The role of local authorities in implementing health care
wit the gender perspective: The case of the Women's Total Health Care Program in Sao
Maria José de Oliveira Araújo
Coordinator of National Feminist Network on Health and Reproductive Rights Brazil
The purpose of this paper is to discuss the role of local governments in introducing a gender perspective to the implementation of governmental womens health care policies and programs. This paper also aims at a contribution to national governments for the effective implementation of womens health care programs as defined in the Beijing Platform for Action.
This paper will focus on a concrete experience of mainstreaming the gender perspective into the design, implementation and monitoring of governmental health policies: a program carried out in the city of São Paulo from 1989 to 1992named Womens Total Health Care Program PAISM. The impact of this experience initiated in the late 80´s on governmental policy-making in other Brazilian cities and towns and its contribution to the advancement of womens rights at national level will also be analyzed. Also pointed out here is the importance of the involvement of gender-aware health professionals and the role of womens organizations in securing continuity of governmental programs within stable economical and political contexts.
Health and Human Rights
The principle of equal rights for men and women set forth in the 1945 UN Declaration of Human Rights was reinforced in the World Conference on Human Rights (Vienna, 1993) by the addition of ampler womens rights. This Conference recognized for the first time womens rights as inalienable, as an integral and inseparable component of universal human rights.
This recognition inaugurates a new era for women in that it assures no hierarchical levels based on sex for positions and policies by national governments. This has been ratified in the Beijing Platform for Action (1995) and the Programme of Action of the International Conference on Population and Development (Cairo, 1994) as comprehensive policy proposals aiming at gender equality.
In respect to Brazil, although the 1988 Brazilian Constitution assures equal rights for the sexes, this basic constitutional principle is frequently violated in respect to women and discrimination against females is still a serious social problem. Women are frequently discriminated in interpersonal relationships, at the workplace, in access to health care and other public services, and in decision-making governmental spheres. All this poses some questions in respect to full exercise of democracy as a right of all citizens and a driving force for a countrys development.
This discrimination is also reflected in the distribution and appropriation of opportunities for social mobility, access to education, childcare, health care, environment sanitation and public amenities.
In this context, the relationships developed by public health providers with users are impregnated with a culture based on hierarchy between the genders both at decision-making and service provision levels. The health care system reproduces not only gender inequalities, but also social class differences and racial discrimination. Lower-class women and black females are predominant in maternal mortality figures; indigent living conditions and poverty, as well as difficulty of access to the health care system cause deaths. Such are typical, preventable gender and poverty related deaths.
The Programmes of Action of almost all global conferences in the 90´s clearly indicate the need for improved attention to womens health and easier access of women and teens to health system services. Womens organizations have been active in such UN gatherings, participating in pre-conference events and activities, and have contributed to many victories of the womens health movement. The role of womens organizations has been especially visible in the dialogue with parties who are traditionally resistant to discussions about womens issues. Although UN conferences have not yielded positive results in respect to all feminist claims, a lot has been achieved for women in their struggle for equality, respect and self-determination.
Even though the UN conferences themselves can be considered as victories and the agreements signed by the national governments all important, women are concerned with the disparity between the discourse supporting equality and daily practices. In fact, actions to promote improved womens health care and womens sexual and reproductive rights have not been effectively prioritized.
From a socioeconomic point of view, the application of structural adjustment policies in Third World countries has brought about strong contradictions involving Conference recommendations and realities in individual nations, where the privatization of health care and heavy cuts in public spending block the access of poor and vulnerable population sectors to health system services.
In most developing countries, such policies have contributed to the collapse of the public health system and the reduction of the systems preventive and healing capacities. As a result, the poor population sectors have become more vulnerable to diseases, health indicators deteriorated, and there has been an incidence of diseases and conditions such as malnutrition, tuberculosis, cholera, and sexually transmitted diseases that had been eradicated in many regions. In some countries, Brazil included, maternal mortality rates have increased in the last three years, revealing a perverse reality in which poor women have no conditions to exercise their reproductive rights as recommended by the United Nations Conferences.
