many EGGSI national reports, programmes
of two typical masculine forms of cancer: prostate and
addressing osteoporosis are the most frequently cited
testicular cancers. The first one occurs in older men while
among prevention programmes targeting old age.
the second usually occurs in young or middle-aged men.
This disease, in which the bones become porous and
While prostate cancer is widespread, being the fifth
break easily, is one of the most common, debilitating,
most common cancer in the world and the second most
and costly chronic diseases in Europe. Wrongly often
common in men (191), testicular cancer is far rarer.
thought of as an ‘old woman’s disease’, osteoporosis
affects not only one in three postmenopausal women,
According to the WHO-Regional Office for Europe (192)
but also one in five men over the age of 50, younger
‘there are no obvious preventive strategies, therefore
women and even children. ‘DXA (195) scans are vital in
screening has been considered to reduce the number
order to properly diagnose and monitor osteoporosis.
of deaths. Opportunistic screening is widely carried out
Yet access to bone mineral density measurement is sub-
but there are no known national programmes to screen
optimal in many European countries. Reasons include
for prostate cancer.’ In several EGGSI national reports,
limited availability of densitometers, restrictions in
the experts specify that there are no national screening
personnel permitted to perform scans, low awareness
programmes for these types of cancers: this is explicitly
of the usefulness of BMD testing, limited or non-
mentioned for example in UK, Poland and Estonia. On
existent reimbursement. Many of the DXA scanners
the contrary, in the EGGSI national report of Austria
are not available to the public healthcare system, or
it is stated that 55 % of all men above 40 underwent a
regional disparities mean that some parts of a country
prevention check-up for the early detection of carcinoma
are under-serviced’ (196).
of the prostate, increasing to 70 % for men above 65 (193).
In Finland in the 1990s, the Cancer Society of Finland
Guidelines are effective tools for promoting
developed new methods of mass screening tests also
evidence-based clinical practice. Since some aspects
for typically male cancers to indicate the amount of
of osteoporosis management vary according to
prostate specific antigen (PSA) (194). In the Netherlands a
country (i.e. availability of resources), country-specific
population-based prostate cancer screening programme
guidelines are required. In 2004, the majority of
is under scientific and policy discussion.
European countries had guidelines (apart from some
cases such as Ireland and Cyprus), but an important
Another example is osteoporosis: a pathology that is
next step is to ensure that they are endorsed by their
perceived as predominantly affecting women, even
governments (197).
191
( ) ‘There were 679 000 new cases of prostate cancer worldwide in
2002, making this the fifth most common cancer in the world
and the second most common in men (11.7 % of new cancer
cases overall); testicular cancer is relatively rare, with 49 000 new
cases annually of 0.8 % of cancers in men’ Parkin, M., Bray, F.,
Ferlay, J., Pisani, P. (2002), Global Cancer Statistics, International
Agency for Research on Cancer, Lyon.
192
( ) WHO, Should mass screening for prostate cancer be introduced
at the national level?




195
( ) DXA is the Dual energy X-ray absorptiometry: it is a means of
http://www.euro.who.int/HEN/Syntheses/prostate/20040518_3
measuring bone mineral density (BMD).
193
( ) The survey was carried out from March 2006 to February
196
( ) International Osteoporosis Foundation (2005), Osteoporosis in
2007. Data presented in: Federal Ministry of Health, Youth and
Europe: Indicators of progress and Outcomes from the European
Family (2007), Austrian Health Survey 2006/2007, Vienna. www.
Parliament Osteoporosis Interest Group and European Union
gesundheitsministerium.at/cms/site/artikel.pdf?channel=CH07
Osteoporosis Consultation Panel Meeting, November 10, Nyon.
13&doc=CMS1187768952223
197
( ) International Osteoporosis Foundation (2005), Osteoporosis in
194
( ) Finnish cancer organisation (2008), Finnish mass screening
Europe: Indicators of progress and Outcomes from the European
registry 40 years old.



Parliament Osteoporosis Interest Group and European Union
http://www.cancer.fi/english/?x22567552=27328166
Osteoporosis Consultation Panel Meeting, 10 November, Nyon.
65

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Numb
Figur
er of diagnostic sc e 2‑6 — Number of diag
anners in the EU
nostic scanners in the EU — ranking
No of diagnostic (hip DXA) scanners/million population
Hungary
1.1
Latvia
1.8
Luxembourg
2.2
UK (Scotland)
2.6
Lithuania
2.9
Czech Rep
2.9
Poland
3.9
Slovakia
4.1
UK**
4.7
Estonia
5.4
Spain
6.2
The Netherlands
7.2
Italy
7.5
Denmark
8
Ireland
10.1
Sweden
10.2
Recommended
10.6*
Finland
10.9
Germany
10.9
Slovenia
14.2
Malta
17.6
Austria
19.7
France
20
Portugal
24.8
Greece
26
Cyprus
29.5
Belgium
33
* Recommended No of DXA scanners put to optimal use within the public healthcare system from Kanis J.A. Johnell O.
Requirements for the management of osteoporosis in Europe. Osteoporosis Int (2005) 16:229-238
** England, Wales, Northern Ireland
Source: International Osteoporosis Foundation (2005), Osteoporosis in Europe: Indicators of progress and Outcomes from the European
Parliament Osteoporosis Interest Group and European Union Osteoporosis Consultation Panel Meeting, 10 November, Nyon.
http://www.iofbonehealth.org/publications/eu-policy-report-of-2005.html
Table 2‑4 — Reimbursement policy in the public healthcare system for diagnostic (DXA) scan
of the hip and spine and average charge for a diagnostic scan of the hip and spine combined
Reimbursement
No reimbursement
Euro
Austria
YES */**
Finland
Free of charge
Belgium
NO
Poland
10 to 15
Cyprus
YES***
Lithuania
10 to 15
Czech Republic
YES
Czech Republic
18
Denmark
YES*
Latvia
25
Estonia
YES*
Germany
30
Finland
YES*
Slovakia
30
France
NO
Hungary
32
Germany
YES*
Slovenia
33
Greece
YES*
Estonia
35
Hungary
YES*
Belgium
40
Ireland
NO
Austria
50
Italy
YES*
France
50
Latvia
NO
Luxembourg
50
Lithuania
NO
70–100 (when paid privately because of lack
UK
Luxembourg
YES*
of access in the public healthcare system)
Netherlands
YES
Italy
75
Malta
YES
Cyprus
78 (for those not eligible for coverage)
Poland
YES****
Ireland
80
Portugal
YES
Spain
90
Slovakia
YES
Netherlands
100
Slovenia
NO
Portugal
100
Spain
YES
Greece
104
Sweden
YES
188 (covered by healthcare. Patients cannot pay
Denmark
UK – England, Wales,
for examinations performed in a public hospital)
YES
Northern Ireland
Malta
190
UK – Scotland
YES
Sweden
335
* With restrictions;
** Varies by region;
*** Extent of reimbursement depends on the individual’s income;
**** Only as part of consultation
Source: International Osteoporosis Foundation (2005), Osteoporosis in Europe: Indicators of progress and Outcomes from the European
Parliament Osteoporosis Interest Group and European Union Osteoporosis Consultation Panel. Meeting, 10 November, Nyon.
http://www.iofbonehealth.org/download/osteofound/filemanager/publications/pdf/eu-report-2005.pdf
66

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2. Gender differences in access to healthcare
2.1.3. General treatment
Gender differences in the use of healthcare
services
This section focuses on general treatment provisions
where gender differentiation is clearly detectable, such
Generally women are more aware of their health
as treatment for reproductive care and for gender-
status and are more frequent users of healthcare
specific diseases and health risks, as, for example,
services than men, due to their reproductive role,
treatments for eating disorders, sexually transmitted
their role as caregivers for dependants (children,
diseases, breast and cervical cancer, home accidents
the elderly, the disabled), their higher number
and domestic violence. Treatment provisions for other
among the older population and also due to gender
health issues which present gender differences in
stereotypes, since men usually do not consider it
terms of the extent and form of the health risks are
normal to complain about their health and visit
also considered, such as health and mental disorders,
physicians.
heart and cardiovascular diseases, work-related
illnesses and age-related illnesses.
Men and women show different patterns in the types
of health services they use. Overall, women are more
The issue of general treatment is considered in a
likely than men to make use of preventive services.
threefold manner: description of the difference
Available Eurostat data relative to the year 2004 shows
between women and men in the use of care; selected
that in most European countries, women represent a
treatment provisions and their gender specificities in
higher percentage of inpatient hospitalisation and
a lifecycle perspective; and programmes to support
consult doctors more often than men (Figures 2-7 and
the access to healthcare for disadvantaged women.
2-8 and Annex, Table 2).
Figure 2‑7 — Inpatient hospitalisation of women and men during the past 12 months
(%) in some EU Member States and Iceland and Norway, 2004 (increasing order)
20
Women
Men
15
10
5
0
.
e
ia
ia
ay
y
ia
y
UK
eec
onia
alta
tvia
ep
w
ium
lands
Spain
M
man
eland
vak
Gr
Est
La
Austr
Nor
er
Ic
Romania
Cyprus
Poland
Bulgar
Belg
Slo
G
Hungar
Czech R
Nether
Source: Eurostat data based on national Health Interview Surveys (HIS round 2004: period 1999–2003).
Explanatory note: This indicator is not included in the Indicator list of the EU-level Open Method of Coordination for Social Protection and
Social Inclusion. Data refers to the number of persons (15 years and older) who were hospitalised for more than one day. Data refers to persons
living in private households and for some countries also in institutions like homes for the elderly.
67

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Figure 2‑8 — Consultation of a medical doctor during the past 12 months by women and
men (%) in some EU Member States and Iceland and Norway, 2004 (increasing order)
100
Women
Men
80
60
40
20
0
.
e
y
y
ia
ay
ia
ia
ep
tvia
alta
eec
onia
w
ium
venia
La
eland
M
vak
lands
Spain
man
Gr
Cyprus
Romania
Slo
Bulgar
Ic
Est
Austr
Nor
Finland
er
Slo
Hungar
Belg
G
Lithuania
Czech R
Nether
Source: Eurostat data on Population and social conditions, Healthcare, based on Indicators from the national Health Interview Surveys (HIS
round for 2004: period 1999–2003).
Explanatory note: This indicator is not included in the Indicator list of the EU-level Open Method of Coordination for Social Protection and
Social Inclusion. The 2004 data refers to the years 1999–2003. For most countries, the population covered consists of all persons aged 15 and
over living in private households, and for some countries also in institutions like homes for the elderly.
The share of women who declare they have consulted
individuals with lower incomes are more likely to
a medical doctor during the past 12 months varies
use primary healthcare more intensively, whereas
greatly from country to country, ranging from 94.6 %
specialised assistance tends to be underutilised (198). As
(compared to 89.4 % for men) in the Czech Republic
long as women tend to have lower income levels than
to 46.8 % in Romania (compared to 32.6 % for men).
men, these different patterns in access to healthcare
Inpatient hospitalisation rates are much lower, from
may also have a gender specificity.
18 % in Hungary (compared to 12.5 % for men) to 7.2 %
in Greece (compared to 7.4 % for men). The rates of
Education also appears to especially affect access to
inpatient hospitalisation among women compared
specialist care rather than other healthcare services,
to men are especially high in the reproductive age:
as better-educated women and men are significantly
women’s rates are much higher than men’s until the age
more likely to visit healthcare specialists than women
of 44, while in old age, men present a higher inpatient
and men with a lower level of education. According
hospitalisation rate than women in most countries
to a recent study considering data collected in nine
(Table 3 in Annex).
European countries (Belgium, Denmark, Estonia,
France, Germany, Ireland, Latvia, Hungary and Norway),
Besides age, income and education are also other
differences in accessing specialist services between
important determinants for access to healthcare for
individuals of low and high educational levels are
women and men. For similar levels of health needs,
higher for women than for men (199).
198
( ) See for instance: Urbanos, R. M. (2004), El impacto de la
financiación de la asistencia sanitaria en las desigualdades,
Gaceta Sanitaria 2004, No 18 (Supl. 1), pp. 90-5 (2004) and
London School of Economics (2007), Health Status and Living
conditions in an enlarged Europe, Monitoring Report prepared
by the European Observatory on the Social Situation — Health
Status and Living Conditions Network, London.

http://ec.europa.eu/employment_social/spsi/docs/social_
situation/sso2005_healthlc_report.pdf,
199
( ) Mielck, A., Kiess, R., Stirbu, I., Kunst, A. (2007), Educational level
and utilisation of specialist care: Results from nine European
countries, chapter 26 in ‘Taking Health Inequalities in Europe:
An Integrated Approach, Eurothine Project.’

http://mgzlx4.erasmusmc.nl/eurothine/
68

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2. Gender differences in access to healthcare
Selected treatment provisions in a life cycle
recorded and are thus left out of the statistics. Also,
perspective
the treatment of some diseases related to gendered
behaviours, such as alcohol addiction and alcohol-
Gender-specific health-related risk behaviour is
related diseases, which are predominantly — although
starting to be documented (200) and knowledge
not exclusively — a male problem, do not consider
about the necessity to provide gender-specific health
gender differences sufficiently.
treatment is increasingly diffused. However, gender
differences in most treatments are often not taken into
Health service provisions targeted specifically at men
account, apart from reproductive care (basic service
are also little recognised, even if in some countries
provisions for pregnant women and childbirth). Some
there is an increasing attention to these issues. For
other common health policies specifically addressed
example in Austria and in Norway health and resource
to women’s health include treatment of breast and
centres for men have been established with the aim
cervix cancer.
to increase knowledge on health issues relevant for
men and to provide advice on the psycho-social
The 2009 EGGSI national reports show that women
dimensions of men’s health (203).
and men are usually treated in similar ways despite
the fact that problems, resources and needs are often
Since age is an important determinant in the health
different. In many cases the knowledge utilised is
status of women and men, as in the previous sections
based on studies conducted on men, which results
on healthcare promotion and prevention the analysis
in treatment that is in some cases poorly adjusted to
of access to general treatment services is based on a
the needs of women. A recent European Parliament
life-cycle perspective.
comparative study also indicates that ‘most research
and clinical trials are done on men and extrapolated to
Treatment provisions in childhood and adolescence
women, and research on the kinds of treatment that
are best for women remains limited’ (201). In other cases,
Gender differences in access to medical treatment
different patterns of medical responses towards female
occur starting from childhood. According to a WHO
and male patients emerge in treatment, showing, for
Study in childhood (204) boys are presented to doctors
example, that the prescription of psychoactive drugs
more often than girls, while from puberty onwards,
is much more frequent among women (202).
girls seek medical care more frequently and suffer
more frequently than boys from psychosomatic
The physical, psychological and social barriers that
complaints and emotional disturbances (headaches,
prevent many women from making healthy decisions
nervousness, sleep disorders).
are often less visible and seldom addressed by health
treatment programmes and regulations. For example,
In some countries specific programmes have been
there is usually little recognition of gender specificities
implemented for the treatment of eating disorders and
in the treatment of some pathologies such as: heart
sexually transmitted diseases which particularly affect
diseases, sexually transmitted diseases, mental
girls, while specific healthcare centres for adolescents
disorders, or work-related illnesses and of the long-
have been set up in only a few European countries.
term consequences on women’s health of violence
An example is the NGO ‘Friends of the adolescents —
and abuse. Regulations regarding health and safety
centre for the prevention and healthcare of adolescents
in the workplace usually do not cover housework
(KEPYE)’ set up in Greece in 2006 within the University
and serious domestic accidents are not regularly
of Athens (205). The centre provides advice, diagnosis,
200
( ) See for instance European Parliament (2007), Discrimination
against women and young girls in the health sector, Directorate-
General Internal Policies, by the European Institute of Women’s
Health, Brussels.




http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
203
( ) In Austria the Männergesundheitszentrum (M.E.N),

201
( ) European Parliament (2007), Discrimination against women and
http://www.men-center.at/


young girls in the health sector, Directorate-General Internal
and in Norway the Ressurssenter for Men.

Policies, by the European Institute of Women’s Health, Brussels.
http://www.reform.no/index.cfm?kat_id=11
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
204
( ) Kolip, P. And Schmidt, B., Gender and Health in Adolescence,
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
Health policy for children and adolescents (HEPCA), series No 1.
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
Copenhagen, WHO (1999).
202
( ) Velasco Arias, S. (2008), Recomendaciones para la práctica del
205
( ) European Institute of Women’s Health — EIWH Greece Country
enfoque de género en programas de salud, Observatorio de
Reports to the European Parliament, 2006.


Salud de la Mujer, Ministerio de Salud y Consumo, Madrid.
www.eurohealth.ie/countryreport/word/greece.doc
69

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
preventive and curative treatment to adolescent
also an increasing phenomenon. The proportion of
girls for eating disorders, sexually transmitted
women who are obese is usually lower than men, but
diseases [such as condyloma virus infections (206)],
among 13 year olds, obesity is higher in girls than boys
pregnancy and abortion, menstruation difficulties,
because girls are less involved in sports and physical
cervical inflammations. The centre’s staff is trained in
activities (209). Being overweight during adolescence
adolescent medicine and healthcare, and the opening
compromises long-term health, and is associated
hours, contacts and interviews are organised so as to
with coronary heart diseases, arteriosclerosis (210) and
meet adolescents’ needs (207).
colorectal cancer.
Healthcare for sexually transmitted diseases
While in many western EU countries there are
specialised clinics or medical centres for treating these
As discussed in the first chapter, women (especially
disorders, in eastern EU countries, the healthcare
young women) are more vulnerable to sexually
provision for eating disorders is still underdeveloped,
transmitted diseases compared to men and the
even if the necessity to establish specialised care is
consequences are more serious for them. Since many
increasingly recognised.
sexually transmitted diseases are asymptomatic in
women, they often go untreated and this represents
For example, in Bulgaria the National action plan
a risk factor for HIV.
on food and nutrition and the National programme
and action plan on mental health have some targets
In some European countries there are programmes
directed to reducing anorexia and bulimia. The
monitoring and treating sexually transmitted and other
Ministry of Health is planning to establish special
communicable diseases. An example is the National
sectors in psychiatric hospitals and to develop
programme for communicable diseases implemented
specialised standards and programmes for treating
in Romania, which aims at monitoring and controlling
eating disorders (211).
communicable diseases such as HIV/AIDS, tuberculosis,
hepatitis, etc. The programme is aimed at the
In Slovenia the Clinical department for mental health,
identification and treatment of infected individuals,
which is part of the Psychiatric Clinic in Ljubljana, is
early diagnosis/treatment and follow-up of infected
specialised in the treatment of adolescent psychiatry,
cases. Across the country, different district public
eating disorders, crisis interventions, psychotherapy,
health authorities, hospitals and providers of primary
and alcohol abuse (212).
assistance and research institutes are involved (208).
An interesting programme aimed at increasing
Healthcare for eating disorders
knowledge about eating disorders is the Swedish Riksät
(National Quality Registry for Specialised Treatment for
Eating disorders, such as bulimia and anorexia, are
Eating Disorders) programme which was created in
more likely to affect teenagers and young women
1999 in order to collect data, increase knowledge and
rather than men (even if cases are becoming more
reduce both personal suffering and costs. In 2007, 64
frequent among young men). Knowledge about
clinics reported data to Riksät. From 2003 to 2007, 5 396
eating disorders is still limited and the percentage of
new treatments started with adolescents and young
people with eating disorders is unknown. Obesity is
women as main beneficiaries (213).
209
( ) European Institute of Women’s Health (2006), Discrimination
against Women and Girls in the Health Sector, Brussels.

http://www.eurohealth.ie/countryreport/pdf/euparlcountryrep.pdf
210
( ) Arteriosclerosis is a condition where arteries become thick,
blocked and inelastic as a result of a film of fat (atheromas)
206
( ) Condyloma refers to an infection of the genitals caused by a
forming on their walls. It hinders effective blood circulation
virus called human papilloma virus (HPV), which can affect
depriving the body organs of oxygenated blood.
both men and women. It is also known as: wart, genital
Source: http://arteriosclerosis.org/
wart, venereal wart, which can be transmitted during sexual
211
( ) European Institute of Women’s Health, 2006, Discrimination
intercourse. Infection with HPV is very common, although the
against Women and Girls in the Health Sector, Brussels.

majority of people have no symptoms (asymptomatic).

http://www.eurohealth.ie/countryreport/pdf/euparlcountryrep.pdf
Source: http://www.condyloma.org/main.html
212
( ) Psihiatricna Klinika Ljubijana.

207
( ) European Institute of Women’s Health (2006), Discrimination
http://www.psih-klinika.si/index.php?id=113/
against Women and Girls in the Health Sector, Brussels.

213
( ) Riksät (2008), Nationellt kvalitetsregister för ätstörningsbe-
http://www.eurohealth.ie/countryreport/pdf/euparlcountryrep.pdf
handling, Rapport 2006–07.



208
( ) The Romanian Ministry of Health-Programmes 2008.

http://www.kpvcentrum.se/register/riksat/arsrapport_2006-2007.pdf
70

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2. Gender differences in access to healthcare
Treatment provisions in reproductive age
Box 2‑9 — Good practice examples
Gender-specific health treatment in reproductive age
in the treatment of cardiovascular
mostly involves care services for pregnant women
diseases (CVD)
and childbirth, the treatment of specifically female
diseases such as, for example, breast and cervical
Treatment of CVD — the Swedish Go Red
cancer and the treatment of domestic violence. In
campaign
the other cases, health treatment is usually gender
The Go Red campaign was initially started in 2004 by the
neutral, even if women and men present differences in
American Heart Association (217). In Sweden the Heart–
symptoms and outcomes. This is the case for example
Lung Foundation promotes the campaign in cooperation
in the treatment of heart and cardiovascular diseases,
with 1.6 million sports clubs and the Swedish Society of
mental health and addiction, work-related diseases.
Cardiologists. The main objective is to raise awareness
and funds so as to secure future research on the female
Heart and cardiovascular diseases
heart, necessary for equal treatment of heart disorders.
During the 2009 campaign, the programme collected
This is an area where usually general treatment is
SEK 5 million (218) to finance two research positions to
considered gender neutral, but where sex- and gender-
increase knowledge on the female heart (219).
based differences in detection rates, medication
The Icelandic Association of Heart
treatment and survival rates have been observed (214).
Patients, Hjartaheill
Women and men experience heart problems differently
The association, founded in 1983, runs a well-equipped
and show different symptoms, which complicates
rehabilitation centre in Reykjavík in cooperation with
diagnosis. Men appear to have a better long-term
other organisations for the treatment of heart patients.
survival rate than women.
The heart and lung training centre assists about 400
patients, providing daily rehabilitation and permanent
A European Parliament Study (215) refers to recent
physical training programmes. The main aim of the
research which suggests that fewer women than
association is to improve general health services and
men with suspected acute heart attack symptoms
social conditions for heart patients, to improve facilities
are referred for non-invasive tests and fewer are
and medical equipment in hospitals for research
recommended for further testing and treatment.
and the treatment of heart diseases and to create
proper conditions for rehabilitation. They also provide
Since women often present different symptoms than
heart patients with information on their social rights,
men, there is a higher incidence of unrecognised
e.g. taxation, financial support, insurance, pension,
myocardial infarction (216) in women than in men. Thus
medical treatment abroad. The association is actually
women treated with ‘male-based’ treatments may not
implementing a special division for women in order to
respond in the expected way and may require different
raise awareness and reach out to more women (220).
treatments. There is, however, too little knowledge
about the female heart, given that the majority of
Source: EGGSI network national report 2009 – Sweden and Iceland.
studies have been made on male hearts. Since women
have a high fatality rate associated with a first heart
217
( ) Go Red Foundation.



attack, it is necessary that women with suspected heart
http://www.goredforwomen.com.au and

attack be carefully and promptly evaluated.
http://www.1.6miljonerklubben.com/aktiviteter/gored/
218
( ) Equivalent to approximately EUR 0.5 million (August 2009).
219
214
( ) European Institute of Women’s Health (2006), Discrimination
( ) h t t p : / / w w w. h j a r t - l u n g f o n d e n . s e / K a m p a n j - - -
against Women and Girls in the Health Sector, Brussels.

kvinnohjartan-2009/om-kampanjen/
220
h t t p : / / w w w . e u r o h e a l t h . i e / c o u n t r y r e p o r t / p d f /
( ) Icelandic Association of Heart Patients, Hjartaheill.
euparlcountryrep.pdf
http://www.hjartaheill.is/index.php?option=com_content&
215
( ) European Parliament (2007), Discrimination against women
task=view&id=107&Itemid=87
and young girls in the health sector, Directorate-General
Internal Policies, by the European Institute of Women’s Health,
Brussels, p. 21.




http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
216
( ) A myocardial infarction (known more commonly as a heart
attack) occurs when the supply of blood and oxygen to an
area of heart muscle is blocked, usually by a clot in a coronary
artery. Often, this blockage leads to arrhythmias (irregular
heartbeat or rhythm) that can cause a severe decrease in the
pumping function of the heart and may bring about sudden
death. If the blockage is not treated within a few hours, the
affected heart muscle will die and be replaced by scar tissue.
Source: http://www.patient.co.uk/health/Myocardial-Infarction-
(Heart-Attack).htm
71

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
The EGGSI national reports present evidence of gender
mental health (225). According to the WHO (226), in fact
differences in treatment from heart attacks and
caregivers are frequently depressed and anxious,
coronary diseases in some European countries.
and are likely to use psychotropic medications to
treat their psychological distress due to the heavy

■
In Finland, according to recent studies, men receive
load of their care work.
more active treatment than women (221).
The seeking of help and treatment patterns for

■
In Sweden, 55 women per day die from heart
mental and psychological disorders are also gender
disease and 42 women suffer a cardiac infarction,
differentiated. Women are more likely to seek help from
yet women are not offered the same treatment as
their primary care doctor, while men are more likely
men (222). According to the Swedish Heart–Lung
to seek specialised care and are the principal users
Foundation, of four different examined methods
of inpatient care. Women are also more likely to be
of treatment, women were undertreated in 89 % of
diagnosed with depression and be prescribed mood-
the cases (223). The campaign Go Red — introduced
altering psychotropic drugs than men with identical
in March 2006 (see Box 2-9) — is an important symptoms (227). Girls are heavier medication users as
initiative for improving treatment for women
compared to boys, and these differences persist in
suffering from heart diseases, by raising awareness
adulthood (228).
on female specificities in heart disease and raising
funds for research on the female heart.
Gender differences in addiction patterns and in
mental illnesses are usually not recognised in medical

■
In the United Kingdom, men are more likely than
treatment, even if they may affect response to
women to be referred to heart specialists for surgery
treatment. For example, there is evidence to suggest
for cardiovascular diseases (CVD) and to be treated
that drugs to induce cessation are not equally effective
intensively once diagnosed, due to a cultural
for both sexes. In recent years some countries have
perception that this is a male disease (224).
promoted specific programmes for the treatment of
addiction and mental health problems targeted at
Mental healthcare and the treatment of addiction
women (229).
As discussed in Chapter 1, recent research shows that
In Iceland a hospital and detoxification clinic run by
women are twice as susceptible as men to developing
an NGO created a special detoxification treatment
depression and depression-related problems. In
programme for women in 1995 (see Box 2-10). In Spain
addition, some common mental disorders present
a programme of the Health and Social Services of the
gender specific risk factors: domestic abuse
Women’s Institute, on the basis of an agreement with
usually results in high rates of depression and
the Ministry of Health and Consumption, included a
anxiety; female single parents and retired women
project for bio-psychosocial assistance to women. This
living alone are at high risk for social isolation
programme is mainly oriented towards some aspects
and anxiety; the role overload of working women
of women’s mental health that deserve specific psycho-
with care responsibilities have further impact on
social attention by primary healthcare professionals.
225
( ) European Parliament (2007), Discrimination against women and
221
( ) Kattainen, A. et al. (2006), Coronary heart disease: from a
young girls in the health sector, Directorate-General Internal
disease of middle-aged men in the 1970s to a disease of elderly
Policies, by the European Institute of Women’s Health, Brussels.
women in the 2000s, European Heart Journal, 27(3), 296–301.
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
and Kiiskinen, Urpo, et al. (2008), Terveyden edistämisen
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
mahdollisuudet. Vaikuttavuus ja kustannusvaikuttavuus
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
[Evaluation of Health promotion opportunities — effectiveness
226
( ) WHO (2003), Key policy Issues in Long-term care, Geneva.
and cost-effectiveness], Publications of the Ministry of Social
http://www.who.int/chp/knowledge/publications/policy_
Affairs and Health 2008:1, Helsinki.
issues_ltc.pdf
222
( ) According to statistics from the NBHW, the municipalities
227
( ) http://www.who.int/mental_health/prevention/genderwomen/en/
of Sweden, the Open Comparison Registers of the County
228
( ) Kolip, P., Schmidt, B. (1999), Gender and Health in Adolescence,
Councils and national registers of heart intensive care. Source:
World Health Organisation, HEPCA series, No 1.
Hjart Lungfonden (2009), Kvinnor underbehandlas vid
229
( ) National Centre for Chronic Disease Prevention and Health
hjärtinfarkt,





Promotion Tobacco Prevention and Information (2001), Women
http://www.hjart-lungfonden.se/HLF/Pressrum/Pressmeddelanden/
and Smoking — A report of the Surgeon General, cited in:
Kvinnor-underbehandlas-vid-hjartinfarkt/
European Parliament (2007), Discrimination against women and
223
( ) This might be related to scarce research and knowledge on the
young girls in the health sector, Directorate-General Internal
female cardiovascular disease.
Policies, by the European Institute of Women’s Health, Brussels.
224
( ) Wilkins, D., Payne, S., Granville, G., Branney, P. (2008), The Gender
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
and Access to Health Services Study, Department of Health,
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
London.
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
72

---

2. Gender differences in access to healthcare
In Germany a network for depression and suicide
treatment and rehabilitation services for addicts is
addresses post-partum depression.
only open to men (230). In Malta too, a good-practice
programme aimed at reintegrating people suffering
On the other hand, according to the EGGSI expert
from mental problems back into the community after
in Cyprus the only closed facility offering long-term
years of institutionalisation is only targeted at men (231).
Box 2‑10 — Good practice examples in the treatment
of addiction and mental healthcare
The SAA National Centre for Addiction
Health and Social Services supported by the Women’s Institute
Medicine in Iceland
in cooperation with the Public Health Service of Murcia, and
assisted by an external consultant. According to the evaluation
A special treatment programme for addicted women was report of the programme, professionals have increased their
started in the city of Vik in 1995. Women can go for a four-week knowledge and capacity to address these problems, and they
treatment special y designed for them at Vik Rehabilitation have acquired greater control over their own stress. Some 77 %
Centre. They also receive support from the outpatient wards of patients have shown a noticeable clinical improvement of
in Reykjavik and Akureyri (on the north coast of Iceland) for symptoms and a reduction of medicine consumption. Some
a year after completing the treatment programme at Vik. improvements in the efficiency of the health system have
The outpatient programme includes individual interviews also been detected: greater patient satisfaction, less overuse
and a women’s support group. Since the start of this special of primary healthcare, reduction of medicine consumption,
programme for women, far fewer women drop out of and less overuse of complementary tests. The project was
treatment before the end of the programme than before. identified as a good practice by the information system
The programme has encouraged a special type of bonding ‘Practical Experiences and Initiatives in Social Cohesion’ of the
among women with alcohol and drug addiction problems project EUROsociAL, by EuropeAid (234).
resulting in the establishment of support groups for women
around the country (Kjarnakonur-Strong women), which The ‘German Network for Depression and Suicide’ is a
help to tackle the distinct types of problems and isolation widespread German network — present in more than
experienced by female patient groups (232). In addition, a 50 regions and cities — aimed at improving the knowledge
cohabitation centre for women started operating at the regarding ‘depression’ through information campaigns, to
beginning of 1996, housing 15 women at a time with room sensitise the German population on the issue, improve the care
for children who accompany their mothers. The patients system and improve the living conditions of people affected by
themselves are responsible for covering part of the costs (233).
depression. The activities of the network include information
The programme on bio‑psychosocial
campaigns targeting children and youth, the migrant
assistance for women in primary
population, or other, different campaigns, such as ‘Depression
after giving birth’ or ‘Depression of the elderly’ or ‘Depression
healthcare in Spain
at the workplace’. A pilot project implemented in Nurnberg
The main action of the programme is the provision of training in 2001, included hospitals, general practitioners, specialists,
courses for health professionals (mostly primary healthcare churches and other organisations, aimed to support people
doctors) in order to implement a new treatment model for at risk of suicide and to reduce the number of suicides through
certain unmet psychosomatic needs identified in women. an intensive information campaign. The campaign was
The programme is exclusively oriented to enhancing women’s financed by the Ministry for Education and Research for two
mental health and quality of life, although the results of the years, and is now supported by charitable donations (235).
programme have been monitored in both male and female
patients. It was implemented within the Programme on Source: EGGSI network national reports 2009 — Iceland, Spain and
Germany.
232
( ) Kjarnakonur, support groups for women and their relatives
after receiving treatment.


234
( ) EPIC databe, Eurosocial.
http://www.saa.is/islenski-vefurinn/felagsstarf/kjarnakonur/
http://epic.programaeurosocial.eu/buscador/buscar.php
233
( ) SAA, National Centre of Addiction Medicine.

235
( ) Deutsches Bündnis gegen Depression.
http://www.saa.is/enski-vefurinn/rehabilition-program/
http://www.buendnis-depression.de/
230
( ) The ‘Ayia Skepi Therapeutic Community’ is an impatient long
term (12–18 months) therapeutic community that serves
adult depended users of illicit substances. Its main aim is to
assist addicts in recognising and adopting new strategies and
therefore become able to live without the use of substances.
The programme is based on the bio-psychosocial model and
cognitive behavioural theory.



http://www.emcdda.europa.eu
231
( ) Malta National Report on Strategies for social protection and
social inclusion, 2008–10, http://ec.europa.eu/employment_
social/spsi/docs/social_inclusion/2008/nap/malta_en.pdf
http://ec.europa.eu/employment_social/spsi/docs/social_
inclusion/2008/nap/malta_en.pdf
73

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Work­related diseases
related explanation. As reported in the 2003 study by
the European Agency for Safety and Health at Work ‘if a
Regulations on health and safety at the workplace
multi-factorial work exposure is present, as in many jobs
mainly cover the risks that men are more commonly
dominated by women, the resulting disease is much
exposed to, while little consideration is given to health
less likely to be covered by industrial compensation
risks women are more likely to experience in female
arrangements, or even, if covered, it is much less likely
intensive occupations and sectors. Criteria for hard
to actually receive compensation’ (239).
work is still based on a traditional vision of heavy work
in construction and industrial sectors as masculine,
In addition there appear to be relevant barriers to
and not on work relating to service provision, care
women’s participation in rehabilitation programmes.
(children, older people) and housework. In addition,
Some studies conducted in the Netherlands (240) have
the fact that more women than men are employed in
found that fewer women than men are rehabilitated
low-paid, precarious jobs, often entailing poor working
into the workforce after a long spell of ill health; other
conditions and high health and safety risks (such
studies (241) show that women have a higher risk of
as domestic (care) work) is not recognised and paid
being diagnosed as disabled for work purposes after
domestic work is usually excluded from coverage (236).
the first year of absence due to sickness, whereas men
are more commonly provided with therapeutic support
The notion of professional illness is interpreted in a
aimed at their return to work. This also appears to be
restrictive way and numerous repetitive strain injuries
due to the attitudes of occupational health physicians
(RSI) (237) are usually dismissed by insurance schemes (238).
and of employers, who feel that rehabilitation is more
Still little attention is paid by regulations on health
important for men than for women (242).
and safety at work to work-related stress due to lack
of job security, psychological and sexual harassment.
Disabilities or diseases related to home care and the
Compensation arrangements are more likely to cover
care of dependants are usually not considered in
work-related injuries in male-dominated jobs, because
insurance schemes, and no preventive and long-term
these types of injuries have a more evident work-
care programmes are envisaged in most countries.
236
( ) Fagan, C., Burchell, B. (2002), Gender, jobs and working
239
( ) European Agency for Safety and Health at Work (2003), Gender
conditions in the European Union, European Foundation for the
issues in safety and health at work, a review, Luxembourg, p. 107.
Improvement of Living and Working Conditions, Dublin.

http://osha.europa.eu/en/publications/reports/209
http://www.eurofound.europa.eu/pubdocs/2002/49/en/1/
240
( ) Veerman et al. (2000), cit. in: European Agency for Safety and
ef0249en.pdf
Health at Work (2003), Gender issues in safety and health at
237
( ) Repetitive strain injury, also known as Cumulative Trauma
work, a review, Luxembourg, p. 106.


