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Background Paper 13 1996-97
Women's Health in Australia: A Status Report
Paul Mackey
Social Policy Group
Major Issues Summary
Introduction
What is the Status of Women's Health?
Illness
Mortality
Women's Use of the Health System
Use of Medicare Services by Women
Specific Initiatives to Address Women's Health
Needs
National Women's Health Policy and National Women's Health Program
BreastScreen Australia
National Breast Cancer Centre
Kathleen Cuningham Foundation
National Cervical Cancer Screening Program
Maternal and Child Health Initiatives
Australian Longitudinal Study on Women's Health
Women In The Medical Profession
Where to Now for Women's Health?
Endnotes
Women's health has been a substantial focus of attention in the health
policies of Commonwealth governments since the 1970s. A continuing commitment
to this area has recently been reaffirmed by the Commonwealth Government,
including the provision of ongoing funding for the National Women's Health
Program in the 1997-98 Budget. This paper provides a concise survey of
the state of women's health in Australia, the major Commonwealth and Commonwealth-State
programs that are underway in this area, and possible future directions
in women's health policies.
The issue of women's health in developed countries has tended to provide
something of a conundrum for researchers and commentators because, while
on the one hand women have a longer life expectancy at birth than men,
they also tend to suffer a greater amount of illness during their lives.
Women also make greater use of the health system than men, but some commentators
attribute much of this extra use to reproductive health matters, including
contraception. These commentators argue that contraception, in particular,
may account for much of the 'extra' use of medical services and pharmaceuticals
by women.
Other researchers argue that not enough is yet known about the ways
in which biological, behavioural and environmental factors combine to
cause the differing health status, mortality and service use by women
and men. They caution also that a focus on gender alone can tend to mask
some significant differences between the health of men and women at different
stages of life and, more particularly, the reality that low income women
and low income men suffer far higher rates of ill health than women and
men with higher incomes.
Much still remains unknown about the interrelationship of factors such
as education, income, Aboriginality, employment status and family type
on women's health. It is anticipated that some of the gaps in current
knowledge about the cause and effect relationship in women's health will
be addressed by the 20-year Australian Longitudinal Study on Women's Health,
which was launched in 1995.
The women's health movement, which led to the development of women's
health centres in the 1970s, has tended to characterise Australia's health
system as patriarchal, because men have traditionally dominated both the
decision-making structures and the delivery of medical services. This
situation is being addressed and, arguably, remedied, on two fronts: through
gender-specific women's health programs and through the increasing representation
of women in the medical workforce.
In order to meet the specific health needs of women a range of initiatives
are now in place and are given coherence through the National Women's
Health Policy, which was launched in 1989. The policy is implemented through
the National Women's Health Program and a range of other initiatives directed
towards meeting the specific health needs of women. These initiatives
include BreastScreen Australia, the National Cervical Cancer Screening
Program and programs directed at maternal and child health.
There is an increasing presence of women in the medical workforce but
a considerable gender gap remains in the medical specialties, particularly
surgery, where women comprise only 3.1 per cent of surgeons and only 8.9
per cent of surgical trainees. This has recently been reported on by the
peak advisory body on medical workforce issues, the Australian Medical
Workforce Advisory Committee, and the Australian Institute of Health and
Welfare. The report's findings indicate a clear preference of women patients
for female clinicians, particularly for reproductive health consultations.
Although increasing numbers of women are graduating in medicine and working
as general practitioners, the shortage of women in specialties such as
surgery may lead to problems of access and equity for women seeking a
female specialist. In addition, the current preference of female medical
practitioners for urban practice may lead to problems of access for women
in rural and remote areas.
The importance of the social context of women's health is acknowledged
under the National Women's Health Policy, but it is not clear that this
is always recognised adequately at all levels of the health system. This
is an important issue for consideration because the overwhelming bulk
of medical and hospital services which women receive are delivered via
mainstream services, not gender-specific services.
The central issue of access to health and medical services has largely
been addressed through Medicare with the availability of free (albeit
rationed by waiting list) public hospital services and bulk-billed (at
least in urban areas) general practitioner services. There are, however,
other crucial issues to be addressed, including redirecting the focus
of the health system away from what has been called 'sick' care and more
towards the prevention of illness through the greater use of adequately
funded, appropriately designed and effectively delivered health promotion
and disease prevention strategies.
