Dr. Sheila Dinotshe Tlou, Department of Nursing Education,

University of Botswana, Gaborone, Botswana.

Introduction

The health care delivery system of most countries is a complex interaction of many interest groups (clients, physicians, nurses, etc.) all competing for limited resources. In the past decade, efficiency driven perspectives have dominated international health policy debates (Gilson, 1998), but as the decade draws to a close, persistently high levels of ill health, exacerbated by HIV/AIDS, and inequalities in health and access to health care indicate that equity issues in health care are still inadequately addressed.

The purpose of this paper is to analyse the key issues pertaining to management of human and financial resources in nursing when applying a gender perspective. The main limitation of this analysis is that it is confined only to the western model of health care; therefore, information on how traditional and other health systems interact to provide or not provide gender sensitive health care is not included.

Since the declaration of Health for all at Alma Ata in 1978, the health care systems of most countries have generally improved for the better, as evidenced by increased life expectancies, lowered mortality rates, and higher standards of living. The principle of community participation has led to the concept of self care and self determination by consumers of health care. It must be pointed out, however, that consumer rights approaches, i.e. the need to raise individual rights and obligations, has led to greater emphasis on responsibility for one’s own health, to regulations which restrict unhealthy choices, and to obligations to health care under conditions of limited resources (TARSC, 1998). This has led to bureaucratic health care systems that restrict choice and allocate resources on the basis of risk assessment rather than health promotion.

At present, most health information is disaggregated in the form of mortality and morbidity rates according to age, race or ethnicity, socio-economic status, urban or rural, and sex, although the latter category is seldom used in some countries. It is, however, the relationship between the various indicators that provides greater information on equity rather than each indicator taken separately; for example: Mocumbi (1997) uses a quadrant analysis to relate health needs with health care provision to indicate efficiency and equity between need and supply of health care services.

Applying a gender perspective would necessitate that all health statistics be engendered and a comprehensive women’s health profile be made. The International Council of Nurses (ICN, 1995) has come up with the following guidelines for developing a women’s health profile for any one nation.

Guidelines for Developing a National Women’s Health Profile

Demographics

Population, percentage women by age group and geographically (urban and rural), birth and crude death rates by gender and age, infant mortality rate, mean age of first marriage, literacy rates by gender and age.

Socioeconomics

Per capita income, women’s income as percentage of men’s, breakdown of employed and unemployed women, women’s occupational breakdown, percentage female-headed households, women’s social security/welfare benefits, educational level by age group and sex, male/female ratio with university degree.

Health Status

Life expectancy by age and gender; maternal mortality broken down by cause, age, rural, urban; mortality rates, by sex and age, from circulatory, heart, cerebrovascular diseases, malignant neoplasms, accidents, suicides, AIDS; women mortality from cervix, breast and other cancers; incidence of HIV/AIDS by age, gender; percentage of population with different long-term disabilities, by age and sex; and other morbidity/mortality trends according to socio-economic group, geographical area, etc. if available.

Lifestyle

Percentage of neonates with birthweight under 250 grams; percentage of children breastfed; alcohol consumption by quantity, age, sex; use of illicit drugs and tobacco by sex and age; incidence of domestic violence, rape and sexual assault; number of women in prison, prostitutes.

Environment

Trends in incidence of disease attributed to air, soil and water pollution and occupation; access to health services/child care at workplace in rural and urban areas.

Health Care Services

Distribution of services geographically, by type, expenditure per capita (is there pattern of lower expenditures on problems mostly suffered by women); number of health workers per region, per capita, by type; for family planning services, include availability and cost of contraceptives (including condoms), insurance coverage and other information if available; breakdown of problems suffered by women by region and age (unplanned pregnancies; number of live births; number of induced abortions; prevalence of pelvic inflammatory disease, caesarean rate; births to HIV affected women; diabetic complications).

Health Service Use

Number of women using clinics, special hospital services for women, family planning and other health care services, by age, region, per capita, etc. Use of home help and home nursing, particularly by elderly women, and use of support services by women affected by HIV/AIDS. In sum, are services accessible to all women and what ratio of the women population (including the elderly) are using them?