Disorder (CTD) and Musculoskeletal Disorder (MSD), is a
http://osha.europa.eu/en/publications/reports/209,
potentially debilitating condition resulting from repetitive,
241
( ) Houtman et al. 2002, cit. in European Agency for Safety and
forceful or awkward body movements. Workers in many
Health at Work (2003), Gender issues in safety and health at
jobs (such as those working at assembly lines, cashiers, sign
work, a review, Luxembourg.


languages interpreters) or employers using a computer (such as
http://osha.europa.eu/en/publications/reports/209
using keyboards and mouse) are especially at risk.
242
( ) Vinke et al. (1999); Cuelenaere (1997) and Doyal (2002), cit. in:
238
( ) Vogel, L., L’insoutenable légèreté du travail professionnel des
European Agency for Safety and Health at Work (2003), Gender
femmes, in Les politiques sociales ont-elles un sexe Ed. Vogel-
issues in safety and health at work, a review, Luxembourg.
Polsky E, 2001, p. 107.
http://osha.europa.eu/en/publications/reports/209
74

---

2. Gender differences in access to healthcare
Box 2‑11 — Current EU directives on health and occupational safety
The European Commission has set minimum requirements occupational diseases. It applies to all public and private
in the field of labour rights and work organisation through sectors of activities (industrial, agricultural, commercial,
specific directives for ensuring safety and health at work administrative, service, educational, cultural, leisure,
and for promoting high-quality workplaces and healthy etc.), except certain specific activities in public and civil
working environments. The legislation is related to: general protection services. The directive covers general provisions
provisions, the workplace and the protection of specific for psychosocial issues, such as violence from the public
groups of workers (such as pregnant women, young people and work organisation, stress, work-related limb disorders,
(below 18 years) or temporary workers) (243).
which are not covered by other directives.
The 1989 EU framework directive (Council Directive Directives regarding safety at work (Council Directive
89/391/EEC) (244) introduced measures (245) to encourage 89/654/EEC) (246) or personal protective equipment
the improvement of safety and health of workers at work (89/655/EEC) (247) concern the minimum level of worker
(Art. 1), by including preventive measures for eliminating safety by general obligation of a wel -equipped workstation
occupational risks due to accidents at work and and adequate personal protective equipment.
The protection of specific groups, such as women who
243
( ) European Agency for Safety and Health at Work (2003), Gender
are pregnant or recently gave birth, is guaranteed though
issues in safety and health at work, a review, Luxembourg, p. 124.
Council Directive 92/85/EEC (248), which introduces
http://osha.europa.eu/en/publications/reports/209
measures to improve the safety and health of pregnant
244
( ) Council Directive 89/656/EEC of 30 November 1989 on the
workers and those who have recently given birth. It includes
minimum health and safety requirements for the use by
requirements for identifying risky work conditions, risk
workers of personal protective equipment at the workplace
assessment and provisions for pregnant or new mothers
(third individual directive within the meaning of Article 16
regarding restrictions, such as provisions for avoiding
(1) of Directive 89/391/EEC).



contact with chemicals and other hazardous products,
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX
exclusion from night work, as well as female employment
:31989L0656:EN:HTML
rights issues, maternity leave, ante-natal examinations, and
245
( ) For instance, employers are obliged to identify and evaluate
occupational risks, to provide adequate protective and
protection against discriminatory dismissal.
preventive services, report on accidents, and to inform, consult
and train their workers and representatives on safety aspects.
Source: http://europa.eu/legislation_summaries/employment_and_
This includes, for example, the correct use of machinery
social_policy
and the means of production, use of adequate personal
protective equipment and safety devices, as well as seeing
246
( ) http://www.ueanet.com/facts2/summ/sum-89-654-en.pdf
to the fulfilment of security requirements by the workers. In
247
( ) http://www.ueanet.com/facts2/summ/sum-89-655-en.pdf
accordance with national laws and practices, the health of the
248
( ) http://europa.eu/legislation_summaries/employment_and_
workers has to be regularly monitored.
social_policy/health_hygiene_safety_at_work/c10914_en.htm
Reproductive care
care services are offered to pregnant women and
children through local health promotion programmes.
As already mentioned, most European countries offer
In addition to specialised centres and clinics, family
widespread services for reproductive healthcare.
doctors in most countries provide counselling on
In most European countries, accessing the services
family planning and contraception methods. A parallel
of gynaecologists and obstetricians is easier than
network for family planning is usually implemented
accessing other specialised services, and pregnant
by non-governmental organisations. The follow-
women usually receive medical treatment for free even
up offered by health professionals, including home
if they are not insured.
visits and health check-ups, usually provides a good
continuation of contact between the family and
In many countries (such as Norway, Hungary, Italy,
health services. Some examples of good practices are
France, Slovenia) besides healthcare at birth, maternity
presented in Box 2-12.
75

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Box 2‑12 — Good practices in maternity care services
in some European countries
In Slovenia home-care nursing is available for pregnant from worry about incontinence, sexual performance and
women and women with infants right after the birth of a future pregnancies (255). SFINX was implemented in 2000 at
child. Home-care nursing is well developed and operates the County Hospital Ryhov in Jönköping with the aim of
within local community healthcare centres. It is financed lowering III and IV degree perineal tearing to below 2 %
mainly by the Ministry of Health and the Health Insurance for all deliveries, as well as to decrease the amount of all
Institute (249).
perineal tearing to less than 5 % and to reduce the number
of assisted deliveries. In order to do this, the staff received
In Hungary, the Health Visitors’ services has been operating continuous education and training one to two times a
since 1915 and is based on a network of district health year and all perineal tears are analysed and documented.
visitors (usually women), who inform all families with small In 2008, only 1.3 % of all deliveries had III or IV degree
children and (young) mothers as to the benefits they are perineal tearing (256).
entitled to and support their accessibility. They pay special
attention to pregnant women and to young mothers, In Norway, municipalities are required to offer maternity
initiating social assistance when needed, and placement care through local programmes providing follow-up visits
in shelters for expectant mothers. They also initiate child by health professionals, including home visits and health
protection measures by providing prophylactic care (250) and check-ups. This facilitates a continuing contact between the
all mandatory inoculations and they guarantee continuous family and health services (257).
health and social monitoring. Activities include visits to
families, ongoing care for pregnant women and families with In Bulgaria the Maternal health programme guarantees
children, as well as measures for preventing, recognising, free access to systematic healthcare from the beginning
and eliminating health problems and mental and social of the pregnancy until 42 days after delivery. Women and
risks. Since the Health Act of 1997, health visitors have been adolescent girls are the main targets, but access is still
included within the primary care framework (
problematic in remote rural areas (258).
251).
In Sweden, the SFINX (
In the Czech Republic, since 2005 the Freedom of choice
252) programme is aimed at reducing
perineal tearing (
programme (Možnost volby) (259) has aimed at mapping the
253). The percentage of deliveries with third
and fourth degrees of perineal tearing has increased (
main critical points of the current maternity care system and
254)
from approximately 1 % in 1990 to 4 % in 2004, with over designing viable reforms. The project is divided into three
3 000 women affected each year. Possible reasons are the stages: the first stage was mapping the existing system of
increased number of assisted deliveries and the increased natal care, with particular focus on care during physiological
size of the babies. Most women recover and do not suffer pregnancy, childbirth and puerperium. These results are
from permanent damage, but they still suffer emotionally summarised in the ‘Report on the current status of obstetric
care in the Czech Republic.’ (260) The second stage is focused
on the comparison model of natal care in the Czech Republic
and in selected EU countries. In the third phase the current
249
( ) Slovenian Ministry of Health,

http://www.mz.gov.si/en/
system of maternity care in the Czech Republic will be
and Slovenian Health Insurance Institute.

analysed and changes will be proposed.
http://www.zzzs.si/zzzs/internet/zzzseng.nsf
In France the National Perinatal Plan 2005–07 (261) is aimed
250
( ) The basic meaning of prophylactic is to prevent or protect from.
at reducing maternal mortality from 9 to 5 per 100 000 and
Prophylactic treatment, then, is an approach to preventing
a disease or condition before it affects a patient. This might
perinatal mortality from 6.5 to 5.5 per 100 000, by improving
include, for example, vaccination and regular controls.
251
( ) Hungarian Government (2004), National Action Plan on Social
255
( ) SKL and Socialstyrelsen (2008), Quality and Efficiently in
Inclusion, Hungary, 2004–06, drafted by the Committee to
Swedish Health Care, Regional Comparisons 2007, Stockholm.
combat social exclusion.



256
( ) Dagens Medicin, Målmedveten satsning mot bristningar gav
h t t p : / / w w w. s t o p c s b e . h u / d o w n l o a d . p h p ? c t a g = -
resultat.




download&docID=14303
http://www.dagensmedicin.se/nyheter/2008/08/26/
252
( ) Boij, R., et al. (2008), Aktivt perinealskydd förebygger
malmedveten-satsning-mot-b/index.xml
sfinkterskador, Stockholm.



257
( ) Norwegian Directorate of Health (2008), Health creates welfare
h t t p : / / w w w . s f o g . s e / p r e s e n t a t i o n e r _ s f o g v 0 8 /
— the role of the health system in the Norwegian Society.
Perinealskydd%20boj_Roland%20Boij.pdf
http://w w w.helsedirektoratet.no/vp/multimedia/
253
( ) Perinatal tearing means that — when giving birth — the
archive/00062/Health_creates_welfa_62299a.pdf
perineum may tear or the caregiver may decide it should be
258
( ) Eurohealth (2006), Country report on Health care, Bulgaria.
cut to make a wider opening for the baby’s head, a procedure
http://www.eurohealth.ie/countryreport/word/bulgaria.doc
called an episiotomy. Tears are more common in women
259
( ) Aperio, Healthy parenting association.
having their first vaginal birth and range from small nicks and
h t t p : / / w w w . a p e r i o . c z / p o r o d n i c t v i / p r o j e k t y .
abrasions to deep lacerations affecting several pelvic floor
shtml#moznostvolby
muscles, See: Online Medical Library.


260
( ) Mrzílková Susová, I. (2005), Zpráva o stávajícím stavu
http://www.merck.com
porodnické péče v České republice 2004 [Report on the
254
( ) Boij, R, et al. (2008), Aktivt perinealskydd förebygger
current status of obstetric care in the Czech Republic], Praha.
sfinkterskador.




261
( ) Col et, M. (2008), Satisfaction des usagères des maternités
h t t p : / / w w w . s f o g . s e / p r e s e n t a t i o n e r _ s f o g v 0 8 /
à l’égard du suivi de grossesse et du déroulement de
Perinealskydd%20boj_Roland%20Boij.pdf
l’accouchement, Etudes et résultats, Drees, No 660, September.
76

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2. Gender differences in access to healthcare
the quality and security of maternity care. Another aim is to services for new-born babies. The programme offers health
improve pregnancy monitoring through interviews before prevention interventions for prophylaxis, screening for the
and after childbirth.
early diagnosis of birth defects, prenatal and postnatal
services, check-ups and testing for HIV and syphilis, as well
In Poland, the Decent Birth Giving campaign (262) is aimed as the provision of powdered milk free of charge. Teenage
at improving the quality of care and medical services mothers are specific targets of the programme.
at maternity clinics and obstetric wards. The campaign
was launched in 1994 by a newspaper and has received In the UK postnatal depression prevention intervention was
considerable feedback and support. Friendly maternity carried out in primary care. Health visitors (nurses) were
clinics are nominated and a Foundation with educational trained in the clinical assessment of postnatal depression
and promotional goals was created in 1996.
in order to offer psychological intervention sessions to low-
risk women. Evaluation studies report a 32 % reduction in
In Romania the National Programme for Mother and Child the numbers of new episodes of depression in mothers (264).
Health (263), implemented in 2004 but based on a precedent
programme from 1993 onwards, aims at decreasing Source: EGGSI network national reports 2009. For the UK case:
maternal mortality by improving the quality and efficiency European Commission (2008), Prevention of Depression and Suicide,
of maternity care and supporting intensive therapy Consensus paper prepared by Wahlbeck, K. and Makinen, M.,
Luxembourg.
262
( ) http://www.rodzicpoludzku.pl
263
( ) The Romanian Ministry of Health — Programmes in 2008.
264
( ) Wahlbeck, K., Makinen, M. (2008), Prevention of depression
http://www.ms.ro/fisiere/programe_nationale/17_51_520_
and suicide, Consensus paper, European Commission,
anexa_2-30.03.doc
Luxembourg.
However, some recent trends described in the EGGSI
limited access to information on the importance
national reports may have negative effects on women’s
of monitoring pregnancy and how to care for
access to reproductive care and the quality of treatment
themselves during this period.
they receive. The following present some examples.
Abortion remains a particularly controversial issue for

■
In some countries (such as Italy and Poland), as a
public health services in many countries. According
result of the restructuring of the health sector (in
to a recent survey on abortion legislation in Europe
Italy) and the increased quality standard in service
carried out by the by the IPPF European Network (267),
delivery (in Poland), in recent years there has been
the provision of services varies greatly in the different
a decrease in the number of clinics and health
European countries.
services available to women. This especially affects
decentralised and rural areas, where delivery rooms

■
For example, in many countries, such as Poland,
and maternity wards in small hospitals and clinics
Cyprus, Belgium, Italy, France, Luxembourg and
have been closed.
Portugal, legislation allows for abortion in specific
cases, usually when pregnancy constitutes a threat

■
In Greece, caesarean sections in childbirth are much
to the life or the health of a pregnant woman. In
more frequent than in other European countries,
these countries, if the pregnancy is not considered
representing 52 % of all childbirths, due to the
a ‘threat to the woman’s health’, access to (legal)
financial reimbursement system applied in this
abortion may be denied. In addition, abortion is only
country (265).
rarely performed free of charge in public hospitals,
and women may also face conscientious objection

■
In Romania a high number of deliveries occur
by health personnel and long waiting lists. In the
at home, often without medical assistance and
private health sector, on the other hand, abortion
appropriate prenatal care (266). It is estimated that
services are usually routinely provided, often upon
as many as half of maternal deaths occur due to
the woman’s request. In Cyprus, abortion is only
obstetrical risks and that nearly half of the pregnant
available through private physicians at a relatively
women who die during delivery have not received
high price, which makes it particularly difficult for
prenatal care. Women from poor communities
women from lower income groups, as well as migrant
(including the Roma and immigrant women)
women, to have recourse to the procedure.
or women living in rural/isolated areas have

■
In some European countries (like Ireland), abortion
is strictly regulated and not covered by the state
265
( ) Mossialos, E., Allin, S., Karras, K., Davaki, K. (2005), An investigation
insurance, so that women travel abroad. In Austria
of Caesarean sections in three Greek hospitals: The impact of
financial incentives and convenience, European Journal of
Public Health, 15 June: pp. 288–295.
267
( ) IPPF (2007), Abortion legislation in Europe, International
266
( ) European Observatory on Health Systems and Policies (2008),
Planned Parenthood Federation European Network.
Healthcare systems in transition, Vol. 10, No 3, Romania Health
http://www.ippfen.org/en/Resources/Publications/
System Review, p. 112.
Abortion+Legislation+in+Europe.htm
77

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
abortion is legal, but not covered by public health
cancer-related surgery due to the lack of personalised
insurance and difficult to access in the western and
care in the public sector. For example, patients are not
rural areas of the country.
able to choose their physician and may be treated by a
different doctor depending on availability.

■
In other countries (such as Bulgaria, the Czech Republic,
Denmark, Hungary, Iceland, the Netherlands, Norway,
The EGGSI national reports provide the following
Spain, Sweden, the UK – except for Northern Ireland),
examples of oncological care, paying specific attention
abortion services are freely accessible and free of
to women’s needs:
charge under certain conditions concerning the stage
of pregnancy and are also available to girls under
In Bulgaria specialised territorial units (Regional
18 years of age with the informed consent of one
Dispensaries for Oncological Diseases) provide
of the parents. Non-residents are, however, usual y
integrated care to cancer patients. Breast cancer
excluded from access to free abortion services, except
patients receive treatment and care at all the stages of
for spontaneous abortions.
the disease and all costs are covered by the national
health system.

■
In Finland, Estonia, Latvia, Lithuania and Slovakia,
women have to pay part of the costs (either the
In Greece the ‘Everybody Pink’ programme has
hospital fees or a quota of total costs).
provided psychological support to women with breast
cancer through a dedicated telephone line since 2006.

■
In Romania, where contraceptive use remains
The programme is promoted by the Greek Association
low (only 23 % of women and men use modern
of Women with Breast Cancer and is co-financed by
contraceptive methods and only 10 % of persons
Roche Pharmaceuticals. In the 2007–08 period, over
aged 15 to 49 use condoms) (268), the high rate of
1 200 calls were registered.
abortion indicates that many women still use this
method as a substitute for contraception.
Treatment for domestic violence
Oncological care
In some European countries there is increasing
recognition of domestic violence as a source of physical
As previously discussed, in most European countries
and mental illness among women and children and
there is a wel -developed system of screening and
special healthcare treatment services have been
treatment for breast and cervical cancer, while for other
implemented. Specialised training has been provided
cancer typologies, which are considered men’s diseases,
in some cases to general practitioners (GPs) and
women tend to face higher barriers in accessing
emergency room personnel in order to increase their
oncological care. For example, a recent Spanish study (269)
awareness regarding the physical or mental complaints
showed that in the case of colorectal cancer (270), women
of women, victims of partner abuse or domestic
are less likely than men to be readmitted to the hospital, violence.
even after a check-up for tumour characteristics,
mortality, and co-morbidity (271).
As shown in the good practices examples described
in the box below, in many countries special initiatives
In some cases even accessing treatment for breast
have been put into effect to strengthen the quality of
cancer is becoming more difficult. For example in
public health services in treating sexually and physically
Cyprus, despite free availability through the public
abused children and women. Greater awareness of
health services to all cancer patients, there has been
domestic violence within all kinds of public services,
an increase in the use of private services for breast-
including health and medical services is emphasised.
268
( ) European Observatory on Health Systems and Policies (2008),
Healthcare systems in transition, Vol. 10, No 3, Romania Health
System Review, p. 112.
269
( ) González, J.R., et al. (2005), Sex differences in hospital readmission
among colorectal cancer patients, Journal of Epidemiology and
Community Health 2005, No 59, pp. 506–511.
270
( ) Colorectal cancer can begin in either the colon or the rectum.
Cancer that begins in the colon is called colon cancer, and
cancer that begins in the rectum is called rectal cancer.
271
( ) Other studies also indicate that women are less likely to be
screened, as colorectal cancer is considered a men’s disease. See
for example: Stewart, Susan C. (1999), Screening for Colorectal
Cancer in Women: Not Just a Man’s Disease.
78

---

2. Gender differences in access to healthcare
Box 2‑13 — Good practices in the treatment of women victims of domestic
violence and abuse
The Memosa programme (272) in the Netherlands was the itinerant treatment of women who have experienced
promoted in 2006 by the regional public health authority violence (274).
of Rotterdam-Rijmond, together with the Medical Faculty
of the Radboud University Nijmegen (Women’s Studies). In Norway, the recent action plan against domestic violence
Ten mothers with children in the area of Rotterdam were 2008–11 (275) emphasises the importance of acknowledging
trained as mentors to support other young mothers at-risk groups of women who are less likely to seek help in
with children suffering from partner abuse and living in case of domestic violence, such as disabled women, women
isolated situations. For up to 16 weeks, mentors made with poor language skills, women that have been in Norway
weekly home visits to pregnant women and mothers of for a short period and women with poor integration in
children up to 12 years old who suffered abuse or were the labour market. Women with a history of drug abuse or
at risk of abuse, to promote professional support for women with mental health problems are also considered at
depression, prevention of partner abuse and general risk. The central goal of this new action plan is to offer all
health and mother-child relations. The main target group women that have experienced domestic violence a secure
was informed and supported to adequately respond to and independent life-situation. A crisis centre for women is
the threat of domestic violence and positively influence going to be implemented. Training will also be provided for
the behaviour of the abuser. This decreased the chances the personnel at the women’s crisis centre to address special
that the threat could turn into real domestic violence. In needs for disabled women, women with a history of drug
some cases, the abuser asked for the advice and support of abuse and women with poor language skills (276).
the mentor and was subsequently referred to the mental In Spain the Women’s Institute has promoted a new Protocol
health sector. In addition, the programme provided for the detection of domestic violence cases, which was
specific training to 25 general practitioners in order set up in various regional administrations, together with
to recognise and cope with cases of domestic violence training courses for health professionals, in order to acquire
and partner abuse and to cooperate with local support a better understanding of the physical and psychological
organisations. The programme evaluation showed high evidence of this phenomenon.
participation rates of women of ethnic background.
Despite the overall low number of participants, the In Iceland, the Emergency reception for victims of rape was
outcomes were significant: partner abuse was reduced established in 1993 at Landspitali Hospital in Reykjavik in the
by 50 %; complaints about depression were reduced Crisis Centre. It is staffed by professionals who have expert
by 37 %; and the mentors indicated an improvement of knowledge and special training in treating people who
their social support network. Furthermore, the mentors have experienced a sudden major crisis, like the suicide of
reported in over 55 % of the cases that their support in a loved one, natural catastrophes, serious accidents, house
(domestic) education turned out very positively and fires, etc. The Emergency unit for victims of rape recruits
helped to improve the family situation. In some cases, the specialised professionals to treat this particular group
partner/father asked the mentor for supportive advice.
of patients, offering appropriate services not only to the
victims but also to the abusers. The programme consists of a
In Germany the Signal intervention project to end medical examination upon arrival by a medical doctor, and
violence against women (273) was started in 1999 in the a more comprehensive interview by a nurse and a medical
emergency room of the Benjamin Franklin University doctor specialised in legal medicine. This is followed up by
Hospital of Berlin. It provides abused women with support psychological treatment, support and rebuilding of self-
and treatment. Nurses and physicians have been trained awareness and assertive training provided in 10 individual
to identify violence and inquire on abuse, to document sessions. Finally, the patient is appointed a legal adviser/
injuries and health problems for use in legal proceedings, lawyer who will follow her throughout and take care of all
to develop a health plan and to inform and refer victims the necessary procedures involved in the process of the
to counselling programmes and women’s shelters. judiciary system in the event that legal action is undertaken.
The project has shown the importance of emergency This service is free of charge for the victims. The great
departments as first contact points for women who majority of the users are female, but a growing number of
have been victims of abuse and violence. Since 2008,
this project is also active in the German region Baden–
274
( ) The project has been implemented in Baden-Wuerttemberg in
Württemberg and has implemented a programme for
2008, supported by the Ministry of Labour and Social Affairs,
See: Pflegebrief (2008), Signal — Intervention gegen häusliche
Gewalt, Modellprojekt in Baden-Württemberg, 18.07.2008.
http://pflegen-online.de/nachrichten/aktuelles/signal-
272
( ) ZonMw — http://www.zonmw.nl/
intervention-gegen-haeusliche-gewalt.htm?nlp=20080723
273
( ) European Parliament (2007), Discrimination against women and
275
( ) Ministry of Justice and the Police (2004), Action Plan Domestic
young girls in the health sector, Directorate-General Internal
violence (2004–07), Norway. http://www.regjeringen.no/
Policies, by the European Institute of Women’s Health, Brussels.
upload/kilde/jd/reg/2004/0028/ddd/pdfv/227003-action_
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=
plan_domestic_violence_2004_2007.pdf
42D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//
276
( ) Ministry of Justice and the Police (2007), Vendepunkt,
EP//TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
Handlingsplan mot vold i nære relasjoner 2008-2011, Norway.
see also: Bundesministerium für Gesundheit —

h t t p : / / w w w. re g j e r i n g e n . n o / u p l o a d / J D / Ve d l e g g /
http://www.bmg.bund.de/
Handlingsplaner/Vendepunkt.pdf
79

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
males are now among the users. Research indicates that the In some European countries, the project Formation des
number of male victims of sexual crimes or violence might professionnels de santé à la violence conjugale (279), funded
be higher, since male victims might find it more difficult to by the Daphne Initiative in 1999, aims at improving the
seek help (277). Therefore, in order to reach and to address treatment of women suffering from domestic violence
problems of access due to gender differences, the staff gives by providing working and training tools for healthcare
lectures, speaks at conferences and runs seminars for health workers. Partners of the project were health professionals
and social care professionals. Clinical guidelines addressing and members of aid organisations from France, Spain,
gender differences are now being developed. Since many Portugal, Italy and Belgium, which took advantage of
of the victims are children under 18, the team has had to interactive Internet to provide information on practical
mobilise a wide range of professional social networks (278).
advice, detention and medical care for female victims and
their children and practical information, such as guidance
277
( ) Tryggvadóttir, A.B. (2008), Eðli og alvarleiki kynferðislegs
towards other, non-medical assistance.
ofbeldis hjá þolendum sem leita til Neyðarmóttöku LSH:
Er munur á áfengis- og/eða vímuefnatengdu og öðru
Source: EGGSI network national reports 2009
kynferðislegu ofbeldi?, University of Iceland, Social Sciences
Department.
279
( ) European Commission, Daphne Report, Illustrative case No 19
278
( ) Agnarsdóttir, G., Skúladóttir, S. (1994), A New Rape Trauma
on domestic violence.




Service at the Emergency Department of the Reykjavik City
http://ec.europa.eu/justice_home/daphnetoolkit/files/
Hospital, Arctic Medical Research, Vol.53, Suppl.2., pp. 531–533.
others/illustrative_projects/19_domestic_en.pdf
Treatment provisions for the elderly

■
In Bulgaria (282) the ‘Treatment of osteoporosis with
a pathological fracture programme’ involves only
Women live longer than men and, thus are more
menopausal women with osteoporotic fractures. The
likely to be affected by age-related illnesses and
National Health Insurance covers the cost of diagnostic
disabilities. From the scattered research and
and treatment procedures, the specialist’s fol ow-up
data available, it appears that older women are
exams and part of the cost of the medication. However,
more affected than men by chronic ailments and
for women not in the programme, the treatment
psychological disorders (especially those which
costs are not covered by the state and remain largely
increase with age, such as sleeping disorders and
unaffordable. To overcome these problems, a National
anxiety problems) (280), but they usually receive
programme for the limitation of osteoporosis (2006–
less treatment than older men, even if they rely
10) was launched, to make osteoporosis one of the
more often on institutional care than men do (see
priorities of Bulgarian health policy. The main target
Chapter 3 on Long-term care).
groups are menopausal, pregnant and breastfeeding
women. A national network of 56 specialised centres
As anticipated in previous chapters, menopause and
has been set up for prevention, screening, diagnosis
osteoporosis are treated as women-specific diseases
and treatment. However the financial resources for
in old age. However, not all European countries have
this programme have not been set.
specific treatment programmes, and in some cases
discrimination against men has been reported. This

■
In Denmark a specific healthcare programme
is the case in Belgium where reimbursement for
is aimed at the elderly over 75 years old. The
osteoporosis medication was until recently exclusively
programme provides home visits by specialists who
reserved to women. The situation changed after various
assess the elderly persons’ needs, inform them of
legal actions leading to a man affected by the disease
their rights and help them to get the necessary care,
winning his case (281).
as well as train them in the prevention of home
accidents (283).
Specialised programmes for the treatment of
osteoporosis and other old-age-related illnesses are

■
In Hungary a national osteoporosis programme
reported in the following countries.
includes several initiatives for the prevention and
treatment of osteoporosis (284).
282
( ) European Institute of Women’s Health (2006), Discrimination
against Women and Girls in the Health Sector, Brussels.

h t t p : / / w w w . e u r o h e a l t h . i e / c o u n t r y r e p o r t / p d f /
euparlcountryrep.pdf
283
( ) Højgaard, B., et al. (2006), Evidensbaseret forebyggelse i kom-
munerne, Dokumentation af effekt og omkostningseffektivitet,
280
( ) European Institute of Women’s Health (2006), Discrimination
København, DSI.
against Women and Girls in the Health Sector, Brussels.

284
( ) http://www.harmonet.hu/cikk.php?rovat=104&alrovat=129&ci
h t t p : / / w w w . e u r o h e a l t h . i e / c o u n t r y r e p o r t / p d f /
kkid=8125 and Poor, G. (n.y.), A csontritkulás népegészségügyi
euparlcountryrep.pdf
jelentõsége, a Nemzeti Osteoporosis Program eddigi
281
( ) IEFH, informant from legal service. This is also the case for
eredményei, Society for Osteoporosis

reimbursement of medication to men having breast cancer.
http://www.konzilium.hu/csontrit/content/nop.htm
80

---

2. Gender differences in access to healthcare
Treatment provisions for disadvantaged women
Although equal access to the healthcare systems is
guaranteed in various countries, as is the right to access
Access to healthcare treatment is often difficult for
public health services in emergency situations, in some
women who present specific disadvantages, such
countries access is related to the individual’s legal and
as immigrant women and women of ethnic origin,
employment status and private health services are very
disabled women, lone mothers, prostitutes, homeless
expensive. The result is that a significant number of
women. These groups of women often need targeted
migrants and stateless groups have no proper health
programmes able to help them overcome the isolation
insurance and support. Actual y, many immigrants have
and multiple disadvantages they often suffer from.
no public health insurance due to the lack of a job or
informal employment, so they have to pay high fees for
Women of ethnic origin
private health services. For instance, in Bulgaria, ethnic
minority women are often excluded even from services
In general, the ethnic minority population, and
provided for pregnant women and their children. In the
especially the Roma population, have worse health
Czech Republic, pregnant women without legal resident
conditions than the national population, due to the
status are excluded from the public health insurance and
effects of hard working conditions, social and economic
therefore obliged to pay for the more expensive private
exclusion, lack of information and isolation (285).
health insurance, which might be denied them due to
their high risk. In Greece pregnant migrant women may
Women from an ethnic minority background usual y
experience serious financial difficulties with regard to
report ‘bad health’ to a greater extent and consider
their hospitalisation fees (287).
their health situation worse than men of the same
ethnic group and women of the majority population.
In Cyprus as in other southern European countries,
In addition, pregnancies and childbirth tend to present
immigrant women are often employed as domestic
more difficulties (286).
workers in households and often cannot take time
off and are hesitant to ask for time off for healthcare,
Differences in language, culture and religious beliefs,
especially when needing reproductive care.
practices and interpretations may lead to less effective
care for ethnic minority women. For example, Muslim
In France immigrants are often rejected by health
women, or their partners, may be reluctant or even refuse
professionals (288). However, migrant women, less often
to be treated by male medical doctors in hospitals, and
than migrant men, renounce medical consultations,
al the more by a male gynaecologist. On the other hand,
examinations or prescriptions (32 % of men declare they
healthcare workers usual y have insufficient experience
have totally renounced healthcare compared to 19 %
and training to address the cultural and religious issues
of women). Immigrant women consult healthcare for
posed by ethnic minority women. The lack of adequate
different reasons than men: pregnancy and childbirth
preparation by health professionals to adapt to these
represent 3 out of 10 consultations for women and 7
aspects reduces the accessibility of these services for
out of 10 hospitalisations, with a high frequency of risky
ethnic minority women. In most countries there is also a
pregnancies and complex childbirths (28 % of women
lack of information material in minority languages, and
hospitalised) because of precarious life conditions and
there is a need to develop interpreting and mediating
because foreign immigrant women (particularly African
services to assist ethnic minority women in hospitals.
women) consult doctors less than other pregnant
women. According to doctors, AME beneficiaries
285
( ) Corsi, M., Crepaldi, C., Samek Lodovici, M., Boccagni, P., Vasilescu,
tend to consult doctors in emergencies (15 % of AME
C. (2008), Ethnic minority and Roma women in Europe: A case
patients) after having waited until it is quite late (5 %),
for gender equality?, report prepared by the Network of experts
this is even worse in the case of hospitalisations (289).
in gender equality, social inclusion and health- and long-term
care (EGGSI network) for the European Commission, Directorate-
General for Employment, Social Affairs and Equal Opportunities.
http://ec.europa.eu/social/BlobServlet?docId=2481&langId=en;
Fagan, C., Burchel , B. (2002), Gender, jobs and working
conditions in the European Union, European Foundation for
287
( ) Based on information of the EGGSI network national reports,
the Improvement of Living and Working Conditions, Dublin.
2008 for Bulgaria, the Czech Republic and Greece.
http://www.eurofound.europa.eu/pubdocs/2002/49/
288
( ) According to the French EGGSI network national report, 2009,
en/1/ef0249en.pdf


two obstacles are reported as limiting immigrants’ access to
Fagan, C., Hebson, G., ‘Making work pay’ debates from a gender
healthcare: their own financial difficulties and the refusal from
perspective. A comparative review of some recent policy reforms in
the part of health professionals because of existing delays for
thirty European countries,Report prepared by the Group of Experts
reimbursement or because they are forced to apply basic social
on Gender, Social Inclusion and Employment for the Unit Equality for
security tariffs to these patients. More than one third of the AME
women and men, Directorate-General for Employment, Social affairs
(Medical state aid — AME) beneficiaries have experienced such
and Equal opportunities of the European Commission, Office for Official
a refusal, essentially on the part of a doctor or a chemist.
Publications of the European Communities, Luxembourg, 2005.
289
( ) Boisguérin, B. (2004), Etat de santé et recours aux soins des
286
( ) Based on information of the EGGSI network national reports,
bénéficiaires de la CMU, Etudes et résultats, Drees, No 612,
2008 for Estonia, Austria, the UK and the Netherlands.
December.
81

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
In Slovakia, immunisation has become a problem
services reach immigrant women satisfactorily. In
in poorer Roma communities living in rural areas. In
Italy and Germany, while prenatal diagnosis is usually
2005, 6.2 % of paediatric districts did not reach the
less widespread among immigrant women, social
90 % level of vaccination (290). The highest percentage
protection for pregnancy, maternity and children’s
of under-immunised districts was in the eastern part
health is usually ensured for immigrant women (291).
of Slovakia (Prešov, Košice) which suffer from the
highest unemployment levels, especially in rural areas.
The distribution of information material in different
In under-immunised districts, paediatricians have
languages and the multicultural training of health
been doing vaccination directly in Roma settlements
workers are among the actions carried out to reduce
in cooperation with municipalities. In some cases the
cultural and language barriers and facilitate the access
insufficient vaccination result depends on the low
of ethnic minority women to the healthcare system.
number of paediatricians per 10 000 inhabitants in
regions with high demand for paediatric services, the
Some projects, on the other hand, focus on specific
under-financed local hospital and health centres and
health problems, for example helping the disabled
the expensive public transport services from distant
of national minorities (Latvia), African women with
rural areas to district towns.
HIV and women who have suffered from violence or
have mental health problems (Belgium), as well as
In some countries specific programmes are aimed
women exposed to health risks having suffered genital
at immigrants. For instance, in Finland, maternity
mutilation (such as Somali women in Sweden).
Box 2‑14 — Good practices in the treatment of disadvantaged communities
The ‘Tesserino di Temporaneo Soccorso’ is a programme young (under 25) or older (55 and over) patients; nine out
implemented by the Italian region Emilia-Romagna since of 10 are foreigners, especially from Sub-Saharan Africa,
2002 to support access to healthcare treatment for illegal Maghreb and Romania (293).
immigrants, the homeless and people living in situations of
great social disadvantage. Specific attention is given to the In Slovakia, a programme aims to increase the number of
health needs of female immigrant prostitutes. Since 2002, health insurance cards issued and the sensitiveness of
10 000 persons have used this service.
outpatient doctors regarding the health problems of the
Roma, in order to attract disadvantaged communities, such
In Sweden, people of foreign background but with a as refugees and the homeless, to make use of available
residence permit have the same rights to medical care as healthcare. Community workers carry out outreach training
people born in Sweden. All children in Sweden have the in health education, disease prevention, maintaining
right to health and medical care including those seeking healthy lifestyles and distribute health education
asylum or who are in hiding (292). Asylum-seeking adults have materials in selected Romani settlements. The programme
the right to a health conversation/medical check-up and the supports the cooperation of the 30 Community workers
right to ‘immediate health and medical care which cannot with schools, field social workers and doctors (general
wait’, if the doctor deems it is necessary if the injury or illness practitioners for adults, general practitioners for children
is life threatening or may lead to serious permanent injury and adolescents, gynaecologists, dentists) together with
if untreated. If a person is in great pain, she/he may also municipal authorities, health insurance companies and
receive care. If a woman is pregnant, she will receive free non-governmental organisations. Due to the involvement
maternity care. If a woman so chooses, she has a right to an of different groups, the disadvantaged groups are expected
abortion as well as contraceptive advice services which are to be better reached (294).
free of charge. There are two reception offices available for
asylum-seeking adults in the Stockholm region.
Source: EGGSI network national reports 2009 — Italy, Sweden, France
and Slovakia.
In some areas of France, Médecins du monde (MDM)
provides free healthcare to socially disadvantaged and
excluded people and to illegal immigrants in particular.
293
( ) Boisguérin, B., Haury, B. (2008), Les bénéficiaires de l’AME en
There are 31 free medical centres managed by the
contact avec le système de soins, Etudes et résultats, Drees,
association, one in Paris and others in different towns.
No 645, July.
294
Women represent an increasing proportion (45 %) of the ( ) Based on the report of the European Commission (2007), Social
patients consulting the MDM centres, they are mostly quite
Determinants of Health in the Slovak Republic: A Case Study,
Report prepared by the Expert Group on Social Determinants
and Health Inequalities.


http://ec.europa.eu/health/ph_determinants/socio_
292
( ) Vårdguiden, Stockholms läns landsting.
economics/documents/slovakia_rd01_en.pdf
290
( ) Kusá, Z. et al. (2007), Tackling child poverty and promoting the
social inclusion of children, a Study of National Policies, Institute
for Sociology of the Slovak Academy of Sciences, Bratislava.
http://ec.europa.eu/employment_social/spsi/docs/social_
291
( ) EGGSI network national reports 2008, for Finland, Italy and
inclusion/experts_reports/slovakia_1_2007_en.pdf
Germany.
82

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2. Gender differences in access to healthcare
Disabled women
presented in a recent report by the Irish National
Disability Authority (297).
Women with disabilities are particularly vulnerable to
inequalities in the health system, despite their being

■
In Great Britain, in some hospitals there are special
usual y eligible for free public healthcare. Women with
needs advisors in maternity wards which help in
disabilities, including hearing and sight impairment as well
identifying disabled women’s needs and assess
as physical disabilities, are more at risk of poverty and social
any possible restrictions facing pregnant women
exclusion due to the lack of education and employment
with disabilities. In addition, Maternity Alliance has
opportunities, physical and social barriers, dependence on
produced guidelines for disabled mothers and for
carers, among other reasons. There is very little research
health practitioners to improve the care of disabled
and information on the needs of and healthcare services
women during pregnancy and after childbirth (298).
received by disabled women in European countries.