The 1997-98 Budget provided ongoing funding for the National Women's
Health Program for the next two years, but the nature of the program's
funding is to change. Under the proposed Commonwealth/State Public Health
Agreements, announced in the 1996-97 Budget, the National Women's Health
Program, which has been funded via Specific Purpose Payments, will be
broadbanded with seven other public health programs from 1997-98 and funding
provided to the States and Territories by way of one block grant. Discussions
on the implementation of these changes are continuing between the Commonwealth,
States and Territories and it is expected that a Public Health Agreement
will be signed between the Commonwealth and each State and Territory by
1 July 1997.
After having been ignored for many years, the state of women's health
has, in more recent times, often been the subject of public debate. This
debate can be stimulated by high profile court cases involving issues
of medical negligence,(1) but has also been characterised recently by
a more negative form of discussion following the belated discovery by
researchers and commentators that the state of men's health was quite
poor and that the health system did not appear to be meeting their needs.(2)
The tenor of this public discussion has tended to be that Australia is
perhaps spending too much attention (and dollars) on women's health at
the expense of men's health. However, what has often tended to remain
hidden in this debate is the impact of other factors such as socio-economic
background in determining health status.
Women have a longer life expectancy at birth than men, but experience
more illness through life. Women also make greater use of the health system
than men, but much of this extra use appears to be related to contraception
and reproductive health matters. Explanations which have been advanced
to account for these sex differences include: biological risks (differences
between the sexes based on genes, physiology and hormones); acquired risks
(such as lifestyle and health habits); illness behaviour (for example,
perceptions and awareness of illness and likelihood of seeking treatment);
health reporting behaviour (how people talk about their health); and prior
health care (how the treatment provided can influence the course of disease).(3)
Some researchers believe that the advantage females hold with regard
to life expectancy may be a result of biological factors, while their
disadvantage in illness is linked more to social factors such as lower
levels of employment and higher reported levels of stress.(4) However,
other researchers caution that 'it has not yet been possible to account
fully for discrepancies between male and female morbidity [illness] rates
and health care utilisation patterns'.(5)
Feminist commentators have traditionally characterised the health system
as patriarchal, with men dominating both the decision-making structure
and the delivery of medical services, particularly specialist medical
services. The realisation that women received poor service from the health
system led to the development in the 1970s of gender-specific health services,
notably women's health centres. A National Women's Health Policy was launched
in 1989 together with the implementation of the National Women's Health
Program. Subsequent years have seen the introduction of the National Program
for the Early Detection of Breast Cancer (now BreastScreen Australia)
and the launch of the Australian Longitudinal Study on Women's Health,
which began in 1995 and will run for 20 years.
This paper addresses a range of current issues to provide a snapshot
of women's health. It does not attempt to deal with every health-related
issue, but rather, draws together a wide range of data in order to present
a coherent overview of women and health. The paper discusses the status
of women's health, looking at the major causes of death and major conditions
of illness. The paper then examines how Australia's health system responds
to the health needs of women both in a general sense and specifically
through canvassing a range of gender-specific health programs. The National
Women's Health Policy and Program which underpin the delivery of women's
health services are also discussed. The third major element addressed
by the paper is the changing role and participation of women in the medical
workforce. The paper closes with a brief discussion of the future for
women's health services.
The issue of women's health in developed countries has tended to provide
something of a conundrum for researchers and commentators because, while
on the one hand women have a longer life expectancy at birth than men,
they also tend to suffer a greater amount of illness during their lives.
Mathers has noted that 'the differences between men and women in mortality,
reported illness and hospitalisation reflect an as yet unknown combination
of biological, behavioural and environmental factors'.(6) In addition,
generalising by gender can tend to mask some significant differences between
the health of men and women at different stages of life and, more particularly,
the reality that low income women and low income men suffer far higher
rates of ill health than women and men with higher incomes.
The most recent data on the status of women's health can be drawn from
the 1995 National Health Survey conducted by the Australian Bureau of
Statistics (ABS). This survey, also conducted in 1977-78, 1983 and 1989-90,
is a comprehensive source of data on the health status of Australians
and while it is a valuable source of comparative data over time (and will
become even more so), its reliance on self-assessment limits comparisons
with other health-related data.