Sexuality

Incidence of female genital mutilation; marriage laws; contraceptive laws/practices; abortion laws/practices, number of deaths from septic abortion; extent of commercial sex, forced prostitution, etc.

Policy Development

Number of women in government positions; policies promoting health for women and reducing inequalities; current reform of health services to women; status of debate of women’s health issues (abortion, family planning, teen mothers, elderly women) and objectives for women’s health (occupational, mental, reproductive, middle-aged, adolescent, etc.); strategies for implementation of policy, particularly how these address national, intersectoral and local action.

Other Gender Specific Aspects Relating To Women’s Health

It is a fact that mainstreaming a gender perspective in health would greatly improve access to quality health care for both men and women. It has been found that, in most countries, the health care system may be controlled by men but it does not serve their health needs; morbidity and mortality rates for pneumonia, tuberculosis, cardiovascular diseases, accidents and homicide are significantly higher among men than among women, yet there are very few specific national health policies targeted towards them (Tlou, S.D, 1997).

Management of Human and Financial Resources in Nursing

Health care institutions have, partly because of their religious, army and medical foundations, traditionally functioned as bureaucracies with well defined hierarchical structures and very rigid policies and procedures. Physicians, most of whom are male, continue to hold almost all of the authority for patient care and, to some extent, determine the costs of health care services.

Nursing on the other hand, is a female dominated profession; and it has been shown that such professions have lower wages, entail longer and more inconvenient hours than male dominated ones, and entail numerous health risks such as physical exertion, mental stress, poor ventilation, and exposure to chemicals and other toxic substances (ICN, 1995).

A gender based approach would mean recognising and rewarding the great work that nurses do in promotive, preventive, curative and rehabilitative aspects of health care delivery. Organisational changes have to occur whereby the role of the physician is analysed and demystified, and nurses have input into decisions about their work and how it can meet their needs and their clients’ needs. It has been found that in institutions where nurses are autonomous and had more decision-making about their work they were more satisfied and tended to remain in their positions longer (Sullivan, E. and Deeker, P. 1992). Botswana is one of the few countries in the world where nurses earn almost as much as medical doctors but even this is perceived as an anomaly and has caused a lot of unhappiness among medical doctors. The rationale behind the salary structure is that nurses account for more than 80 per cent of the workforce in the health care system and although their activities and experiences within Primary Health Care have not been well documented, they have contributed more to the greatly improved health status of the nation. Indeed nursing research in Botswana has contributed to the improvement in health care delivery for men and women. More countries need to analyse the role of nurses and reorganise their structures accordingly.

Nurses are also exposed to violence in the health care setting. A survey on sexual harassment in Botswana revealed that nurses are harassed by male physicians, colleagues, patients, and even patients’ family members (Mosimaneotsile, B. 1996). Such harassment is seldom reported by male nurses and other male health personnel.

What is needed are legislative measures to ensure equity and avoid exploitative trends in all jobs as well as enforced policies against violence and sexual harassment in the workplace.

Health care financing is a political process which determines who receives health care, where they receive it, from whom, etc. In most countries, two levels of health care exist: one for the poor (public hospital, clinic, health post), and one for the middle and upper classes of society (private physician, or institution). Very often the public institutions are the ones which are under financed and have limited resources (staff, equipment, drugs), thus providing less than quality services. It is these institutions that women, because of their often low socio-economic status, frequent for the inadequate health care.

Applying a gender approach would entail ensuring that at best, all citizens have access to quality services or, at worst, governments subsidize the costs of services in such a way that there is minimum payment on a sliding scale. Most governments can afford to subsidize health care costs if the money they spend on arms and ammunition is instead channelled towards providing needed services for the population.

Any financial changes require that nurses be prepared at baccalaureate and graduate levels to do research and come up with a good understanding of nursing costs, budgeting, and other aspects of financial management. Such nurses should be involved in defining the mission, philosophy and policies of their institutions, especially regarding third party payments for services rendered.

