Introduction

1999 will mark the 10^th anniversary of dramatic political changes in Eastern and Central Europe, which began with democratic changes in Poland, followed by the fall of the Berlin Wall and the final collapse of the Soviet Union. The entire process of political and economic transformation in this region has resulted in the establishment of many new independent countries.

Countries in Central and Eastern Europe and Asia, most of them newly established, have been named and officially recognized by the international community as countries in transition or countries with economies in transition due to the common post-communist and totalitarian heritage and, therefore, shared problems resulting from political and economic transformation. These countries do not fit easily into either description for the developed or developing countries and they break the so far well grounded duality of this world into North and South.

The region embraces the countries of Central and Eastern Europe and Asia, including those established after the fall of the Soviet Union. These countries could be subdivided into:

- Countries of Central and Eastern Europe (CCEE) (Albania, Bulgaria, Czech Republic, Hungary, Poland, Romania, Slovakia),
- Republics of former Yugoslavia (Bosnia and Herzegovina, Croatia, Macedonia, Slovenia, Serbia),
- Commonwealth of Independent States (CIS) (Armenia, Azerbaijan, Belarus, Georgia, Republic of Moldova, Russian Federation, Ukraine),
- Central Asian Republics (Kazakhstan, Kyrgystan, Tajikistan, Turkmenistan, Uzbekistan),
- Baltic States (Estonia, Latvia, Lithuania).

In spite of many commonalities between these countries, there have been significant differences within the region due to the level of development, conditions, resources and cultural backgrounds. These differences tend to become even greater over time as political independence enables individual countries to choose different developmental patterns and solutions to common problems. Nevertheless, comparison of this region with the countries of the North or the South still justifies the differentiation and recognition of the particular specificity of the region.

Women in the region

The position of women in the region significantly varies from women in developing and developed countries. Women in the region enjoy relatively good standards of education as the region has attained high levels of education overall. Literacy rates both for the overall population and for women are high. Although, women have achieved higher levels of education than in most parts of the world, they have never been able to take full advantage of their educational opportunities, and the economic transition is making matters worse. There are signs that the educational gains could be threatened by the economic collapse in some countries.

In most countries in the region women constitute roughly half of the labor force. However, women in managerial and other influential positions are very few. Moreover, even highly educated women in the region have not enjoyed the same economic and political opportunities as men.

Active participation of women in the labor market has not led to the transformation of family patterns. Women are still primarily responsible for household and care-giving duties, regardless of whether they are professionally active or not. Heavy burdens of double work and growing economic disadvantages directly impact women=s health status and their well-being. They pose serious limits on viable options for women to choose healthy lifestyles.

The burden of the transition to the market economy weighs more heavily on women than on men, particularly because of the decline of social and public services and growing unemployment and inflation, both of which adversely affect the financial situation of families. The feminization of poverty has been observed as a very significant indicator of this process and has its impact on the financial accessibility of health services for women.

Erosion of the state supported social infrastructure

The countries of the ECE region have traditionally provided a broad range of social benefits and maternity support. The benefits may include prenatal and maternity allowances, paid maternity leave and allowances for the care of sick children.

Since 1989, state-supported infrastructure in education, health and child-care has been seriously curtailed in all countries of the region, except for the Czech Republic, Slovakia and Hungary. Few countries made direct cuts in social welfare; instead the reduction in social benefits is often hidden and characterized by decreasing quality of services, restricted access to free services or simply shortages of supplies. The costs of social security coverage have been increasingly transferred from the state to households and added to by the process of partial commercialization of some services, such as child-care and/or education and health care.

Though women have been affected by all these changes, the most serious losses occurred in the area of child-support benefits and child-care infrastructure. Real value has been quickly falling in most countries in the region. In Russia, allowances for children below 18 months old decreased from 14.2 per cent to 1.5 per cent of the average wage between January 1992 and September 1993. At the same time the state-supported system of child-care facilities, including creches and kindergartens, has been affected by the lack of funding and many of them have been closed. Between 1989 and 1993 the number of creches and kindergartens in Poland fell by over 20 per cent. In 35 regions in Russia, 2 - 8 per cent of pre-school children's institutions were closed, primarily due to lack of funding. The erosion of family benefits and the child-care infrastructure has significantly increased women's functions as care givers and thus their workload within the family.