As yet, summary results only are available from the 1995 survey, which
indicate that some 83 per cent of women aged over 15 years report their
health as either good, very good or excellent. Interestingly, a lower
proportion of women in age groups 45 years and over reported fair or poor
health than did men, while a higher proportion of women in the age groups
15 to 34 years reported fair or poor health than did men in these age
groups. Twenty-six per cent of females surveyed had consulted a doctor
during the previous two weeks, while some 74 per cent took some form of
medication during this period. Less than one per cent of females surveyed
had been hospital inpatients, while 2.6 per cent had attended a hospital
outpatients/emergency unit during the previous two weeks.
The success of screening programs in reaching women appears to have
increased since the 1989-90 National Health Survey, with some 28 per cent
of women aged 18-64 years reporting having had a mammogram during the
last 3 years compared with 13 per cent in 1989-90. Seventy-three per cent
of women reported having had a pap smear in the last three years, a slight
increase over the 71 per cent who reported having had a pap smear in the
1989-90 survey.(7)
The results of the 1995 survey also indicated that compared with 1989-90,
health risk factors for women had generally improved. Fewer females considered
themselves to be underweight, overweight or obese. Fewer reported being
smokers, fewer drank alcohol at high and medium risk levels and many more
women reported taking sun protection measures. On the debit side, slightly
more women reported that they did not exercise.
Although details are not yet available from the 1995 National Health
Survey, the results of earlier reports indicate wide disparities in the
health status of women in different socio-economic groups. For example,
a 1994 study found that the reporting of fair or poor health was 145 per
cent higher for women from low income families, who were 33 per cent more
likely to report suffering serious chronic illness and 159 per cent more
likely to report suffering mental disorders than women from high income
families. Indicating the link between good health and happiness, women
from low income families reported much higher rates of unhappiness (301
per cent) than women from high income families.
Compared with other mothers, single mothers reported 370 per cent more
ulcers, 263 per cent more insomnia, 131 per cent more bronchitis and emphysema,
54 per cent more serious chronic illness, and 14 per cent more visits
to the doctor. Arguably, 'a substantial part of the worse health status
of single mothers is related to income'.(8)
If the health status picture looks bad for low income women, particularly
single mothers, the situation is even bleaker for indigenous women (note
that the health of indigenous men is similarly poor). The following snapshot
of the health of Aboriginal and Torres Strait Islander women is drawn
from Women's Health (ABS 4365.0), which based its findings on the
results of the 1989-90 National Health Survey.(9)
- the life expectancy of Aboriginal and Torres Strait Islander females
in the Northern Territory was 20.4 years shorter than the life expectancy
of the total Australian female population;
- indigenous females accounted for almost 15 per cent of all maternal
deaths between 1985 and 1987, despite the fact that they only constituted
1.5 per cent of the Australian female population in 1986;
- a higher proportion of indigenous women aged 18 years and over were
smokers (42%) than all Australian women (25%);
- indigenous women aged 18-64 years were less likely to have had a doctor
or medical assistant examine their breasts (59%) than the total female
population of the same age (71%);
- twenty per cent of indigenous women were obese compared with 10 per
cent of all Australian women; and
- fifty per cent of indigenous women aged 18-50 years who had a child
or children aged five years or less in 1989-90 breastfed their children,
compared with 77 per cent of all women in Australia. It should be noted,
however, that this low figure for indigenous women masks considerable
variability throughout the country. The findings of the 1994 National
Aboriginal and Torres Strait Islander Survey (NATSIS) indicated that
about 90 per cent of indigenous children aged 13 years or under in the
Northern Territory were or had been breastfed, while this figure fell
to less than 75 per cent in New South Wales, South Australia and Victoria.
Breastfeeding was more commonly reported in rural areas than urban areas.(10)
However, the health of indigenous women is not all bad news. For example,
drawing on the 1989-90 National Health Survey, the ABS found that:
- a lower proportion of indigenous women drank alcohol (38%) in the
week prior to their interview for the 1989-90 National Health Survey
than all Australian women (52%); and
- similar proportions of indigenous women and all Australian women had
had a pap smear.(11)
Curiously, notwithstanding the evidence above, only about two per cent
of indigenous women perceive their health as poor, with about 80-90 per
cent of respondents to the 1994 NATSIS describing their health status
in the range between good and excellent. These figures were broadly similar
for females and males. The ABS and Australian Institute of Health and
Welfare (AIHW) believe that this apparent inconsistency between self-assessed
health status and the evidence of poor health 'could result from low expectations
of personal health or different interpretations of 'health' by respondents'.(12)
However, this apparent inconsistency also raises the question of the reliability
of health-related data collected via self-assessment, particularly where
subjective judgement is required of the respondent.