The greatest challenge to both central and local governments despite the unfavorable economic situation is to foster equality in health care by means of policies ensuring freedom and dignity to women, advancement of womens rights and the development of nations. We do hope that the promises made by governing authorities in UN Conferences will not get pigeonholed but become concrete policies to restore the right to health care as human rights for women and adolescents.
Mainstreaming the Gender Perspective into Governmental Policies PAISM
In 1989, as a result of pressure by womens organizations, the São Paulo city government created the Womens Health Care Office (WHCO), a division of the Municipal Health Secretariat (under direct supervision of the Health Secretarys staff). In full operation in the period 1989-1992, the office was in charge of the management of womens health care services offered at the municipal health facilities in all city districts. But the WHCO´s main achievement was the implementation of the Womens Total Health Program PAISM. The WHCO board comprised female health professionals belonging to womens organizations and having a long record of participation in the design, implementation and monitoring of governmental policies for women.
The challenge posed to WHCO was to implement a total health program with the gender perspective in order to raise health indicators in the city as claimed by the womens organizations.
Introducing the gender perspective into health policies means first of all recognizing that there are social differences between men and women, how these differences are reflected in the organization of health services at all levels, and how this system interfaces with female users. Inequality pervades the health systems structure: all visible positions, such as health secretaries, division chiefs, and managers are all men; also unequal is the access to public resources for the promotion, prevention and healing capacities.
In the last few decades, the concept of health has undergone a deep change; it no longer means the absence of disease but involves more complex paradigms of total health integrated with other dimensions of human life. In respect to womens health, the socio-cultural impositions based on the vision of women as servants to others and maternity as the pillar for the building of female identity, challenge us to rethink the concepts and approaches to health care. It implies critically rethinking the practices at health centers, which negatively affect womens physical and mental health.
Therefore, in order to achieving better health standards for the population, and more specifically, improved health care for working women and female users of health system services, will require the commitment of the government to a global and integrating health plan and policy-making assuring human, technical and financial resources in order to meet womens specific needs.
This new approach allows us to rethink the role of both providers and users in the building of an effective health care system. We believe that protagonism and the participation of women in decision-making is critical to womens growth as social actors. This means that women will be able to see themselves and being seen not only as patients but as players, with the capacity to expose their views, intervene and make decisions about health care. In this sense, implementation of health care models based on total health and the gender perspective contributes to the development of womens autonomy and self-esteem, empowering them to make decisions about their own bodies and health and strengthening their rights as well.
The utilization of a gender category as a tool for the assessment of the health sector will not render the analysis poor or restrict it to social factors and conditions affecting the lives of men and women. Introducing the gender perspective into the analysis makes room for interaction and deeper understanding of the nexus of social and biological elements, so that diagnoses and proposals can be in tune with reality and peoples daily lives. Also, it will help us to explain with more precision the health/disease processes and their differences according to sex and sex/social classes.
The simplistic view of the health/disease process as a biological and individual phenomenon still pervades health care actions. This view sees individuals as "patients" only, people with a disease history not a life history, a family, a job, unique emotions and feelings.
It is in this context of deep social differences and hierarchical roles that we should analyze womens health/disease processes and the health care programs designed for them. In most countries, women are in their majority the poorest among the poorer population sectors. Inequality prevails in the distribution and use of resources for health care promotion and disease prevention, as well as in the ways health/disease determining factors operate. These work differently for men and women and define different living and work conditions, health, sickness and death conditions as well.
The organization of the health system as a gender system makes unequal power relationships between the sexes something "natural"; this is reflected in the hierarchically structured health institutions and their relationships with men and women at all system levels. This negatively affects women, restricting satisfaction of their needs and their well being. In practice, health institutions reinforce gender stereotypes through subtle forms of oppression, such as refusal to recognize womens knowledge and wisdom or using their bodies to test invasive procedures without informing them. The absence of health data disaggregated by sex in health services and the privileges granted to the male in several diagnostic and treatment procedures also reflect the absence of gender awareness prevailing in most health system services.