Paradoxically, the social infrastructure has contributed to increased discrimination against women both in the labor market and in public life. Since maternal benefits are attributed primarily to women rather than to both parents, employers perceive women as expensive and unreliable employees. Therefore, many women consciously decide not to take full advantage of their entitlements in order to keep their employment. Thus, the shrinking social infrastructure is almost fictional and on paper.

Health care system and services

The heath care systems of the ECE regions are experiencing increasing difficulty in providing health care services under deteriorating conditions. Historically, the governments have been responsible for health systems, with health care expenditures financed from general revenues. In principle, the population received services free of charge in government clinics and hospitals. In practice,"informal payments under the table"have been routinely required and still are to an even greater extent.

Over time and as resources have become more scarce, the systems of health services have become inefficient. Their main characteristics are: many redundancies, over-investment in tertiary care, and neglect of essential services such as primary care and health promotion and education. In many countries health facilities are outdated and in poor shape. Shortages of drugs, equipment and supplies are common. In Moldova, for example, it was estimated that 60 per cent of the nation's medical equipment in 1994 was non-functional due to a lack of spare parts, and patients in hospitals were expected to bring their own syringes, medications and bed linen.

On the other hand, excessive emphasis is placed on high technology, expensive tests and procedures. In some places (e.g. Poland), high-tech equipment in some hospitals is often underused and/or available mainly for doctors' "private" patients.

Health care services in the ECE region, medical and non-medical, are essentially provided by women. In some countries women constitute a large majority of physicians. They are, however, seriously underrepresented in leadership position in the health sector and have little impact on the structure and organization of health services.

The health care systems operate hierarchically with the privileged position of doctors at the top and the very inadequately defined role of nurses and midwives at the bottom. Health personnel tend to treat women in a paternalistic manner. Providers usually neither recognize nor encourage individual responsibility for decision making in health. At the same time, they often blame women for not taking responsibility for their health.

Many studies, including those carried out among Latvian, Czech and Slovak gynecologists, show that providers need more education on various aspects of reproductive health, in particular on family planning methods. For example, they often have misconceptions about the effectiveness, safety, risks and benefits of hormonal contraception, intrauterine devices etc. Sometimes they are strongly biased against some aspects of reproductive health and rights, including family planning and abortion (Poland).

There has been evidence in some places that medical schools and professional training courses often fail to address women's basic health needs adequately. They fail to promote providers'attitudes that would encourage more partnership-based relationships with their patients, based on principles of informed choice, respect, confidentiality and privacy.

Individual women or women's NGOs can hardly determine the type of services provided or the way in which they are organized. Little attention is paid by health personnel to patient satisfaction. A major source of women's dissatisfaction with health care services is being left out of decisions about their treatment and care. Insufficient information about causes of diseases and treatment options is another important reason for dissatisfaction.

Health services available for women

Services developed specifically for women are essentially limited to reproductive needs, especially childbearing. Services addressing other women's health problems have been underdeveloped, and are non-existent or inaccessible within public health care. Thus, girl-children, elderly women, the disabled, the unemployed and others with special needs have had limited access to medical services. Women from rural areas throughout the region have particularly limited access to health services. Many rural areas suffer severe shortages of health personnel, medical equipment and other supplies. Women often must travel long distances to health centers.

The inadequacy of health services to meet women's needs can be observed best with respect to reproductive health. Family planning counseling and services usually do not constitute an integral part of reproductive health services. Women in most countries have easier access to free abortion services (with the exception of Poland where abortion is illegal) while contraceptives, when they are available at all, are usually not reimbursed.