Almost 59 000 females died in 1995 from a wide range of causes, principally
from different types of cancer and diseases of the circulatory system
(e.g. heart disease and stroke). These two categories accounted for 24.9
per cent and 46.1 per cent respectively of female deaths in 1995. Although
there is a high profile (particularly a high media profile) accorded to
conditions such as breast cancer and melanoma, notwithstanding that deaths
are increasing for both types of cancer, most female deaths occur as a
result of heart disease and stroke.
The death of females from diseases of the circulatory system presents
some concern from a preventative health care viewpoint because, while
the annual figures are volatile, the trend in the numbers of women dying
from these conditions is decreasing at a slower rate than males. For example,
the number of females dying from diseases of the circulatory system has
fallen from 28 522 in 1985 to 27 144 in 1995, a decrease of 1 378. Over
the same period, male deaths from the same causes have fallen from 29
006 to 26 258, a decrease of 2 748. Female deaths in 1995 outnumbered
male deaths from diseases of the circulatory system, the reverse of 1985.
The table below indicates the numbers of deaths of females from selected
causes at two yearly intervals between 1985 and 1995.
FEMALE DEATHS: SELECTED CAUSES, AUSTRALIA, 1985-1995
Selected causes
of death 1985 1987 1989 1991 1993 1995
Breast cancer 2 207 2 258 2 431 2 513 2 641 2 629
Cancer of
genito-urinary
organs 1 719 1 703 1 835 1 957 1 938 2 003
Melanoma of
skin 269 287 281 302 279 327
All heart
disease 18 306 18 169 18 912 17 609 17 663 17 748
Suicide 399 467 438 513 394 495
All causes 54 652 53 710 57 306 55 079 56 509 58 878
Source: Causes of Death, Australia, various years (ABS 3303.0).
As is the case with illness, socioeconomic status and Aboriginality
appear to be key indicators of early death for women. For example, using
socioeconomic disadvantage of area of residence, women living in the
quintile of most disadvantage have a total death rate which is 50 per
cent higher than women living in the quintile of least disadvantage.(13)
There are no national figures of the causes of indigenous mortality
because of differing practices in various jurisdictions in the recording
of indigenous status on death records. Only Western Australia, South
Australia and the Northern Territory are regarded as having procedures
in place to allow for the adequate identification of indigenous people
on death records. Based on data from the 1991 Census, approximately
37 per cent of Australia's indigenous population lives in these three
jurisdictions. The available data indicates that age-specific death
rates at all ages are much higher for indigenous females compared to
non-indigenous females and the difference is largest for indigenous
women 25-54 years of age. As is the case for females generally, diseases
of the circulatory system are major causes of death for indigenous females.(14)
How well does the health system meet the needs of women? There is
a dearth of detailed qualitative research measuring how well the health
system meets the needs of women (or men). While obviously difficult,
such research may help to redress the lack of knowledge, for example,
that exists about the relationship between expenditure on health and
health status. One mechanism for addressing this issue is the 20-year
Australian Longitudinal Study on Women's Health which commenced in 1995.
Such data as does exist provides an indication of the use which women
make of the health system and some estimates are also available of the
cost of providing these services. The overwhelming bulk of health and
medical services used by women are provided through mainstream services
and statistics indicate that women make greater use of these services
than men. Supplementing and complementing these services are several
initiatives which have been developed to address the specific health
needs of women which are not well met by mainstream services. The following
section examines women's use of the health system and provides a brief
overview of the special programs put in place to address the specific
health needs of women.
In 1995-96, females received an average of 12.78 Medicare services
per person, while males received an average of 8.63 services. However,
averaged figures can present a distorted picture. For example, almost
29 per cent of females enrolled in Medicare used three services or less
in 1995-96, while nearly 9 per cent used 31 services or more (the respective
male figures are 45 per cent and nearly 5 per cent).(15) These figures
refer to those services where a Medicare benefit has been paid and do
not include public hospital services provided to public patients. Separation
(discharge) rates from public acute and repatriation hospitals in 1992-93
(latest available) were 194.6 per 1 000 of the female population (169.7
for males), while occupied bed-days were 1 136.2 per 1 000 of the female
population (964.9 for males).(16) At 30 June 1994 some 51 877 females
were residents of nursing homes, which equated to 0.58 per cent of the
female population (20 622 males; 0.23 per cent of the male population).