Sex discrimination is likely to be identified if the gender perspective is introduced into the health sector. This would contribute to determine that due to biological differences and different social roles the health sector must be able to process different health needs and risks according to peoples sex and implement policies to foster equality in the access to and control of public resources generated by all social actors.
Introducing the gender perspective into health system services will imply deep changes in the systems culture and hierarchical structure, demanding new forms of relationship among health professionals and among these and female system users. This will mean sharing power with women, as well as new methods to perform epidemiological diagnoses, planning and the application of equality principles in the investment and distribution of resources.
Several strategies may be used to introduce the gender perspective into the health system. To some extent, the use of strategies require a favorable political and administrative conjuncture both at central and local levels. In this sense, it is important to point out the role of health authorities in the São Paulo democratic administration (1989-1992) that provided the necessary conditions for an effective implementation of the Womens Total Health Care Program. Such conditions included prioritizing the health sector and womens health care, creating decentralized decision-making levels, District Health Authorities (SILOS) in order to understand realities in the various city regions and encouraging community involvement.
Inspired by this concrete experience, we believe that the following strategies may contribute to the advancement of implementation of gender-oriented womens health care programs. Such strategies comprise a number of mutually reinforcing initiatives involving integrated actions at several decision-making levels.
Creating womens health advising/ coordinating offices at Municipal Health Secretariats and District Health Authorities staffed by women who support the gender perspective. Such offices would assure the introduction of gender policies into general health policies in the city. Other office tasks shall include: helping to conduct a general womens health epidemiological survey which will take into account the gender perspective and the demands of womens organizations; using survey findings to suggest priorities in tune with global municipal health policies; and setting up technical norms and procedures for the program.
Office leaders shall foster sensitization of planners and professionals at health centers to the importance of having governments obey the Constitution and other national laws that assure womens rights and compliance with agreements sealed at UN Conferences, in order to promote improved womens health care and access to health services.
The proposed health advising/coordinating offices shall operate as a mechanism integrated to global health policies and local decision-making spheres, and not as a vertical organism that plans and decides autonomously, without taking into account decentralized power mechanisms. Integration of these decision-making spheres shall result in experience sharing and formulation of integrated policies with higher levels of effectiveness for the proposed programs.
Epidemiological diagnosis and health planning with a gender perspective. In the city of São Paulo experience, an important WHCO initiative was the creation of District Health Authorities Local Health Systems. These were fundamental for the introduction of the gender perspective in the implementation of programs. According to the Pan-American Health Organization, District Health Authorities help to promote more equality and effectiveness in the implementation of health policies, specially in situations where resources are limited and the demands and diversity of risk groups too great.
Operating as a true womens health care advising/coordinating office, WHCO supplied permanent technical support to District Health Authorities. This has contributed not only to introduce the gender perspective into the global Health Secretariat mission, but also into epidemiological diagnoses conducted at district level.
This strategy proved useful to raise awareness of municipal health system staff about gender issues in the services. Generally, epidemiological diagnoses which serve as a basis for health care planning and resource allocation only consider as health problems those spontaneously reported by patients. In truth, the service dynamics usually help to hide important issues of high impact on womens lives, such as gender-based and domestic violence, sexuality problems, mental health conditions and high workloads at workplace and at home. Diagnoses are frequently based on chronic female health complaints women usually report because they are often ashamed to talk about their real problems. Health services generally regard womens complaints as "female stuff", making them seem less important than they usually are, which sometimes lead to faulty diagnosis or treatment procedures.
Equally neglected in the epidemiological diagnosis, womens organizations´ requests are generally considered "superfluous" when compared to the eternal needs of populations who are deprived of almost everything in their daily lives. We have found out that, due to the fact that they sometimes lack information on proper diagnosis procedures, health services resist to introduce even elementary questions for womens health statistics, such as figures on breast cancer, an important cause for morbidity-mortality among women.