■
In Ireland the Health Service Executive (HSE)
The situation in Cyprus is indicative of a more generalised
provides a counselling nurses service offering
situation. Representatives of associations and
support to disabled mothers with home visits and
organisations representing disabled people report a lack
referral to other agencies and organisations of
of specialised health personnel in public health centres
home support service.
and hospitals, and difficulties in access to information
on family planning and sexual and reproductive health,

■
In Belgium: Tof Service provides domestic assistance
resulting in the reduced provision of primary and
to mothers with disabled children.
preventative care (such as breast cancer screening,
Pap tests, etc.). For example, representatives of the

■
In Sweden there is an assistance service for the disabled
Pancyprian Organisation for the Deaf report that there
where it is the disabled person who chooses the
are no interpreters for the deaf in public hospitals and
assistant, the content and time schedule of assistance
health centres. Furthermore, representatives from the
(which may go from help in caring for children, to help
Cyprus Paraplegics Organisation state that there are no
in getting training or for leisure activities).
specialised personnel for prenatal care and that women
with physical disabilities usually undergo caesarean
Other disadvantaged groups
sections in order to avoid possible complications. In
terms of psychological support, there is no permanent Single mothers often present higher health risks than
personnel for psychological support and counsel ing for
average. They present a higher incidence of mental
women (and men) with disabilities in public hospitals,
problems than married mothers. In terms of access
and patients do not have the freedom to choose their
barriers, single mothers predominantly have the
health provider and the location of such health provider.
problem of finding time to consult a health service.
Thus, despite being eligible for free care in the public
More flexible opening hours and the possibility for
health system, women with disabilities often opt for
childcare provision during the utilisation of health
private healthcare citing privacy, personalised care, and
services are crucial factors in improving access.
choice of health provider as a priority (295).
Prostitutes are another group particularly at risk. There are
In Ireland, the National Women’s Council argue that
no up-to-date statistics on the number of prostitutes and
the rehabilitation needs of Irish women with mental
their living situations. In some European countries there
illness have been neglected and that health and
are however specific healthcare programmes targeted
social service provision needs to expand to include at prostitutes. In Austria, registered prostitutes undergo
housing for mothers with mental illness. In addition,
a regular health check-up at the local health authority.
the need for improving access for reproductive health
Since the early 1990s, a continuous decline in registered
services for women with disabilities and for disability
prostitutes and an increase in the number of il egal
awareness training among health professionals has
prostitutes has been reported. However, the situation of
been highlighted (296).
immigrant sex workers and trafficked women is particularly
precarious: they have little or no access to the regular
Some interesting programmes to support disabled
labour market and the public health system, and there
mothers or mothers with disabled children are
is hardly any information available for these women in
295
( ) This information was provided during a conference entitled
‘Women with Disabilities and Long-term illnesses: Opportunities
297
( ) National Disability Authority (2006), Exploring the research and
for access to Life’, organised by the National Machinery for
policy gaps — A review of literature on women and disability,
Women’s Rights, Cyprus Ministry of Justice and Public Order, on
Disability research series No 7. Women’s Education, Research
17 March 2009.
and Resource Centre (WERRC). Dublin.


296
( ) National Women’s Council of Ireland (2005), Women’s Mental
http://www.nda.ie/cntmgmtnew.nsf/0/BF3A14B644017A64802
Health: Promoting a Gendered Approach to Policy & Service
5729D0051DD2B?OpenDocument
Provision, Dublin: The Women’s Health Council.
298
( ) Maternity Action. http://www.maternityaction.org.uk/id1.html
83

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
their native languages (299). In Cyprus, the Family Planning
2.1.4. Gender mainstreaming in
Association (CFPA) has launched a specialised educational
healthcare: recent trends
programme entitled ‘Age Education for Foreign Artists’
which provides information on different issues, such as
In many European countries, (like Austria, Bulgaria,
HIV/AIDS, sexual y transmitted diseases, contraception.
Germany, Iceland, Ireland, Italy, Norway, Slovenia,
The programme addresses female third country nationals
Spain, the Netherlands, and the UK) there is increasing
who came to Cyprus under the status of ‘artists’, but which
awareness of the need to acknowledge gender
are often employed to work in establishments considered
differences in healthcare. This is the case among
‘high risk’ for trafficking in women for the purpose of
governmental institutions, universities, and especially
sexual exploitation (300). Since 1998 the programme is
NGOs which have traditionally been very active in
sponsored by the Ministry of Health. Even though the
providing specialised services to women, ethnic
‘artiste visa’ is no longer applicable foreign women are
minorities and other disadvantaged groups. Gender-
stil assisted by the CFPA. About 60–70 lectures per year
sensitive strategies have been implemented within
are conducted, usually in Russian or English, by CFPA-
healthcare and medical research, and resource centres
trained staff and volunteer doctors, including training on
and research institutes with special knowledge of
HIV/AIDS, sexual y transmitted infections, and safer sex.
women and health have been created. In addition,
Participants are provided with free condoms.
specific training programmes aimed at general
practitioners and healthcare providers have been
Homelessness was, until recently, seen as a problem
implemented. It must nevertheless be noted that
that affected mainly men. It is hard to say to what the gender-mainstreaming approach to healthcare
extent women are actual y affected, as there are no
is generally still underdeveloped and, aside from
representative studies on this problem. Women are often
reproductive care, little taken into account when
‘invisibly’ homeless, i.e. they react by seeking temporary
offering service provisions.
solutions: living with family, friends, ‘convenience
partners’ or casual acquaintances. This is in part influenced
In Austria women’s health was placed on the
by specific female behaviour patterns, but could also be
institutionalised political agenda for the first time
due to a lack of female-specific alternatives in this area.
at the beginning of the 1990s. Various health
A good practice in supporting access to healthcare for
programmes for women have been established in the
homeless women is the ‘women and homelessness
main Austrian cities. The Vienna and Innsbruck Women
programme’ implemented in Austria.
Health Centres are the most advanced examples of
clinical centres providing integrated services, including
Box 2‑15 — Good practice:
inpatient treatment and outreach activities targeted at
The Austrian programme
women who face barriers in accessing healthcare, such
for homeless women
as women of ethnic origin or lower educated women.
Furthermore, gender mainstreaming is beginning to be
Since 2003 the Supervised living group of the Fonds Soziales
applied in the Austrian health sector, aimed at analysing
Wien has been responsible for housing and supporting
the gender sensitivity of healthcare, health promotion
homeless people. ‘Women and homelessness’ was one of the
and health prevention. Since 1995, several women’s
central topics of the Fonds Soziales Wien in 2004. An outreach
health reports have been published at the federal and
programme was developed by the neunerAMBULANZ, a
provincial level, such as the Women’s Health Report
healthcare service of the private association Neunerhaus,
Austria 2005/2006 (302).
together with the Women’s Health Centre FEM to provide care
for homeless women and men in Vienna who require special
In Bulgaria, the National action plan for gender equality
medical or psycho-social attention due to chronic or mental
health problems and to provide assistance for homeless
promotion (2008–09) for the first time envisages an
women which goes beyond mere basic gynaecological care.
annual analysis of the health status of men and women
The project started at the beginning of 2005 with a mobile
in a comparative perspective to be elaborated. The
medical team. A follow-up project was launched in 2006 (301).
principles of gender equality in access to healthcare
are also addressed in the national programmes for
Source: EGGSI network national report 2009 — Austria.
the prevention, treatment and rehabilitation of drug
addicts, smoking cessation, mental health and the
301
( ) Federal Ministry of Health, Youth and Family (2008), Women’s
treatment and control of HIV/AIDS and STD (303). In
Health Report Austria 2005/2006: Best practice examples, Vienna.
299
( ) City of Vienna (2006), Women’s Health Report 2006, Vienna.
302
( ) City of Vienna (2006), Women’s Health Report 2006, Vienna.
w w w . o e b i g . o r g / u p l o a d / f i l e s / C M S E d i t o r / W I E N _
pp. 40–68.





Frauengesundheitsbericht2006.pdf
w w w . o e b i g . o r g / u p l o a d / f i l e s / C M S E d i t o r / W I E N _
300
( ) Mediterranean Institute of Gender Studies (2007), Mapping the
Frauengesundheitsbericht2006.pdf,


Realities of Trafficking in Women for Sexual Exploitation in Cyprus.
303
( ) European Institute of Women’s Health (2006), Discrimination
http://www.medinstgenderstudies.org/wp-content/uploads/
against Women and Girls in the Health Sector, Brussels.
migs-trafficking-report_final_711.pdf
http://www.eurohealth.ie/countryreport/pdf/euparlcountryrep.pdf
84

---

2. Gender differences in access to healthcare
most of these programmes, the main focus is on the
in Italy’ was produced (307). In addition, a National
reproductive and sexual health of women. In addition,
Observatory on Women’s Health (ONDa) (308) was created
women’s health is one of the main programme
in 2006 with the aim of increasing research on the main
directions of the Centre for women’s studies and policy
pathologies affecting women, to propose preventive
foundation in Bulgaria.
strategies and develop actions to promote gender
mainstreaming in healthcare policies. The Observatory
In Germany a department specifically devoted to
has implemented a nationwide evaluation programme
women’s health has been set up within the Federal
which awards a ‘pink ribbon’ to those hospitals showing
Ministry of Health. In addition, the ministry has
a commitment to women’s healthcare and high quality
conducted two gender mainstreaming projects. Other
standards in service provisions.
governmental institutions, universities and NGOs
have been very active in supporting projects and
In Norway, the Strategy for women’s health 2003–13
programmes in the area of women’s health (304).
emphasises the need to develop all health and
care services from a gender perspective. A gender
In Iceland in the 1980s, the influence of the feminist
perspective is also acknowledged within clinical
movement and Women’s Alliance in Parliament in
research and development. The government follows
Iceland resulted in policy initiatives which progressed
up the national strategy to promote health on a yearly
into general treatment programmes in which
basis, by focusing on the various measures that are
gender differences were recognised and the more
discussed within the plan. National statistics and an
gender-specific needs were addressed. Examples
annual seminar monitor the progress with respect to
of this approach are the creation in 1995 of a special
the objectives of the plan. The gender perspective is
treatment programme for women with alcoholic and
also acknowledged for ethnic minority policies.
drug addiction problems and the creation of an open
multidisciplinary emergency centre for victims of
In Slovenia, there are some gender specific
sexual assaults.
arrangements in the healthcare system. Special
attention is given to the access to health treatment for
In Ireland the national ‘Plan for women’s health 1997–
women in the field of reproductive health, as they are
99’ and the creation of the Women’s Health Council in
entitled to (personal) gynaecologists. Also special focus
1997 initiated the formal recognition of the gender
is given to pregnant women and women with infants —
dimension in health policy. The National Health
through visits of nurses at home. In the field of health
Strategy (2001) identified issues of specific concern to
promotion prevention programmes for early discovery
women and, in parallel, issues of concern to men. Each
of breast cancer and precancerous changes to the
of the then existing Health Boards (305) was required to
cervix are implemented. Some promotion campaigns
produce a health plan for the women in its area. The
target specific topics which are relevant for women,
main achievement appears to have been the beginning
such as coping with stress after birth and the rights of
of preventive screening programmes. The current
pregnant women.
National Health Strategy identified five target areas
which relate specifically to women (reducing smoking
In Spain a Quality plan for the national health system
by young women, national roll-out of cervical and
is exclusively devoted to cutting down inequalities
breast cancer screening, a crisis pregnancy strategy,
in health, with particular emphasis on gender issues
policies against domestic violence, a plan for high-
(Strategy 4). In order to comply with this goal, the plan
quality maternity care).
defines two separate lines of action: first, to promote
knowledge on gender inequalities in health and to
In Italy increasing attention is being paid to gender
strengthen the gender approach regarding health
differences in healthcare. Gender differentiated data are
and the training of health professionals, and second,
becoming available, the national Ministry of Health has
to promote awareness on issues regarding inequality
implemented an Internet portal on women’s health (306).
through the dissemination of good practices on equity
In 2008, a ‘Report on the health situation of women
promotion, aimed at all disadvantaged groups. Most
of these actions are performed by the Observatory of
Women’s Health, created in 2004 as an inter-ministerial
304
( ) European Parliament (2007), Discrimination against Women
institute, mostly providing publications, intervention
and Young Girls in the Health Sector, Directorate-General
guides and holding congresses for experts and
Internal Policies, Brussels.



professionals. Although gender issues have been
http://www.europarl.europa.eu/sides/getDoc.do;jsessionid=42
D62CA22BDD5134ABE684A2B6C616BC.node1?pubRef=-//EP//
TEXT+TA+P6-TA-2007-0021+0+DOC+XML+V0//EN
307
( ) Ministro del e Salute (2008), Lo stato di salute del e donne in
305
( ) As reported above, Health Boards have now been replaced by
Italia, Rome.





the Health Services Executive (HSE).
http://www.assodisfvg.it/files/rapporto_salute_donna_2008.pdf
306
( ) Ministero del Lavoro, della Salute e delle Politiche sociali.
308
( ) Osservatorio Nazionale sulla Salute per la Donna, Italy.

http://www.ministerosalute.it/saluteDonna/saluteDonna.jsp
http://www.ondaosservatorio.it/index.asp
85

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
included regarding specific women’s needs (pregnancy,
especially by NGOs. They are usually focused on women
menopause, etc.) or the prevention of domestic
reproductive rights and reproductive care. In Poland,
violence, there are no specific provisions regarding
women NGOs are numerous and promote relevant
unequal treatment concerning common pathologies.
programmes aimed at women in reproductive age,
women victims of domestic violence and the elderly (309).
In some eastern European countries, such as the Czech
Republic and Poland, projects focused on gender equality
Interesting examples of good practices are presented
in access to healthcare treatment have been carried out,
in Box 2-16.
Box 2‑16 — Good practice examples in some European countries
Austria — Women Health Clinic Innsbruck
Many also offer ‘well man’ clinics which are specialised
Considered to be a very good practice since it is one of the few healthcare for men. They offer men health check-ups,
initiatives pursuing an integrated approach for promoting which usually involve having a blood and urine test
and treating women’s health, this programme not only and offer general advice about health issues. Well man
provides numerous services including inpatient treatment, clinics are less diffused than well women clinics (311).
but also aims at addressing a clientele that often faces barriers The Netherlands — Gender Guidelines for
in accessing medical institutions — such as migrant women.
The provision of childcare during the opening hours of the General Practitioners
outpatient clinic is particularly positive.
The programme Gender Guidelines for General Practitioners
was initiated in 1997 by the University Medical Centre St.
The centre provides information for women of all ages and Radboud (Nijmegen) and financed by ZonMw (312). This
from various social and ethnic backgrounds on medical promotion programme was cal ed ‘Sex specific care in the work
issues and medical treatment. The focus of the services is of general practitioners: three flies in one go’ (‘Seksespecifieke
on the provision of integrated, creative, interdisciplinary zorg in de huisartspraktijk: drie vliegen in één klap’) (313). The
health services for women, information on women’s health, key priorities of this programme were threefold: (a) Gender
an outpatient clinic and inpatient clinic exclusively for specific recommendations regarding the NHG (314) standards
women. The Women’s Health Clinic is also active in research for angina pectoris, depression and urine incontinence; (b)
on women’s health issues which shall be integrated into the Training in professional behaviour regarding sex specific
daily work at the clinic.
recommendations for general practitioners (c) Consolidation
The outpatient clinic provides second opinions; considers of sex-specific quality measures in the quality policy of the
the risk of cardiovascular diseases, breast cancer and participating healthcare practices. A training module was also
malignancy; deals with the clarification of grievances developed for medical doctors in training and their trainers
when psychological strain predominates; offers after-care on the gender-specific aspects of angina pectoris, depression
for female patients discharged from the gynaecological and urine incontinence. At the end of the project a qualitative
department, performs risk evaluation, prevention, check-
study was carried out among general practitioners. The
ups, supplies information on current events and lectures interviews had the implicit goal to draw attention to gender-
on women’s health issues. In addition, there are special specific consulting and to emphasise that this topic should
clinics for Turkish women, Serbo-Croatian women, evening be further included in the everyday practice of general
hours for professional women and specific counselling for practitioners. The programme was disseminated on a
nutrition, social issues and physical therapy.
national level and the Dutch Council for General Practitioners
supported the diffusion of gender-specific guidelines for the
The inpatient clinic is aimed at women who cannot be treated diseases mentioned. According to the existing evaluation,
as outpatients, e.g. elderly and ill people, women living far the key priorities have been attained.
away, or women who prefer female doctors for religious
or cultural reasons. Outreach services include: ‘diagnosis Source: EGGSI network national reports 2009 — Austria, the
streets’, health days and outreach work in mosques to reach Netherlands, United Kingdom.
Turkish women in particular, for which services are carried
out in Turkish with Turkish medical staff, covering the Tyrol
area and with support from Muslim institutions (310).
UK — ‘Well woman’ clinic
311
( ) Banks, I. (2001), No man’s land: men, illness, and the NHS,
Many General Practitioners’ surgeries offer a ‘well
British Medical Journal, No 323, 3 November.
woman’ clinic where patients may be seen by a female
312
( ) ZonMw — http://www.zonmw.nl/en/
313
doctor or a female practice nurse to check current ( ) See also: http://www.zonmw.nl/nl/system/zoekresultaten/
delfi/projecten-database/project-detail/?tx_videlfiprojecten_
health status and provide advice on health promotion.
pi1[project_id]=2000124154
314
( ) Nederlands Huisartsen Genootschap/Dutch Council for
310
( ) Vienna Programme for Women’s Health. http://www.diesie.at
General Practitioners.
309
( ) See for instance www.oska.org.pl which gives the most
comprehensive information on support activities of women
NGOs [‘pomoc’ or ‘grupy wsparcia’].
86

---

2. Gender differences in access to healthcare
2.2. Bar

riers to accessing service
higher percentage of unmet medical needs, the figures
provisions
ranging from 15.6 in Hungary (women 13.4), 11.7 % in
Germany (w: 10.7), 7.2 % in Spain (w: 5.4 %) to 5.7 % in
Healthcare access means the ability to obtain
the Czech Republic (w: 5 %), 5.5 % in Luxembourg (w:
appropriate healthcare services in a short time and at
2.9) 2.7 % in Ireland (2.5 %) and 1.8 % Austria (w: 1.7 %).
a low cost. Even if universal or nearly universal rights
The Baltic countries, Poland, Sweden and Hungary
to care are basic principles in most Member States
present higher percentages of both women and men
and most of the EU population is covered by public
declaring unmet medical needs than the average of
health insurance, these basic principles do not always
the considered European countries, while the lowest
translate into equal access to and use of healthcare
percentages are in Slovenia, Belgium, Denmark, Austria
services. Socioeconomic factors can affect accessibility
and the Netherlands. The countries where women’s
to healthcare for specific groups. Low income levels,
unmet medical needs are the highest are Latvia (28.6 %),
lack of mobility (the disabled) or language competence
Poland (18 %), Sweden (16.4 %), Lithuania (14.3 %),
(migrants), as well as lack of information (people with
Hungary (13.4 %) and Estonia (11.4 %), while the lowest
low levels of education), time constraints (single
are in Slovenia (0.2 %), Belgium (0.7 %), Denmark (1 %),
mothers) or lack of services for specific groups explain
Austria (1.9 %) and the Netherlands (1.9 %).
differences in access to health systems.
Gender differences are more relevant when considering
EU-SILC 2006 data (315) on unmet medical needs show
the reasons for unmet medical needs: women are
that women in general are more likely than men
usually more likely than men to be constrained by
to perceive unmet medical needs, even if gender
barriers to access, such as the cost of medical care,
differences are small: in the EU-25, on average 7.7 %
time and geographical barriers (‘could not afford’,
of women respondents declare unmet medical needs
‘waiting list’, ‘too far to travel’), while men are more
relative to 7.5 % of men. Out of these countries, only in
likely than women to declare other reasons such as:
seven (Hungary, Germany, Spain, the Czech Republic,
‘could not take time’, ‘fear’, ‘wait-and-see strategies’,
Luxembourg, Ireland and Austria) do men show a
‘didn’t know any good specialist or doctor’ (Figure 2-9).
Figure 2‑9 — People with unmet needs for medical examination (%),
EU‑25 and Iceland and Norway, 2006
30
25
20
15
10
5
0
EU* BE CZ DK DE EE
IE EL ES FR
IT CY LV
LT LU HU MT NL AT PL PT
SI SK
FI SE UK
IS NO
Problem of access (could not afford to, waiting list, too far to travel)
Left bar: Men
Other (could not take time, fear, wanted to wait and see, didn't know any good doctor or specialist, other)
Right bar: Women
Source: Eurostat data based on the EU-SILC survey 2006.
Explanatory note: EU refers to EU-25. Data for Bulgaria and Romania are not available for 2006. The reference population is private households
as wel as current members over 15 years of age within the national territory at the time of the data col ection.
315
( ) Eurostat (2009), Perception of health and access to healthcare
in the EU-25 in 2007, by Baert, K. and de Norre, B., Statistics in
Focus, No 24/2009, Luxembourg.



http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-
SF-09-024/EN/KS-SF-09-024-EN.PDF
87

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Barriers to access appear to be particularly relevant
levels especially affect the perception of financial
for women in the Baltic countries (especially in Latvia),
and geographical barriers to healthcare access. The
in Poland and in Greece. Portugal, Germany and Italy
Baltic countries, Poland, Portugal, Italy, Germany,
also show perceptions of unmet needs among women
Hungary and Sweden present the highest perception
due to problems of access above the average.
of unmet needs among women and men in the
lowest quintile and the largest differences between
Income levels significantly affect the perception of
the respondents’ perception in the lowest and in the
unmet medical needs. As shown in Table 2-5, income
highest income quintile.
Table 2‑5 — Unmet needs for medical examination of women and men by lowest
and highest income quintile (%) and reason, EU‑25 and Iceland and Norway, 2006
Problems of access (could not
Other (could not take time, fear,

All reasons
afford to, waiting list, too far to
wanted to wait and see, didn’t know
travel)
any good doctor or specialist, other)

< 20 %
> 80 %
< 20 %
> 80 %
< 20 %
> 80 %

women
men
women
men
women
men
women
men
women
men
women
men
EU‑25
10.5
10.4
5.8
6.0
6.5
5.7
1.9
1.5
4.0
4.7
3.9
4.5
Austria
2.9
2.2
2.1
1.6
1.0
0.8
0.4
0.1
1.9
1.4
1.7
1.5
Belgium
2.1
2.2
0.1
0.2
2.0
1.5
0.1
0.2
0.1
0.7
:
:
Cyprus
9.2
8.5
3.2
3.1
7.0
6.1
0.6
0.5
2.2
2.4
2.6
2.6
Czech Republic
6.5
6.8
4.7
6.4
1.4
1.4
0.4
0.1
5.1
5.4
4.3
6.3
Denmark
1.8
2.0
1.1
1.1
0.4
:
0.2
0.2
1.4
2.0
0.9
0.9
Estonia
17.2
20.2
6.0
3.7
12.9
17.0
4.2
2.1
4.3
3.2
1.8
1.6
Finland
4.8
4.9
1.6
1.1
4.8
4.6
1.1
0.8
0.0
0.3
0.5
0.3
France
6.9
7.9
2.3
2.9
3.9
4.7
0.7
0.5
3.0
3.2
1.6
2.4
Germany
15.3
17.2
6.9
8.2
9.6
9.2
2.0
2.3
5.7
8.0
4.9
5.9
Greece
10.0
8.1
3.4
3.7
8.5
7.2
1.9
2.1
1.5
0.9
1.5
1.6
Hungary
15.1
18.6
10.6
13.8
4.6
3.1
0.8
0.9
10.5
15.5
9.8
12.9
Ireland
3.5
4.4
0.5
1.7
2.6
2.9
0.2
1.1
0.9
1.5
0.3
0.6
Italy
12.7
10.8
5.0
4.2
9.8
8.3
2.6
1.6
2.9
2.5
2.4
2.6
Latvia
39.1
34.1
18.9
17.7
31.5
24.8
7.0
4.6
7.6
9.3
11.9
13.1
Lithuania
18.3
20.0
10.8
7.5
14.7
12.2
5.0
2.8
3.6
7.8
5.8
4.7
Luxembourg
5.2
7.7
2.1
4.7
0.7
1.1
0.5
0.3
4.5
6.6
1.6
4.4
Malta
6.0
5.5
2.8
2.4
4.0
2.7
1.1
0.6
2.0
2.8
1.7
1.8
Netherlands
3.1
2.3
1.1
0.4
1.5
0.2
0.5
0.2
1.6
2.1
0.6
0.2
Poland
21.9
16.9
16.7
16.6
15.7
10.8
7.2
5.5
6.2
6.1
9.5
11.1
Portugal
11.3
8.6
1.8
1.5
11.2
7.6
1.1
1.0
0.1
1.0
0.7
0.5
Slovakia
12.0
9.0
6.2
5.0
7.7
4.6
0.8
0.7
4.3
4.4
5.4
4.3
Slovenia
0.4
0.3
0.3
0.1
0.3
0.2
0.3
:
0.1
0.1
:
0.1
Spain
6.2
7.4
5.5
8.1
0.9
1.0
0.1
0.3
5.3
6.4
5.4
7.8
Sweden
15.7
16.0
12.9
8.7
4.8
3.2
1.2
1.1
10.9
12.8
11.7
7.6
UK
5.7
5.1
4.3
3.5
2.5
2.8
2.0
1.1
3.2
2.3
2.3
2.4
Iceland
2.8
6.0
3.0
1.1
1.0
1.9
:
0.4
1.8
4.1
3.0
0.7
Norway
4.8
2.3
1.5
1.5
2.2
0.9
0.4
0.9
2.6
1.4
1.1
0.6
Source: Eurostat data based on EU-SILC survey.
http://epp.eurostat.ec.europa.eu/portal/page/portal/product_details/dataset?p_product_code=HLTH_SILC_08
Explanatory note: The equivalised income quintiles are constructed by country; it is an ordered measure of the equivalised income of a
respondent. If a respondent belongs to the first quintile (0 –20 %), this means that they are amongst the 20 % of respondents of their country with
the lowest equivalised income during the income reference period. The equivalised income is calculated from the household income taking into
account household size and composition.
88

---

2. Gender differences in access to healthcare
The following sections describe the main financial,
of the public healthcare systems and are often only
cultural and geographical barriers which impede access
guaranteed emergency care services.
to healthcare, focusing on barriers which especially
affect women or men and, among women, the most
The need to contain increasing healthcare costs due
disadvantaged groups: disabled women, women of
to ageing and new technologies have encouraged
ethnic origin, older women, teenagers, poor women
many countries to reform their public–private mix
and single mothers, based on information provided by
and introduce cost-sharing schemes with the aim of
the EGGSI network.
reducing costs, moderate healthcare demand and
improve efficiency (317).
2.2.1. Financial barriers: insurance
coverage and individual costs
Most European countries have introduced out-of-
pocket fees to be paid for healthcare services and
The financial cost for the individual is one of the main
medicines; reduced exemptions and introduced
barriers to accessing healthcare services. While all
procedures aimed at containing the demand for
European countries are committed to ensuring access
health services; supported the development of
to adequate healthcare and long-term care, significant
private insurance schemes and rationalised the supply
inequalities remain, especially due to the lack of
of services by closing clinical centres in peripheral,
insurance coverage, the cost of certain (specialised)
low-populated areas. Reproductive care, screening
types of care (such as dental, ophthalmic and ear
programmes and mandatory preventive programmes
care) which are often not covered by public insurance
are usually excluded, but these trends still may
schemes, the increasing role of private insurance
negatively affect access to healthcare, especially for
schemes and of out-of-pocket costs for care, as well as
individuals with poor economic and educational
the persistence of informal payments in many eastern
backgrounds and of ethnic origin.
(such as Slovakia, Romania, Bulgaria, Hungary, Poland,
Lithuania, Latvia) and southern European (such as
Tax-based public health insurance schemes remain
Italy and Greece) countries.
however the main funding sources for healthcare
systems in European countries, even if the incidence
All European countries have achieved almost
of out-of-pocket payments and, to a lesser extent, of
universal coverage for healthcare costs for at least
private insurance in financing total health expenditure
a core set of services (316). EU health systems cover
has been increasing in most European countries.
preventive and public health services, primary
Their incidence over total healthcare expenditure
care, ambulatory and inpatient specialist care,
varies greatly from country to country. In 2005, the
prescriptions pharmaceutical, mental healthcare,
incidence of private expenditure on total healthcare
dental care, rehabilitation, home care and nursing
expenditure (Figure 2-10) ranged from the low levels
home care. There is however some variation across the
of Luxembourg (8.2 %), the Czech Republic (11.1 %),
European countries in the range of services covered
the United Kingdom (12.9 %), Sweden (15.4 %) and
by public insurance schemes and the extent of cost
Denmark (15.8 %) to the highest incidence in Greece
sharing required. In addition, in some countries there
(57.2 %), Cyprus (55.7 %) and in some eastern European
is a gap between what is officially covered and what
countries such as Latvia (43.4 %), Bulgaria (42.4 %) and
is actually available and in some countries informal
Romania (33.9 %).
additional payments increase the financial barriers to
healthcare. Given that residency is the most common
Since 1996, public expenditure as a proportion of total
basis for entitlement to healthcare in the EU, some
expenditure on health has fallen in 17 Member States,
population groups are not usually covered by public
with the largest decline in Belgium, Bulgaria, Estonia,
insurance: ethnic minorities and especially the Roma
Hungary and Slovakia; 10 Member States have instead
people, homeless people, asylum seekers and illegal
increased public spending, with the largest rises in
immigrants without identity documents are outside
Cyprus, Malta and the UK (318).
317
( ) London School of Economics (2007), Health Status and Living
conditions in an enlarged Europe, Monitoring Report prepared
by the European Observatory on the Social Situation — Health
Status and Living Conditions Network, London, p. 113.
http://ec.europa.eu/employment_social/spsi/docs/social_
situation/sso2005_healthlc_report.pdf
316
( ) Thomson, S., et al. (2009), Financing healthcare in the European
318
( ) Thomson, S., et al. (2009), Financing healthcare in the European
Union, Chal enges and Policy responses, European Observatory
Union, Chal enges and Policy responses, European Observatory
on Health Systems and Policies, Observatory Studies Series, No 17.
on Health Systems and Policies, Observatory Studies, No 17, p. 30.
http://www.euro.who.int/document/e92469.pdf
http://www.euro.who.int/document/e92469.pdf
89

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Figure 2‑10 — Public and private expenditure on health as a proportion
of total expenditure on health in the EU‑27, 2005 (*)
100
Total public
Private Insurance + Out-of-pocket payments
80
60
40
20
0
.
y
y
e
ia
ia
ia
e
k
g
UK
ep
tvia
ium
onia
alta
Italy
eec
La
lands
Spain
tugal
vak
venia
M
man
eden
Cyprus
Gr
Poland
Est
er
Austr
Franc
Finland
Ireland
enmar
Bulgar
Romania
Belg
Por
Hungar
Slo
Sw
Lithuania
Slo
G
D
embour
Czech R
Nether
Lux
Figure elaborated by IRS.
Data source: European Commission, New common indicators from 2006 for the Open Method of Coordination.
http://ec.europa.eu/employment_social/spsi/common_indicators_en.htm, Indicator HC-C3, based on OECD Data.
(*) 2004 data for RO, HU, LT, SI, EE, MT, LU.
Explanatory note: No data on Private Insurance + out-of-pocket payments available for NL, data for BE + NL: share of current expenditure, data
of EL +UK: separate estimates of private health insurance not available, LU: Only covers cost-sharing element of out-of-pocket spending. Total
public expenditure includes government spending plus social security funds according to System of Health accounts (SHA). Out-of-pocket
payments expenditure is presented as a percentage of total health expenditure.
While all European countries have exemptions or
Private insurance schemes may lead to a regressive
reductions in relation to cost sharing (319) for specific
distribution of the financial burden for health services
groups of the population (usual y minors, pregnant
(low-income people pay proportionally more than
women and mothers of young children, the unemployed,
high-income people, due to the difficulty in reducing
low-income individuals, the disabled and the chronical y
health expenditures and their usually worse health
il ), some countries have actual y increased the number
status) and increase inequalities in access to treatment,
of cost-sharing schemes (Czech Republic, France, the
especially when private schemes substitute (as in
Netherlands, Latvia) or reduced exemptions (Ireland).
Germany and in the Netherlands prior to the 2006
The financial cost of healthcare is especial y high in
reform) or complement (as in France, Denmark and
Cyprus and Greece. On the other hand, some countries
in Slovenia) statutory public health insurance (321). In
(Hungary, Slovakia) have withdrawn the cost-sharing
addition, these schemes tend to attract and insure
schemes that were implemented, or improved system
people with a lower than average expected risk of ill
coverage (as, for example, Portugal for dental care) (320).
health and deter those with higher than average risks.
319
( ) Exemptions usual y refer to the exemption from out-of-pocket
payments for prescription pharmaceuticals and/or for medical
321
( ) Private schemes substitute public health insurance when they
examinations for specific groups of population (such as minors,
cover groups of people either excluded from the statutory system
pregnant women, the unemployed, the chronical y il , low-income
or who are allowed to opt out from it, as in Germany and in the
people) or for treatment of chronic il nesses (as, for example,
Netherlands before the 2006 healthcare reform. Private insurance
diabetes). Reductions in cost-sharing usual y refer to the lower rates
is complementary to the statutory system, when it either covers
applied for those with income below a certain threshold and for
services excluded from the publicly financed benefits package
those who exceed the annual ceiling in out-of-pocket payments.
(like specialist care in most EU countries) or it covers statutory
320
( ) European Commission (2009), Proposal for the Joint Report on
cost-sharing requirements (as in France, Belgium, Denmark,
Social Protection and Social Inclusion 2009, Commission staff
Slovenia, Ireland, Italy, Latvia, Portugal and Luxembourg).
working document, accompanying document to the Decision
Supplementary schemes, on the other hand, cover faster access
of the European Parliament and of the Council establishing a
to care or access to care in the private sector (as in the UK, Ireland
European Microfinance Facility for Employment and Social
and in most of the Member States). Source: Thomson S., et al.
Inclusion, COM(2009) 58 final, SEC(2009) 141, Brussels.