Maternity services, although often much better than other health services available to women, also provide limited options. Fathers are generally not allowed to be present during labor and delivery. New-born babies are usually not kept with their mothers, but in nurseries.

The most fundamental weakness of health care systems is the lack of attention to health education and health promotion services. Counseling and services focused on disease prevention and health promotion are usually neither integrated into the public health system nor available in other places. Women lack information crucial to their health and to the health of their families, particularly in the areas of nutrition and breast feeding, prevention of unwanted pregnancy and family planning, self-care during pregnancy, prevention of female cancers and other health problems. Services for STDs are not integrated into the general range of services. Violence against women is not addressed by the health sector in any systematic way.

The range of services for older women is very limited, which negatively impacts the well-being and health of this constantly growing population. Women in this region, as in all parts of the world, live longer than men and are exposed to many specific health problems. Moreover, community options for their support and care are usually lacking. The limited number of old age facilities that exist are overcrowded, short of sanitary equipment and lack sufficient medical care and humane treatment.

Women's health

Since 1989, all societies in the countries of Eastern Europe, the CIS and the Baltic States experienced a rapid deterioration of all health indicators. A number of studies concluded that changes in mortality rates, life expectancy and fertility rates show patterns not seen even under wartime conditions.

In 1990, average life expectancy for women in the CIS was 6 years less than the average for women in the EU. The difference for women in CCEE was 5 years. In some countries, life expectancy dropped from 76.3 years in 1990 to 75.86 in 1991. The health gap between the CCEE and CIS and the rest of the European region widened in all respects between 1981 and 1990 and the new data for 1991/1992 shows even greater disparities as the economic crisis deepens. Two main causes of women's mortality in the region are cardiovascular disease and cancer. Most countries lack adequate screening services and preventive medical services for female diseases such as breast and cervical cancers. As a result, cancers, particularly breast cancer, often reach an advanced stage before being detected. Other health problems include lack of community-based mental health services and drugs to treat serious illnesses, and high suicide rates.

Women's reproductive health

The problems of women's reproductive health include high levels of maternal mortality, a large number of abortions per woman in her life time and per live birth, poor availability of information and services for family planning and the growing incidence of STDs. Teenage pregnancy, which has a serious impact on young women's education, has also increased. Maternal mortality is still very high. The highest maternal mortality rates are found in the Central Asia Republics and in Romania. Maternal mortality in Romania and Albania fell dramatically after the legalization of abortion in 1989. Nevertheless, abortion remains a major cause of maternal mortality in both countries. As a result of the absence of or limited access to affordable contraceptives, abortion is still a main method of family planning and one of the leading causes of maternal mortality. Abortion rates are among the highest in the world. Social phenomena such as violence against women, increased trafficking in women and prostitution contribute to the worsening of reproductive health.

Abortion

In most countries of the region, abortion was legalized much earlier than in the developed countries. In most countries it has been performed broadly, because family planning was not sufficiently popularized. In Russia and other countries of the former Soviet Union, abortion remains the most common and effective means of family planning. As a result of pro-natalistic tendencies in some countries, there have been attempts in the early 90s to restrict liberal abortion laws or at least to limit access to abortion services. The most extreme example of such policies is the case of Poland where abortion was finally restricted after almost forty years of being legal and widely available.

Under communist policies promoting motherhood, some countries in CCEE attempted to increase birth rates by making contraception and abortion illegal ( Romania, Albania). Naturally, these policies failed. Instead of achieving their purpose, these policies led to extremely high maternal mortality in some countries. After having abolished such policies, the situation began to improve. For example, the very high abortion-related mortality for Romania in 1990 actually represents a decline when compared to earlier figures and the improvement appears to be continuing. Nevertheless, abortion is still a major cause of maternal death. Decreasing maternal mortality rates have also been observed in Albania after abortion was legalized in 1991.