Health professionals, planners and managers included, are not prepared for a new health care model based on gender-oriented diagnosis. Medical and nurse schools do not educate professionals to address issues related to service users´ lives. Epidemiology as a science has so far failed to include gender as a tool for deeper analysis and real diagnosis of sicknesses or health conditions afflicting both men and women. Current practices still make use of indicators and instruments which in their majority are not useful to assess basic issues to be considered in health care planning, such as womens health troubles related to sex role.
Whenever we take gender into consideration for strategic health care planning, demands that had never been faced by health professionals might surface. These new needs and old ones may clash, as cited before, at the moment decisions on priorities for the various strategic areas must be made. The important role of gender-oriented diagnosis and planning lies in the fact that more gender-aware professionals can be included to participate in decision-making at central or local (district) level. Introducing new needs in womens health care planning is not an easy task. It brings into play differences in access to and control of resources within the system.
In gender-oriented strategic planning, implementation of new services will certainly be demanded, such as contraception guidance, care to victims of gender-based or domestic violence, legal abortion and humane care to women who ended their pregnancies. Issues like mental health and womens double shift shall be considered in program actions.
Based on the experience gained by performing gender-oriented diagnosis and strategic planning, the Womens Health Care Office (WHCO) of the Health Secretariat, in partnership with District Health Authorities, implemented traditional health programs as well as pioneer womens health care programs, such as the first legal abortion service abortion permitted by law for life-risking pregnancies or pregnancies resulting from violence (e.g. rape) to women; assistance to women and adolescents in situations of sexual abuse or violence in the home; access to information and planned parenthood services including emergency contraception (day after pill) at all municipal health centers; and the formation of a Maternal Mortality Prevention and Survey Committee, with community participation. It also had the first municipal law passed in the country providing mandatory creation of maternal mortality prevention committees at public health facilities in order to prevent so many unnecessary deaths. At municipal hospitals and maternities, WHCO implemented new practices at childbirth, such as allowing the father to stay in the operation room and overnight with mom and baby. This practice was considered revolutionary because unusual in the public health system and for low-income people.
Diagnosis and health care planning with equality implies changes in the ways both human and material resources are allocated. It means distribution according to priorities indicated in the diagnosis and the assurance of proper use of such resources. What generally happens in health system services is that gender-oriented epidemiological surveys are not taken into consideration when setting priorities. Therefore, womens health programs either have no resources of their own or are part of other health programs run at state or municipal level, depending on the goodwill of governing bodies to be effectively operated.
Again, decentralized health system management may also contribute to better use of resources according to priorities. Decentralization allows better understanding of the populations health problems and better control by the community. In this sense the involvement of organized women in all participation and control mechanisms is critical to ensure full operation of planned programs and compliance of authorities with commitments to prioritize health.
Having a clear picture of budgetary priorities and the pressure of organized community sectors help planners to decide, for example, to ensure access to contraceptive methods to all women in a health district or region, without the feeling of leaving other priorities behind.
The use of financial resources in health systems is controversial since it depends on how the system is organized. In some countries decentralization mechanisms have advanced with Health Ministries operating only as supervisory commissions for norms and prevention campaigns for a number of endemic diseases; in other countries, centralized planning and decision-making are still in operation. In either case, it is important to assure allocation of resources in the budgets to fund womens health program activities and thus ensure continuity to policies.
Despite their limitations, most decentralization processes have proved more democratic and participatory because they reflect community needs and possible solutions more accurately. Decentralization and community participation in decision-making contribute to ensure sustained governmental policies and community control over public resources. These are mechanisms that are still badly needed in Third World countries.
The gender perspective and health professionals. Funding the empowerment of health professionals is one of the requirements of gender-oriented planning and diagnosis processes. It means improved health services and more satisfaction both for professionals and users.
This new equality-based health model requires cultural changes in the discriminating, hierarchical behavior health professionals entertain with users. It requires a new mentality about womens health and its interaction with the social environment. Investment in education is critical to implement and maintain policies. Gender-aware health professionals involved in the programs will assure that the next mayor elected will not be able to abandon the programs created by his predecessor. Education requires that the health systems rethink their educational proposals and introduce womens rights into the educational processes. Technical expertise of health professionals should incorporate elements favoring total health and womens more control over their lives, that is, addressing issues beyond biological and cultural issues.