The experience is similar in other industrialised nations such as
the United States, where 'even excluding pregnancy-related care, women
have more appointments with doctors, experience more hospital care and
have more operations'.(17)
As noted earlier in the paper, not enough is yet known to explain
the gender differences in use of the health system, but it is likely
that research to date, which has often tended to treat men and women
as undifferentiated categories, has not allowed sufficiently for social
factors.(18) In addition, commentators such as Kane caution that
much of the apparent 'excess' use of services by women is for conditions
which have nothing to do with ill-health. For example, contraception
accounts for a substantial proportion of GP consultations by women and
for the 'medicines' which women say they take.(19)
It has been estimated that females account for around 60 per cent
of Australia's health expenditure and expenditure was higher on females
in each of the main components (hospital services, medical services,
pharmaceutical services and nursing homes) of health expenditure. Due
to their greater use of services, females also had higher average out-of-pocket
costs for these services. The last survey (1992) of health insurance
by the ABS indicated that a higher proportion of females than males
held private health insurance.(20) More recent figures will be available
in the latter part of 1997.
The women's health movement of the 1970s and 1980s, which grew out
of the women's movement, drew on feminist theories of power and society
to conclude that the health system of the time was patriarchal in design,
definition and delivery. It was a health system where men dominated
both the decision-making structure and the delivery of services. The
development of women's health centres in the 1970s was an outcome of
the realisation that the health system was not really meeting women's
health needs. This was particularly evident in the relationship between
some general practitioners and their female patients.
Since the 1970s, a series of initiatives have been implemented to
address both the more general issue of access to services, as well as
to meet specific health needs of women. A range of women's health programs
are outlined below.
National Women's Health Policy and National Women's Health Program
The overarching policy response to meeting the specific health needs
of women is articulated through the National Women's Health Policy and
implemented under the National Women's Health Program. Launched in 1989,
the principal goal of the National Women's Health Policy and Program
is 'to improve the health and well-being of women in Australia with
a focus on those most at risk and to encourage the health system to
be more responsive to the needs of women'.(21) The National Women's
Health Policy places women's health within a social context which recognises
that 'health is determined by a broad range of social, environmental,
economic and biological factors'.(22)
The National Women's Health Program commenced in August 1989, initially
as a four-year program. Following an evaluation which reported in 1993,
it was extended for a further four-year period from 1 July 1993. An
evaluation of this second four-year phase of the program is currently
under-way and a final report is expected in June 1997. The program is
cost-shared by the Commonwealth and the States and Territories and has
been overseen by the Australian Health Ministers Advisory Council (AHMAC)
Subcommittee on Women and Health. The subcommittee reports to the Australian
Health Ministers' Conference through AHMAC. Although the program is
administered by the States and Territories, some funding is retained
and disbursed by the Commonwealth for national projects.
The Commonwealth has provided more than $48 million over the eight
years of the National Women's Health Program. Funding for the program
was scheduled to cease on 30 June 1997 but it was announced in the 1997-98
Budget that funding is to be continued for a further two years. The
nature of the funding will change, however, because the National Women's
Health Program is expected to be broadbanded with seven other public
health programs and funding provided to the States and Territories as
one block grant. These arrangements will be underpinned by the proposed
Commonwealth/State Public Health Agreements which were announced in
the 1996-97 Budget. A Public Health Agreement is expected to be signed
between the Commonwealth and each State and Territory by 1 July 1997.
The key objective of the National Women's Health Program is to provide
funding for the promotion of primary health care for women, emphasising
health promotion, illness prevention, information, counselling and referral
rather than the provision of secondary treatment services.
To complement the broad objectives of the National Women's Health
Program, several initiatives are funded to address specific health needs
of women. These are outlined below.
BreastScreen Australia
This program, formerly known as the National Program for the Early
Detection of Breast Cancer, was launched in 1991. Funding has been cost-shared
between the Commonwealth and the States and Territories and the program
is currently operating in more than 400 locations in all States and
Territories. Funding of $33.8 million was provided by the Commonwealth
in 1995-96 and over 570 000 women received free screening mammograms
under the program in 1995-96. Access to free mammograms through BreastScreen
Australia is available to women aged 40 years and over and, because
age is the key risk factor for breast cancer, women over 50 years are
particularly targeted by the program. It is recommended that women over
50 receive a screening mammogram every two years.