In Russia, abortion has been legal since 1956 and is widely available and performed. Abortion rates per 1,000 births have reversed their steady decline, from 253 in 1970 to 170 in 1987, and rose to 216 by 1992. The number of abortions is believed to be significantly underreported, among others, due to the fact that official abortion statistics reflect mainly D&C procedures. Abortions done by vacuum aspiration known as "mini-abortions" are considered officially as a regulation of menstrual cycle and often are not reflected in abortion statistics. Considerable regional differences in abortion rates are believed to exist, with rates twice the national rate reported in some areas, including the far eastern areas of Russia.

Family planning

A fundamental prerequisite for women to have control over their lives is to be able to maintain control over their reproduction. Family planning, however, continues to be considered from a demographic perspective in the region. As a consequence, the low population growth experienced in the region often makes it difficult to promote family planning. Many national programs do not recognize family planning as a priority. As a result, women's reproductive choices remain limited. The most outstanding example is the widespread availability of abortion free of charge while contraceptives, when they are available at all, are usually not reimbursed. In general, family planning services are not sufficiently integrated into primary health care programs; rather they are provided by non-governmental organizations whose capacity to meet needs of women is relatively limited.

Moreover, the lack of or inadequate access to sex education in schools or other forms of family planning counseling contributes to insufficient contraceptive use. In Romania, according to the Romanian Reproductive Health Survey, only 34 per cent of women stated that their most recent pregnancy had been planned, whereas 12 per cent said that the pregnancy was ill-timed and 51 per cent said it was unwanted. The proportion of women with unwanted pregnancies rose with greater number of living children. Women with low levels of education were more likely to say that their last pregnancy was unwanted.

In Russia, tremendous unmet needs for family planning exist. The options available to Russian women were increased by the legalization of female sterilization in 1990 and male and female sterilization on social grounds in 1993. Nevertheless, abortion still remains the main method of birth control.

AIDS and other sexually transmitted diseases

Although the numbers of people with AIDS in the in the CCEE and CIS are small, they are rapidly increasing. In the Ukraine for example, AIDS has increased almost 50 times during the last five years. There is little knowledge about the prevalence of HIV infection. Fear, denial and lack of information are barriers to knowing the extent of the HIV and AIDS problem in the CCEE and CIS. Lack of sex education increases the risks of HIV transmission. Although the numbers of HIV-positive women are not high, the lack of services and programs for women and for particularly vulnerable young girls may soon result in increased numbers of HIV/AIDS infected women.

The incidence of other sexually transmitted diseases has dramatically increased in recent years in most countries of the former Soviet Union, particularly in Russia, Belarus and the Baltic Republics. In Russia, the rate for syphilis grew from 4.9 per 100,000 of the male population in 1989 to 92.0 in 1994 with a similar increase for the female population. In 1996, syphilis prevalence has increased from 10 to 30 per cent in comparison with 1995 data. The same trends have been noted with relation to chlamydia and gonorrhea. In the Ukraine, syphilis has increased 16-fold in the last five years among women. Among 16-18 year old girls, syphilis has increased from 5.2 per 100,000 population in 1990 to 63.3 out of 100,000 in 1996.

Impact of environment on women's health

The pollution of air, water and soil have become major threats to health in the ECE region.

A range of environmental problems, including deforestation, desertification, soil degradation and loss of biodiversity, were inherited from the former system In many industrialized parts of the region, pollution exceeds recommended standards for environmental protection and inadequate or nonexistent environmental protection policies will have severe consequences for future health and development.

The main sources of contaminated air are the industrial sector, low quality and poorly maintained cars and the massive use of low quality coal for heating. Water supplies are contaminated with untreated sewage and industrial waste, which are dumped directly into rivers and lakes. Fertilizers and pesticides are major sources of both water and soil pollution. Radiation from Chernobyl of 1986 was one of the biggest ecological catastrophes in the region with devastating effects on the lives and health of millions of people. As it has been almost impossible to determine the exact extent of contamination from radiation as a result of the explosion of the Chernobyl nuclear reactor, a number of young women in Ukraine decided not to have children because they do not want to have deformed offspring.