In this sense, the consolidation of a sustained evaluation process will be necessary. This will be an essential stage in planning and a critical political tool to build a different logic in health service provision.
Intersector networking as a means to face health problems of the female population and capitalize the actions of other secretariats and institutions operating in womens health care. Information on effective global policies for women in other cities and towns are fundamental to make health policies advance. One example of intersector networking is the work developed to assist women who are victims of gender-based violence. The health sector needs to dialogue with public security secretariats, police stations, shelters and non-governmental organizations. This networking is even more important with education, housing and labor secretariats, areas directly related to womens total health.
Networking with womens organizations, by means of participation in policy planning, implementation and monitoring. In Brazil, the implementation of governmental programs for women has been more frequent in states and towns with strong and demanding womens organizations. This pressure has been a relevant factor to secure implementation and maintenance of proposals in the areas of womens health care, reproductive rights and violence against women, as well as dissemination and amplification of agreements signed by the Brazilian Government at United Nations Conferences.
Political Factors Contributing to the Success of the Experience
When we assess the results of one of the first Brazilian experiences in implementing womens health care programs with a gender perspective, it is important to highlight factors which strongly contributed to have the claims of womens organizations incorporated in the programs.
Although several factors have influenced this experience, we will analyze only the strongest aspects of the implementation procedure of actions devised to improve womens health especially indigent and excluded women in low-income classes in the city of São Paulo.
As a backdrop for the implementation of a series of actions directed to the female population, there was a favorable political situation, in which a democratic administration was committed to improve the populations health in general, in special its more vulnerable segments (women, children and the aged). Since its inception, the program proposed by the municipal government prioritized not only actions based on traditional epidemiological diagnosis, but also on other factors such as the requests of the organized social movements, including the womens organizations, and providing access to poor population sectors to health care.
According to the São Paulo democratic administrations priorities, health and education were considered strategic sectors to the improvement of the quality of life in the city. Pursuant to this, the municipal budget for the health sector jumped from 6 per cent in the first year of the administration (1989) to 16 per cent in the last year (1992), ensuring compliance with recommendations that health budgets should be around 15 or 16 per cent of total city budget. Since health became a priority sector, investments were made to improve health facilities all over town, especially in the poor neighborhoods that displayed higher rates of preventable deaths. Many other facilities were built, such as day-hospitals and community centers in highly violent areas ,shelters for victims of sexual abuse or domestic violence, plus an increase in the number of maternity beds and other measures which helped to decrease maternal mortality rates in the period.
It is important to mention that all priorities of the Municipal Health Secretariat were jointly defined by the board, employees and community representatives, in order to assure proper use of resources to solve major health problems and assist city areas lacking such resources.
Another important factor contributing to make womens health a governmental priority was the presence of female managers committed to gender issues and public policies for women. With a long history of participation and intervention in the design of policies, the Brazilian womens movement has been active in several important moments in Brazilian life, among them, as members of coordinations of womens health care programs run by the Health Ministry, and State and Municipal Health Secretariats.
The participation of women committed to secure womens rights to health care took several forms. Besides the WHCO´s management, the Womens Affairs Coordination (WAC) directly connected to the Mayoress´ office was created. WAC was in charge of formulating governmental policies for women in the city. These two bodies entertained a permanent and fruitful dialogue, designing and proposing policies for several areas, which resulted in a number of projects, such as the shelter for victims of sexual abuse or domestic violence, communal laundries at poor neighborhoods and other innovative initiatives.
Setting up such bodies at City Government was not free of conflicts. Several sectors in the administration opposed the creation of bodies to deal with specific female issues and policies. Strongest opposition came from the Health Care Reform Movement. Although they had the most advanced agenda for the sector, they believed that WHCO was a vertical instrument that should not be allowed into the new health care model.