(2009), Financing healthcare in the European Union, Chal enges
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2
and Policy responses, European Observatory on Health Systems
009:0058:FIN:EN:PDF
and Policies, Observatory Studies series, No17.
90

---

2. Gender differences in access to healthcare
For these reasons, some groups of people may not be
relation to insurance coverage and financial barriers
able to obtain an affordable level of coverage or any
in accessing healthcare services. While it is difficult to
coverage. Finally, private insurance schemes usually
identify systematic differences, it is possible, however,
enable insured people to bypass waiting lists in the
to identify at least three different groups of countries
public sector or to obtain higher quality care.
when considering the public–private mix of health
insurance schemes and the coverage and financing of
Cost-sharing requirements and lack of public coverage
public insurance systems (as shown in Table 2-6) (323).
for certain types of care also create financial barriers
to access healthcare services which may lead to
The first group is characterised by the presence of
significant inequalities in access and health status, by
a tax-based, comprehensive national public system
reducing the use of healthcare (especially for specialist
providing universal coverage. In the second, more
and quality care and prescription drug use) for people
numerous, group of countries the public healthcare
with a low income.
system is mainly financed through compulsory social
insurance contributions, while the third group presents
The increasing role of private health insurance and
a high incidence of out-of-pocket payments and private
out-of-pocket payments may also give rise to gender
insurance schemes.
inequalities in accessing healthcare, men being more
likely to be covered by private insurance than women and
In countries with comprehensive national public
women being higher consumers of healthcare services
systems, the system is usually based on individual
and medicines. Women usually have a lower income and
citizenship rights and funded mainly through general
do not benefit from the same kind of company-based
taxation. It is usually centrally organised with some local
private insurance coverage as men. Women present
level of responsibility (local and/or regional bodies)
lower employment rates in the regular economy (many
and provides universal coverage, with a very limited
women are either inactive or work at home or in the
presence of private supplementary insurance. Targeted
informal sector) and, when employed, they are more
programmes are often implemented to facilitate access
likely to be employed in the public sector or by small
to healthcare for disadvantaged groups.
firms (which are less likely to provide supplementary
private insurance schemes) with part-time and/or with
The Nordic countries (Denmark, Finland, Iceland,
temporary contracts in low-paying jobs. In addition,
Norway and Sweden), the UK and Ireland are included in
private insurance schemes are less attractive to women
this group of countries and present the lowest financial
since contributions are usually defined considering age
barriers to low income and disadvantaged groups. In
and gender-specific risks. Women who bear the ‘risk’ of
general, healthcare is either free of charge or offered
pregnancy and birth and have a longer life expectancy
at very reasonable, state-supported prices up to a pre-
risk paying higher contributions than men of the same
defined cost ceiling. Ireland is however different from the
age group, even if Directive 2004/113 establishes the
other countries of this group, because private insurance
principle of gender-neutral tariffs (322).
schemes cover more than half of the population, playing
a mixed supplementary and complementary role and
Women from ethnic minorities and poor households
offering faster access to care, access to private sector
may be especially penalised by the privatisation of
care and reimbursement of cost sharing.
health services and the increase in out-of-pocket
spending on healthcare.
Some southern European countries (Italy, Spain, Portugal
and Malta) also present a National Public Health Service
Gender effects of financial barriers in national which provides universal coverage, without distinction
healthcare systems
by gender, age, income and occupational status. In
Italy, Spain and Portugal, however, the management of
European countries use a wide variety of institutional
healthcare is decentralised to local authorities and this
arrangements to provide health insurance coverage
has increased territorial differences in the quality and
and to finance and deliver healthcare services. National
accessibility of healthcare services. In Malta the free
differences are relevant in explaining gender gaps in
comprehensive public healthcare system is coupled with
means-tested entitlements to pharmaceuticals, dental
322
( ) European Community (2004), Council Directive 2004/113/
and optical care for those with low incomes and the
EC of 13 December 2004 implementing the principle of equal
chronically ill. Around 25 % of the population is covered
treatment between men and women in the access to and supply
by voluntary private health insurance for basic care.
of goods and services.




http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:
2004:373:0037:0043:EN:PDF



323
( ) The adopted classification fol ows the one considered in
Since the directive allows for exceptions under certain
Thomson, S., et al. (2009), Financing healthcare in the European
conditions, all Member States have introduced rules which
Union, Chal enges and Policy responses, European Observatory
allow them to make use of the exception clause and apply
on Health Systems and Policies, Observatory Studies Series No 17.
gender differentiated tariffs.

http://www.euro.who.int/document/e92469.pdf
91

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Table 2‑6 — Health insurance coverage, share of population in the EU‑27, 2005
Private health
Primary private
Public health insurance
insurance (all
health insurance
types)
1997
2000
2005
2005
2005
Belgium
99
99
99
:
44
Bulgaria
:
:
n.a.
:
:
Czech Republic
100
100
100
:
:
Denmark
100
100
100
:
6.8
Germany
90.8
90.9
89.6
10.2
24.3
Estonia
:
:
94.5
:
:
Ireland
100
100
100
:
51.6
Greece
100
100
100
:
15.6
Spain
99.8
:
99.5
:
11.9
France
99.4
99.9
99.9
:
87.2
Italy
100
:
100
:
:
Cyprus
:
:
n.a.
:
:
Latvia
:
:
n.a.
:
:
Lithuania
:
:
n.a.
:
:
Luxembourg
97.6
98.2
100
:
:
Hungary
100
100
100
:
:
Malta
100
100
100
:
:
Netherlands
74.6
75.6
62.1
35.8
92.8
Austria
99.0
99.0
98.0
:
:
Poland
:
:
97.3
:
:
Portugal
100
100
100
:
17.4
Romania
:
:
n.a.
:
:
Slovenia
:
:
98.7
:
:
Slovakia
100
98.8
97.6
:
:
Finland
100
100
100
:
:
Sweden
100
100
100
:
:
United Kingdom
100
100
100
:
11
Source: European Commission, New common indicators from 2006 for the Open Method of Coordination, http://ec.europa.eu/employment_
social/spsi/common_indicators_en.htm, Indicator HC-P3, based on OECD health data.
Explanatory note: The percentage of the population covered by public health insurance (defined as tax-based public health insurance and income-
related payrol taxes including social security contribution schemes) and the percentage of the population covered by private health insurance
including private mandatory health insurance, private employment group health insurance, private community-rated health insurance, and
private risk-rated health insurance.
In some of these countries the number of cost-
increase in user co-payments in the public system, a
sharing and private insurance schemes has increased
growing utilisation of private providers with direct
in recent years, with negative effects on gender and
out-of-pocket payments and an increased number of
income inequalities in accessing healthcare services.
people with private insurance. In contrast to other EU
For example, according to the EGGSI national reports,
countries, the private insurance sector mainly provides
in Denmark, Iceland and Sweden the introduction
services that substitute rather than complement those
of user charges and private insurance schemes
supplied by the NHS. Private health insurance is either
may have increased financial barriers, especially for
provided by employers as a fringe benefit or directly
women. In Italy in recent years there has been an
purchased by individuals.
92

---

2. Gender differences in access to healthcare
Box 2‑17 — Trends in comprehensive national health systems
In Denmark, user charges prevail especially in relation to
to free primary care from a local GP and free prescription
medicine consumption and dental treatment. No systematic
medicines as well as other medical services. There is a
knowledge is available to document that user charges
separate means-tested GP card for those with incomes above
have a gender dimension, but given the income difference
the medical card threshold which entitles holders to free GP
between men and women, user charges might imply a
visits only. Those without either medical card must pay their
weaker position for single mothers and ethnic minority
own costs and therefore purchase health insurance which is
women, especially those outside the labour market. The
tax deductible. Traditionally medical cards covered over a
chronically ill might also face an implicit reduction in
third of the population (327). Recent government policy has
medicine consumption, even though special rules reduce
involved a major reorganisation and centralisation of the
the total costs. A more pronounced problem is the increase
public health system and a greater use of private provision.
in private healthcare insurance paid for by individuals
According to the most recent data, 25 % of the population
and/or companies, especially to cover the costs of surgical
has a medical card, and 49 % have private insurance, while
treatments. The data is not distributed according to sex,
3 % have both medical card and health insurance (328).
however based upon the yearly report on fringe benefits
(such as supplementary health insurance, company car,
In Sweden, since the mid-nineties, inequalities in accessing
etc.) (
healthcare re-emerged with low-educated people using
324), men have access to these types of benefits to a
higher degree. This implies a gender difference in the degree
outpatient care to a lesser extent than those with a higher
of access to these types of insurance. Furthermore, private
educational level. In 2006, 15 % of the population in need of
healthcare insurance is prevalent in the private sector, and,
medical attention was not getting it, which is high compared
this implies a gender difference due to gender-segregated
to other EU countries (329) . This is still more common among
labour markets.
female blue-collar workers: 16.1 % of female blue-collar
workers were in this situation, relative to 10.7 % female
Since the enactment of the Social Security Act in 1971, the
white collars, 12.0 % male blue collars and 8.4 % male white
Icelandic healthcare system has provided all citizens with
collars. In the 2006 Swedish national public health survey,
universal, comprehensive healthcare services. Thus the
people were asked whether they had refrained from buying
whole population is covered and no groups are excluded.
medicine for which they had received a prescription (330)
Since 1993, the eligibility criteria are based on six months
during the preceding three months. The result showed
residence in the country. The system is financed through
that more women (7 %) than men (6 %) had refrained from
general taxation in which earmarking for health or other
buying medicine. This was also more common among the
public services does not take place. In 2007, public health
unemployed women with long-term illnesses.
expenditure made up 82.5 % of total health expenditure.
Private health expenditure only exists in the form of out-
In Finland, public healthcare services are open to
of-pocket payments from users. Although out-of-pocket
everyone. Local healthcare centres and public hospitals
payments for healthcare in Iceland are quite similar to
charge customer fees for which there is a state-regulated
other Nordic countries and charges are not very high,
maximum amount (ceiling) per year. Individual ceilings for
there is evidence of financial barriers impeding access to
yearly healthcare costs have been introduced to reduce
healthcare in Iceland. National sources (
the financial burden on users of healthcare. The ceiling
325) report evidence
that household out-of-pocket health expenditures
for municipal healthcare fees is EUR 590 per year and it
increased by 29 % in real terms between 1998 and 2006.
accumulates from all municipal healthcare services except
The largest expenditure items in 2006 were drugs, dental
health services during home visits or dental healthcare.
care, equipment, drugstore items, and physician care (in
Once a patient has exceeded the yearly ceiling, outpatient
this order). The highest household expenditure burden was
healthcare becomes free of charge and the fee for short-
observed among women, younger and older individuals,
term inpatient care in hospitals drops to about a half of the
single and divorced, smaller households, the unemployed
original. There are separate ceilings for yearly payments for
and non-employed, individuals with the lowest education
prescribed medication (EUR 643 per year) and transportation
and income, the chronically ill, and the disabled. This
costs (EUR 157 per year) regarding healthcare. Medication
study concluded that household out-of-pocket healthcare
and transportation fees below the ceiling are partially
expenditures differ substantially between population
compensated by the National Health Insurance. If the
groups in Iceland, and have reached a risky level in affecting
ceilings are exceeded, medication will cost EUR 1.5 per
individual and group access to health services (
medicine and transportation becomes free of charge (331).
326).
In Ireland, all residents with income below a certain level are
327
( ) Tussing, A.D., Wren, M.-A. (2006), How Ireland Cares: The case
entitled to a means-tested medical card. Holders are entitled
for healthcare reform, Dublin.
328
( ) Smith, Samantha (2009), Equity in Health Care: A view from the
324
( ) http://www.skm.dk/public/dokumenter/publikationer/
Irish Health Care System, Adelaide Hospital Society, Dublin.
personalegoder/personalegoder2007_rev.pdf
329
( ) Eurostat, data based on EU-SILC survey: People with unmet
325
( ) Rúnar Vilhjálmsson, (2009), Direct household expenditure
needs for medical examination in Sweden, by sex and median
on healthcare in Iceland, Læknablaðið (The Icelandic Medical
equivalised income quintile (%).
Journal), Forthcoming.
330
( ) Folkhälsoinstitutet (2008), Health on Equal Terms, Results from
326
( ) Rúnar Vilhjálmsson, (2009), Direct household expenditure
the 2006 Swedish National Public Health Survey, Östersund.
on healthcare in Iceland, Læknablaðið (The Icelandic Medical
331
( ) Finnish Ministry of Social Affairs and Health.

Journal), Forthcoming.
http://www.stm.fi/sosiaali_ja_terveyspalvelut/asiakasmaksut
93

---

ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Most of those who exceeded the payment ceiling for providers who are not accredited by the NHS, which usually
municipal healthcare costs or medication costs were over ensures easier, quicker access to services and often more
the age of 75, but some middle-aged groups also exceeded comfortable healthcare settings.
the ceiling for medication costs. Categorised by income
levels, the majority of those who exceeded ceilings were In the UK, the NHS offers universal healthcare, free at the
from low-income groups. Information on the accumulation point of need and access. In theory, the only potential
of costs towards ceilings is not available by gender. There financial barrier to effective treatment is the cost associated
is no ceiling for costs accumulated from services of private with prescriptions in England. The cost from 1 April 2009
healthcare specialists. NHI reimbursements for specialist for a single prescription is GBP 7.20 or GBP 104.00 for a
care nowadays counts for about 25 % of the total costs 12-month prepayment certificate (PPC). However certain
compared with about 40 % in the 1990s. At the household categories of patients are exempt from prescription
level, the share of households that use private specialist charges. These include pregnant women and patients on
services decreased from 33 % to 22 % between 1990 and low incomes, many of whom are women (333). In January
2006 in the lowest income deciles and increased from 59 % 2009 the government announced a plan to exempt patients
to 64 % in the highest income deciles. At the individual level, with long-term conditions, starting with cancer patients.
the women’s share of the use of private specialist services In Wales, prescription charges were scrapped altogether
also increased according to income level. Their use of the on 1 April 2007 and in 2007 the Scottish executive
services was, however, much higher than men’s in all income announced plans to reduce charges annually with the
levels, and the income level affects men’s use of private aim of phasing them out completely by 2011. In addition,
services very little if at all (
the government has recognised that the traditional ‘one-
332). The main reason why women
use private specialist services more than men is because size-fits-all’ approach of the NHS is not working and that
specialist services in gynaecology are available mainly in service provisions need to become more responsive to the
the private sector.
needs of disadvantaged communities, through specific
programmes such as the Health Inequalities Public Service
In Italy, since the nineties user co-payments both for Agreement started in 2004 (334).
medicines and health services have been increasing,
together with private insurance coverage. Private insurance Source: EGGSI network national reports, 2009.
coverage allows services to be obtained through private
332
( ) Haataja, Anita et al. (2008), Yksityisiä terveyspalveluja käyttävät
333
( ) Due to the gender pay gap in the UK, more women than men
kaikki väestöryhmät. Toiset enemmän kuin toiset [All population
are on low incomes.
groups use private specialists, some however more than others,
334
( ) Department of Health (2003), Tackling Health Inequalities: A
only in Finnish], Sosiaalivakuutus 6/2008, 34–35.
Programme for Action, London.
The largest group of European countries includes
supplemented by basic universal tax-based coverage.
those which finance healthcare mainly through
The Netherlands, since the 2006 health insurance
compulsory social insurance contributions, usually the
reform, has implemented a dual system composed
contributions of employees and the self-employed.
of: (i) compulsory, individualised basic health
Continental countries (Austria, Belgium, France,
insurance system for every adult citizen (children
Germany, Luxembourg, and the Netherlands) are
up to 18 years old are free of charge, being insured
included in this group, as are most eastern European
via one of the parents), regardless of occupational
countries (the Czech Republic, Estonia, Hungary,
status; (ii) coverage against long-term care costs
Lithuania, Poland, Slovakia and Slovenia). In these
(non-insurable costs) financed by contributions of
countries, the welfare system is largely based on the
the working population.
(male) breadwinner model, with insurance coverage
based on the occupational condition of the family
In many of these countries, a large share of the
breadwinner and derived rights for family dependants population is covered by supplementary private
(spouse and children). The system of derived rights
insurance schemes, which in the Netherlands also cover
covers non-employed married women, but penalises
primary care and thus complement public insurance.
single mothers, divorced and single women, as they
In Germany, supplementary private insurance schemes
are not co-insured within the family.
cover specialised care.
In some of the continental countries, as in France
Some of these countries have increased the number
(since the reform of 2000) and the Netherlands
of cost-sharing schemes with negative effects
(after the 2006 reform) there is a mixed system,
on gender and income inequalities in accessing
with the mandatory social contribution mechanism
healthcare services.
94

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2. Gender differences in access to healthcare
Box 2‑18 — Recent trends in some continental countries
In Austria, recent health reforms have primarily dealt with In France the 2000 reform introduced universal coverage
cost containment, leading to the increasing individualisation through CMU and free complementary private health
of health costs. According to a study carried out by the insurance for people with low incomes, while the 2004 reform
Austrian Federal Institute for Health Planning (335), these increased the patient’s financial participation in medical
reforms have reduced access to healthcare for low-income consultations or interventions. Women consult doctors
groups. Cost containments have a regressive effect, since the more often and declare that they renounce consultation for
less one earns the more — proportional to income — one financial reasons more often than men (338).
has to pay. For women, the at-risk-of-poverty threshold is
higher than for men (13 % relative to 11 %) (
In Liechtenstein with the health reform of 1 April 2000,
336). In particular,
women above the age of 65 have the highest percentage several cost-control and cost-reduction measures in the
(19 %) due to the generally low old-age pension payments health insurance sector were introduced and the insured
for women; also single mothers and homeless women are must choose between the general practitioner (‘family
negatively affected. Therefore, elderly persons, in particular doctor’) system (GP) and a free choice of doctors. Insured
women, and chronically ill people, as well as people with a persons on low incomes, minors and the elderly are granted
lower income, are financially burdened by cost containment a reduced premium rate. These reductions, however, are
for health services.
only granted when the insured person joins the family
doctor scheme. Pensioners on low incomes also have the
In Germany, with the 2007 health reform, al citizens are possibility to avail themselves of supplementary benefits
obliged to be insured. Almost 88 % of the population has funded through general taxes in addition to their pension.
mandatory health insurance, while another 9.7 % is insured Expenditure on health insurance premiums and health costs
by a voluntary private health insurance scheme. Men are (doctor and dentist costs, etc.) is also taken into account
more often insured by private health insurance schemes within the context of such supplementary benefits.
than women (337). This can be explained by differences in
income — more often men earn an income above the In the Dutch healthcare system, considering the individual
income threshold for public health insurance. In addition, costs for all diseases, women paid more than men on an
contributions to private schemes do not fol ow the principle individual level in 2005: EUR 2 333 against EUR 1 915 (339).
of solidarity, but gender- and age-specific risks which may There are also large differences in insurance coverage,
penalise women who have gender-specific pregnancy and which can be ascribed to age and country of origin. In 2006,
childbirth ‘risks’ and live longer than men. Because of the the Dutch policy on curative healthcare and long-term
gender pay gap and lower average income, women are more healthcare changed drastically with a new Health Insurance
often concerned by the fact that more and more health risks Act that came into effect on 1 January 2006. Initially, it
are not ful y covered by the public health insurance scheme. had a (limited) negative financial impact on the lowest
income groups, especially on vulnerable groups such as the
chronically ill. Income compensations were thus introduced
335
( ) Federal Ministry for Women and Health (2006), Men’s
for the lowest income groups and for the chronically ill. In
Health Report Austria 2005, Vienna. http://www.oebig.
order to curb the rising costs of healthcare, Dutch citizens
org/upload/files/CMSEditor/1._Oesterreichischer_
were asked to decrease their demand for healthcare as much
Maennergesundheitsbericht.pdf
as possible. Further curbing of the costs was achieved by an
336
( ) Austrian Federal Institute for Health Planning (Österreichisches
implementation and increase of out-of-pocket payments.
Bundesinstitut fuer Gesundheitswesen, ÖBIG). http://www.
The minimum amount of out-of-pocket payments for each
goeg.at/de/OEBIG.html and Federal Ministry for Women and
Dutch citizen, male or female, is EUR 150 a year.
Health (2006), Men’s Health Report Austria 2005, Vienna. www.
oebig.org/upload/files/CMSEditor/1._Oesterreichischer_
Source: EGGSI network national reports 2009.
Maennergesundheitsbericht.pdf
337
( ) Bundesministerium für Familien, Senioren, Frauen und Jugend,
BMFSFJ (2005), Gender-Datenreport, 1. Datenreport zur
Gleichstellung von Frauen und Männern in der Bundesrepublik
Deutschland, Berlin. http://www.bmfsfj.de/bmfsfj/generator/
338
( ) Insee (2008), Femmes et hommes, regards sur la parité, La
Publikationen/genderreport/01-Redaktion/PDF-Anlagen/ges
documentation française, Paris.
amtdokument,property=pdf,bereich=genderreport,sprache=
339
( ) Duch National Institute for Public Health and the Environment
de,rwb=true.pdf
(RIVM). http://www.kostenvanziekten.nl
In Belgium, France, the Netherlands, cost-
out-of-pocket payments (as in Belgium) or extending
containment measures have been integrated with
insurance coverage (as in France and the Netherlands)
special measures extending entitlement to publically
to support healthcare access for low-income and
financed healthcare, such as exemptions and caps to
disadvantaged groups.
95

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Box 2‑19 — Measures to reduce financial barriers in Belgium and France
In Belgium, recent measures have been geared towards insurance funds), to individuals who have no entitlements
a reduction of cost sharing for groups at risk. The BIM or who have lost their rights to the social security, under
(Bénéfice de l’intervention majorée) (340) sets a higher rate for means-tested conditions. Since 1 January 2005, additional
the reimbursement of medical services for certain social help for accessing complementary coverage (CMUC) has
categories as beneficiaries of the ‘revenu d’intégration social’ been proposed to individuals belonging to a modest
or for households whose annual income does not exceed a household but not eligible for CMUC (because they exceed
certain threshold (maximum annual income of EUR 2 707 — the income threshold). Statistical surveys show that women
1/9/2008). The MAF (Maximum à facturer) sets a maximum and young people represent the majority of the 4.3 million
amount of annual expenditure per family on healthcare (2007) CMUC beneficiaries. Manual workers and clerks
that varies according to household income. However, are also over-represented as well as precarious workers at
their impact on improved access to health, in particular for high unemployment risk. Single parent families (essentially
women of lower social groups, has not been evaluated. In single mothers) represent a large and increasing part of the
addition, the threshold of EUR 450 per year to be charged CMUC beneficiaries. Statistical surveys also show that CMUC
to patients is still quite high and can represent a substantial beneficiaries more often declare that they have renounced
part of the household budget. The dossier medical global dental or optical care during the past 12 months for financial
initiative (DMG — Global medical file), introduced in 1999 reasons (women more than men) than people benefiting
and available to the whole adult population, reduces from private complementary insurance, but less than people
medical costs for people opting for it and gives them access who have no complementary health insurance coverage
to free cancer screening every three years. This measure is at all, showing that the CMUC is effective in reducing the
an important complement to reduce financial barriers to giving-up of healthcare. The highest renouncement rate to
healthcare. However, this initiative is not well known: there dental or optical care is for women without complementary
are no data by sex, but people from the lower income groups insurance coverage: 40 % renounce healthcare (versus
have 8 % less chance to have a DMG (341).
29 % for men) (342). Another obstacle that prevents them
from accessing healthcare is the refusal of care from health
In France, derived rights for the dependant spouse professionals: 15 % of CMU beneficiaries declare they
cover some inactive or unemployed married women have experienced such a refusal, mainly from dentists or
without individual entitlement. These rights, however, specialised doctors (343).
are becoming more and more uncertain, due to the
combination of increasing employment flexibility and the Since 1 January 2000, another measure to ensure health
rise of break-ups in unions and marriages. This explains protection was implemented for foreigners who are not
why several ‘universal’ rights linked to citizenship have stable or regular residents in France. The Medical state aid
been developed in the French system for those, essentially (Aide médicale d’Etat — AME) complements the CMU to give
women or immigrants, who do not benefit from individual illegal foreign immigrants access to free medical care and
employment entitlements or from derived rights to social hospitalisation under residence (the person must have been
security. Individuals who lose their entitlements may in France for at least three months) and resource conditions.
usually keep their rights to social protection for one year. According to a recent survey (344), in the Parisian Region,
After that period, they may benefit from ‘universal rights’ AME beneficiaries who are ‘in contact’ with the healthcare
under means-tested conditions. In 2000 the government system (who consult a doctor or are hospitalised) are mostly
introduced Universal illness coverage (Couverture maladie educated young adults (70 % aged 20–39) who have been
universelle — CMU) to support individuals who have no residing in France for less than five years.
other entitlement to the social security system. CMU gives
access to basic social security coverage (basic CMU), and Source: EGGSI network national reports 2009.
eventually to complementary coverage (mutual health
340
( ) The basic principle of compulsory healthcare insurance is that
patients pay care providers directly, at tariffs agreed. Health
342
( ) Boisguérin, B. (2009), Quelles caractéristiques sociales et quel
mutuals reimburse patients partially or wholly according to
recours aux soins pour les bénéficiaires de la CMUC en 2006,
an agreed rate of intervention, excluding some categories of
Etudes et résultats, Drees, No 675, January.
medical costs or providers. The reimbursement is depending
343
( ) The explanation may be that doctors have to comply with
on the income level, and is higher for those with a low income
the Social security tariff for CMU beneficiaries and sometimes
— the bénéfice de l’intervention majorée (BIM) (increased
experience long delay in reimbursement on the part of social
intervention benefit).
security. Boisguérin, B. (2004), Etat de santé et recours aux
341
( ) Mutualité chrétienne, Inégalités sociales de santé: observations
soins des bénéficiaires de la CMU, Etudes et résultats, Drees,
à l’aide de données mutualistes, MC Informations 233,
No 612, December.
septembre 2008.




344
( ) Boisguérin, B., Haury, B. (2008), Les bénéficiaires de l’AME en
h t t p : / / w w w. m c. b e / f r / 1 0 9 / i n fo _ e t _ a c t u a l i t e / m c _
contact avec le système de soins, Etudes et résultats, Drees,
informations/index.jsp

No 645, July.
96

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2. Gender differences in access to healthcare
A mandatory social insurance contribution system is
countries also introduced legislation allowing for private
also present in most eastern European countries (the
insurance schemes and out-of-pocket payments. In
Czech Republic, Estonia, Hungary, Lithuania, Poland,
some of these countries, private expenditure accounts
Slovakia and Slovenia), with Lithuania and Poland
for a large share of total spending, so that access to
having switched from tax-based to social insurance
quality healthcare is expensive and largely affected by
in the mid-nineties (345). During the nineties, all these
income levels and occupational positions.
Box 2‑20 — Financial barriers in some eastern European countries
Among the Baltic countries, the Estonian healthcare system In Poland the role of NGOs is relevant to financially support
is mainly funded by solidarity-based mandatory health access to healthcare services, especially for pregnant
insurance contributions in the form of earmarked social women and children. Public healthcare is financed through
payroll tax. Overall, at the end of 2006, 95 % of the population mandatory health insurance contributions which cover a
was covered by mandatory health insurance, and Estonia large part of the total population. However, actual coverage
appears to be the most inclusive among the Baltic countries, is not complete, and it is slightly biased in favour of men. The
even if it does not adequately cover non-registered, main groups not covered include: homeless people (mostly
unemployed adult men and women. According to the EGGSI men), except for those under special social programmes,
national report, 8.2 % of women in the 45–54 age bracket are unregistered people, unemployed people with no family
not insured, nor are 67.3 % of unemployed men and 54 % relations to the insured person (mostly women), adults
of unemployed women (346). Since the beginning of 2003, who never worked (mostly women) or studied (gender
voluntary coverage has been extended to those who might neutral) or live in families without insurance coverage.
otherwise remain uninsured. Private expenditure accounts Voluntary private health insurance is available but not
for approximately a quarter of all health expenditures, widespread. In most cases it is offered and (co-)financed
mostly in the form of co-payments for pharmaceuticals and by employers and its use is two times higher among men
dental care. The share of private funding (out-of-pocket than women (351). Specialised services (including many
payments and voluntary insurance) has increased from dental and ophthalmological services) are not provided for
19.6 % of the total expenditure on healthcare in 1999 to at all under public health insurance. While, basic healthcare
25.6 % in 2006 (347). By 2005, the incidence of healthcare during pregnancy and birth is available to all women,
services in total expenditures had become equal in the case some procedures, such as anaesthesia during delivery, are
of the poorest and the richest income deciles. While poorer not included in the universal health insurance, and must
(and usually older) residents spend their money primarily be financed by individuals. In order to overcome financial
on buying medicine, the healthcare expenses of wealthier barriers in accessing healthcare, NGO projects support the
(and usually younger) residents are mainly related to dental financing of selected procedures or diseases not covered by
care and spa services (348). However, since 2007, all registered the universal health insurance, especially for children and
unemployed people who participate in active labour market women of reproductive age, female victims of domestic
policy measures are covered by health insurance. In 2002, violence and the elderly. This attention to women’s needs
7.4 % of inhabitants had high healthcare expenses (above reflects a well-organised, self-supporting movement of
20 % of the household budget), 1.4 % of inhabitants were at women in Poland (352). On the other hand, there are very few
risk of poverty due to healthcare expenses (349). Older persons government (central, local) or non-government projects
are especially at risk of high healthcare expenses (350).
concentrating on the financial aspects of men’s health.
Among eastern European countries, Slovenia presents
the lowest inequalities in health insurance coverage. The
346
( ) Koppel, A. et al. (2008), Estonia: Health system review, Health
public scheme covers employees, the self-employed,
Systems in Transition, 2008, 10(1): 1-230.
farmers, recipients of cash benefits (including pensioners)
347
( ) Haigekassa (2007), Annual Report 2007, Estonian Health
Insurance Fund, Tallin.



but excludes persons who do not have permanent
http://www.haigekassa.ee/files/eng_ehif_annual/EHIF_
residence in Slovenia (e.g. asylum seekers, foreigners with
Annual_Report_2007.pdf
temporary residence). The latter are, however, provided
348
( ) Aaviksoo, A. (2009), Health and quality of life, In: Eesti Ekspressi
with emergency healthcare. There are also specific health
Kirjastuse AS (2009), Estonian Human Development Report 2008.
services for people without documents and the homeless
http://www.kogu.ee/public/EIA2008_eng.pdf
349
( ) Võrk, A., Jesse, M., Roostalu, I., Jüristo, T., (2005), Eesti
Tervishoiu Rahastamissüsteemi Jätkusuutlikkuse analüüs.
351
( ) According to the Central Statistical Office — GUS (2007),
Poliitikauuringute Keskus Praxis, Tallinn.
Kobiety w Polsce [Women in Poland], r.2. Zdrowie [ch.2.
350
( ) Habicht, J., Xu, K., Counffinal, A., Kutzin, J. (2005), Out-of-
Health], Warsaw.



pocket payments in Estonia: an object of concern?, HSF
http://www.stat.gov.pl/cps/rde/xbcr/gus/PUBL_Kobiety_w_
Working Document, Health Systems Financing Programme,
Polsce.pdf
WHO Regional Office for Europe.
352
( ) See for instance http://www.oska.org.pl
345
( ) Thomson, S. Et al. (2009), Financing health care in the European
Union. Challenges and Policy responses, European Observatory
on Health Systems and Policies, Observatory Studies series, No.
17. http://www.euro.who.int/document/e92469.pdf
97

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
(in some local areas). However, compulsory health insurance report adequate levels of solvency and subject themselves
covers 100 % of cost of treatment only for certain groups to external audits (355). Insured persons now have the right
(children, pupils, students). Therefore, it is almost obligatory to select their health insurance company, which they may
for people to purchase additional health insurance. Elderly change once per year (always from the 1st of January of the
women are a particularly vulnerable group due to their high following year) by submitting an application to their health
at-risk-of-poverty rate. Since January 2009, Slovenia has insurance company. Healthcare provision is generally paid
funded additional health insurance for low-income groups for by public health insurance.
(i.e. those receiving cash social assistance or are eligible
for receiving cash social assistance) (
The Czech government introduced out-of-pocket
353), offering better
access to healthcare to some of the more vulnerable groups payments for seeking medical treatment from a doctor,
of women (elderly women, single mothers). Additional for prescription pharmaceuticals, and for hospitalisation
amendments to the Health Care and Health Insurance Act in and medical examination, medications and day — hospital
2008 may improve access to healthcare for women. Namely, admissions in January 2008. Fees are not paid for preventive
additional cases previously left out have been included in examinations, mandatory vaccinations, reproductive care,
compulsory health insurance. These are linked to childcare breast cancer screening (mammography), and prescription
— e.g. parents that are on maternity, paternity leave whose of hormonal contraceptives. An annual limit of CZK 5 000
employment contract has expired, parents who pay social has been introduced (lowered to CZK 2 500 as of April 2009)
security contributions and care for a child under 3 years of for the payment of fees. The fees are very low, but for very
age, parents who leave employment to care for four or more low income families (for example single parents), the fees
children, are now included in compulsory health insurance. might mean a barrier in the use of health services (356).
These are in most cases women, even though the measures Source: EGGSI network national reports 2009.
are intended for both men and women (354).
In Slovakia, since September 2006, user fees for services in
the healthcare sector have been lowered. In addition, the
private insurance system has been regulated to prevent
355
( ) General Health Policy for 2007–10, Slovakian Health Policy
abuse. Since 2005, providers have been obliged to respect
Institute, 2008.