POLICY RECOMMENDATIONS

To National Governments

The dignity and worth of women is dependent upon the full implementation of the obligations to provide free or affordable health care. Governments should:

1. consider basic health care as a human right and legislate accordingly. Countries that have considered education as a human right have legislated for free and compulsory education for all; the same is not true for health care, for example, in Botswana education is free but health care is free only for certain groups (children and the elderly), the others have to pay a small amount (US$0.50) which is still too much for poor women, especially those in the rural areas.

2. train nurses and other health care professionals to develop their capacity to be gender sensitive in all aspects of care, for example, violence against women and girls is a universal problem that affects all countries irrespective of culture, religion, class, race and socio-economic status, yet nurses are often not empowered to break the traditional culture of silence and assist survivors of gender-based violence.

3. develop data bases with engendered health statistics to enable various countries to share experiences and best practices in ensuring gender equity in health care.

International Organisations and Agencies should

1. fund research and share research findings on best practices and lessons learned in mainstreaming gender within the national health care systems.

2. fund multinational participatory education programmes to change attitudes, behaviour patterns, and actions to create gender sensitive health care systems.

3. document best practices and workable strategies, and organise regional and international conferences to promote the sharing of experiences and programmes that are effective in the different regions of the world.

4. provide technical assistance for national and regional programmes addressing gender concerns within health care systems, and fund only those initiatives that truly integrate a gender perspective.

The International Council of Nurses (ICN) as the global voice of nursing has, through the National Nurses Associations, formulated guidelines for the Socio-economic Welfare of Nurses (SEW) which emphasize the rights of nurses as professionals and as (mostly) women. These guidelines need to be communicated to all governments, not just to the Nurses’ Associations. ICN (1995) has also encouraged National Nurses Associations to formulate plans of action which address, among others, the following:

- eliminating negative cultural practices such as female genital mutilation, dowry deaths, child marriages, etc.

- supporting programmes to reduce violence against women and girls.

- doing research to promote women’s access to the full range of health services and education. This should include girls and elderly women.

- doing research on the non reproductive health needs, such as the impact on women’s health of diet, drugs, pesticides, solvents, occupational strain, chronic stress, and social violence.

What is desperately needed is funding to undertake these initiatives and research projects.

Other groups from civil society such as NGOs need to:

1. first integrate a gender perspective within their own organisational and operational frameworks. In Botswana, for example, there are organisations which aim at changing social structures e.g. Emang Basadi and its programme on the political empowerment of men and women. However, there are still others which operate to improve the lives of women within the same patriarchal gender-based structure. Needless to say that the latter experience many problems that hinder their progress at attaining gender equity.

2. work in partnership with nurses to mobilize adequate resources for comprehensive public awareness campaigns to demand gender sensitive health care services.

3. do participatory research to find out from the women themselves how gender inequities within the health care system can be best addressed.

In conclusion, the "apartheid of gender" has no age limit; for women it is there from the cradle to the grave. For nursing as a female dominated profession, the industrial models of management have created a lot of dissatisfaction and staff turnover. These trends can only be alleviated by mainstreaming a gender perspective into the management of human and financial resources in nursing and within the health care delivery system.

REFERENCES

Gilson, L. (1998). Readdressing equity: the search for the holy grail. South Africa: Centre for Health Policy.

International Council of Nurses (1995). Women’s Health: nurses pave the way (Monograph). Geneva: ICN.

Mocumbi, P. (1997). "Equity in health, policies for survival in Southern Africa: Mozambique’s experience". Paper presented at the Dag Hammerskjold Foundation Workshop on Equity in Health: Policies for survival in Southern Africa, Kasane, Botswana, March 15-16.

Mosimaneotsile, B. (1996). Sexual harassment among registered nurses in a hospital setting. Bachelor of Nursing Education thesis. Gaborone: University of Botswana.

Sullivan, E. and Deeker, P. (1992). Effective management in nursing. New York: Addison-Wesley.

Tlou, S.D. (1997). Indicators of Health, In Botswana Society (Eds). Poverty and plenty: the Botswana experience. Gaborone: Macmillan.

Training and Research Support Centre (TARSC). Zimbabwe (1998). Annotated bibliography and overview of equity in the SADC region. Harare: TARSC.