WHCO managed to work in tune with the global municipal health care policy and created institutional language that was disseminated among the sectors with fiercest resistance to feminist ideas. Currently, a collective evaluation by several entities about the need for a womens health care office at the Municipal /State Health Secretariats and at the Ministry of Health reveals that the introduction of such a body in public service has been an important factor for the advancement of health policies.
The experience of specific bodies to address gender issues teaches us many lessons about the importance of public policies for women in democratic administrations. For instance, issues such as sexual abuse and domestic violence, family planning and legal abortion rights had for the first time relevance for diagnosis and concrete governmental actions.
We believe that this has been an important achievement of the democratic administration in the city of São Paulo, a truly useful strategy for the advancement of gender issues in the health sector. In Brazil, many States and cities display outstanding achievements in public policies for the womens health sector. Such achievements were the result of participation of professionals from the feminist movement in decision-making spheres.
Many experiences of management in the public health sector have shown the importance of the role of health professionals both planners and doctors, nurses and other employees in the public hospitals or health centers to the advancement of public policy implementation and sustainability. In truth we can affirm that the success of health planning and practical activities alike depends on the professionals involved. The best proposals on paper will fail if professionals oppose them or are not involved. Professionals do assure operation of the health care system and their participation and support is critical for a good outcome for any health care plan.
In the São Paulo city administration under study, it is fundamental to highlight the role of all management spheres. The proposal for administration and power decentralization was from the start a positive aspect to involve professionals and make them support the new health care model implemented in the city. Higher salaries, better work conditions and improved definition of roles and functions as a result of human resource restructuring made room for general acceptance of the new model in which the gender perspective prevailed.
The adoption of this model helped to secure a mass of gender-aware workers within the health care system, professionals open to women and teen issues. This assured that, even after the democratic administration ended, some policies have continued and are still in force in the city.
As a democratic and power-sharing administration, the Workers´ Party´s four years in office at City Hall helped to create several important bodies for social control as provided in the 1988 Federal Constitution and São Paulo Health System Code: The Municipal Health Council, Managing Commissions of Health System Facilities, and Municipal Health Conferences. By request of social and grass-roots movements other bodies were created, such as Councils for the Disabled, for the Black People, for the Aged, and Committees for Survey and Prevention of Maternal Mortality. According to the law in force, all these bodies and mechanisms for social control were comprised by equal numbers of Administration decision-making officials, employees and civil society members.
In addition to said legal mechanisms for population participation, the city of São Paulo, like other Brazilian cities, has important organized sectors in civil society who fight for specific issues and actively participate in Brazilian life, exerting pressure and control over governmental actions at all management levels. Examples of these are health care advocacy movements, womens movements, black movements, and the best organized of them all at the moment, the landless workers movement.
Organized women were active in all mechanisms, in different ways and at different spheres of power. Many have supported what we call "general" health issues, others, womens health issues. In both cases, they played a critical role in the improvement of health standards in the city. As an example, 90 per cent of the members in the São Paulo East Region health movement one of the oldest and strongest in Brazil are women.
The administration created and put into practice social participation and control mechanisms. The most visible of them is the democratic city budget, according to which the organized communities elect the budgetary priorities for the next year, assuring definition of a real priority line and proper application of public resources.
Of course such mechanisms are not built thanks to some national or municipal law only. Various forms of power, ideologies and interests are at play, involving both the private and public sectors. The struggle to conquer opportunities for a true participation of society is indeed one of the greatest challenges in the construction of democratic relations between governments and citizens.
In this sense, the existence of mechanisms for social control and the presence of movements with real power to claim and negotiate were relevant factors to improve management of public resources and health care policies implemented in the city
Impact of the Experience
Ten years have elapsed since the implementation of the Womens Total Health Care Program - PAISM in the city of São Paulo. Several social actors provided evaluations of the city administration in that period (1989-1992). All of them reaffirmed the importance of this experience for the advancement of public policies for womens health care in Brazil. The impact of the program was felt not only in the city of São Paulo, but also in other Brazilian cities.