http://www.hpi.sk/hpi/sk
hard budgetary constraints and health insurance companies
356
( ) The information is based on qualitative research carried out
are obliged to maintain adequate payment discipline,
under the project Processes and Sources of Gender Inequalities
in Women’s Careers in Connection with the Transformation of
353
( ) http://www.dnevnik.si/novice/zdravje/1042233497
Czech Society after 1989 and after the Accession of the Czech
354
( ) Health Insurance Institute of Slovenia (HIIS)(2007), Compulsory
Republic to the EU, Grant Agency of the Academy of Sciences
health Insurance in Slovenia today for Tomorrow, Ljubijana.
of the Czech Republic No IA700280804. see EGGSI Network
http://www.zzzs.si/zzzs/internet/zzzseng.nsf
National report 2009, Czech Republic.
The third group of countries is represented by some
social inclusion and social protection, the Baltic
southern and eastern European countries with different
countries, Bulgaria and Romania have increased the
institutional models, but a high incidence of out-of-
public resources aimed at improving access to and
pocket payments and private insurance schemes:
quality of care. There are however concerns that the
Cyprus, Greece, Latvia, Bulgaria and Romania. In these
economic crisis is halting this trend, reducing the
countries, access to healthcare is more constrained by
public resources available for healthcare (357).
financial barriers than in other European countries and
many disadvantaged groups are completely excluded.
Cyprus and Greece are the European countries that
most rely on out-of-pocket payments. Cyprus is also
High gender and income inequalities in coverage
the only country in Europe still without a universal
are present in Latvia, and in some eastern European
healthcare insurance system, while Greece, even if it
countries (Romania and Bulgaria), which have only
has universal coverage, has a very fragmented system
recently started developing a modern healthcare
with a high incidence of out-of-pocket payments and
system, switching from a tax-based to an insurance
private health insurance schemes. While these schemes
contribution system in the mid-nineties and
provide access to good-quality services and reduce
presenting high out-of-pocket payments. According
waiting times, they also increase inequalities in access
to the 2008 –10 National reports on strategies for
to healthcare.
357
( ) European Commission (2009), Proposal for the Joint Report
on Social Protection and Social Inclusion 2009, COM(2009) 58
final, SEC(2009) 141. Brussels.



h t t p : / / e u r - l e x . e u r o p a . e u / L e x U r i S e r v / L e x U r i S e r v.
do?uri=COM:2009:0058:FIN:EN:PDF
98

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2. Gender differences in access to healthcare
Box 2‑21 — Financial barriers in Cyprus, Greece, Latvia, Bulgaria, and Romania
In Cyprus approximately only 65–70 % of the population
than other income inequalities in health access. The only
has access to free care and 5–10 % has access at a reduced
available chance for women and men (who are not covered
rate (358). However, different qualifying conditions for
by any social security scheme) to tackle financial barriers to
health coverage (free care without income test for some
the healthcare system is to get a ‘certificate of lack of means’,
and means-testing for others) result in inequities in access
which provides access to public healthcare services.
being an inherent part of the system. Exacerbating these
inequities is the limited capacity of the public health
In Latvia healthcare expenditure is still very low as compared
system to provide services even for those that are eligible
to the EU average (6.4 % of GDP in 2005 relative to the EU
for care. Total health expenditure during the 2000–06
average 9 %) and the public system covers only 57 % of
period was one of the lowest in the EU-27 and the public
total expenditures (363). Public insurance only covers basic
share of health spending is the EU’s lowest after Greece,
health services, but not drug prescriptions, dental services,
with the remaining private share being funded mainly
rehabilitation services, etc. Out-of-pocket payments and
by out-of-pocket payments. Women are more likely to
private insurance are becoming a relevant component of
suffer the effects of these inequities, given that they have
funding and Latvia is one of the European countries with a
fewer financial resources, constitute the majority of single
higher share of private financing. There are no disaggregated
parent families, and are at a higher risk of poverty in old
data indicating the proportion of insured men and women;
age. Other vulnerable groups are women with disabilities
however women are less likely to be covered by additional
and migrant women.
private insurance schemes, as they are not usually employed
in large private companies. To protect low-income groups,
The Greek National Health System (NHS) was created in
some exemptions from co-payments have been introduced
1983 with the aim of insuring the entire Greek population,
in recent years, but they have been difficult to maintain in
thus contributing to the achievement of the goal of equity
the recent crisis situation.
in health and healthcare. Even though the expectations of
the NHS were very high at the time of its creation, gradually
In Bulgaria there is a combination of low health insurance
its efficiency was questioned as long as the private health
rates and a large number of non-insured persons. The
sector was expanding. One of the basic characteristics
healthcare system is financed by mandatory contributions
of the Greek NHS is the co-existence of numerous health
to the National Health Insurance Fund (NHIF), central
funds alongside the coverage of the entire population by a
government funding, voluntary health insurance with
public health system, which is often referred to as the ‘Greek
private health insurance funds, and co-payments from
Paradox’. Greece is considered to have the most ‘privatised’
patients. Health insurance mainly covers primary and
health sector in Europe, with highest incidence of private
hospital healthcare services. A serious drawback of the
and out-of-pocket payments as well as ‘unofficial’ or ‘under-
system is the limited access of patients to specialist medical
the-table’ payments in Europe (
services based on prior authorisation from their GP on
359), whereas private health
insurance is not at significant levels (
the basis of a limited number of ‘tickets’ allocated by the
360). High private health
expenditure is believed to be directly linked to increased
NHIF. On numerous occasions, patients are obliged to pay
levels of dissatisfaction from the NHS (
out-of-pocket for these services or they simply do not get
361). The significant
fragmentation of the system is believed to negatively affect
them. Specific social groups (both men and women) face
the performance of the National Health System in terms
additional disadvantages based on their economic status,
of equity. A study (
ethnic origin or disability. According to the Law on Health
362) conducted in 2003 shows that there
are income-related inequalities in the utilisation of 16 basic
Insurance, registered unemployed and people receiving
health services and prevention tests (including diabetes
social benefits are insured by the state through the budget.
tests, breast examinations, breast screening and Pap tests).
The number of people with no health insurance is estimated
With the exception of hearing and osteoporosis tests, the
at 1 million (the total population is 7.6 million): they mainly
utilisation of the other basic services is largely affected by
get emergency care treatment. The Roma people, who for
income levels. The income elasticity of all 16 services is 50 %
different reasons are not among the unemployed or do not
higher for women compared to the rest of the population,
receive social benefits, lack health insurance rights and are
so that gender-related income inequalities are more severe
obliged to pay for medical check-ups, hospital treatment
and medicines. According to the Ministry of Health care
estimates, almost half of all Roma are not covered by health
358
( ) WHO (2004), 10 Questions about the 10, Report written by
insurance. The legislation is not applied so rigorously and
Albena Arnaudova, Copenhagen.


usually Roma are not denied access to health services in
http://www.euro.who.int/Document/E82865.pdf
these cases. In comparison with the 10 Member States
359
( ) Liaropoulos, L., Tragakis, E. (1998), Public/Private Financing in
the Greek Health Care System: Implications for Equity, Health
that joined the EU in 2004, Bulgaria has the lowest share
Policy, Vol. 43, pp. 153–169.
of public healthcare expenditures on GDP — 4.8–5 % on
360
( ) Liaropoulos, L., Tragakis, E. (1998), Public/Private Financing in
average. In 2002 the share of the people unable to pay for
the Greek Health Care System: Implications for Equity, Health
necessary medical care and drugs, reached 47 % among
Policy, Vol. 43, pp. 153–169.
361
( ) Venieris, D., Papatheodorou, Ch. (2003), Social Policy in Greece,
Athens.
363
( ) OECD data (OMC indicator HC-C3), presented in European
362
( ) Mergoupis, Thanos (2003), Income and Utilization of
Commission — New common indicators from 2006 for the
Health Services in Greece, In: Venieris D., Papatheodorou C.,
Open Method of Coordination (OMC), Health and Long-term
(eds.),Social Policy in Greece, Challenges and prospects.
care, July 2008.
99

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Bulgarian citizens of Turkish origin and 62 % of Roma for over 40 % of the total out-of-pocket expenditures (366).
origin. An additional financial barrier is the relatively high Insurance coverage rates are still low: in 2005, an estimated
cost of medication. As compared to the rest of the EU 7 % of the population was not registered with a family doctor
countries, Bulgarian citizens pay the highest proportion for and consequently could not benefit from any public health
medications (56 %) out of their pockets, while the relative services. A survey carried out in 2000 (367) showed that only
share of the public spending is only 44 % (364).
34 % of the Roma were covered by the health insurance
fund, compared to the national average of 75 %. Also, many
In Romania, since the Health Reform Law in 2006, people with poor economic status cannot afford to pay the
private insurance companies have been allowed to offer monthly premium, due to insufficient income or resources.
supplementary or complementary insurance (365). Those The 2008–10 NSR (368) provides for additional resources to
who opt for voluntary health insurance are not excluded improve access and quality of care; however it is not clear if
from participating in the statutory health insurance these provisions will be maintained given the gravity of the
scheme. Pregnant women and postpartum mothers have current economic crisis. A free basic health service package
special rights within the social health insurance system. for deprived population groups has been defined, together
They are insured without paying the insurance premium, with projects for health services for disadvantaged groups,
and if they do not have an income, or if their income is support to private and public providers of medical and
below the minimum national average, they are entitled to social services addressing disadvantaged groups (the Roma,
free of charge outpatient treatments and transport to the street children, families on low incomes, elderly people) and
hospital for delivery or emergencies. Health insurance does access to essential medicines.
not cover all healthcare services. Specialised care must be
paid for directly by the patients or through other sources Source: EGGSI network national reports 2009.
of payment. Informal payments are estimated to account
366
( ) National Statistics Institute (2007), Romanian Statistical
Yearbook 2007, Bucharest.


http://www.insse.ro/cms/rw/pages/index.ro.do
364
( ) Data for 2007 from the Association of the Research-Based
367
( ) Zamfir, C., Preda, M. (2002), Romii in Romania [Roma in
Pharmaceutical Manufacturers in Bulgaria.
Romania], Bucharest.
365
( ) European Observatory on Health Systems and Policies (2008),
368
( ) National Strategic Report for Social Inclusion and
Healthcare systems in transition, Vol. 10, No 3, Romania
Social Protection, 2008, Romania.


Health System Review.




http://ec.europa.eu/employment_social/spsi/docs/social_
http://www.euro.who.int/Document/E91689.pdf
inclusion/2008/nap/romania_en.pdf
2.2.2. Cultural barriers
extent as men. But the most interesting result
of the study was that it was observed that when
The distinct roles and behaviours of men and women
women gave an SOS-alarm, they were generally
in a given culture, resulting from gender norms and
given a lower priority than men, meaning that
values, give rise to gender differences and inequalities
it took longer for the ambulance to arrive. One
in access to healthcare, as well as in risky behaviour and
reason for this might be that women’s symptoms
health status (369).
are not taken as seriously as men’s, but maybe
also men might only call when they are seriously
The first relevant element to be considered while
ill while women call more often. The results were
analysing cultural barriers is connected with gender
used to raise consciousness about gender issues
stereotypes. On the one hand, women deal with
in the staff and formed the basis for discussions
difficulties in accessing healthcare due to prejudices
in the organisations involved in ambulance
concerning women’s health-related behaviour, or, in
medical care.
certain ethnic groups, customs and habits regarding
their role in family and social life. Some examples of

■
Another example comes from Poland where
prejudices and customs are contained in various EGGSI
stereotypes make access to some healthcare
national reports.
procedures difficult for women. This regards,
for instance, treatment of alcohol addiction or
■ In Sweden a project called ‘Ambulance Care’ (370)
alcohol-related diseases. Since these problems
showed that women use ambulances more
are perceived as male-related (in fact, they affect
than men. This could be a result of the fact that
mostly men in Poland), women may be deprived of
more women live alone than men, that women
proper treatment. Some psychiatric hospitals have
live longer and that they might not have access
proved completely unprepared for the admission
to a car or have a driver’s licence to the same
and treatment of women (371).
369
( ) WHO, Gender, Women and Health.


371
( ) Gazeta Wyborcza (2008), Feministki: w szpitalu dyskryminują
http://www.who.int/gender/en/
kobiety, November 11.



370
( ) Ambulansforum, Sweden.


http://miasta.gazeta.pl/radom/1,48201,5888267,Feministki__
http://www.ambulansforum.se/
w_szpitalu_dyskryminuja_kobiety.html
100

---

2. Gender differences in access to healthcare

■
In Romania family opinion is particularly important
propensity to seek help on health issues from
in the demand for contraceptives and family
primary care services. They tend to go to general
planning advice. Resistance by a husband and
practitioners later and are more likely to use
cultural opposition to the use of contraception are
the Accidents and Emergency Department. The
important detriments to the seeking of medical
cultural explanations given for this are that men
advice. Roma adolescents, whose families adhere
have different risk perceptions and are more likely
to traditions that equate a girl’s virginity with
to attribute symptoms to less threatening causes
family honour and place the responsibility for sex
and that they are reluctant to consult with GPs on
education on a mother or sister-in-law, may have
trivial matters as this may appear ‘wimpish’ (374) or
particular difficulties in accessing information on
emasculating (375). Other studies recommended
sexual health. Cultural conventions about the proper
that in order to increase men’s use of health
treatment of health issues may also inhibit access.
information and services, they could be made
Women often accept symptoms of genito-urinary
more male-friendly, anonymous and convenient.
illness as part of life and may be embarrassed to
This could be achieved through increased use of
seek medical care. In many settings, ‘modern’ and
NHS Direct (376), pharmacists, occupational health
‘traditional’ health services still compete with each
and online advice (377).
other. Poor population groups are especially likely
to turn to traditional medicine.

■
In Poland, for example, survey data show that men
avoid visiting doctors more often than women (378).

■
In Cypriot society, with traditional beliefs that
Expectation that a male should be fit and healthy
reinforce patriarchal attitudes toward women,
may be one of the reasons for the lower rate of
gender stereotypes as well as societal expectations
medical care use by men as compared to women.
with regard to gender roles contribute to creating
The report also highlights an additional male
an atmosphere where domestic violence is largely
stereotype: some health-threatening behaviours
tolerated. As a result of this, a general culture of
by men are accepted or at least tolerated, such as
victim blaming exists in all social classes, and this also
drinking alcohol or even occasional risky drinking
seems to be the case among health professionals.
during special events and holidays. This is often
In fact, according to a study on the attitudes of
indicated as one of the main causes of transport
health professionals and domestic violence, health
accident rates and the high male mortality rate due
professionals revealed a general lack of awareness of
to (transport) accidents.
the causes and consequences of domestic violence
and tended to justify the actions of perpetrators
Women use healthcare services frequently in relation
and transfer responsibility to the victims (372).
to maternity care and the delivery of children.
Throughout their lives and due to their reproductive
On the other hand, men also have to face stereotypes in
role, women go through a process of socialisation in
accessing healthcare and prevention programmes. As
which the healthcare system becomes much more a
already mentioned earlier, osteoporosis, for instance,
part of their life experience than for men. Also, women
is perceived as a female disease, and it might be less
live longer and they more frequently use inpatient
obvious that men should be treated for osteoporosis
hospitalisation than men (see Figure 2-7). According
as well, as shown in some EGGSI national reports.
to the Iceland EGGSI report, the fact that men are less
Certain education and health prevention programmes,
familiar with the healthcare system, since they miss
especially anorexia and eating disorders, are targeted
the socialisation process women experience, may
mostly at women, only occasionally mentioning
play a role in explaining the differences in accessing
men. Gender-related cultural barriers may also reflect
healthcare.
stereotypes regarding lifestyle, where for example, men
are expected to be in good shape, dedicated to sport
374
( ) Banks, I. (2001), No man’s land: men, illness, and the NHS, British
and fitness, etc. The following present two examples
Medical Journal, No 323, 3 November.
from EGGSI national reports in greater detail.
375
( ) Wilkins, D., Payne, S., Granville, G., Branney, P. (2008), The Gender
and Access to Health Services Study, Department of Health,
London.
■ Although research is scarce, in the UK, evidence
376
( ) NHS Direct offers 24-hour advice and support by telephone and
suggests that men and women make very
other multimedia channels.


different use of primary care (373). Men have a lower
See http://www.nhsdirect.nhs.uk


EGGSI Network National Report 2009, UK.
377
( ) Banks, I. (2001), No man’s land: men, illness, and the NHS, British
372
( ) Apostolidou, M., et al. (2008), Attitudes of Health Professionals
Medical Journal, No 323, 3 November, pp. 1058–60.
on Violence in the Family, United Nations Development
378
( ) GUS (2008), Podstawowe dane z zakresu ochrony zdrowia
Programme, Cyprus.
w 2007 r., Warsaw, GUS (2007), Kobiety w Polsce [Women in
373
( ) Campbell, J.L., Ramsey, J. and Green, J. (2001), Age, gender,
Poland], r.2. Zdrowie [ch.2. Health], Warsaw; GUS (2007), Ochrona
socioeconomic, and ethnic differences in patients, assessment
zdrowia w gospodarstwach domowych w 2006 r. [Healthcare in
of primary health care, Quality in Health Care, No 10.
households in 2006], Warsaw.
101

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Apart from gender stereotypes, the following issues
Several EGGSI national reports have also described
should also be taken into consideration when analysing
the incidence of social status in the use of healthcare
cultural barriers in accessing healthcare:
and in the perception of health. For example, in
Romania educational attainment and income have
1. social status and level of education;
been reported as relevant predictors of the use of
healthcare, due to missing information or difficulties of
2. cultural differences inherent in ethnicity and
access to care. In Hungary this has been reported as
migration issues (that involve not only language
particularly evident in take-up rates on breast cancer
skills but also traditions and norms of hygiene);
and cervical screenings (which is lower in women
with a low level of education, the unskilled, the Roma,
3. religious practices;
the inactive population, or the poor, particularly in
remote, underdeveloped and rural areas). In Portugal,
4. prejudice concerning sexual orientation;
socioeconomic conditions have been reported as
particularly determinant in relation to age: a large
5. working culture.
percentage of older women (over 65 years old) have low
educational level, which means a more difficult access
These issues are discussed in more detail below, relying
to and acquisition of information on topics relevant to
on information from the EGGSI national reports.
their well-being. This may explain why many in this age
group still use domestic healing practices and home
Social status and low level of educational
remedies to deal with their illnesses.
Social status represents a major source of inequality
Cultural differences
in access to healthcare. Eurostat Statistics in focus
24/2009 (379) investigated the relationship between self-
A rather important area where cultural barriers play
perceived health and unmet medical needs, correlated
a relevant role in accessing healthcare is connected
with demographic and socioeconomic variables. The
with immigration, in terms of cultural and linguistic
explanatory factors considered were gender, age group,
differences with the host country, religious beliefs and
income, country of residence, level of education and
practices, and difficulties linked to the legal and social
activity status. The results show that there is a direct
situation of immigrant populations. This issue presents
correlation between the probability of reporting bad/
two different points of view: the side of the patients
very bad health or unmet medical needs and some of
and the side of healthcare providers. Some relevant
these factors:
elements to be considered from the side of the patients
and their behaviours have been described in EGGSI

■
the probability rises considerably when the level of
national reports and summarised as follows.
income decreases ;
■ Differences in attitudes towards health and

■
the probability rises considerably among inactive
healthcare: a consideration emerging from
and unemployed people;
the Liechtenstein report, for example, is that
‘socially disadvantaged people, of whom many

■
the probability decreases when the level of
are foreign-language migrants, are exposed to
education raises.
higher health and disability risks. They generally
make less use of preventive check-ups and have
So the probability of reporting bad health and
poorer knowledge of health and risk factors
unmet medical needs increases with the decrease
and have different cultural understandings of
of socioeconomic conditions such as the level of
health, sickness, and hygiene compared with the
income, the level of education, and activity status,
Liechtenstein population. Culturally different
while from a gender perspective it should be noted
views than those prevalent in Liechtenstein exist,
that the probability of reporting bad/very bad health
for instance, with respect to the care of infants
is less frequent among women, while the probability
and children, but also with respect to nutrition:
of unmet medical needs is a bit more frequent among
foreign-language migrants are likely to exhibit less
women than men.
healthy behaviour than the native population’ (380).
Dutch general practitioners report unclear health-
seeking behaviour and so-called non-compliance
behaviour (disregarding doctors’ advice) of men
379
( ) Eurostat (2009), Perception of health and access to healthcare
and women from ethnic minorities. A remarkable
in the EU-25 in 2007, by Baert, K. and de Norre, B., Statistics in
Focus, No 24/2009, Luxembourg.



380
( ) Marxer, Wilfried (2007), Migration und Integration — Geschichte
http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-
— Probleme — Perspektiven: Studie der NGO-Arbeitsgruppe
SF-09-024/EN/KS-SF-09-024-EN.PDF
Integration (co-author Manuel Frick), Bendern.
102

---

2. Gender differences in access to healthcare
research finding is that second- and third-

■
In Portugal, access to health services by immigrants
generation migrants experience more difficulties
and ethnic minorities, though recognised as a right
regarding access to qualified healthcare than
for all those who are legally registered in Portugal,
first-generation migrants. This implies that
can often be hampered because of the lack of
language is not such a problem, as second- and
preparation and adjustment to cultural diversity on
third-generation migrants usually speak Dutch,
the part of health professionals and this creates a
meaning the problem is the difference in cultural
gap between immigrants and healthcare services:
background (381).
the immigrant population is not familiar enough
with actual Portuguese health services, making
■ Differences in the role and relevance attributed to
them suspicious and afraid and the difficulty in
genders, in some cases with the legitimisation of
understanding and speaking Portuguese makes
the use of violence against women. In recent years,
communication harder between immigrants and
issues of violence against immigrant women have
technicians.
become the centre of public attention concerning
female genital mutilation (FGM), forced marriage

■
Both Dutch healthcare professionals and healthcare
and trafficking in women and girls: examples have
users from a different ethnic background report
been reported in the Norwegian and Austrian
mutual lack of knowledge, ignorance and
EGGSI national reports (382). In Norway the National
misunderstanding as bottlenecks in access to
action plan to reduce domestic violence 2008–11
healthcare. In Bulgaria, lack of knowledge, ignorance
includes the protection of victims, treatment
and non-consideration by general practitioners and
programmes for those who batter, increased
other health specialists of the cultural differences
knowledge of domestic violence within healthcare,
and traditions of people of Roma and Turkish origin
prevention strategies and an increased focus upon
worsen their contact with these patients. This often
research and development (383). The Action plan to
leads the poorly and less-educated of these groups
combat female genital mutilation 2008–11 clearly
to resort to methods of self-treatment.
places the responsibility for efforts to struggle
against the practice of female genital mutilation

■
In many cases migrants and Roma people are
with national, regional and local authorities. In
described as subject to negative attitudes/racism/
Austria, special attention is given to traditionally
discrimination of some healthcare workers and
influenced violence against immigrant women, e.g.
hospitals. This can be seen most overtly in the case
female genital mutilation (FGM), forced marriage
of Roma women. Roma women face at least two
and trafficking in women and girls. In 2005 the
main obstacles concerning the health services, i.e.
Vienna Women’s Health programme supported the
the poor access to the services due to the difficulty in
establishment of a counselling centre for women’s
obtaining information, and discrimination by those
health and genital mutilation (384).
who work in the healthcare system. It is particularly
women living in the remote parts of the countries

■
Differences in educational attainments of women:
and small villages who do not have sufficient access
ethnic minority women are often characterised
to the healthcare services. As in the case of other
by low educational levels, and in particular within
European countries Roma women in Hungary have
Roma communities, high rates of illiteracy and poor
access to these services in the case of childbirth
school attendance by the children, which hampers
and of urgent situations. Roma women however
their access to services.
suffer from forced segregation even in hospitals,
in rooms where there are only Roma women.
From the side of healthcare providers the impact of
In Romania the EGGSI national report describes
cultural differences in the access of healthcare can be
stigma and discrimination as relevant limits in
summarised by some examples presented in the EGGSI
the access to healthcare for the Roma people. The
national reports.
refusal may be direct discrimination and takes
many forms, including denial of entry into medical
facilities, setting limits on when a patient can be
381
( ) Keuzenkamp, S., Merens, A. (2006), Sociale Atlas van Vrouwen
seen and denial of assistance to family members
uit Ethnische Minderheden, Social and Cultural Planning Office
or visitors. Although existing legislation on equal
(Social Map on Women from Ethnic Minorities), Den Haag.
opportunities and non-discrimination is reinforced,
382
( ) In 2005 the Vienna Women’s Health programme supported the
there are circumstances when members of Roma
establishment of a counsel ing centre for women’s health and
communities may be subject to verbal abuse,
genital mutilation citied in Vienna Women’s Health Report 2006.
383
( ) Justis og politidepartementet, Vendepunkt Handlingsplan mot
delayed care, segregation, or outright denial of
våld i nære relasjoner 2008–11.



services on grounds of their ethnicity. Roma women
h t t p : / / w w w. r e g j e r i n g e n . n o / u p l o a d / J D / Ve d l e g g /
are disproportionately affected by such treatment
Handlingsplaner/Vendepunkt.pdf
given their generally higher interaction with health
384
( ) City of Vienna 2006, pp. 384–398.
103

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
services as mothers and carers for other family
Religious practices
members. Poor communication between health
professionals and Roma health system users limits
Religious beliefs may affect access to healthcare both in
access to information on health issues. Moreover,
the case of immigrants and in the case of nationals, for
the Bulgarian report highlights that residential
different reasons. For example, in Belgium hospitals face
segregation puts the Roma at a greater physical
refusals from women of some ethnic minorities (or their
distance from healthcare facilities, and they often
partners/husbands) to be treated by a male gynaecologist
live in areas without a general practitioner.
even when an urgent intervention is needed. In this
case, intercultural mediation services, available in public
One of the greatest barriers for migrant men and
hospitals (386), can help to deal with difficulties posed by
women in accessing health services are the language
cultural differences. Cyprus has always had a significant
difficulties between migrant patients and health
Muslim minority, which is growing given the influx of
personnel. Difficulties in verbal communication,
immigrants and workers from many countries with
however, not only include language barriers but also
Muslim populations. These changes call for the need to
misunderstandings due to cultural differences in
offer services that are cultural y sensitive and offer options
interpreting health and illnesses. As described in the
that do not clash with an individual’s culture and value
Austrian EGGSI report, ‘the results of these difficulties
system (e.g. female gynaecologists for Muslim women).
in communication between migrant patients and
Also, Maltese NGOs report that, due to their religious
health personnel are wrong diagnoses, inefficient
beliefs, Muslim women may find it unacceptable to be
treatment and long “care history” of patients. In
examined by male medical doctors, and often request
particular in sensitive areas of medical treatment
the assistance of female social workers (387) when in need
such as gynaecology and obstetrics very few
of healthcare, but this may not always be granted in
personnel with migrant background can be recruited.
Malta’s state hospitals. In the Netherlands, considering
Furthermore, there are incisive information deficits
that the Islamic tradition does not al ow women to
by migrants about the services of the Austrian health
talk to men they are not married to, a care-consultant
system. The deficient information about the Austrian
who is equipped with knowledge and experience with
healthcare system and the deficient provision of health
different cultures mediates between the healthcare user
programmes for this particular population group
and healthcare provider. However, the care-consultant
result in a lacking utilisation of preventive, psycho-
cannot replace a medical professional. Therefore, it is still
social and rehabilitation measures’. In Germany, where
necessary to develop intercultural competences among
legal migrants are medically insured and thereby have
healthcare professionals.
access to general medical treatment, a great number
of female migrants who live in traditional family
Other concerns have been presented in the EGGSI national
structures are reported to need language assistance
reports for Cyprus and Poland. In Cyprus, emergency
from relatives when they see a doctor. In certain
contraception is provided by the Cyprus Family
cases, they are accompanied by representatives of
Planning Association (CFPA) and by pharmacies without
organisations offering social assistance for migrants.
prescription. Nevertheless, the CFPA has received several
Many women prefer doctors where the staff is able
reports and complaints by women who were refused to
to speak the same language as they do, in order to
be provided with the pill by pharmacists, who insisted on
be more independent and to protect their privacy.
requesting prescription, either due to ignorance of the
Due to language problems, some women refrain from
regulation or on the basis of conscience issues. In Poland,
seeing a doctor even if necessary — and do not make
89 % of the population is Catholic (388) and the Church
use of preventive check-ups (dentist, gynaecologist,
has a visible impact on sexual (conception, birth control,
etc.). Within the National action plan for integration
in vitro fertilisation) and ethical education at schools as
(Nationaler Aktionsplan für Integration), the federal
wel as on political parties and political life. The Catholic
states agreed on better integration for migrants and
Church stance on abortion, birth control and fertilisation
people with a migration background in the health
methods also affect doctors’ behaviour and their readiness
system through an ‘inter-cultural’ opening (385), with
to implement certain medical procedures (389).
the support of integration counsellors.
386
( ) According to the EGGSI network national report 2009, Belgium,
the Federal Ministry in charge of Health is financing such
services in hospitals.
387
( ) Draws on an interview with the Organisation for the Integration
and Welfare of Asylum Seekers (OIWAS) in February 2009.
388
( ) Central Statistical Office Poland (2008), Concise Statistical
Yearbook, Warsaw.




http://www.stat.gov.pl
385
( ) Bundesministerium
für
Gesundheit,
BMG
(2007),
389
( ) Public Opinion Research Centre (2008), Acceptability of in vitro
Mitglieder, mitversicherte Angehörige und Krankenstand,
fertilization.





Jahresdurchschnitte 1998 bis 2007, Berlin.
http://www.cbos.com.pl
104

---

2. Gender differences in access to healthcare
Sexual orientation
women utilise such service provisions less often, also
due to fear of being stigmatised or discriminated by
A specific cultural issue that affects access to
the health personnel.
healthcare is linked to sexual orientation. Gay and
lesbian organisations frequently report discrimination
Working culture
in healthcare access (390). Lesbian women for example,
often remain ‘invisible’ in the public health system; their
An additional cultural barrier that is worth mentioning
sexual orientation is not addressed. This is due to the fact
mainly affects men and relates to the flexibility of
that both medical staff and health researchers have little
services. An explanation given in the UK for men’s lower
knowledge about the lifestyles, health requirements
use of primary care services is that the opening hours
and specific health risks of lesbian women. It remains
are incompatible with the long working hours that
to be seen whether lesbian women have specific
characterise the UK labour market. Men are unable or
health risks and illnesses, whether they participate
uninclined to access primary care services because they
in early detection examinations less frequently than
are more likely than women to work ful -time and to
other women. In this regard, in Austria in October
work more than 45 hours per week (391). In some cases,
1998, an Anti-discrimination unit for same sex lifestyles
similar difficulties have been reported for single mothers
was established by the Vienna city administration.
in accessing healthcare, due to reconciliation problems.
This was the recognition of the fact that lesbian, gay
and transgender lifestyles have so far not yet been
Good practice examples in overcoming
sufficiently perceived and recognised. In Austria, there
cultural barriers
are no other specific institutions for the promotion of
sexual health for lesbian women, gynaecological health
There are a number of specific programmes organised
services such as family planning institutions, prenatal
throughout Europe to overcome cultural barriers. In
services or birth clinics are predominantly focused on
most cases, there is a general strategy addressing
the needs of heterosexual women. Therefore, lesbian
intercultural barriers, but some peculiarities emerge.
Box 2‑22 — Good practices in some European countries
Italy — Department of Prevention
using family members as translators conflicts with doctor–
Healthcare for Migrants
patient confidentiality. The fact that foreign-language
migrants are mainly present in the Liechtenstein healthcare
Among the existing local experiences of healthcare system as patients and not as professionals aggravates the
specifically targeted at migrants, San Gallicano hospital language problem.
in Rome is particularly interesting, where there is the
Department of Prevention Healthcare for migrants (legal or Based on the results of the 2007 integration report, the
not), ethnic minorities and the homeless. A specific service following measures have been initiated in Liechtenstein:
for female health promotion offers immigrant women (a) In order to improve communication and integration of
gynaecological and oncological examinations. Most of the the healthcare system, the Director of the Office of Public
doctors are female and a translation service is provided.
Health became a member of the Working Group against
Liechtenstein — A programme to improve Racism, Anti-Semitism, and Xenophobia.
communication and integration of the
(b) Physicians were provided with a list of interpreters,
healthcare system
an overview of all contact offices and persons for cultural
In Liechtenstein, the Working Group against Racism, communication in Liechtenstein and Switzerland, and the
Anti-Semitism, and Xenophobia stated that foreigners revised Ordinance on the Movement of Persons. In addition,
and Liechtenstein citizens are treated and provided with the Health and Integration Office of Caritas Switzerland in
medical care equally (392). However, the health expert group Chur offered to serve as a contact point and clearing house.
(part of the Working Group against Racism, Anti-Semitism, Accordingly, physicians in Liechtenstein can also make use
and Xenophobia) points out that physicians often lack of the list of interpreters provided by Caritas.
cultural background knowledge to be able to grasp and (c) Physicians were introduced to the existing overview of
appropriately react to the whole range of foreigners’ integration services in Liechtenstein in the updated social
health problems: communication difficulties with foreign-
encyclopaedia on the Internet. The Information and Contact
language patients make treatment in doctor’s offices and Centre for Women’s brochure in different languages was
hospitals more difficult. The frequently used solution of also sent to doctors’ offices.
392
( ) Working Group against Racism Anti-Semitism and Xenophobia
(d) Since July 2007, the National Hospital in Vaduz uses the
(2007), Integration of the foreign population in Liechtenstein, Vaduz.
telephone interpreter service TeleLingua when communication
391
( ) Wilkins, D., Payne S., Granville, G., Branney, P. (2008), The Gender
390
( ) As an example see Ireland Gay Health Forum.


and Access to Health Services Study, Department of Health,
http://www.irishhealth.com/article.html?id=15671
London.
105