BreastScreen Australia is separate from Medicare, however mammograms
may be subsidised under Medicare if the patient meets several criteria.
National Breast Cancer Centre
The 1994-95 Budget announced the establishment of a National Breast
Cancer Centre with funding of $16.4 million over four years. Its role
is to coordinate research findings and disseminate accessible information
for both doctors and patients on best practice, treatment and management
of breast cancer. The Centre received funding of $3.98 million in 1995-96.
It was announced in the 1997-98 Budget that funding for the National
Breast Cancer Centre, which had been due to expire in 1998-99, will
be continued for a further 12 months.
Kathleen Cuningham Foundation
The Kathleen Cuningham Foundation was also established in the 1994-95
Budget. It is a non-government foundation and its role is to raise funding
for research into breast cancer. It has been funded by the Commonwealth
on the basis of $1 million per year for three years, with additional
matched funding for donations on a dollar for dollar basis, up to a
further $1 million per year. The Foundation received funding of $1.89
million in 1995-96. A decision is yet to be taken by the Minister for
Health and Family Services on funding for the Foundation beyond 30 June
1997.
National Cervical Cancer Screening Program
Most pap smears are taken by general practitioners, tested by pathology
laboratories and are funded under Medicare. However, the National Cervical
Cancer Screening Program, which began in 1992 (known then as the Organised
Approach to the Prevention of Cancer of the Cervix) was established
to provide supplementary funding for special services such as Aboriginal
medical services or women's health centres to ensure that women who
may not have ready access to a general practitioner can be screened.
Maternal and Child Health Initiatives
Two initiatives were each funded for two years from 1996-97. A Breast
Feeding Awareness campaign will receive $1 million in each of 1996-97
and 1997-98 to raise awareness of the benefits of breast feeding. This
campaign aims to increase the proportion of women who breast feed their
children, particularly during the child's first six months of life.
The second initiative is a National Folate Community Education Program
which will receive funding of $200 000 in each of 1996-97 and 1997-98.
This program aims to reduce the incidence of neural tube defects, a
major factor in spina bifida, by increasing the proportion of women
of child-bearing age who consume the recommended intake of folate (folic
acid).(23)
Australian Longitudinal Study on Women's Health
This study, which is fully funded by the Commonwealth government,
began in 1995 and will run for 20 years. Initial funding of $3.5 million
over four years has been provided to study over 40 000 women in three
age groups: 18-22 years, 45-49 years and 70-74 years. Announcing the
first results from the study, the Minister for Health and Family Services,
Dr Wooldridge, argued that research being conducted under this study
'is vital if we are to gain a greater understanding of the cause and
effect relationship in women's health and if we are to build sound,
national public health strategies'.(24)
The first research data from the study, released in late 1996, indicated
that:
- many women complained of being stressed and feeling 'rushed' in
their lives;
- obesity is common in middle-aged women;
- one in four younger women is underweight;
- women in mid-life face significant problems with menstruation and
menopause;
- 90 per cent of younger women wanted to be mothers; and
- a similar proportion wished to be in full-time paid employment.(25)
All of the above, except perhaps for the last item, have implications
for the provision of appropriate health care services for women.
Women have long complained that the practice of medicine has been
dominated by males. This is still the case, but is becoming increasingly
less so, most notably in general practice. The peak advisory body on
medical workforce issues, the Australian Medical Workforce Advisory
Committee, and the Australian Institute of Health and Welfare have together
produced a recent report(26) which provides a comprehensive overview
of the changing nature of women in the Australian medical profession.
Among major findings identified by the report is a clear preference
of women patients for female clinicians. This is particularly the case
for reproductive health consultations. Although increasing numbers of
women are graduating and working as general practitioners, the shortage
of women in specialties such as surgery may lead to problems of access
and equity for women seeking a female specialist. In addition, the current
preference of female medical practitioners for urban practice may lead
to problems of access for women in rural and remote areas, particularly
as rural and remote areas are also likely to experience a shortage of
specialist women's health services.