The implementation of the program proved the feasibility of implementing, in the Public Health System, policies with gender perspective, good quality and covering all the phases in womens lives
This experience also demonstrated that when there is a will and staff committed to womens rights issues, it is possible to overcome certain cultural barriers in the health care services and change the mentality of bosses and management at the top of the system.
Several Brazilian cities and towns running womens health care programs have in many different ways set the São Paulo experience as the management model. Many program actions implemented in the Workers´ Party administration have positively influenced many other administrations all over the country. Legal abortion care has been implemented in 13 public hospitals in various regions in Brazil, with training and advising services supplied by the São Paulo Jabaquara Hospital professionals. Maternal Mortality Prevention and Survey Committees, with the participation of the community, the health care movement, and womens movements have also been found in other cities.
The creation of health care services for women in situations of sexual abuse and domestic violence, and the introduction of emergency contraception at public health centers were also pioneer services Health Secretariats in various states and cities/towns are introducing into their health care plans.
WHCO managed to entertain permanent dialogue with womens organizations, legitimate representatives of women in the city. Fruitful dialogue also involved health movement representatives most of them females, as we mentioned earlier from several city regions. Dialogue was a determining factor in the implementation, follow-up and evaluation of many womens health care actions. These organizations were WHCO partners in many projects, but put pressure at other levels of power and decision-making, thus facilitating a part of WHCO´s work.
Women were also members of central and regional Maternal Mortality Committees as planners and teachers of health professionals, participating in all empowerment courses, in facility managing commissions and in the study for staff career plans at the Municipal Health Secretariat.
This massive participation of women resulted in the introduction in career and public service entrance examinations of issues such as domestic violence and sexual abuse, laws on womens rights, including Criminal Code provisions on legal abortion, and Federal Constitution provisions assuring equality between the sexes. One of WHCO´s proposals was the dismantling of the municipal data information system per sex and skin color. This requirement was met for the first time in the national information system.
As mentioned before in this paper, WHCO´s activities were supported by a favorable political scene at that time. We may affirm that the best intentions of planners and professionals to implement plans or projects may be aborted in an unfavorable administrative environment.
Placing womens health care as one of the local administrations priorities, and recognizing and helping out with "womens health troubles" was one of the impacts of the presence of feminists in local government.
The formation of a gender-aware mass of health care workers helped to create other forms of institutional relationships with service users and a new look into womens issues, resulting in the progress and advocacy of such policies. The attempts to dismantle the womens health care programs by other city administrations have been resisted by a portion of WHCO trained municipal health care workers
We know that the resistance and dedication of a portion of health care workers who believe in a more humane and decent health care model are not sufficient to deter irresponsible administrations that are not committed to improved health care for the population. However, some of the WHCO activities have been maintained because both planners and executives advocate their continuity: the Legal Abortion Service and some Maternal Mortality Prevention Committees, which are in operation despite the current neglect of municipal authorities.
The positive analysis of this experience does not mean that all womens health problems have been solved and all goals achieved.
We know that health promotion, and preventive/healing actions are part of a larger context of public policies and national, state or municipal political and economical conditions where such policies are developed.
The best proposals by democratic governments committed to better health standards for poor population sectors and the best feminist proposals for womens health care sometimes are stopped or restricted due to the countrys structural conditions, its economic policies and social priorities. It is a context of public spending cuts and privatization of services with deleterious effects on project implementation and effectiveness.
The achievements in health care, especially in womens health care in the city of São Paulo in the period 1989-1992 resulted from the joint efforts of several political actors to obtain better living conditions for the population. The approval of the new management plan revealed both recognition and trust of health professionals in a new relationship between local government and a sector living the daily possibilities and impossibilities of dealing with health and disease in third world countries.
Other programs implemented by the administration, such as the Healthy City project, garbage recycling, projects to introduce gender issues in the Education Secretariat agenda, are some examples of projects which have greatly contributed to the Health Secretariat and WHCO´s general policies.
The presence of women committed to gender issues in local government staff required a new look on public policies and new indicators for policy assessment. Today, ten years after implementation, this pioneering experience is still a reference and a model to be followed.