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
difficulties arise between doctors or nurses and foreign-language Slovenia — National programme for the
patients. Nine of the most commonly used foreign languages Roma community
are available. In emergencies and for shorter conversations,
the telephone service is an uncomplicated alternative to the In Slovenia, where the group that stands out as the most
presence of interpreters. In this way, doctors and nurses no vulnerable in terms of cultural (and language) barriers to
longer have to rely on the family members of the patients who accessing healthcare is the Roma population, a National
may speak German, but who often lack the necessary expertise programme of measures for Roma is under preparation,
and for whom the translation is too difficult.
which also includes measures to reduce health inequality in
the Roma community.
Romania — The National programme for
health assistance at community level
Sweden — A programme dedicated to
overcoming cultural barriers
A national network of health mediators has been created,
facilitating contact between health personnel and Roma A programme promoted by the Centre for Clinical Research
communities; mediators are Roma representatives Västerås of the University of Uppsala dedicated to overcoming
(especially women) trained and hired at District Public cultural barriers was initiated by Asylhälsan (Asylum Seekers
Health Authorities. Roma health mediators prove to be Health Care) with participation in an Equal project on
influential in identifying discriminatory behaviour and Asylum seekers in the region of Uppsala and Västmanland
helping healthcare workers to dispel prejudices that cause carried out by the non-governmental organisation of UP
inferior and degrading treatment. They also help in raising AROS ASYL (393). The overal objective of the programme was
awareness in Roma communities about rights, complaint to reach Arabic-speaking women and provide information of
mechanisms and alternative sources of healthcare.
self-care as wel as to develop competencies at the county
council to better treat and understand their needs.
Source: EGGSI network national reports 2009.
393
( ) UP AROS ASYL (n.y.), Asyl- och Integrationshälsan, slutrapport.
http://193.13.74.89/d2/public/153/071025Asylhalsan.pdf
2.2.3. Geographical and physical barriers
should also be noted that care provision within cities
can be equally mixed, exhibiting variations between
Even if in most European countries access to (basic)
richer and poorer neighbourhoods’ (394).
healthcare is a universal right, geographical disparities
(such as distance from hospitals and healthcare centres,
Geographical barriers are first of all a problem due
as well as lack of accessible transportation systems)
to the territorial configuration of the country. Some
and physical barriers (such as facilities for the disabled)
countries suffer greatly from this aspect.
in the delivery of care may prevent actual access.
These barriers affect especially women living in rural
In Greece inequalities in health can have a geographical
or mountainous areas, or disabled and elderly women.
dimension, as the lack of health services in some rural or
The following section explores these difficulties.
remote regions can result in different health outcomes.
The Greek National Health System, consisting of
Geographical barriers
numerous hospitals and health centres across the
country, covers the majority of the Greek regions.
Geographical variations in coverage and provision
Nevertheless, significant disparities between regions
are a relevant barrier to accessing healthcare. ‘Supply
exist in terms of the number of doctors and hospital
is typically greater in bigger cities and more densely
beds per 100 000 inhabitants, mainly due to the specific
populated areas, whilst there is a lack of GPs or
geographical configuration of the country.
family doctors and certain basic specialist services
in small, rural and remote areas. Hospitals are often
Another frequent problem is the unequal distribution
unevenly distributed and as a large proportion
of assistance throughout a country due to the political
of medical staff is concentrated in hospitals this
and administrative configuration of the healthcare
exacerbates geographical disparities. Geographical
system. The main reasons for disparity are linked for
features (islands, mountains) may be an explanation
example to federal structures, allowing consistent
for some Member States but in others (e.g. Finland,
autonomy to local areas for the organisation of the
Spain, Denmark, Italy) disparities are the result of
health system, or to specific choices made in order to
a decentralised decision-making process giving
rationalise and improve the quality or the efficiency of
regional and local authorities policy discretion and
the health system.
permitting regional differences in funding. While
allowing services to adapt to local circumstances,
394
( ) European Commission (2007), Joint report on social protection
local decision-making has led to varying treatment
and social inclusion — Supporting document, SEC(2007) 329,
and coverage as well as to variations in staff levels. It
Brussels.
106

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2. Gender differences in access to healthcare
In the following table several examples across Europe are reported:
Box 2‑23 — The unequal geographical distribution
of healthcare in some European countries
Austria
households have medical aid further than 5 km compared to
The density of practising physicians is subject to considerable
1.4 % in urban areas in 2007 (397). In 2008, a study (398) showed
variation across the country. Rural regions such as the
that going to a family doctor was not easy for 13 % of the
Land of Burgenland in the east (32 physicians per 100 000
population: the main reasons were the distance from home
inhabitants), Vorarlberg (345 per 100 000) or Upper Austria
and the dependence on public transportation (58 % did not
(362 per 100 000) have the lowest density. (
find it easy) which is not always affordable or suitable.
395) In contrast,
Vienna, the federal capital and the largest city by far, has
Hungary
700 practising physicians available per 100 000 inhabitants
The 2006 Health Service Reform was aimed at rationalising
and thus more than twice as many as the abovementioned,
the system. People now have to travel farther, and it takes
largely rural areas. In a ‘location plan’ which is drawn up by
more time and more money. This affects women, who travel
the health insurance funds and the physicians’ chambers,
more often by public transport than men do, and especially
the number and the provincial distribution of self-employed
elderly women, who are often more dependent on family
physicians is specified. The aim of this regulatory measure is
members’ help. This situation is particularly true for people
to avoid imbalance in the provision of healthcare.
who have disadvantaged social positions in general, due to
Belgium
the elevated costs. The 2008 National Strategy Report on
In Belgium, recent measures promote the presence
Social Inclusion and Social Protection cited these difficulties
of general practitioners in less well-off zones through
to some extent by emphasising that deficient service
financial incentives, in order to have ‘care zones’ with
coverage meant serious disadvantage to old people living
facilities accessible within a radius of 20 km. This relates
in small settlements (399).
mainly to preventive and diagnostic care. Meanwhile, an
Italy
emerging concern is the policy to have ‘reference services’
In Italy, geographical barriers are strictly related to strong
within a limited number of hospitals (such as for advanced
disparities between northern and southern regions that are
device) with the aim of lowering health costs and increase
paramount when considering quality healthcare services
efficiency of care. Accessing such ‘reference services’ can
and the diffusion of prevention programmes. The prevalence
be more problematic for people living in more isolated
of screening programmes show a great difference between
zones or for people who have to rely on public transport.
north-central and southern Italy. In the north-central regions
This ‘geographical accessibility’ would be an important
of the country, the extension of mammographic and cervical
aspect to consider when monitoring the policy (396).
screening programmes is nearly 100 % and the extension
Cyprus
of colorectal programmes is over 50 %. In the southern
The main problem is the lack of provision for certain
regions, the figures are considerably lower. This difference
specialised services in (accessible) health centres across
tends to grow if we also consider compliance to invitation.
the island. Thus, women seeking specialised preventative
Compliance is higher in the north-central Italy compared to
care and treatment may be unable to do so due to the lack
the southern part of the country. The combination of these
of available specialised healthcare in rural areas, as most
two parameters (invitation and compliance) increases the
rural health centres provide only primary care. For example,
inequality in early diagnosis between north and south.
women invited to undergo breast cancer screening tests must
Portugal
visit main district hospitals, and although a mobile unit was
Pregnant women constitute a group for whom geographical
donated to the Ministry of Health by Europa Donna Cyprus, it
barriers are considered highly penalising, particularly
is not currently in use. In relation to sexual and reproductive
at the time of delivery. The problem has to do with the
health and family planning, public hospitals, both general
new organisation of health services, committed to the
hospitals in the main cities, as wel as regional hospitals or
concentration of hospital services, with the closure of
healthcare centres, usual y offer only limited services, mostly
many hospitals, which means that many pregnant women
related to pregnancy and reproductive health. For women
have to look for help at the time of delivery in locations far
living in rural areas, this may complicate matters even further,
from their homes. In the last two years (corresponding to
since they may have to travel longer distances to access
the closure of maternity wards), the number of deliveries
private clinics in urban or semi-urban centres.
made in ambulances has increased, with the associated
Estonia
risks to mother and child. This reflects the effect that the
In rural areas, the distance to the closest healthcare facilities
397
is much greater than in urban areas. Some 43 % of rural
( ) National Statistic Institute, Estonia. http://pub.stat.ee
398
( ) Faktum e Arikov (2008), Patsientide hinnangud tervisele ja
arstiabile, Tallin.




395
( ) Hofmarcher, M., Rack, H. (2006), Austria: Health system review,
http://www.haigekassa.ee/uploads/userfiles/Patsientide%20
Health Systems in Transition 2006, No 8(3).
rahulolu%202008.pdf
396
( ) Since recently, travel costs can be reimbursed for cancer
399
( ) National Strategy Report on Social Protection and Social
patients by the compulsory insurance.
Inclusion 2008–10 (NSR), Hungary, Budapest, 2008.
107

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
actual policies of the closing down of maternity units has on towards their citizens. There are only small differences in
women. Moreover, the concentration of the population in accessing medical care in different geographical areas.
certain areas of the country leads to organisational choices UK
that end up providing uneven services. This is the case for
uterine cancer screening, available to women living in the A major issue in the UK concerns the variation in service
metropolitan area of the country’s capital, Lisbon, but it is delivery according to location. There are geographical
not available to women living in other areas.
variations in all aspects of healthcare, for example,
Romania
treatment and death rates in hospitals, cancer survival rates,
or access to drugs to treat multiple sclerosis or Alzheimer’s
Rural residents typically have smaller incomes and lower disease, cancer screening programmes. For women, this
levels of education and are more likely to be uninsured. is particularly important regarding the availability of
Specific problems of access to healthcare by women in rural contraception, IVF fertility treatment, abortion and breast
areas include the lack of healthcare providers, particularly cancer survival rates. In 1999, the National Institute for Health
for primary healthcare and obstetricians, due to recruitment and Clinical Excellence (NICE) established which treatment
and retention issues. Relatively impoverished populations, drugs should be widely available for free on the NHS. Where
lack of facilities and physicians for back-up arrangements drugs are not available, doctors can apply to local health
make obstetrical practice in rural places unattractive. As boards or Primary Care Trusts (PCTs) for exceptional funding
a result, rural women face more challenges related to for individual patients. Treatment therefore depends on a
childbirth and must seek prenatal care and delivery outside doctor’s inclination to make the case for individual patients
of their county of residence. An increase in distance and (or ‘candidacy’, which is gendered) and on the criteria of
travel time to prenatal care facilities decreases the use of a local health board. Differences usually exist between
such care, leading to relatively poor outcomes.
deprived and more wealthy geographical locations. A further
Spain
geographical barrier relates to access to care in rural rather
than urban locations. Access to healthcare is lower for rural
Territorial disparities are probably one of the most worrisome populations: 19 % of people in England and 40 % in Wales
consequences of the federal administrative organisation. and Scotland (402). Mortality rates in road traffic accidents,
The Spanish health system is entirely made up of individual asthma and cancer are worse in rural areas. Cancer is
regional systems, which the central government guarantees diagnosed later and intervention for cardiovascular disease
access to under equal conditions as well as legislating major is lower (403). Increasingly, NHS health services are being
public health issues. However, according to the last health centralised within large, specialised hospitals. Patients can
survey published by the National Institute of Statistics, lose out when health services are provided in such a way
gender disparities in terms of access to health services are and public transport links are poor. Distance to services
not equally distributed among Spanish regions. The share of makes uptake for health services particularly hard for people
the population who suffered from some kind of impediment in rural communities. This may affect women more, as they
to accessing the health system is always higher among are more likely than men to rely on public transport. There
women (except for the case of Castilla-La Mancha), but is also evidence that ethnic minorities in rural locations (e.g.
some regions show particularly worrying gaps according to Scotland (404)) experience multiple disadvantages. Women
gender: La Rioja, Galicia, Valencia, and Catalonia (400).
from these groups might be particularly affected by a lack
Sweden
of female practitioners (405).
In Sweden, 21 county councils and regions are responsible Source: EGGSI network national reports 2009 .
for supplying their citizens with healthcare services.
The population in these 21 areas ranges from 60 000 to
1 900 000 (401). Within the framework of national legislation
and varying healthcare policy initiatives from the national
402
( ) Baird, A. G., Wrights, N. (2006), Poor Access to Care: rural health
government, the county councils and regions have
deprivation?, British Journal of General Practice, August, pp. 567–8.
403
substantial decision-making powers and obligations ( ) Baird, A. G., Wrights, N. (2006), Poor Access to Care: rural health
deprivation?, British Journal of General Practice, August, pp. 567–8.
404
( ) Scottish Executive, Fair for All.

http://www.scotland.gov.uk/library3/society/ffar-15.asp
400
( ) National Institute of Statistics, National Health Survey 2006.
405
( ) Campbel , J.L., Ramse, J., Green, J. (2001), Age, gender,
401
( ) SKL and Socialstyrelsen (2008), Quality and Efficiently in Swedish
socioeconomic, and ethnic differences in patients, assessment of
Health Care, Regional Comparisons 2007, Stockholm.
primary health care, Quality in Health Care, No 10, pp. 94.
Another problem is the difficulty in accessibility due to
The smallest countries (Liechtenstein, Luxembourg and
the lack of public transport. This is the case in Cyprus Malta) tend not to have these kinds of problems, nor
where scarce public transportation limits autonomous
does Slovenia, where a good geographical coverage of
access to healthcare services for individuals who do not
healthcare throughout the country exists. Only 0.3 % had
have their own means of transportation, and may even
unmet needs for medical examinations in 2006, which
to some extent compromise confidentiality. Groups
is far below the EU average (at 7.6 %) (406). In addition,
especially affected by this are elderly women, and
only 0.2 % had unmet medical needs due to access
immigrant or foreign workers living in Cyprus.
problems (too expensive, too far to travel, long waiting
406
( ) Eurostat data based on EU-SILC survey, 2006.
108

---

2. Gender differences in access to healthcare
list). In the Netherlands, qualitative analysis and patient
In Poland 39 % of the population lives in rural areas
experience studies both show that geographical access
(men 40 %, women 37.7 %) but, as far as the gender
is not a major problem for the (large) majority of the
composition of the population is concerned, the rural
population (407). Limited physical access to healthcare
population is more balanced than the urban one. In
may however affect older men and women who might
rural areas, one outpatient clinic serves more than
have problems reaching certain healthcare institutes
4 000 people, in urban areas more than 2 220 (408).
by public transport. The announced restrictions for the
Clearly, geographical barriers may be more important
reimbursement of mobility costs within the Exceptional
for the rural than for the urban population. However,
Medical Expenses Act could have a negative influence
according to a 2006 survey, the share of respondents
on this issue. On the other hand, many local civil society
indicating that they renounced medical consultation
initiatives within the framework of the Social Support
because of the distance from the health centres was
Act have a positive effect, as in many places, especially rather low, being somehow lower for men (2.7 %)
in rural areas, volunteers are mobilised to standby
than for women (6 %). In general, lack of time, money
for the transport of people with specific mobility
and distant dates of consultations were much more
problems. The physical mobility problems of older men
important, both for men and for women (intensity
and women are addressed by these local initiatives.
according to gender was different) (409).
Box 2‑24 — General approach and provisions adopted
to address geographical barriers across Europe
Estonia
Romania
A good example of a strategy to overcome geographical The Ministry of Public Health promoted measures such as
barriers is the breast cancer screening programme which the planning and allocation of human resources according to
includes a mammography bus that drives around the the needs of the population and increasing the professional
southern part of the country to bring the service closer to competency of medical personnel; offering incentives
women in all areas. This is very important in improving the for family doctors to relocate towards isolated rural areas
provision of service throughout the country, as the hospitals (economic and accommodation incentives); developing the
providing mammography are only available in the three infrastructure for health service providers and providing
largest towns. As a result, the participation rate in rural areas medical equipment; reducing the differences in medical
is quite high. In 2009, the Tartu University Hospital will rent practice by elaborating guidelines and clinical protocols (i.e.
the bus from the Estonian Cancer Society in order to perform clinical guidelines for obstetrics and gynaecology have been
about 7 000 mammograms (out of 10 000 performed by approved). Decentralisation of health services is an ongoing
Tartu University Hospital).
process and ensuring adequate resources for the provision
of healthcare is essential to facilitate the access to health
Moreover, the majority of the population (75 %) has the services for people living in poor communities/regions.
possibility to ask for advice from family doctors by phone,
which may help in some cases. There is also a national As an example of good practice, it is worth mentioning
medical phone line providing medical help 24/7 in Estonian a measure promoted by the Ministry of Public Health
and in Russian. However, only 40 % of people are aware of its that proved to be successful: the creation of a network of
existence and 12 % of people have called it (410).
community nurses, including the provision of appropriate
Poland
training for them, in order to create a link between primary
healthcare and community social services. The network of
There are examples of arrangements intended to overcome community nurses contributes to reducing the barriers in
geographical barriers in accessing health treatment, accessing health units for many elderly or disabled women
targeted especially at the female population. Under the and men with mobility problems (especially those living in
programme ‘Early diagnosis of breast cancer’, mobile rural areas).
mammography units, special ‘Mammobuses’ equipped with
units for performing mammography screening have been Concerning in particular Roma Communities, within the
widely used. They function in all regions (voivodships), and National Programme for Health Assistance at Community
the schedule of their operations (places and times) is posted Levels, a national network of health mediators (Ministerial
on the Internet and in local healthcare centres.
Order No 619/2002 approving the health mediator
profession and related technical norms) was created to
facilitate contact between health professionals and Roma
communities; the mediators are Roma representatives
(especially women), trained and hired by District Public
410
( ) Faktum e Arikov (2008), Patsientide hinnangud tervisele ja
Health Authorities. Roma health mediators proved to be
arstiabile, Tallin.




influential in identifying discriminatory behaviour and
http://www.haigekassa.ee/uploads/userfiles/Patsientide%20
helped healthcare workers dispel prejudices that cause
rahulolu%202008.pdf
408
( ) GUS (2008), Demographic Yearbook 2007.
407
( ) Westert, G.P., van den Berg, M.J., et al. (2008), Dutch Healthcare
409
( ) Główny Urząd Statystyczny [Central Statistical Office], GUS
Performance Report, Bilthoven.
(2007).
109

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
inferior and degrading treatment. They also helped in raising for example, mobile mammography screening units, have
awareness in Roma communities about rights, complaint successfully been delivered in rural communities (411).
mechanisms and alternative sources of healthcare.
UK
Source: EGGSI network national reports 2009.
There are initiatives to improve transport access in rural
411
locations and to promote alternative service access, for ( ) Baird, G. A., Wrights, N. (2006), Poor Access to Care: rural health
deprivation?, British Journal of General Practice, August,
example, via NHS Direct and the Internet. Mobile services,
pp. 568.
Physical barriers
A specific case has been reported in the Cyprus EGGSI
national report: women with disabilities experience
Many EGGSI national reports specify that barriers
physical barriers in accessing gynaecological healthcare,
preventing the disabled to access health structures
despite the fact that all public hospitals have a minimum
appear to be gender neutral: these are the barriers that
level of access for physically disabled persons; moreover
reduce the accessibility to preventive medical services
difficulties in accessing information on family planning
and treatments. Not much literature and debate exists
and sexual and reproductive health result in the reduced
on this issue, which deserves much more attention
provision of primary and preventative care (such as
than it has been given so far.
breast cancer screening, Pap smears etc.).
Box 2‑25 — A good practice in Austria
In Austria during 2003, the Year of Disabilities, a number treatment of women with disabilities. Two thirds of the
of initiatives and projects for women with disabilities interviewed physicians envisage an improvement of the
were launched. The Vienna Women’s Health programme situation if the additional expenditure of time for dressing
carried out a project for removing barriers in access to and for the examination was paid, 44 % signalled the need
gynaecological treatment. Issues of sexual and reproductive for subsidies to renovate their surgeries, 40 % asked for
health (contraception, pregnancy, sexual abuse) for women financial support to buy specific equipment to treat disabled
with disabilities have been discussed only marginally for persons, 42 % requested regular training in disability issues.
a long time, although they are equally relevant for them The organisation ‘Bizeps — centre for self-determined living’
as for women without disabilities. Much information and published a brochure on facilities for disabled persons in
awareness-building is still needed, e.g. in training medical hospitals and other health institutions. The brochure is
and nursing staff. The Vienna programme for women’s written for disabled persons as well as physicians and other
health has carried out a project ‘barrierefrei. Gynäkologische health professions. A list with disability-friendly surgeries
Vorsorge und Versorgung behinderter Frauen’ (412) since and hospitals where personnel is competent in sign
2003, to evaluate the experiences of physicians in the language is available.
Source: EGGSI network national reports 2009.
412
( ) Bizeps info — Barrierefrei Gynokologische Vorsorge und
Versorgung behinderter Frauen.



http://www.bizeps.or.at/news.php?nr=4341
110

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3. Gender differences
in access to long-term
care (LTC)
This chapter is aimed at examining gender differences
rehabilitation, basic medical services, home nursing
in access to Long-term care (hereafter LTC) and existing
and empowerment activities (413). In short, LTC consists
programmes and policies addressing barriers to access.
of a wide set of different services provided to people
In order to place these issues in a general framework,
who are dependant in conducting the Activities of
it is helpful to provide an overview on similarities and
daily life (ADLs) (414) or Instrumental activities of daily
differences in LTC systems among European countries.
living (IADLs) (415).
Within the European Union, different LTC schemes
Al over the EU, various provisions concerning LTC have
coexist, in terms of the extent of provision, benefits
been al ocated. Service provision can be distinguished on
and services provided and institutional settings.
the basis of two variables: those who provide care and the
Nevertheless, there are common grounds among
place where care is provided. Concerning the first variable
Member States, in particular from a gender perspective.
— care providers — a difference must be recognised
In most European countries, women are the majority of
between formal and informal care. With reference to
both the beneficiaries and the care suppliers. In some
the second variable — where the care is provided — a
countries the greater number of women among LTC
distinction has to be made between institutional care
beneficiaries is due to their longer lifespan: the death
and care at home. Institutions include nursing homes,
of their husbands leave them alone at home and when
residential care homes and old-age homes where there
their health conditions do not allow their remaining
is a permanent presence of care assistants. Care at home
at home unattended, the only alternative for them is
may include care provided in houses and apartments
institutionalisation. Regarding the role played by women
that are not built specifically for persons needing LTC, as
as care providers, they are the main caregivers, usual y
wel as adapted housing, group living arrangements and
supplying unpaid, informal care which often impacts on
wherever there are no permanent care assistants (416).
their quality of life.
The mix of benefit types — formal/informal,
Concerning barriers in access to LTC, EGGSI National
economic support/direct provision of services and
reports show that women are affected by cultural and
institutionalisation/care at home — varies among
financial barriers more than men, in particular when
European countries, reflecting the organisational
they are of ethnic minority: a specific section below
features of each system more than population structure
further explores this issue. Examples of provisions to
and demographic developments. In particular, these
overcome these barriers have been implemented by
variations reflect different national approaches to
some EU Member States. Existing programmes are
familial solidarity (incidence of informal care and
mainly aimed at removing financial disadvantages,
support for carers) (417).
improving the quality of care and supporting informal
care providers. As women are very often informal care
In the last 15 years, European countries have experienced
givers, programmes aimed at giving support to informal
reforms aimed at removing inequalities in access to
care providers have a relevant gender impact in terms
LTC and at improving the quality of care. These reforms
of quality of life and remuneration for women’s informal
work: some countries have introduced forms of payment
413
( ) Council of the European Union (2008), Joint Report on Social
for caregivers, such as Italy, or other types of support (see
Protection and Social Inclusion, Brussels.
the cases of the Netherlands and Liechtenstein below).
414
( ) ADLs are activities that a person must perform every day such
as bathing, dressing, eating, getting in and out of bed, moving
around, using the toilet, and controlling bladder and bowel.
3.1. O
verview of existing LTC
415
( ) IADLs include preparing own meals, clearing, laundry, taking
medication, getting to places beyond walking distance, shopping,
service provisions
managing money affairs and using the telephone/Internet.
416
( ) OECD (2005), Consumer Direction and Choice in Long-Term Care for
According to the OECD, LTC can be defined as a range
Older Persons, Including Payments for Informal Care: How Can it Help
Improve Care Outcomes, Employment and Fiscal Sustainability?, Paris.
of health and social services provided to individuals
417
( ) Council of the European Union (2008), Joint Report on Social
in need of permanent assistance due to physical or
Protection and Social Inclusion, Directorate-General for
mental disability for short or long periods. LTC includes
Employment, Social Policy, Health and Consumer Affairs, Brussels.
http://register.consilium.europa.eu/pdf/en/08/st07/st07274.en08.pdf
111

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
present different features across countries as the solutions
central European countries. It relies on the family as
provided resulted from the traditional LTC framework in a
the primary, responsible caregiver for the elderly,
given country. While northern European countries have
with intermediate organisations providing services
rationed service provision, continental countries have
that replace informal care when necessary (422). These
proceeded to increase the number of people receiving
countries are in a middle position with reference to the
LTC considerably, and Mediterranean countries have
models previously described.
basical y not changed their delivery system.
The UK is in the middle position, more inclined than
According to the Centre for European Social and
continental European countries towards the state
Economic Policies (hereafter CESEP) (418), in European
responsibility model, with widespread service provision,
countries, the social care model — including LTC — can
especially in home care and a widespread programme
be placed on a ‘continuum’ with the family care model
of cash transfers, such as attendance allowances (423).
at one extreme and the state responsibility model at
the other (419). A third model, called the subsidiary
Eastern European countries cannot be assimilated to a
model, can be found in the middle.
specific model, despite sharing some common traits.
They reveal different characteristics in relation to social
Some authors call the first model informal care-led
policy systems adopted that are strongly influenced
model (420). This model is characterised by limited
by their specific path towards democracy and their
public service coverage. The mix of services is generally
experience of market economy.
imbalanced, with a predominance of institutional
services, and involves a certain level of cash transfers.
The balance between health services and social
Public intervention is generally aimed more at
services in LTC provision is another element that varies
supporting the incomes of persons in need of care than
among Member States. While healthcare provides
providing them with the LTC services they need. Public
specific nurse or medical support for health problems,
intervention occurs when family support isn’t sufficient
social services aim at making the living conditions
or the income of the person is very low and is not
more bearable providing supports concerning patients
sufficient to pay informal caregivers. Typical examples
daily care. Yet, the boundary between social and health
of countries characterised by this model are Portugal,
services is often not so clear.
Spain, Greece and Italy, where home care, provided by
public institutions, is traditionally underdeveloped.
The provision for health matters is usually regulated
through the framework of a national health system
In the second model, public services are much more
(such as Greece, Italy, the Nordic countries and the
developed and public institutions more often provide
United Kingdom) or a national social insurance system
direct care rather than cash transfers. The underlying
(such as Austria, France, Germany and the Netherlands),
objective of this model is to promote a high level of
while the social welfare systems to address social care
regular employment in the care giving sector and
issues are usually administered by regional or local
to meet the care needs of those who are not self-
governments. In most countries, the right to health
sufficient (421). This model has historically been adopted
is thus defined quite differently than the right to
in the Nordic countries.
social care. Different legal arrangements and funding
bodies may also produce different accountability and
The subsidiary model is typical of the francophone
performance management regimens and targets,
continental area (France and Belgium) and other
and these can ultimately constitute major barriers to
integration (424).
418
( ) CESEP is an independent research consultancy specialising in the
development and assessment of employment policies, as well
Considering all these premises, it is clear that different
as on policies for ensuring equal opportunities and combating
forms of provisions can be found all over European
discrimination. CESEP col ects and analyses qualitative and
countries according to the institutional framework for
quantitative information, and provides econometric testing
LTC. The following box shows different institutional
and model ing. CESEP provides policy recommendations for
settings in European countries.
the integration of disadvantaged groups, the management of
European programmes and the evaluation of projects and policies
(from CESEP website: http://www.cesep.eu)
422
( ) CESEP ASBL (2007), Exploring the synergy between promoting
419
( ) Ranci, C., Pavolini, E. (2007), New Trends of Long-Term Care
active participation in work and in society and social, health
Policy in Western Europe, paper presented at the APSA Annual
and long-term care strategies, Brussels.


Meeting 2007, Chicago, Illinois.
http://ec.europa.eu/employment_social/spsi/docs/social_
420
( ) Ranci, C. Pavolini, E. (2007), New Trends of Long-Term Care
protection/final_report_en.pdf
Policy in Western Europe, paper presented at the APSA Annual
423
( ) CESEP ASBL (2007), Exploring the synergy between promoting
Meeting 2007, Chicago, Illinois.
active participation in work and in society and social, health and
421
( ) Ranci, C., Pavolini, E. (2007), New Trends of Long-Term Care
long-term care strategies, Brussels.
Policy in Western Europe, paper presented at the APSA Annual
424
( ) WHO (2008), Home care in Europe, Copenhagen.

Meeting 2007, Chicago, Illinois.
http://www.euro.who.int/Document/E91884.pdf
112

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3. Gender differences in access to long-term care (LTC)
Box 3‑1 — LTC institutional settings
Belgium
The main types of service provided are (i) home help and home
In Belgium, long-term care is part of the integrated healthcare
nursing care, meals, cleaning and other services, (ii) sheltered
system. A distinction must be made between the provision of
accommodation, (i i) rehabilitation, assistance devices and health
services, which can be: (i) linked to specific needs in healthcare
services, (iv) services for veterans and (v) institutional care. Even
that are performed by care institutions (day care, hospitals
though receiving the services and benefits are needs tested, the
or convalescent or old people’s homes) that are covered by
prices of municipal services are normal y means tested. The fee
health insurance benefits; (ii) aimed at helping people who
collected from clients covers less than 10 % of the costs of the
have lost autonomy, either due to il ness, disability or old age.
services. The rest is covered by taxes.
These services can take different forms: financial benefits or
France
organised care services. In this area, competences are mainly
In France, existing service provisions for LTC (both cash and
the responsibility of regions and communities.
kind) have recently changed and become broader. Policies
Czech Republic
address two distinct categories of beneficiaries: dependant
LTC is ensured by two systems: a healthcare system organised
elderly subjects and handicapped adults, covered by different
by the Ministry of Health which is mainly financed by public
policies. Regarding LTC for the elderly, several cash provisions
health insurance, and social services within the Ministry of
exist to facilitate access to LTC, according to the degree of
Labour and Social Affairs, which in turn is funded primarily
autonomy: the ‘allocation personnalisée d’autonomie’ (APA) (425)
by the redistribution of state taxes.
for dependant persons and the ‘Cleaning aid’ for autonomous
elderly people who need help in everyday life. Regarding LTC for
Cyprus
handicapped persons, a new handicap compensation provision
There is no public long-term care insurance system in Cyprus.
(Prestation de compensation du handicap) has been created. As
Under the Public Assistance and Services Laws 1991–2003,
with the ‘allocation personnalisée d’autonomie’, the ‘Prestation
a person legally residing in Cyprus whose resources are not
de compensation du handicap’ is personalised and calculated
sufficient to meet his/her basic and special needs may be
according to the beneficiary’s needs.
entitled to social assistance in kind and/or cash. The social
Germany
welfare services of the Ministry of Labour and Social Insurance
are responsible for the implementation of the above legislation.
There are around 11 000 itinerant nursing services with
Welfare Officers assess needs for LTC on an individual basis.
214 000 employees, about 10 400 nursing homes with
LTC is provided directly by government, community or private
approximately 546 000 employees. The majority (58 %) of
institutions with state financing.
itinerant nursing services are provided by private suppliers,
41 % are provided by non-profit organisations and the share
Denmark
of public services is only 2 % (426).
The organisation of long-term care is the responsibility of the
Greece
municipalities based upon state legislation aimed at helping the
elderly to take the best care of themselves. Local municipalities
There is no specific branch of the insurance system responsible
decide whether a person is eligible to receive care.
for granting LTC benefits (both in cash and in kind); these are
granted through the system of sickness invalidity and survivors.
Estonia
The typical LTC services are provided by state and by private
LTC is provided by the Social Welfare Act (Sotsiaalhoolekande
(both profit and non-profit) organisations.
seadus). Long-term care services are financed by the local
Hungary
government and by the person in need of care or his/her family.
LTC is provided as in-kind social service and it is organised
LTC stil does not have a separate system: services providing
regional y. Vocational rehabilitation is provided by the Labour
long-term care to people are supplied within the healthcare and
Market Board. Local authorities are responsible for the provision
social service system. Professional policies pertaining to long-
of social rehabilitation (e.g. special transportation for disabled
term care are basical y shaped by the ministries in charge of
persons, adaptation of the dwelling, personal assistant).
health and social affairs.
Finland
425
( ) The Personalised autonomy al owance (APA Al ocation
The main policy aim of long-term care is that as many persons in
personnalisée d’autonomie) is addressed to persons aged 60 and
more, living at home or in an institution, who are experimenting
need of LTC as possible should be able to live independent lives in
a loss of autonomy. This al owance is personalised, according to
their own homes, and in a familiar social and living environment.
the beneficiaries’ needs (degree of autonomy, requested aid and
Living at home is supported with rapid-access professional
services) and income (but it is not means tested). It is provided with
social welfare and healthcare services. The elderly over the age of
an Aid plan (Plan d’aide): for beneficiaries living at home, a medico-
75 years are guaranteed an assessment of their service needs by
social team visits the patients and assesses their needs and necessary
social care professionals. This is important since the vast majority
aids to al ow them to stay at home (the APA depends on the needs
of elderly women live alone, far away from relatives. A home
and the resources of the patient); for beneficiaries in an institution,
visit programme al ows the elderly to be under continuous
the APA helps beneficiaries to pay for the ‘dependency tariff’
supervision and in contact with social care professionals.
calculated according to the degree of autonomy/dependency.
426
Residential services and different forms of institutional care are
( ) Backes, G. M., Amrhein, L., Wolfinger, M. (2008), Gender in der
Pflege, Herausforderungen für die Politik, Expertise im Auftrag
provided to people who no longer manage to live at home.
der Friedrich-Ebert-Stiftung, Bonn.

http://library.fes.de/pdf-files/wiso/05587.pdf
113

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Italy
disabilities. Benefits in kind are granted under the national
LTC in Italy is provided by two separate sectors (healthcare and
health scheme and subsidiary legislation is administered by
socially related healthcare) even if integration has increased
the Department for the Elderly and Community Care. The
in the last few years, especially in the northern regions of
benefits include free treatment and care at all state hospitals
the country. Both of these sectors are programmed and
and clinics and free medicines, and are subject to a means test.
governed by regions, while local-level healthcare provisions
Free medicine is given to people with chronic diabetes.
are the responsibility of the Local Health Units and social y
Residential care is provided by the state or by non-profit
related healthcare provisions are the responsibility of the
predominantly religious voluntary organisations and by the
municipalities. With regard to public home care, there are two
private commercial sector. The state’s provision for residential
types of provision: home care assistance (Servizio di Assistenza
care can be divided into two categories: high (mostly in quasi-
Domiciliare — SAD) and integrated home care assistance
hospital settings) and low support (in smaller residential
(Assistenza Domiciliare Integrata — ADI). SAD is supplied by
homes based in the community).
municipalities through specifical y trained social workers who
identify the needs and plan a tailored assistance project. ADI is
The Netherlands
supplied by local health units, which provide the patient with
In the Netherlands, the Exceptional Medical Expenses Act is
nursing and therapeutic care. With regard to residential LTC, a
the basis for the financing and organisation of LTC. Before a
national survey on social healthcare structures shows that just
person can qualify for care under the Exceptional Medical
2.0 % of over 65 year olds and 4.0 % of over 75 year olds live in
Expenses Act, it is necessary to establish whether care is really
a nursing home (427).
required and, if so, what type of care and how much care is
Liechtenstein
needed. This ‘indication’ is issued by an organisation called
CIZ (Independent assessment organisation), responsible for
In Liechtenstein an independent care insurance law is
impartial y, objectively and thoroughly determining the care
lacking. The same is true for a legal definition of the concept
required.
of ‘requirement for care’. Social protection in the case of need
for care is primarily guaranteed by the law regarding sickness
Most care under the Exceptional Medical Expenses Act is
insurance and the law regarding accident insurance. There are
provided by institutions. The Exceptional Medical Expenses
private organisations and public organisations that provide
Act insurance scheme is funded through premiums paid by
care services in the home or inpatient services for medical
the people covered by the scheme, by state subsidies and by
and geriatric care. Private as wel as the public organisations
personal contributions from care recipients. Contributions are
are non-profit organisations or non-profit foundations.
collected through the income and payroll tax systems.
Lithuania
Norway
There is no official definition of LTC in Lithuania. LTC is granted
The municipalities are responsible for providing reasonable,
through several branches: social services, invalidity and sickness.
high-quality healthcare and social services to everyone in need
of them, regardless of age, gender or social background. There
Provision of LTC benefits are organised at national, regional
are several relevant long-term strategies and programmes
and local levels. Government adopts long-term national
i.e. the 2015 Care Plan, the National Strategy for Specialised
programmes and strategies for the social integration of
Health Care 2008–12 and the 2008–12 Dementia Plan. The aim
the disabled. Heads of the counties implement social
of the 2015 Care Plan is to address the main future challenges
programmes and projects for the disabled at the county
in elderly care in a long-term perspective (428).
level. Counties establish regional social service institutions
when the establishment of municipal ones would not be
Poland
economical. Heads of Counties are also responsible for the
In Poland, public long-term care (LTC) is administered by the
provision of secondary specialised medical treatment.
Ministry of Health and the Ministry of Labour and Social Policy.
While the former is responsible for healthcare and nursing
Municipalities prepare and implement municipal programmes
service provisions, the latter is in charge of providing nursing and
for the social integration of the disabled. They are also
daily-living care — but not specialised healthcare — services.
responsible for determining the need and the provision of
These responsibilities may sometimes overlap in part and
common and special social services for their residents.
cooperation is needed. LTC granted within the social security
Malta
sector involves local government to a large extent. This is not
Long-term care benefits are granted under different legislative
so much the case with healthcare procedures. Both sectors are
and administrative measures. Cash benefits are granted
widely supported by non-governmental organisations.
under the Social Security Act and are both contributory
Romania
and non-contributory. Contributory benefits include mainly
Local councils are responsible for service organisation and
invalidity pensions and disability pensions; non-contributory
provide services directly or through partnership contracts with
benefits consist in disability pensions, pensions for the blind
non-governmental and/or religious organisations. General y,
and social assistance for long-term invalids.
assignment to these care homes only becomes available upon
Additionally, Agenzija Sapport, a government agency,
the death of a resident. Referral places (i.e. for a patient to be
provides limited long-term care benefits in kind to people with
accepted there after hospitalisation) do not exist.
427
( ) Istat (2003), L’assistenza residenziale in Italia: Regioni a
confronto, Rome.
428
( ) For further information see the last section of this chapter.
114