All aspects of environmental pollution contribute to the health dangers faced by women in their daily lives, but women working in agriculture are often exposed to the synergetic effects of multiple pollutants. The unskilled jobs undertaken by many women, often involving direct and concentrated exposure to dangerous chemicals, are a serious threat to women's health due to the lack of or inadequate enforcement of occupational safety standards and rules. In the Commonwealth of Independent States, approximately 4 million women work night shifts, much more so than men and at comparatively lower pay in relation to men. Many women are exposed to excessive radiation, noise, vibration or dust.

The increase of cancers in women of all ages, but in particular those aged 20-39 is being attributed to the effects of pollution. In more polluted areas infant mortality, premature births, low birth weight and birth defects are higher. In the Central Asian Republics, chemical contamination of food and water is a problem, particularly in areas of cotton cultivation, where the presence of chemical toxins in breast milk has been reported.

In some countries of the region, a decline in women's reproductive health is corroborated by increases in the number of children born prematurely and increase in illnesses of newborns (including Belarus, Albania). In Ukraine birth defects and prenatal mortality doubled due to Chernobyl disaster.

Infectious diseases

In some countries of the region, including Russia and the Central Asian Republics, there has been a substantial increase in infectious and parasitic diseases. While the prevalence of the most serious infections like typhus remain low, the population is increasingly affected by several communicable diseases whose incidence were previously low. In Russia for example, the incidence of diphtheria was recorded as 0.4 per 100,000 population in 1989 but it has risen to 27 in 1994 with the number of death cases increasing rapidly. The incidence of scabies (not recorded in 1989) was 28.6 per 100,000 in 1990 and as high as 389.7 in 1994. Starting from 1990, official statistics report incidents of pediculosis (infestation with lice) at an annual rate of 200-220 per 100,000 annually. One of the apparent factors that caused the diphtheria epidemic is that immunization coverage is no longer enforced. Besides, epidemiological surveillance seems to be less effective than before. According to the 1995 Russian Government report, only 79 per cent of Russian children received a complete immunization package in 1993 as opposed to 100 per cent before. During the same period, overall adult immunization levels dropped to about 30 per cent. Another factor associated with the increasing incidence of various communicable diseases is the inflow to major urban centers of certain marginal groups (who are especially vulnerable to diseases and have the least access to medical care).

The prevalence of tuberculosis has grown significantly in many countries of the region. In the five Republics of Central Asia, the high incidence of diarrhoea - the second or third leading cause of infant mortality - is attributed to generally poor sanitation and low public awareness of hygiene practices. Deficiencies in access to water supply and poor water quality contribute to high incidence of infectious diseases. In Ukraine, the incidence of diphtheria and tuberculosis have all risen. New cases of diphtheria have risen from 100 in 1989 to nearly 3,000 in 1993. During 1994, cholera returned to parts of southern and western Ukraine, resulting in approximately 20 deaths.

Gender specific data is not available with respect to infectious diseases.

Mental Health

Women appear to have more mental problems than men. Although in most age groups women suffer more mental problems, elderly women are particularly prone. Women suffer depression, neurosis and use tranquilizers more often than men (e.g. Bulgaria, Poland). It is estimated that current unfavorable socio-economic conditions contribute to increased stresses and depressions (Belarus).

There is one important indicator of mental disorders, namely suicide. In many countries of the ECE and former Soviet Republics, women die from suicide more often than women in the European Union. Particularly high death rates of women from suicide and self-inflicted injury are found in Hungary, followed by the Baltic States, Russian Federation and the former Yugoslavia.

Although eating disorders such as anorexia and bulimia have been known for a long time, they have only recently been recognized as public health problems. The accompanying emotional disturbances can range from lack of concentration and depression to sleeping problems.

Women from the Republics of the former Yugoslavia experience particular psychological problems due to the war conditions. Women carry the major burden in wartime. Many Bosnian women, particularly the displaced, have had to cope with practical and emotional tasks that have become increasingly demanding, while simultaneously coping with losses, threats and the overall dramatic change of life conditions. Many displaced women have witnessed or/and experienced killings, torture, sexual harassment or rape. War-related psychological problems require special approaches, facilities and services which could hardly be obtained by those in need.