Every time we visit cities or towns in this big country to support implementation of new experiences in womens health care, we are reassured that the experience implemented in São Paulo by the PT democratic administration was indeed innovative and fully met the proposed goals: the advancement of a new health care model, according to which health is part of the citizens´ human rights.
The following recommendations are based on varied experiences of public policies for women implemented both by the public sector and NGOs operating in health care, reproductive rights and combating violence against women. These recommendations were made collectively, based on concepts and practice, and on experiences that contributed to the advancement of womens rights in the areas previously cited.
It is important to note that these recommendations should be analyzed and adapted to national realities, taking into account the contexts in which they will be implemented. Models and experiences not always work fine in contexts other than those where they were first successfully implemented. They are useful as model guidelines and possibilities to be followed rather than a monolithic block to be implemented without previous assessment and adaptation.
Recommendations to governments
Providing mechanisms to assure at all levels of power and decision-making funding for the implementation of health policies with gender perspective;
Promoting womens health as a human right and a social asset, as a means to achieve equality and human development;
Effective implementation as a political and social priority of a Womens Total Health Care Program PAISM as part of womens fundamental Human Rights; this program should be based on humane and ethical assistance, covering all phases of womens lives, as well as womens specific needs;
Assuring womens access to legal abortion services at public hospitals in countries where legal abortion legislation is in force, and providing humane care in cases of induced abortion;
Access to contraception as a political and budgetary priority within ampler concepts of reproductive rights, not as womens responsibility but as a social need;
Creating Maternal Mortality Prevention and Survey Committees with womens participation, as a way to prevent and detect preventable maternal death causes;
Creating Integrated Services to assist victims of violence in all their needs: health care, security, housing, justice, and employment;
Promoting affirmative actions for victims of violence, such as priority in jobs, housing programs, professional training and access to day care and schools for the children;
Creating mechanisms to have sexual and domestic violence regarded as a problem to be faced by other sectors besides the health sector due to its importance for womens reproductive health;
Promoting the participation of women committed to womens claims and human rights in decision-making positions at governments (central, state or municipal governments), as a way to assure the gender perspective in the design and implementation of public policies;
Creating mechanisms to protect women against violation of reproductive rights, such as institutional neglect and irresponsibility in the application of such needs;
Promoting changes in contents and attitudes in human resource reskilling, giving them the chance to work according to a new health care model contemplating womens issues;
Creating mechanisms to formulate, monitor and assess health care programs, by means of health councils, maternal mortality prevention and survey committees, reproductive rights commissions and other organisms, assuring participation of organized women from social movements;
Supporting and respecting the autonomy of NGOs and networks who develop work in womens health care, reproductive rights and violence against women, in order to assure the inclusion of womens claims in the design and evaluation of health policies;
Encouraging health professionals to learn about national laws covering womens human rights and agreements signed by governments at UN Conferences in the 90s;
Promoting campaigns to raise awareness and information of the female population about their rights as citizens and health care.
Recommendations to Congresswomen and Congressmen
Fostering the provision of national laws promoting equality among men and women in health sector proposals;
Fostering the provision of laws to control all governmental levels in order to secure womens rights in the health sector;
Encouraging the creation of Health Care Codes at local governmental levels, including gender-perspective contents and their application in health services;
Creating mechanisms to assure women the rights provided in Federal Constitutions or National laws which, in many countries, are threatened with extinction.
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-ARAÚJO, M.J.O. e VILLELA, W.-Monitoramento do Plano de Ação do Cairo-Jornal da REDESAÚDE n.15. maio de 1998
-NU, DCPDS, Informe de la Cuarta Conferencia Mundial sobre la Mujer, 17 de octubre de 1995
-OPS, Desarrollo y Fortalecimiento de los sistemas Locales de Salud en la Transformacíon de los Sistemas Nacionales de Salud:la participación social, Washington, D.C., 1990.
-WHO-World Health Day 1998, Information Kit. Geneva