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3. Gender differences in access to long-term care (LTC)
Slovenia
parliament and the government have set out policy aims
LTC in Slovenia is not uniformly organised or centrally and directives by means of legislation and economic steering
coordinated: it is linked to different systems, mainly in the measures. At the regional level, county councils or regions are
field of healthcare and social protection.
responsible for the provision of health and medical care. And
at the local level, the 290 municipalities are legal y obliged
Spain
to meet the social service and housing needs of the elderly.
In Spain the endorsement of the Law 39/2006 on the Services provided by doctors are not included in the care for
Promotion of Personal Autonomy and Care for Dependant which municipalities are responsible. Some municipalities
Persons, known as the Dependant care law (DCL), has have contracted out their elderly care services to private
implied a highly remarkable advancement in the field of providers and in certain areas the elderly are allowed to
social protection. In particular this law (DCL) created the choose whether they want help at home or in special housing
National system of dependency (NSD), which is managed managed by public or private operators.
by the Territorial council of national system of dependency UK
(NSD), for the arrangement of LTC system. With regard to
financial resources, the Dependant care law has established Long-term care in the UK is predominantly provided in
a contribution system for LTC: (i) Central government, which private households rather than communal or residential
finances a guaranteed minimum; (ii) Regional governments, homes. Some provisions for care in private homes derive
which provide contributions of an amount no smaller than the from public services. However, the majority of care provision
one from central government.; (iii) Beneficiaries, depending on is from (mostly female) relatives and friends. Over the last
their income and wealth, participate in co-payment, common 25 years there has been a marketisation of residential and
everywhere in Spain, determined by the Territorial council of domestic care provision to increase flexibility and choice.
autonomy and dependence attention system (ADAS).
Local authorities no longer provide most social care directly.
Rather, three quarters of private care services are now in the
Sweden
private for-profit sector.
The responsibility for the welfare of the elderly is divided
among three governmental levels. At the national level, the Source: EGGSI network national reports 2009.
3.2. O
verview of existing service
2. informal LTC consists in services provided by
provisions for LTC from a
someone who provides care without any form
of employment contract (430).
gender perspective
According to OECD, informal caregivers can be divided
In order to outline the existing service provisions for
into three categories. The first includes relatives, friends or
LTC from a gender perspective, there are two key issues
volunteers that do not receive any form of compensation
to be addressed:
for their engagement. The second category includes
informal caregivers that receive cash benefits/al owance
a. the role of women as informal caregivers;
as part of cash benefit programmes and consumer-
choice programmes. They are usually relatives or friends.
b. the increasing demand and use of LTC by women.
The last category includes undeclared/illegal informal
caregivers. They are caregivers who receive some form
The role of women as informal caregivers
of payments by care recipients but without any form of
employment contract (431).
As far as existing service provisions for LTC are
concerned, a crucial difference from a gender
In conformity with the OECD report, the majority of LTC
perspective is between formal and informal care.
workers, both formal and informal are women, and this
According to the OECD (429), the difference between
is also what emerges from the EGGSI national reports.
formal and informal care depends on who provides the
services. In particular:

■
In Greece 80.9 % of help-providers are female and
the majority of elderly recipients are also women
1. formal LTC includes care provided in institutions,
(with an incidence of 50.7 %) (432). Informal care-
such as nursing homes, or care provided to
givers are often middle-aged and frequently the
recipients living at home by professional y trained
relationship between care providers and care
care assistants. Formal care is provided by care
receivers is a child–parent relationship.
assistants under an employment contract with
LTC-service recipients or agencies providing LTC;
430
( ) OECD (2006), Projecting OECD Health and Long-term care
Expenditures: What are the main Drivers? Paris.
429
( ) OECD (2006), Projecting OECD Health And Long-Term
431
( ) OECD (2009), The Long-Term Care workforce: overview and
Care Expenditures: What Are The Main Drivers? Economic
strategies to adapt supply to a growing demand, Paris.
Department Working Papers No 477, Paris, p. 9.
432
( ) Triantafyllou, J. et al., (2006), The Family that Takes Care of
http://www.oecd.org/dataoecd/57/7/36085940.pdf
Dependant Older Persons, Eurofarmare, Athens.
115

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?

■
In Austria about 80 % of the required LTC services
anxious, and are likely to use psychotropic medications
are rendered by relatives or other private helpers,
to treat their psychological distress.
particularly women.
Given the relevance of informal care in many societies and

■
In Bulgaria, the active involvement of family members
women’s predominance as carers, measures supporting
and close relatives in LTC service provision for the
informal carers have a positive gender impact. Support for
elderly puts a lot of pressure on women as caregivers
informal caregivers may include information and training,
(daughters, granddaughters, sisters, etc.) in terms of
respite care, tax benefits and payments, regulations of
time spent, job loss, lower pension, psychological
businesses or initiatives by private organisations aimed
burden. Al of these aspects seriously damage women’s
at making it easier for family members to combine work
health. Women take on the majority of responsibility
and care-giving (434). With reference to the last issue,
for care, and they are especial y subject to problems of
‘some governments have mandated that businesses
reconciliation between work and caring responsibilities
make medical leave available for family members to care
and insufficient social security. Existing regulations do
for their sick or disabled relatives, and some businesses,
not encourage men to take over care responsibilities.
on their own initiatives, have sought ways to help
informal caregivers’ (435). A few countries also provide
The impact on women of informal care giving is relevant,
pension credits for caregivers who provide a substantial
as shown in Chapter 2: according to the WHO (433)
amount of care, in order to partial y compensate for the
primary caregivers are frequently depressed and
time spent away from the labour market.
Box 3‑2 — Programmes aimed at supporting informal caregivers
France has innovated considerably in recent years: the In Liechtenstein, care work which takes place within the family
introduction of national assistance programmes for disabled and has not yet been legally regulated. It is mostly provided on
dependant people has been accompanied by the development a voluntary basis, in particular by relatives. The family care
of measures aimed at ‘rewarding’ caregivers, or at the purchasing federation (Familienhilfeverband) performs voluntary work in
of services on the private market. The main programme is the some cases and is financially supported by the state. A ‘social
‘allocation personnalisée d’autonomie’ (APA), introduced in 2002 time card’ (volunteer work certificate) is issued for those who
for dependant persons over 60. Thanks to the plan, beneficiaries work on a voluntary basis. Volunteers are able to use the
receive cash benefits of up to EUR 1 106 per month. It is a form of volunteer work certificate to record their accomplishments
‘co-payment’ for expenses incurred by beneficiaries. According and how much time they have spent. The idea was that
to the programme, teams of medical and social workers suggest evidence of volunteer work and corresponding training could
the best kind of assistance for each individual case (436).
be important in particular for re-entering the workforce.
However, participation in these few activities was not as high
In Italy some measures aimed at recognising and giving financial as expected. It is unclear whether this was due to a lack of
support for the social assistance of families have been introduced interest or to limited opportunities (440).
at the local level, while a national policy is still lacking (437).
In Finland informal care has been a relevant issue of the policy
In the Netherlands a national association for informal carers and agenda for many years and some support has been provided:
volunteers, Mezzo (438), provides information and support for the carer may be entitled to receive an informal/family care-
informal carers, professionals and local member organisations. givers’ allowance paid by the local government to the carer,
There are several local initiatives, often initiated and/or who often is a spouse or mother (or other relative). These carers
supported by local governments, to support informal carers are also entitled to ‘free days’ from care. The system presents
with information and guidance concerning social security work some critical points although the allowance and leave system
leave arrangements, tax issues, and also with the provision of is better than no compensation at all. Gender problems occur
temporary replacement or the provision of childcare (439).
when informal carers are working-age women: there has been
little attention and encouragement to promote their return to
436
( ) Ranci, C., Pavolini, E. (2007), New Trends of Long-Term Care
the labour market. Another relevant problem concerns older
Policy in Western Europe, paper presented at the APSA Annual
Meeting 2007, Chicago, Illinois.
carers, who are often in need of care services themselves.
437
( ) Ranci, C., Pavolini, E. (2007), New Trends of Long-Term Care
Policy in Western Europe, paper presented at the APSA Annual
Source: EGGSI network national reports.
Meeting 2007, Chicago, Illinois.
438
( ) Information provided by the non-profit making organisation
‘Mezzo’.




440
( ) Liechtenstein Familienhilfe Verband — allgemeine Prinzipien.
http://www.mezzo.nl/
h t t p : / / e c . e u r o p a . e u / e m p l o y m e n t _ s o c i a l /
439
( ) http://www.mezzo.nl/
missoc/2006/02/2006_02_li_de.pdf
434
( ) WHO (2003), Key policy Issues in Long-Term Care, Geneva.
http://www.who.int/chp/knowledge/publications/policy_
issues_ltc.pdf
433
( ) WHO (2003), Key policy Issues in Long-term care, Geneva.
435
( ) WHO (2003), Key policy Issues in Long-Term Care, Geneva.
http://www.who.int/chp/knowledge/publications/policy_
http://www.who.int/chp/knowledge/publications/policy_
issues_ltc.pdf
issues_ltc.pdf
116

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3. Gender differences in access to long-term care (LTC)
The increasing demand and use of LTC

■
In Austria, more than two thirds (68 %) of recipients
by women
of the federal LTC allowance are women. At the end
of 2007, a total of 351 057 people received a long-
According to Eurostat, by 2060, 30 % of the population
term care allowance on the basis of the Federal Act
in the 27 EU countries will be over 65. This means that
for Long-Term Care Allowance (446).
European countries will move from having four people
of working age for every person aged over 65 to a ratio

■
In Bulgaria women constitute 54 % of the patients
of 2 to 1 (441).
in specialised establishments for social services in
communities (also including home care patronage,
Demographic ageing, however, does not necessarily
day centres for elderly people, adults with
mean an increase in demand of LTC (442). It is the increase
disabilities, street children etc.) (447).
in life expectancy and the incidence of dependency
that creates increase in the demand for LTC. The

■
In Estonia home services were provided to 6 428
increase in life expectancy at birth (443) has implications
persons, including 3 960 with special needs (i.e.
on the percentage of healthy life years, and therefore
disabled) in 2007. Some 76 % of all service receivers
on incidence of dependency: longer lifespan influences
were women. Personal assistance service was
needs in terms of LTC (formal and informal). Therefore,
provided to 22 289 persons with special needs who
this clearly affects women more than men.
were assigned a personal carer, and 61 % of recipients
were women. Concerning the institutionalisation of
What is important to note is that demographic
adults, according to the Ministry of Social Affairs, in
trends are quite different across Europe: the old-age
2006, of 4 737 recipients, 62 % were women (448).
dependency ratio (444) is projected to be more than
60 (%) in Bulgaria, the Czech Republic, Latvia, Lithuania,

■
In France, regarding LTC for the elderly, women
Poland, Romania, Slovenia and Slovakia, and less than
represent the majority of beneficiaries, both at
45 % in Denmark, Ireland, Cyprus, Luxembourg and
home and in institutions. In June 2008, 1 094 000
the United Kingdom (445). In addition, there are great
persons received APA (449), among which women
differences within the European countries in life
represented a majority (seven out of 10). As shown
expectancy and in healthy life years (see Chapter 1,
by the age and gender structure of the ‘allocation
Table 1-1 — ‘Life expectancy and healthy life years for
personnalisée d’autonomie’ (APA) beneficiaries,
EU-27, and Iceland and Norway, 2006’). Nevertheless,
APA beneficiaries are mostly both elderly (85 %
in all the countries, women live a shorter percentage
are at least aged 75 and 45 % are at least aged 85)
of their life in good health than men, so more women
especially when in institutions (55 % are aged 85
need LTC and for a longer period of time.
and more) and female (women represent 77 % of
the APA beneficiaries aged 75 and more, while they
What emerges from the EGGSI national reports is that
represent 64 % of the whole population in the same
there is an increasing demand and use of LTC by women.
age bracket) (450).
It is in fact women who are the main beneficiaries of
LTC (both of service in kind and benefits in cash) in
the majority of the European states, considering their
446
( ) Statistik Austria (n.y.), Social benefits at federal level: Federal
longer life expectancy and their reliance on formal
Long Term Allowance.



http://www.statistik.at/web_en/statistics/social_statistics/
care. Women’s reliance on formal care is linked to the
social_benefits_at_federal_level/federal_long_term_care_
fact that they often have no care alternatives in their
allowance/index.html
household. Generally speaking, elderly women are
447
( ) Information provided by the Center for Women Studies and
more likely to live alone than men.
Policies for the elaboration of the Thematic Report 2008.
448
( ) Sotsialaministeeriumi (2008), Sotsiaalvaldkonna arengud 2000–06,
Toimetised No 2/2008, Tal inn.
441
( ) European Commission (2009), The 2009 Ageing Report.
449
( ) The Personalised autonomy allowance (APA Allocation
Economic and budgetary projections for EU-27 Member States
personnalisée d’autonomie) is addressed to persons aged 60 and
(2008–60), Brussels.
more, living at home or in an institution, who are experimenting
442
( ) European Commission (2008), Long-term care in the European
a loss of autonomy. This allowance is personalised, according to
Union, Brussels.



the beneficiaries’ needs (degree of autonomy, requested aid and
http://ec.europa.eu/employment_social/news/2008/apr/long_
services) and income (but it is not means tested). It is provided
term_care_en.pdf
with an Aid plan (Plan d’aide): for beneficiaries living at home,
443
( ) European Commission (2008), Long-term care in the European
a medico-social team visit the patients and assesses their needs
Union, Brussels.



and necessary aids to allow them to stay at home (the APA
http://ec.europa.eu/employment_social/news/2008/apr/long_
depends on the needs and the resources of the patient); for
term_care_en.pdf
beneficiaries in an institution, the APA helps beneficiaries to pay
444
( ) The age-dependency ratio is the proportion between elderly
for the ‘dependency tariff’ calculated according to the degree of
and people in working age in a given country.
autonomy/dependency.
445
( ) European Commission (2009), The 2009 Ageing Report.
450
( ) Espagnol, P., Lo, S.-H., Debout, C. (2008), ‘allocation personnalisée
Economic and budgetary projections for EU-27 Member States
d’autonomie et la prestation de compensation du handicap au
(2008–60), Brussels.
30 juin 2008’, Etudes et résultats, Drees, No 666, October.
117

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?

■
In Latvia there are more women in the long-term
twice as likely as men to live in a communal
social care centres (on 1 January 2008 there were
establishment (5.9 % against 2.8 %) (457).
4 564 men and 5 716 women). The average age of
women is higher than that of men (in municipal
care the average age of women is 78, for men it
3.3. G
ender barriers to access LTC
is 68) (451).
All European Member States are committed to
■ In Norway women are in majority of long-term
ensuring universal access to LTC for their citizens. As the
care users. Among users over 80 years old, 3 out of
population grows older, the challenges to achieve this
4 are women (452).
goal depend more and more on national health and
social policies. Therefore, one’s universal right does not

■
In Poland, LTC recipients are mostly women,
necessarily mean universal service. All over European
especially as recipients of nursing care. In 2007,
states, access to LTC might be restricted by many kinds
there were almost 15 000 patients for stationary
of barriers. These include lack of insurance coverage,
care and treatment and women represented 65 %
lack of coverage/provision of certain types of care,
of the total. The proportion of women in nursing
high individual financial care costs and geographical
and care amounted to 71 % of the total (453).
disparities in supply. They also include lengthy waiting
lists for certain treatments or in certain areas of a given

■
In Sweden, 153 000 elderly persons in ordinary
country, lack of knowledge or information and complex
housing were granted home help services as of 30
administrative procedures (458).
June 2008, of which 68 % were women and 32 %
men. In relation to the population aged 65 or older,
Moreover, some barriers may particularly affect women (or
the share corresponds approximately to 10 %. In
men) in a given country for demographic, socioeconomic,
relation to the population aged 75–94, the share
cultural or financial reasons. Gender is a cross-cutting
was bigger among women than among men (454).
issue with reference to barriers to access LTC.
Both in the youngest age group (65–74) and the
oldest (95+), the share with home help was similar
3.3.1. Gender and financial barriers
for women and men. Almost 149 000 persons were
equipped with safety alarms devices (455), of which
High private costs which are seemingly higher than
73 % women and 27 % men (456). Of 94 000 persons
in healthcare impose a major financial burden on LTC
65 years and older living permanently in special
users and their relatives and act a barrier to access,
forms of housing, 70 % are women and 30 % men.
particularly for low-income groups (459).

■
In the UK LTC is predominantly provided in private
Many countries have a system of co-payments to
households rather than communal or residential
access LTC (for example Cyprus, Ireland and Estonia) or
homes: 95.4 % of British people aged 65 or over live
voluntary/private complementary insurance. Generally
in private households as opposed to 4.6 % who live
speaking, financial barriers include both restrictions
in communal establishments. Women are, however,
depending on co-payment for low-income groups and
differences in access observed for population groups not
451
( ) Data are collected from Social Service Board Annual Report.
yet fully covered by social insurance schemes. Policies
Website: http://www.spp.lv
to reduce the individual direct costs of care include:
452
( ) Helse og omsorgsdepartment (2005), St. Meld. Nr.25
co-payment exemptions and co-payments based on
(2005–06), Mestring, muligheter og mening. Framtidas
income; extra financial aid/welfare benefits granted
omsorsutfordringer. Oslo.


to the elderly dependant, disabled and chronically ill;
http://www.regjeringen.no/Rpub/STM/20052006/025/PDFS/
STM200520060025000DDDPDFS.pdf
state coverage of social long-term care for low-income
453
( ) Główny Urząd Statystyczny [Central Statistical Office] (2008),
households within a social assistance framework;
Podstawowe dane z zakresu ochrony zdrowia w 2007, Warsaw.
nationwide standardisation of co-payments; and state
http://www.stat.gov.pl/cps/rde/xbcr/gus/PUBL_WZ_podstaw_
subsidies to use private services (460).
dane_z_zakre_zdr_2007r..pdf
454
( ) Statistiska Centralbyrån — SCB (2009) Statistisk årsbok 2008.
Stockholm, p. 426.
457
( ) Del Bono, E., Sala, E., Hancock, R., Gunnell, C., and Parisi, L., (2007), Gender,
455
( ) Socialstyrelsen (2009) Äldre — vård och omsorg den 30 juni
older people and social exclusion, A gendered review and secondary
2008, Kommunala insatser enligt socialtjänstlagen samt hälso-
analysis of the data, ISER Working Paper 2007–13, Colchester.
och sjukvårdslagen, Stockholm.
458
( ) Council of the European Union (2008), Joint Report on Social
456
( ) The aim of municipal care provision is to ensure that older people
Protection and Social Inclusion, Directorate-General for
and those with disabilities are able to live normal, independent
Employment, Social Policy, Health and Consumer Affairs, Brussels.
lives. This includes living in their homes for as long as possible.
459
( ) OECD (2009), The Long-Term Care workforce: overview and
They can have access to support of various kinds, such as meals
strategies to adapt supply to a growing demand, Paris.
delivered at home, help with cleaning and shopping, safety alarms
460
( ) Council of the European Union (2008), Joint Report on social
devices and transportation service. Safety alarms devices are useful
protection and social inclusion, Directorate-General for
to call for help in case the patient is in a dangerous situation.
Employment, Social Policy, Health and Consumer Affairs, Brussels.
118

---

3. Gender differences in access to long-term care (LTC)
Nevertheless, in some countries financial barriers
so they may experience more difficulties than men
remain an important issue.
in the same age bracket.

■
In Bulgaria LTC services are usually provided by close

■
According to a recent study (461), elderly Greeks pay
relatives at home. In some cases, Bulgarian citizens
7.5 % of their annual income for health services. The
pay for them in cash (out-of-pocket) to professional
consequence of this high expenditure for healthcare
caregivers (retired nurses, rehabilitators, doctors),
is that the elderly have to cut down their expenses.
which is very expensive by Bulgarian standards,
Additionally, Greece has a very high proportion of
above all because there is no specific insurance.
elderly people who spend between 15 % and 25 %
of their income for private health services. This

■
Spanish citizens do not have sufficient economic
happens above all with people living on a lower
support. Among the different economic benefits
income.
gathered in the DCL (Dependant Care Law), the
payments aimed at financing market services have

■
In Norway women are the great majority among
proved to be insufficient to cover full costs. This
the elderly receiving minimum level pensions.
could imply certain unwanted effects regarding
Recent statistics show that while only 10 % of men
the proliferation (or preservation) of an informal
received minimum level pensions, 48 % of women
market, which employs a vast majority of women
pensioners received the lowest pensions (462). At
under deficient labour conditions.
the same time, statistics show that more men
receive treatment at hospitals, while more women
Moreover, financial barriers may be experienced more
use municipal care services. To ensure similar
by women than by men because the average income
medical treatment for elderly women and men, the
of older women is much lower than that of older men,
government ensures that a gender perspective on
and the at-risk-of-poverty rate of older women is higher
treatment be integrated in the activity of hospitals.
than that of older men, so many women may find their
income insufficient for covering co-payments, private
3.3.2. Gender and geographical barriers
health costs and costs of voluntary insurance.
LTC (both social and health) services are typically the

■
In Belgium an analysis of contacts with home-based
responsibility of local authorities or regions. This causes
services shows that women call on these services
substantial differences in service provision among
more frequently than men and the reliance on
regions, within urban and rural areas or within cities (463).
such services increases with age. Any initiative to
It often results in different waiting times according to
reduce the costs of these services will therefore be
different areas of a given country.
an improvement for women, considering that they
rely more on such services and that they generally
In some countries, such as Denmark, Hungary, Slovenia
have lower incomes than men.
and Bulgaria, geographical differences play a crucial
role in accessibility, because social institutions are

■
In France, difficulties in access to long-term care still
not evenly spread in the country and this affects the
exist for individuals belonging to a poor or modest
efficiency of LTC. Furthermore, in some countries, such
household. In particular, beneficiaries of the old-
as Slovenia, there are also significant regional financial
age minimum income are over the income ceiling
differences in the payment for these services. Namely,
and consequently cannot benefit from free access
some of the regions or municipalities co-finance the cost
to the Complementary Universal Health Coverage
of these services and some municipalities even offer
(CMUC), however, they may experience difficulties
them for free, while others do not. Elderly women and
in affording private complementary coverage.
men living in regions with low service coverage and/
Women aged 60 and over are overrepresented in
or with higher service costs therefore face significant
the beneficiaries of the old-age minimum income,
barriers in accessing LTC.
461
( ) Mergoupis, T. (2003), Income and Health Services in Greece , in
Venieris, D., Papatheodorou, C., Social Policy in Greece, Athens.
462
( ) Helse og omsorgsdepartementet, Nasjonal Strategi for
spesialisthelsetjenester for eldre 2008–12.

http://w w w.regjer ingen.no/upload/HOD/Vedlegg/
Spesialisthelsetjenestestrategi%20for%20eldre.pdf
463
( ) Council of the European Union (2008), Joint Report on Social
Protection and Social Inclusion, Directorate-General for
Employment, Social Policy, Health and Consumer Affairs, Brussels.
119

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
In Romania, Greece and Portugal, geographical barriers
3.3.4. Gender and cultural barriers
have led to a concentration of LTC services in the urban
centres to the detriment of rural areas. For example, in
Cultural barriers in accessing LTC services are linked
Greece there is a special LTC programme, called ‘Help
to social status, because poorly educated people have
at home’. It is an example of geographical disparity
more difficulty in accessing services. Additionally,
because it is not provided in every municipality.
some ethnic groups don’t accept care provision for
socioeconomic reasons, linked to their cultural heritage.
Geographical barriers remain an important issue in
This is the case of the Roma in some countries such as
other European countries as well: for example in Spain,
the Netherlands and Portugal, who do not accept the
where geographical and physical barriers are not
LTC system for cultural reasons: as described in the
addressed evenly, especially in depopulated areas. In
EGGSI Synthesis Report of 2008 on ethnic minority and
many cases, there are also unused day-care centres in
Roma women in Europe, ‘Traditionally, Roma family ties
rural areas, due to the lack of transport infrastructures.
are strong and institutionalisation can be considered
The main issue in these areas is not the lack of places,
an extreme alternative for older family members.
but difficulty in reaching the institutions. Geographical
Normally, Roma women are first expected to care
barriers have a gender dimension: as women are
for other dependant family members in addition to
more frequent users, they have to travel more often,
other work related to domestic responsibilities. Elderly
in addition to the fact that they tend to rely more on
people, men and women alike, enjoy a high social
public transport or on someone to take them.
status in Roma communities. This is one of the reasons
why elderly people are accustomed to remaining with
3.3.3. Gender and bureaucratic and
the family in old age and do not apply for long-term
administrative barriers
care services, even in the cases where these services are
accessible/affordable’ (464). In addition, in Austria there
LTC services are provided through the coordination of
are bureaucratic barriers affecting elderly migrants
different care levels and different administrative levels
in particular, because to be entitled to receive some
(national, regional and local levels of governments).
benefits, it is necessary that recipients have worked for
This fragmented system may reduce accessibility to LTC
a few years in that country.
services because dependant and elderly patients have
tailored multiple needs, due to their social, health and
Women are overexposed to cultural barriers, both as
economic conditions. In addition, their needs may only
carers and as persons in need of care: this especially
be satisfied by a combination of different institutions,
affects immigrant and ethnic minority women. For
depending on different levels of government or different
them, in some countries such as the Netherlands,
departments of government. For example, in Spain’s LTC
cultural barriers seem to make access to long-term care
system there is a lack of coordination between regional
more difficult than for the general public. A study in
and local administrations, which may be particularly
Austria on age and migration in the Vienna area showed
burdensome for users, who due to their advanced age or
that female migrants feel very worried about their old
disability are not always capable of ful y understanding
age (465). Moreover, in Malta, the language barrier is
the process and the rights they are entitled to.
often a hindrance to accessing health information
and services among migrant women with long-term
A typical example of limited accessibility caused
illnesses. Women with refugee status, humanitarian
by bureaucratic/administrative barriers is hospital
protection, and rejected asylum seekers living in Malta
discharge, which ought to be followed up by specific
have access to free medical care in state hospitals and
home-care provisions. In order to ease this transition,
state healthcare centres, however, data drawn from
Germany has created a ‘case manager’ who deals with
the 2005 Malta Census suggest there are more women
‘transfer care’ from hospital to a home care setting for
than men suffering from long-term illnesses and/or
people entitled to it.
health conditions (466).
464
( ) Corsi, M., Crepaldi, C., Samek Lodovici, M., Boccagni, P.,
Vasilescu, C. (2008), Ethnic minority and Roma women in
Europe: A case for gender equality? — report prepared by the
Network of experts in gender equality, social inclusion and
health- and long-term care (EGGSI network) for the European
Commission, Directorate-General for Employment, Social
Affairs and Equal Opportunities.



http://ec.europa.eu/social/BlobServlet?docId=2481&langId=en.
465
( ) Kienzl-Plochberger, Reinprecht, C. (2005), MigrantInnen im
Gesundheits- und Sozialbereich, Vienna.
466
( ) Elaborations on Malta Census 2005, National Statistics Office, Malta.
120

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3. Gender differences in access to long-term care (LTC)
Box 3‑3 — Main barriers accessing LTC in European countries
Austria
Romania
For elderly migrants there are some structural barriers Health and long-term care in Romania suffer from
in accessing available institutions and entitlements regional disparities, particularly from uneven coverage of
to specific allowances. First, to be entitled to old-age medical services and healthcare workers. Differences are
pensions, one has to have worked for 15 years within the particularly marked between rural and urban areas. There
last 30 years in Austria. Many migrants reach this minimum are also issues of inadequate medical equipment and a
by adding their working experiences abroad, however shortage of medical staff in many rural areas. It may be
those years are not always accepted. The same problems assumed that as women tend to live longer and as the
regard the entitlement to the federal care allowance which number of women surpasses the number of men, more
is dependent on pension payments and on continuous women compared to men are affected by difficulties in
residence in Austria. If migrants or refugees cannot fulfil accessing long-term care facilities.
the requirements for the federal care allowance, they can
apply for provincial care allowance.
There are still old people who are not registered with a
family doctor or people that have no identity documents
Denmark
(i.e. many Roma, homeless), which denies them access
Generally speaking, no barriers to LTC exist in the Danish to social health insurance or to any type of healthcare
model as the main part is based upon a local evaluation (except for emergency treatment). Reduced availability
of the needs in order to get support. Depending on the of services and lack of volunteer services deprive many
municipality, there can be waiting lists for a place in a elderly people that live on their own of the support they
hospice, whereas support in the private homes has no need for housework (cleaning, getting food supplies).
waiting time.
Many people are excluded from health or LTC because of
the very real perception of having to pay additional costs
The main difference between men and women is that in order to receive proper attention, or in many cases,
women often have to take care of men with more limited people will postpone their medical care until it becomes
support and, when they themselves are in need of care, an emergency.
nobody might be available to help them.
Slovenia
Estonia
The main barriers are bureaucratic. The fact that the
The main problems with LTC are the lack of provision and high existing services and income are not linked to an even
costs of services. For instance, the cost of a care home (i.e. long-
system, in addition to the fact that, in practice, there is a
term care in institution) varies according to the institution. lack of coordination among the institutes which provide
A study of disabled persons carried out in 2007 showed these services, hinders access to services and reduces their
that 85 % of them saw a need for rehabilitation services, quality. It is also acknowledged that waiting periods are
but only 47 % of them received it (467). The main obstacle in relatively long. Elderly women and men living in regions
receiving these services is the lack of information (54 %), with low service coverage and/or with higher service
economic reasons (45 %), and transport problems (41 %). costs therefore face significant barriers in accessing long-
The need for physiotherapy is especially great.
term care.
Italy
Spain
There are several regional disparities in service provision. The main barriers can be summarised as follows:
According to Istat, three quarters of beneficiaries of lack of procedural homogeneity among different
residential LTC live in the northern regions. Geographical administrations; excessive delay in the provision of
barriers exist with regard to public home care, because services; complexity of the process; individualised
the financial resources allocated vary among regions and programmes limited by inadequate resources; lack of
municipalities. Moreover, the amount of users’ co-payments agreement between regional and local administrations;
varies across regions and cities and the average income insufficient economic support; geographical barriers.
varies greatly according to region. Additionally, women’s
average old-age pension is lower than men’s.
Sweden
Portugal
Most of Sweden’s local authorities have a small number
of elderly people belonging to the national minorities
There are three main barriers for access to long-term care: or of foreign background. However, the metropolitan
(i) the low supply of services; (ii) lack of technical expertise regions, and regions bordering neighbouring countries,
and management of existing difficulties, (iii) cultural have a large proportion. The number of different ethnic
issues. LTC institutions are located mainly in urban areas, groups in the elderly population also varies according
which imply that non-autonomous elderly people living to different areas. This, together with the fact that the
in rural areas might have barriers to accessing LTC. The health and social service system for the elderly in Sweden
other difficulty is the lack of human resources prepared to is operated and funded by local governing bodies, has
provide assistance.
led to different strategies to meet their needs and to
differences among the municipalities in terms of service
467
( ) Masso, M. (2007), Puuetega inimeste uuring, Sotsiaalministeerium,
coverage and availability. Some local authorities offer
Viide täpsustada.
121

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
special housing, home help and/or day activities specially inconsistencies across local authorities exist regarding
intended for or adapted to elderly people of a different what care is provided and who pays for what (470).
ethnicity. Other local authorities have staff from different
ethnic backgrounds in their units, matched with users Access to informal care among those over 65 varies
of the same background. Family-care providers are also greatly. According to Del Bono et al. (471), the differences
common among these groups.
are not so much dependent on gender but on age, car
ownership and marital status. Older men are more likely
United Kingdom
to be married than older women. Although men over the
There are criticisms that the current funding system for age of 65 carry out more caring activities than younger
formal care is unsustainable, unfair and unclear (468).
men, as women live longer than men they are less likely
According to Collins: it is unsustainable because without to be able to rely on care from a spouse and will be more
reforms, older people — even those on modest incomes likely to have to resort to public care facilities. More men
— will have to pay more from their own funds; it is unfair than women have access to a car and so women are more
because there are inconsistencies regarding who pays dependent on public services.
what; and it is unclear because there is often confusion
regarding who is responsible for payment — entitlements Source: EGGSI network national reports 2009.
vary between local authority areas (469). Even in Scotland,
where there is more universal provision, perceptions of
470
( ) Bel , D., Bowes, A. (2006), Informing Change: Lessons from
468
( ) Collins, S. (2009), Options for Care Funding: What could be
the funding of long-term care in Scotland, Joseph Rowntree
done now?, Joseph Rowntree Foundation.


Foundation.




http://www.jrf.org.uk
http://www.jrf.org.uk
469
( ) Collins, S. (2009), Options for Care Funding: What could be
471
( ) Del Bono, E., Sala, E., Hancock, R., Gunnell, C., Parisi, L., (2007), Gender,
done now?, Joseph Rowntree Foundation. p. 2.
older people and social exclusion, A gendered review and secondary
http://www.jrf.org.uk
analysis of the data, ISER Working Paper 2007–13, Colchester.
3.4. P
rogrammes aimed at
aim of the programme is to identify people with
overcoming barriers to LTC
specific financial problems and people who do
not make use of all potential financial support
Some examples of provisions to overcome barriers to
mechanisms. The aim is to help them fulfil the
accessing LTC can be found all over Europe.
necessary requirements for receiving extra
financial support. The target population of this
The kind of programmes offered can be summarised as
programme includes not only old people but also
follows:
children, single parent families, young people,
people with chronic diseases, ethnic minorities,
a. supporting low income and most disadvantaged
and people with disabilities. This programme is
groups;
not specifically oriented to healthcare access, but
the overall financial problems of specific target
b. improving the quality of care;
groups might influence also financial access to
healthcare.
c. supporting relatives.