Key issues of gender analysis

In order to address women's health needs and improve their health it is essential to understand the social context of their lives. The analysis of the social environment should be done on various levels such as:

- the individual/family level;
- the community level;
- health services;
- laws and policies.

In analyzing key issues affecting women's health, it is necessary to assess whether women have:

1) the necessary autonomy to protect or/and look after their health, including:

- power of decision-making
- mobility

2) access to and control of resources to protect and/or look after their health including:

- knowledge/information
- money
- time
- economic, political and social support

3) rights and freedom to use or stop using heath services and facilities, what are:

- laws and policies with respect to health
- social and cultural factors
- health services factors

Within this context, it is also important to understand whether women see themselves as empowered and whether others see women as entitled to equal and respectful treatment.

It is also necessary to analyze males'roles and attitudes towards women's health issues, in particular reproductive and sexual health.

As has been indicated, women in Eastern and Central Europe generally enjoy higher social status than many women in developing countries. They have gained certain rights which have not been achieved by many women in other parts of the world: the right to education, the right to work, the right to social benefits, the right to maternity care and many others. At the same time, gender inequalities affecting womens health, health services addressed to women and budgetary allocations for women's health are of a more subtle, indirect and complicated nature. Therefore, they are much more difficult to ascertain: they demand horizontal, intersectoral and multiple analysis in order to be properly identified and addressed.

Mainstreaming gender perspective into the health care sector

Gender mainstreaming (GM) is an important strategy for achieving gender equality. The concept of gender mainstreaming in all areas and all levels of policy, including the health sector, raises some difficulties in addressing it.

Gender mainstreaming is the (re)organization, improvement,. Development and evaluation of policy processes so that a gender equality perspective is incorporated in all policies at all levels and at all stages, by the actors normally involved in policy making.

Definition developed by the Group of Specialists

It requires closer cooperation between policy departments, including health, education, social, finances, legal and environmental, which formerly had exclusive competencies. It can involve reorganization of the policy process and cooperation with external political actors such as NGOs or the private sector.

GM puts people at the center of policy-making. Governments may better address people's needs and make full use of human - both men and women - potential, recognizing diversity among sexes.

Policy recommendations

Develop or reorient integrated health policy on women within the framework of gender equality and equity and in the context of other social issues related to existing gender inequalities

It is necessary to recognize that health is not only a medical issue but is an issue of rights and justice, equality and equity. It must be seen in the social context of women's lives. All social and political barriers stopping women from achieving good health status must be properly addressed in policy formulation.

The policy should be formulated by multiple actors representing various sectors, including finances, education, social, environmental and legal. Women's NGOs should be invited to participate in this process. Such issues like women's autonomy, access to resources, rights and male roles need to be undertaken. Human rights of women in all aspects of health need to be addressed, including reproductive and sexual health. Women's health needs must be seen throughout the entire life-span not only in the reproductive functions.

In order to achieve these goals it is necessary to

- (re)allocate sufficient funds;
- improve systems of collecting statistics on health to be segregated by sex and data collection which is not gender biased;
- increase and expand research on factors affecting women's health;
- provide gender training for policy makers;
- involve women in planning, implementation and evaluation of health policies.

Improvement of health services requires:

- introducing innovative approaches to women's health issues into medical curricula;
- adopting the human rights approach (based on the principles of respect, privacy, confidentiality, and informed choice) in all stages of medical school training;
- integrating health prevention education and counseling into health care services;
- creating enabling environment and increase decision-making options for women patients.

Wanda Nowicka
The Federation for Women and Family Planning
ul. Rabsztynska 8
01-140 Warsaw, Poland
ph/fax 48.22.632 0882, 48.22.631 0817
e-mail: polfedwo@waw.pdi.net