■
In the UK there is a programme, started in 2002,
The gender impact of these programmes may be both
called ‘Free Personal Care’. It is implemented only in
direct and indirect.
Scotland. It is aimed at offering free personal care in
care homes and at home. The programme is a good
Programmes supporting low income and
practice to overcome financial gender barriers
most disadvantaged groups
thanks to a substantial reduction in care home fees
for elderly people (especially women).
Almost all European countries, with the exception
of Italy and Greece, have a basic income scheme

■
In Austria there is a local programme (in Vienna),
covering also old people in need, helping them to
specifically aimed at overcoming cultural barriers,
sustain the economic burden of LTC. Some countries
called ‘Integration of elderly migrants into social
have introduced specific programmes to overcome
centres for elderly people’. The programme is aimed
barriers to access LTC for most disadvantaged groups
at establishing a counselling, information and
(specifically low income groups and cultural minorities).
socialising centre for elderly people. Specifically,
Here are some interesting examples:
elderly migrants are the target of this programme.
The counselling centre provides non-bureaucratic
■ In the Netherlands there is a local programme,
counselling for elderly people on social issues,
called ‘Prevention Information Team Eindhoven’,
financial and legal questions following illness and
promoted by the municipality of Eindhoven. The
need for LTC.
122

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3. Gender differences in access to long-term care (LTC)

■
In Romania there is a programme called ‘Socio-
development, research and planning, raising skil s and
medical assistance for disadvantaged groups’. The
knowledge, improving col aboration between health
key point of the programme is the diversification of
professionals, partnerships with families and local
services at the local community level by developing
communities. The focus is on women as private and
social and medico-social assistance for women
professional carers for the elderly. The plan clearly
and men belonging to disadvantaged groups. The
identifies women as the majority among caregivers,
programme aims at the development of a network
both professional and private.
of medico-social services in two counties (Alba and
Mures) for elderly people (both women and men)

■
In Finland there is a local programme called ‘Act on
living on their own with no family or community
assessment of service needs for people over 80 (2006)
support, who have difficulty in accessing existing
and over 75 (2009)’. The objective of the programme
social and medical services.
is to make a broad assessment of the need for social
and health services. The programme does not have
Programmes aimed at the improvement of
a specific gender orientation, but most people aged
the quality of care
75 or over are women, and most of them live alone.
Moreover the Ministry of Social Affairs and Health
Improving the quality of care is a crucial point for the
(MSAH) and the Association of Finnish Local and
LTC system within European states, so some countries
Regional Authorities issued a recommendation on
have introduced programmes aimed at improving the
good practice in LTC (National framework for high-
professional skills of workers in LTC provision.
quality services for older people) in 2008 (472). The
focus of the framework is to reform the content of

■
In Germany, the Federal Ministry for Family Affairs
home care and 24-hour care services with new ideas.
has promoted the campaign ‘Modern care for
The framework also presents examples of good
the elderly’ to promote the occupation field of
practices from the field regarding the coordination
professional care. In particular, the initiative is aimed
of health and social care issues at the local level, such
at improving public awareness and at promoting a
as ‘service selection houses for elderly people’ and
high level of training for elderly caregivers.
‘new concepts for home care’ developed by NGOs.

■
In Norway there is a national programme called

■
In Italy there is a programme, called ‘Nonne-Care’. It is
‘Care plan 2015’. The aim of the plan is to address the
a regional programme promoted by the Municipality
main future challenges within elderly care in a long-
of Naples, the Campania Region, Campania Local
term perspective. In particular, the plan is focused
Health Units and other semi-public bodies. The
on research and development, increased quality of
objective is to enhance the possibility to meet new
care, increasing qualification among workers within
assistance and healthcare needs in order to keep
elderly care, specialised healthcare for the elderly
elderly women at home instead of in residential
and increased emphasis on volunteers and relatives
public care facilities, thanks to telephone and tele-
as carers. The care plan is important from a gender
assistance. The target group of the programme are
perspective, as women are in the majority among
elderly women (over 70 years old) who live alone
carers and those who are cared for. This gender
and suffer from specific pathologies.
perspective is clearly emphasised in the plan.
Support programmes to the relatives

■
Another programme promoted in Norway is the
‘National strategy for specialised healthcare for the
LTC provision by informal carers plays a crucial role, so
elderly 2008–12’. The main aims of the strategy are
some countries have introduced programmes aimed at
to strengthen elderly people’s access to specialised
supporting those who provide care to people in need
healthcare, create cooperation with primary
in their household.
healthcare, preventive care and emphasise research
and development within the area of the elderly

■
In Sweden a local programme (implemented by
and of their needs for specialised healthcare. The
the Municipality of Jönköping) called ‘Support in
programme emphasises equal treatment within
partnership 2006’ helps relatives to care, making life
specialised healthcare, which is important as elderly
easier for the carers and the cared for and to receive
women use it less than elderly men, despite the fact
good quality help and support (473). The programme
that women are in the majority among the elderly.
aims at planning, following up and evaluating the
individual support of relatives. The COAT (carers

■
The Dementia plan 2008–12, promoted in Norway,
aims at increasing the knowledge, col aboration and
472
( ) Ministry of Social Affairs and Health — MSAH (2008), National
quality of the care of dementia patients. In particular,
framework for high-quality services for older people, Ministry of
the programme is meant to increase the quality of care,
Social Affairs and Health’s publications, Helsinki.
473
( ) Socialstyrelsen (2005), Planeringsinstrument för anhörigstöd.
123

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
outcome agreement tool) does interviews, keeps in
is provided — a distinction has been made between
contact and relieves the relatives. The programme is
institutional care and care at home. Institutions include
addressed to relatives who take care of the elderly,
nursing homes, residential care homes and old-age
mostly women, and therefore has very relevant
homes where there is the permanent presence of
indirect gender effects. The programme is important
care assistants. Care at home may be provided by care
as it recognises the carers’ needs and the important
professionals or by informal care (as it often happens in
work they do.
countries characterised by family care model).

■
In Cyprus the national programme ‘Expansion of
With reference to service beneficiaries, women are
and improvement of care services for children, the
more often institutionalised than men.
elderly, disabled persons and other dependants’,
implemented period 2005–08 by the Social Welfare
One of the main elements to be considered while
Services, is aimed at improving and expanding social
regarding LTC in a gender perspective is the role played by
care services at the local level, in order to enable
women in informal care: women are the majority among
women to cope with the care needs of children, the
informal care providers (according to the WHO, women
elderly, disabled persons and other dependants.
represent two thirds of informal caregivers) and so the
The ultimate aim is to encourage their integration in
programmes aimed at supporting those who provide
the labour market as economically active members.
homecare are very relevant from a gender perspective.
The largest portion of these actions concerns the
financing of social-care structures which operate
Women are also the majority among LTC recipients for
under the responsibility of voluntary organisations
biological and socio-demographic reasons, but the
and local authorities. Within this framework,
EGGSI national reports have shown that they have to
financing was approved for 31 programmes for the
face additional barriers to access with respect to men.
pilot phase of the programme, implemented by Local
Even in those countries where the system is particularly
Authorities and Non-Governmental Organisations all
evolved and where there are no institutional barriers
over Cyprus. It does not target women as receivers
in accessing services, cultural barriers play a relevant
of care specifical y, but as carers, and thus can have a
role, in particular in countries with a high level of
positive impact on women as carers (474).
immigration or a large presence of Roma communities.
In these cases, specific difficulties have been reported

■
In Finland there is a programme called ‘Voimapolku’
in relation to cultural norms, habits and traditions
(Path to empowerment), aiming at promoting an
connected with the role of women in the community.
operational model for informal carers who plan to
This is particularly the case of countries such as
return to or access the labour market for the first
Austria, Germany, France and the Netherlands, where
time, in particular finding methods and practices to
there are large communities of cultural minorities. In
support the empowerment process of carers.
eastern countries, such as Bulgaria and Estonia, the
most consistent barriers reported are, on the contrary,
bureaucratic and administrative.
3.5. O
verall conclusions about
gender barriers to access LTC
Access to LTC is also affected by financial barriers for
low-income groups, which often includes elderly
Different institutional and organisational LTC settings
women, because their average income is lower than
exist throughout European countries. Service provision
men’s. In many countries, forms of co-payment may
can be described on the basis of two variables: the in particular lead to gender barriers due to the weaker
typology of care providers and the place where care is
economic position of women.
provided. In the first case the differentiation is between
formal and informal care. Formal care is provided in
LTC systems in Southern countries are mainly
most of the cases by municipalities for the social support
affected by geographical barriers, as it happens in
and/or by local healthcare services for the health
Italy, Spain, Portugal and Greece. These countries
component. In those countries where public service
are characterised by disparities in service provisions
coverage is less developed, informal care plays a crucial
between different regions and cities. For example,
role in service provision. This is the case in particular in
in Italy in terms of the extent of the provisions and
southern European countries such as Greece and Italy.
expenditure for citizens, the differences between
With reference to the second variable — where the care
the northern and the southern regions play a crucial
role. In Spain geographical barriers are mainly due to
474
( ) Ministry of Labour and Social Insurance (2008), National
lack of public transport. With regard to Portugal and
Strategy reports on Social protection and social inclusion
Greece, the main issue for geographical barriers is the
2008–10, Social Welfare Services.


backwardness of rural areas. In these countries the
http://ec.europa.eu/employment_social/spsi/docs/social_
inclusion/2008/nap/cyprus_en.pdf
family care model is dominant.
124

---

4. Conclusions
While healthcare systems have contributed to
disadvantaged women, such as homeless women,
significant improvements in health in Europe, access to
immigrant women, disabled women and single
healthcare remains uneven across countries and social
mothers, have also been carried out.
groups, according to socioeconomic status, place of
residence, ethnic group, and gender.
The comparative analysis presented in this report,
however, has shown that in most countries, besides
Gender plays a specific role both in the incidence and
reproductive care, there are still few gendered
prevalence of specific pathologies and also in their
healthcare strategies and services.
treatment and impact in terms of well-being and
recovery. This is due to the interrelation between sex-
Programmes promoting healthy behaviour are in
related biological differences and socioeconomic and
some cases gender oriented, targeted at either
cultural factors which affect the behaviour of women
women or men. The promotion of breastfeeding is
and men and access to services.
the most widespread promotion programme across
Europe. Other programmes are aimed at reducing
The report has highlighted the main differences in the
the consumption of alcohol and smoking, promoting
health status and health-relevant behaviours of women
diet and physical activity, as well as promoting mental
and men in European countries, in the accessibility of
health and occupational health. Health promotion
existing healthcare and long-term care services and the
programmes and campaigns specifically targeted at
main barriers to accessing these services for women
more vulnerable groups also exist.
and men.
On the other hand, health prevention programmes
Generally, women are more aware of their health status
are usually mainly targeted at women. Screening
and make greater use of healthcare services then men
programmes are important preventive measures, since
due to several reasons, such as their reproductive role,
many diseases can be avoided through early detection.
their role as caregivers for dependants (children, the
The most important and widespread gendered
elderly, the disabled), their higher share among the older
prevention programmes implemented in Europe are
population and also gender stereotypes, according
breast and cervical cancer screenings. Across Europe,
to which men usually do not consider it normal to
many prevention programmes address maternity:
complain about their health and visit physicians.
prenatal tests, support for mothers with newborn
children and family development, support for groups
Gender differences in healthcare
of children and mothers with special needs. Other
widespread prevention programmes across Europe
In some European countries (for example: Austria,
concern sexual and reproductive health. On the other
Bulgaria, Germany, Iceland, Ireland, Italy, Norway, Spain,
hand specific masculine pathologies, where prevention
the Netherlands, the United Kingdom, Slovenia), there
could be useful (such as prostate or testicular cancer)
is increasing awareness of the need to acknowledge
are less addressed by prevention programmes, even
gender differences in access to healthcare among
if in some countries there is an increasing attention to
governmental institutions, universities, and especially
these issues.
NGOs, which have traditionally been very active in
providing specialist services to women, ethnic minorities
The physical, psychological and social barriers that
and other disadvantaged groups. Gender-sensitive
prevent many women from making healthy decisions
strategies have recently been introduced within
are often not visible or addressed by healthcare
healthcare and medical research, research centres and
treatment programmes and regulations. For example,
research institutes with special knowledge regarding
there is usually little recognition of gender specificities
women and health have been created, observatories
in the treatment of some pathologies such as heart
on women’s health have been set up to support the
diseases, sexually transmitted diseases, mental
development of sex-disaggregated data and gendered
disorders, or work-related illnesses, and of the long-
medical research. In addition, some countries have
term consequences on women’s health of violence
implemented specific training programmes aimed at
and abuse. In many cases, the knowledge utilised is
general practitioners and healthcare providers, to raise
based on studies conducted on men, which results
their awareness of the importance of gender-specific
in treatment that may, in some cases, not address the
treatment. Specific programmes for the treatment of
needs of women. For example, there is still too little
125

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
knowledge about the female heart and since women
and the persistence of informal payments in many
often present different symptoms than men, there
eastern (such as Slovakia, Romania, Bulgaria, Hungary,
is a higher incidence of unrecognised myocardial
Poland, Lithuania, Latvia) and southern European (such
infarction; and in addition, women treated with
as Italy and Greece) countries.
‘male-based’ treatment may not respond in the same
ways as men. Regulations regarding health and safety
The growing role of private health insurance and
in the workplace usually do not cover housework
out-of-pocket payments may also increase gender
and serious domestic accidents are not regularly
inequalities, as men are more likely to be covered by
recorded and are thus left out of the statistics. Also,
private insurance than women, yet women are higher
the treatment of some diseases related to gendered
consumers of healthcare services and medicines.
behaviours, such as alcohol addiction and alcohol-
Women usually have a lower income and do not benefit
related diseases, which are predominantly —
from the same kind of firm-based private insurance
although not exclusively — a male problem, do not coverage as men do. They present lower employment
consider gender differences sufficiently.
rates in the regular economy (many women are either
inactive or work at home or in the informal sector) and,
While some programmes address these issues, this is
when employed, they are more likely to be employed
still an underdeveloped area for implementing gender
in the public sector and in small firms (which are not
equality principles.
likely to provide supplementary private insurance
schemes) with part-time and/or temporary contracts in
It has also been noticed that sometimes women and
low paying jobs. In addition, private insurance schemes
men are treated differently, not because their specific are less attractive to women since they often consider
needs are recognised, but because of prejudiced and
age and gender-specific risks in defining contributions.
stereotyped attitudes by health practitioners. For
Women from ethnic minorities and poor households
example, therapeutic support aimed at returning to
may be especially penalised by the privatisation of
work after work accidents is more frequent among
health services and the increase in out-of-pocket
men than women, also due to the attitudes of
spending on healthcare.
occupational health physicians and employers, who
feel that rehabilitation is more important for men than
Among European countries, financial barriers to
for women.
access appear to be particularly relevant in the Baltic
countries (especially in Latvia), Greece, Cyprus, Bulgaria
Even if universal or nearly universal rights to care are
and Romania, where the incidence of cost sharing is
basic principles in most Member States and most
particularly relevant. In the Baltic countries, Poland,
of the European population is covered by public
Sweden, Hungary and Germany, women’s perceptions
health insurance, these basic principles do not always
of unmet needs due to problems of access are higher
translate into equal access to and use of healthcare.
than the EU-25 average.
Residency, socioeconomic and geographical factors
can affect the accessibility to healthcare for specific
Geographical variations in coverage and provision
groups. These include the lack of insurance coverage are another relevant barrier to healthcare access. The
(affecting those without residency or citizenship, the
distance from hospitals and healthcare centres and
long-term unemployed and the homeless in countries
the lack of accessible transportation particularly affect
based on social security contribution systems), the
women living in rural or mountainous areas, disabled
direct financial costs of care (affecting low income
women and older women, as they are less autonomous
groups), the lack of mobility (affecting disabled
concerning mobility than men (they drive cars less
and old persons), the lack of language competence
frequently then men), and live more years in old age
(affecting migrants and ethnic minorities), the lack of
and ill-health.
access to information (affecting the low educated and
migrants/ethnic minorities), time constraints (affecting
The distinct roles and behaviours of men and women in
single mothers) or lack of services for specific groups.
a given culture, resulting from gender norms and values,
In all of these factors there are specific gender issues
give rise to gender differences and inequalities in access
to consider.
to healthcare as well as in risk behaviours and in health
status. Cultural barriers can be expressed in terms of
Financial barriers are particularly relevant for low
prejudices and lack of knowledge among healthcare
income groups and women. Income inequalities are
professionals concerning gender specificities in needs
especially related to the lack of insurance coverage,
and types of care to be provided. Language barriers, as
the cost of certain (specialised) types of care (such as
well as traditions and cultural practices also play a role,
dental, ophthalmic and aural care) which are often not
as certain groups of immigrant women and women
covered by public insurance systems, the incidence of
of ethnic origin have more difficult access to health
private insurance systems and of out-of-pocket costs
facilities and information on sexual health.
126

---

4. Conclusions
On the other hand, men also have to face stereotypes
The most important is the need to adopt a gender
in accessing healthcare and prevention programmes.
perspective in healthcare policies, considering the
Osteoporosis, for instance, is perceived as a female
biological, economic, social and cultural factors which
disease, and it might be less obvious that men should be affect the health condition of women and men and
treated for osteoporosis as well. Education and health
their access to healthcare. A gender mainstreaming
prevention programmes are also targeted mostly at
approach to healthcare policies, addressing gender-
women and only occasionally address men. The report
specific risk factors in medical research, service delivery
shows that it is important to take into consideration a
(considering promotion, prevention and treatment
variety of elements while analysing cultural barriers in
policies) and the design of financing systems enhances
accessing healthcare. These are prejudices and gender
the effectiveness of the care provided for women and
stereotypes, social status and level of education, cultural
men and reduce inequalities in access, as shown in
differences inherent in ethnicity and migration issues
some of the good practices presented in the report.
(that involve not only language skills but also traditions
and norms of hygiene), religious practices, prejudices
Gender-based health research increases knowledge
concerning sexual orientation, and working culture.
regarding the complex ways in which biological,
social, cultural and environmental factors interact to
Gender differences in long-term care
affect the health of women and men. Gender-based
medical research also improves the attention of health
There are two key issues to be considered from a
practitioners to gender differences and supports the
gender perspective when discussing access to long-
provision of gender-differentiated treatment when
term care. First of all the role of women as caregivers,
necessary. For example, it is important that research in
that is usually in unpaid informal care. Being relatives,
cardiovascular diseases considers gender differences in
friends or volunteers they do not receive any form of
morbidity and mortality and in reaction to treatment;
compensation for their engagement, while as informal
occupational health and safety research and practices
caregivers they receive cash benefits/allowance in
should take gender-specific factors into account, such
many cases without any form of employment contract.
as the different health risks that women and men are
Secondly the increasing use of LTC by women:
exposed to, due to occupational gender segregation
because of their longer lifespan, women are the main
and the health risks resulting from precarious
LTC beneficiaries, both in kind and in cash. Women’s
employment, domestic work and informal care work
reliance on formal care is linked to the fact that they
performed by women.
often have no care alternatives in their household, as
generally speaking, elderly women are more likely to
The implementation of gendered health information
live alone than men. Elderly women are also likely to be
systems and analysis tools (such as gender impact
more negatively affected than men by the forms of co-
assessment), upgrading quality in data collection
payment for access to LTC which have been introduced and analysis, is essential to support medical research
in many countries, because their average income is
and the systematic gender-specific monitoring and
lower than men’s.
evaluation of healthcare systems.
Examples of provisions to overcome barriers to
The promotion of capacity building for gender
accessing LTC can be found across Member States
sensitivity in healthcare systems and gender-specific
and they have important gender impacts. Interesting
training for healthcare professionals is likely to improve
examples which may positively affect women both as
the attention paid to gender differences in service
LTC users and providers have been found for example in
delivery and the effectiveness of healthcare services.
the Netherlands, where specific measures support the
lowest income groups, where women are the majority;
Attention to the gender impact of recent trends in health
in Germany, Norway, and Romania, where there are
sector reform, especially when addressing healthcare
measures improving the quality of care; in Sweden
financing and delivery, is particularly relevant. The fact
and Finland, where measures supporting informal care
that healthcare reforms increase the incidence of cost-
providers, especial y relatives, have been implemented.
sharing through private insurance schemes and out-of-
pocket payments may adversely affect women more than
Addressing gender inequalities in access to
men, since women are the majority among healthcare
healthcare and long-term care
users and the low income groups. Recent trends in
cost containment are also likely to increase gender and
The comparative analysis presented in this report has
income inequalities if not adequately addressed: the
highlighted some important issues which have to be
limitation in the basic care provisions included within
addressed in order to reduce gender inequalities in
primary care; the rationalisation of healthcare services
access to healthcare and long-term care and provide
which, in many countries, has reduced the number of
cost-effective and high quality care.
local clinics and services in rural or low-populated areas
127

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
and increased patient/staff ratios, may have negative
a gender mainstreaming approach to healthcare
consequences on women more than on men, as women
policies in order to improve their effectiveness. This
are the main healthcare users and providers. These
is even more relevant as the current financial and
issues are particularly relevant for long-term care, where
economic crisis may reduce the available resources for
gender plays an even more relevant role, with women improving the quality and coverage of healthcare and
being the main care providers (formal and informal) and
LTC provisions, with pilot gender-based programmes
care users.
risking more from budget cuts. Eastern European
countries, in the process of improving the quality and
To conclude, the evidence emerging from this
extension of their healthcare systems, present such
comparative report underlines the need to adopt
a risk.
128

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5. Annex – Statistical tables
Table 1 — Consultation of a medical doctor during the past 12 months
of women and men, by education 2004
Pre‑primary,
Lower secondary
Post‑secondary
primary education
Upper secondary
or second stage of
non‑tertiary and

Total
or first stage of
education —
basic education —
tertiary education —
basic education —
level 3
level 2
level 4,5 and 6
level 0 and 1

Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Austria
86.7
87.8
82.1
83.1
:
:
90.4
83.2
92.0
92.2
Belgium
92.5
84.0
95.7
88.9
92.1
82.8
91.0
83.7
91.7
81.9
Bulgaria
73.8
60.9
77.8
65.8
74.9
62.1
72.1
58.2
71.7
62.4
Cyprus
74.9
56.7
84.8
70.2
64.9
45.8
72.1
53.2
71.0
54.3
Czech Republic
94.6
89.4
92.8
90.2
96.3
88.5
95.1
88.7
93.8
93.1
Estonia
78.6
66.1
71.2
62.6
74.8
67.2
79.6
65.0
84.1
70.9
Finland
88.4
75.9
:
:
85.5
78.6
89.6
77.6
89.4
71.2
Germany
94.5
84.6
92.8
90.9
94.4
85.8
95.9
82.3
94.2
79.3
Greece
72.4
54.3
83.9
71.2
64.5
41.3
58.2
38.9
64.8
49.9
Hungary
90.3
81.8
89.0
80.0
91.0
81.6
89.8
82.1
93.6
84.4
Iceland
78.1
71.2
72.2
64.7
79.1
67.0
79.4
74.1
82.1
76.6
Latvia
74.9
60.1
66.3
64.3
74.1
61.2
75.0
58.2
78.1
62.8
Lithuania
82.6
67.9
:
:
78.9
66.2
85.5
64.5
82.0
69.9
Malta
80.2
80.9
82.1
78.7
77.8
81.4
82.6
82.6
80.5
81.5
Netherlands
86.4
74.2
89.0
78.7
84.3
73.3
85.5
73.1
84.4
70.9
Norway
81.6
74.1
:
:
84.1
80.0
80.8
74.3
81.2
70.2
Romania
46.8
32.6
57.6
42.4
43.6
29.6
43.4
28.9
47.5
44.1
Slovakia
83.8
76.6
89.2
79.2
78.5
74.3
83.7
78.8
84.9
74.6
Slovenia
73.3
67.6
76.5
65.2
62.0
71.7
74.5
62.5
77.9
72.5
Spain
88.1
76.4
91.8
81.8
84.5
73.9
85.0
73.9
85.2
70.1
Source: Eurostat data based on national health interview surveys (HIS round 2004: period 1999–2003).
Explanatory note: Data refers to the number of persons who consulted a medical doctor (including general practitioners, specialists) during the
past 12 months. It refers to persons from 15 years and older, living in private households and for some countries also in institutions like homes for
the elderly. Data are expressed as relative percentages within population groups defined (475).
475
( ) For further information see Eurostat metadata.

http://epp.eurostat.ec.europa.eu/portal/page/portal/product_
details/dataset?p_product_code=HLTH_CO_INPA
129

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Table 2 — Inpatient hospitalisation of women and men during the past 12 months
by educational level (%) in some European countries, 2004
Pre‑primary,
Post‑secondary
Lower secondary
primary education
non‑tertiary
or second stage of
Upper secondary

Total
or first stage of
and tertiary
basic education — education — level 3
basic education —
education — level
level 2
level 0 and 1
4,5 and 6

Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Austria
13.4
13.1
15.6
15.0
:
:
12.0
12.7
11.5
11.6
Belgium
15.4
13.3
20.6
16.5
14.5
16.8
14.1
12.0
13.1
10.7
Bulgaria
9.3
8.4
14.3
15.9
10.2
9.9
7.4
6.0
7.0
6.3
Cyprus
9.7
8.1
12.6
11.2
9.7
7.0
8.9
7.7
7.0
5.8
Czech Republic
15.7
10.4
20.0
10.7
15.6
12.1
12.1
9.9
13.5
4.8
Estonia
10.6
11.3
12.8
18.9
11.6
13.8
10.5
9.3
8.0
10.6
Germany
14.5
10.5
11.9
13.2
15.3
11.1
12.2
7.7
12.0
9.3
Greece
7.2
7.4
10.5
11.8
4.3
4.2
3.5
3.8
3.8
4.2
Hungary
18.0
12.5
22.9
17.6
19.7
13.2
13.6
10.1
14.5
8.4
Iceland
15.0
7.9
23.4
10.7
17.4
8.0
10.7
7.4
14.4
7.6
Latvia
11.8
10.9
18.2
13.2
14.2
12.9
10.2
10.3
11.9
8.5
Malta
10.7
10.0
11.5
9.5
11.3
10.8
7.1
9.1
10.3
9.9
Netherlands
7.3
5.0
9.4
7.1
5.2
3.8
6.6
4.2
5.9
4.0
Norway
14.1
10.5
:
:
16.4
14.8
12.8
10.0
14.9
8.2
Poland
12.4
8.8
12.4
10.0
:
:
12.8
8.3
10.4
7.0
Romania
8.1
5.5
8.3
6.9
7.9
5.5
7.7
4.9
9.6
7.0
Slovenia
16.0
18.4
20.3
17.9
12.3
15.9
15.1
21.8
10.3
18.8
Spain
10.4
9.2
12.1
12.2
9.0
8.1
8.1
5.4
9.4
7.5
United Kingdom
8.4
6.2
9.3
9.1
8.4
6.5
7.6
6.2
8.1
4.5
Source: Eurostat data based on national health interview surveys (HIS round 2004: period 1999–2003).
Explanatory note: Number of persons (15 years and older) who were hospitalised for more than one day. Refers to persons living in private
households and for some countries also in institutions like homes for the elderly. Data are expressed as relative percentages within population
groups defined. Data are expressed as relative percentages within population groups defined by the background variables: sex, age groups
(10 years intervals) and educational level (according ISCED 97) (476).
476
( ) For further information see Eurostat metadata.
http://epp.eurostat.ec.europa.eu/portal/page/portal/product_
details/dataset?p_product_code=HLTH_CO_INPA
130

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5. Annex – Statistical tables
Table 3 — Inpatient hospitalisation during the past 12 months
of women and men by age in some European countries, 2004
15 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84

Total
> 85 years
years
years
years
years
years
years
years

w
m
w
m
w
m
w
m
w
m
w
m
w
m
w
m
w
m
Austria
13.4 13.1 10.2
9.2
10.0 10.2 10.6 10.7 13.6 12.3 14.5 16.3 18.2 20.7 22.6 25.7 19.8 25.2
Belgium
15.4 13.3 12.2 11.0 15.0
8.6
9.9
11.8 14.1 14.5 16.0 15.7 20.5 18.6 23.7 20.4 29.3 16.2
Bulgaria
9.3
8.4
9.8
4.4
9.4
3.4
6.1
5.8
8.6
10.5
9.1
10.2 11.4 16.8 13.6 18.2
5.6
3.1
Cyprus
9.7
8.1
5.6
7.6
11.1
3.8
8.7
6.1
7.4
7.0
10.1 11.2 16.2 15.1 14.5 16.6 25.5 18.0
Czech Republic 15.7 10.4 11.2
4.9
18.3
3.5
11.9
5.1
12.8 10.0 13.0 17.0 18.3 25.2 29.5 36.2 44.0
:
Estonia
10.6 11.3 10.2
9.7
7.9
8.7
10.3
9.5
11.1 10.0 10.9 13.6 11.9 18.1 15.2 21.5
:
:
Germany
14.5 10.5 11.5
9.5
16.7
4.7
13.4
7.4
11.6 10.0 13.6 14.7 18.4 19.2 17.8 23.2
:
:
Greece
7.2
7.4
2.3
1.5
2.6
2.7
4.2
3.6
4.1
4.2
9.6
9.6
12.7 15.5 15.6 21.6 18.9 25.8
Hungary
18.0 12.5 15.2
7.2
15.6
5.3
13.0
8.4
19.3 16.4 15.4 18.0 23.8 22.8 30.4 21.2 15.3
:
Iceland
15.0
7.9
13.4
6.6
15.7
6.9
15.1
4.7
6.8
8.8
11.3
9.4
30.5 15.8
:
:
:
:
Latvia
11.8 10.9
9.9
7.5
8.4
8.4
7.4
8.7
11.5 11.3 14.6 16.0 20.5 19.8
:
:
:
:
Malta
10.7 10.0 10.8 10.2 10.5 10.4 11.5 10.2 10.2
9.8
9.7
10.4 13.8
9.5
10.0
4.9
20.8
:
Netherlands
7.3
5.0
4.5
1.7
7.3
3.0
5.3
2.9
6.4
4.3
8.0
7.3
11.0 12.0 14.2 16.6
9.3
7.2
Norway
14.1 10.5 10.6
7.2
22.2
8.7
11.1
6.7
10.5
9.3
10.6 16.0 11.9 14.3 22.9 19.8 22.4 15.9
Poland
12.4
8.8
9.8
4.8
13.9
4.6
9.4
7.4
12.3 11.2 13.7 13.5 16.4 16.2 18.8 20.1 12.0 11.6
Romania
8.1
5.5
6.3
1.5
7.4
3.1
7.0
4.9
9.3
8.0
8.9
9.0
11.1 10.3
8.7
8.8
2.3
9.8
Slovenia
16.0 18.4 20.3 15.9 19.4 15.2
6.5
12.3 14.9 16.9 10.3 22.4 19.7 26.1 27.3
:
:
:
Spain
10.4
9.2
3.7
5.0
12.6
5.3
9.5
6.8
6.7
9.7
10.7 12.8 13.1 15.6 18.7 19.2 21.0 24.6
UK
8.4
6.2
6.8
5.5
12.3
3.1
6.7
5.4
7.6
5.7
8.6
9.6
6.5
14.8
:
:
:
:
Source: Eurostat data based on national health interview surveys (HIS round 2004: period 1999–2003).
Explanatory note: Number of persons (15 years and older) who were hospitalised for than one day. Refers to persons living in private households and
for some countries also in institutions like homes for the elderly. Data are expressed as relative percentages within population groups defined (477).
477
( ) For further information see Eurostat metadata.
http://epp.eurostat.ec.europa.eu/portal/page/portal/product_
details/dataset?p_product_code=HLTH_CO_INPA
131

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by Albena Arnaudova, Copenhagen


and Xenophobia, Integration of the foreign population
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http://www.euro.who.int/document/e74558.pdf
145

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ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Websites
Ministerium für Arbeit und Soziales, Germany.

http://www.sozialministerium-bw.de/
Acorus, Avon proti domacimu nasili (Czech Republic) —
http://www.acorus.cz/cz/novinky/29_acorus-je-
Ministero del Lavoro, della Salute e delle Politiche
partnerem-projektu-avon-proti-domacimu-nasili.html
Sociali, Italy.




http://www.ministerosalute.it/saluteDonna/
Ambulansforum, Sweden —

saluteDonna.jsp
http://www.ambulansforum.se/
National Institute for Public Health and the Environment
Austrian Federal Institute for Health Planning
(RIVM).




(Österreichisches Bundesinstitut für Gesundheitswesen,
http://www.kostenvanziekten.nl
ÖBIG) —




http://www.goeg.at/de/OEBIG.html
National Strategic Reports for Social Inclusion
and Social Protection, 2008.


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2006 for the Open Method of Coordination, Health and
strategy_reports_en.htm
long-term care, July 2008.



http://ec.europa.eu/employment_social/spsi/
National Statistic Institute, Estonia —


common_indicators_en.htm
http://pub.stat.ee
European Observatory on Health System and
Nederlands Jeugd Instituut (Dutch Youth Institute),
Policies —





Databank effectieve jeugdinterventies, the Netherlands.
h t t p : / / w w w . e u r o . w h o . i n t / o b s e r v a t o r y /
http://www.nji.nl/eCache/DEF/1/03/055.html
Studies/20040718_5
Norwegian Directorate of Health —

European Directives —
http://www.helsedirektoratet.no/helseogomsorg
http://www.europarl.europa.eu/oeil/search.jsp
OECD Healthcare Quality Indicators Project —
Eurostat database on Health —

http://www.oecd.org/document/31/0,2340,en_2649_
http://epp.eurostat.ec.europa.eu/portal/page/portal/
33929_2484127_1_1_1_1,00.html
health/introduction
Osservatorio Nazionale sulla Salute per la Donna,—
EPIC database, Eurosocial.

http://www.ondaosservatorio.it/index.asp
http://epic.programaeurosocial.eu/buscador/
buscar.php
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www.poverty.org.uk
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http://www.pio.gov.cy/mof/cystat/statistics.nsf/All/D4C
Towards a healthier Europe, 2009.


9C72CE63047EAC2257000002B2646?OpenDocument
http://www.intratext.com/ixt/_EXT-rep/_INDEX.HTM#-.1
Social- och Hälsovårdsministeriet, Finland —
Finnish Ministry of Social Affairs and Health, Finland —
http://www.stm.fi/sosiaali_ja_terveyspalvelut/
http://www.stm.fi/julkaisut/esitteita-sarja/nayta/_
asiakasmaksut
julkaisu/1058533
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146

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European Commission
ACCESS TO HEALTHCARE AND LONG-TERM CARE: Equal for women and men?
Final Synthesis Report
Luxembourg: Publications Office of the European Union
2010 — 146 p. — 21 × 29.7 cm
ISBN: 978-92-79-14854-5
doi:10.2767/93670
Though significant progress has been made in increasing the quality of health care across
the European Union, many inequalities persist. In particular, this report looks at the
inequality in access to healthcare and long-term care between men and women in the EU.
The synthesis presented in this comparative report by the Expert Group on Gender Equality,
Social Inclusion, Health and Long-term Care Issues describes the main differences in the
health status of women and men in European countries and examines how healthcare
and long-term care systems respond to gender specific needs in ensuring equal access.
The report considers the main financial, cultural and physical barriers to access and
provides good practice examples of healthcare promotion, prevention and treatment
programs, as well as of long-term care. It calls attention to the need for promoting gender
mainstreaming in healthcare and long-term care.
This publication is available in printed format in English only, with an executive summary
in English, German and French.

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