The report also indicated that:
- approximately 26 per cent of all medical practitioners employed
in medicine are female;
- the female medical workforce is growing at a much faster rate than
males and it is estimated that the female share of the medical workforce
will increase to 38 per cent in 2014 and to 42 per cent in 2025;
- the numbers of female medical practitioners increased by over 100
per cent between 1981 and 1991 (from 5 290 to 11 090) while male medical
practitioners increased by 22 per cent (from 22 720 to 27 710);
- women comprise nearly 50 per cent of current medical school enrolments
and in 1994, 45 per cent of first degree graduates from Australian
medical schools were women;
- more than 54 per cent of female medical practitioners work in general
practice compared to less than 42 per cent of males;
- females constituted less than 15 per cent of all specialists and
are found in particularly low numbers in surgery (3.1 per cent);
- the situation in surgery is unlikely to be remedied in the short
term because females comprise only 8.9 per cent of surgical trainees,
but the proportion of female trainees is higher in other specialities
such as internal medicine (36.3 per cent) and pathology (30.3 per
cent);
- female clinicians were more likely to be working in major urban
areas than their male counterparts (83 per cent of female primary
care practitioners and 93 per cent of female specialists compared
to 77.5 per cent of male primary care practitioners and 87.3 per cent
of male specialists);
- on average, female clinicians work fewer hours per week than male
clinicians in the direct care of patients; however,
- research indicates that female primary care practitioners (a clinician
engaged in general practice or in the primary care of patients undertaking
unreferred attendances) have a much higher proportion of encounters
with female patients than their male counterparts (70 per cent compared
to 55.8 per cent). Female primary care practitioners also report more
problems on average per patient encounter and consultations by them
are almost twice as frequently billed as long consultations compared
to their male counterparts.(27)
The findings of this report indicate that although many more women
are entering the medical profession and that some of this increased
presence is working through to the specialities, the high status specialities
such as surgery are yet to attract or perhaps admit a significant number
of women to their ranks.
The women's health movement, particularly in the 1970s, identified
limitations in the capacity of Australia's health system to adequately
meet the health needs of women. The outcome of their struggle was the
development of gender-specific health services, beginning with women's
health services and progressing further to the initiatives outlined
earlier. Two key objectives of the women's health movement have been
identified:
to change the overall structure of a society which disadvantages women,
while at the same time providing appropriate health services, health
information and health education to individual women.(28)
It can be argued that these objectives may now largely have been met
and that women's experiences of the Australian health system are no
longer necessarily characterised by patriarchy (notwithstanding that
patriarchal attitudes of some practitioners may persist) because 'today,
women's health is based on information exchange, joint decision-making
and a shared responsibility between doctor and patient for the outcome'.(29)
Other commentators argue, however, that little has actually changed
and that 'the health system has not only failed to recognise how gender-related
factors impacted on women's health experiences but has also failed to
explore the relevance of masculinity to health'.(30)
A major problem in resolving these arguments is a lack of knowledge
of the degree to which spending on health actually affects the health
of the population. This is not a problem confined to Australia, but
is fundamental to any examination of the design and delivery of appropriate
health services. Although greater attention is now beginning to be accorded
to health outcomes, the Australian Institute of Health and Welfare has
observed recently that
it is not known what health expenditure as a percentage of GDP is necessary
to maintain population health, and the relationship between health expenditure
and health itself is not clear cut.(31)
An indication of how little data there is to guide policy makers in
the funding and design of services was apparent from evidence given
in the 'Proudfoot case'(32) by the then director of planning for Victoria's
Health Department and former Secretary of the Commonwealth equivalent,
Dr Stephen Duckett, who stated that 'we assume that the health system
is working for somebody, and it's not working for women, so it must
be working for men'.(33) The rather belated discovery that the health
system is not meeting the needs of at least some men should cause a
reappraisal of this attitude. Because most health and medical services
for both men and women are, and will continue to be, delivered in a
mainstream setting it is appropriate that greater attention be paid
to the social context of health and its impact on the health outcomes
of both women and men.
The importance of the social context of women's health is acknowledged
under the National Women's Health Policy, but it is not clear that this
is always recognised adequately at all levels of the health system.
This is an important issue for consideration because the overwhelming
bulk of medical and hospital services which women receive are delivered
via mainstream services, not gender-specific services. Much still remains
unknown about the interrelationship of factors such education, income,
Aboriginality, employment status and family type on women's health.
It is anticipated that some of the gaps in current knowledge about the
cause and effect relationship in women's health will be addressed by
the 20-year Australian Longitudinal Study on Women's Health, which was
launched in 1995.
Another issue for consideration is the apparent likelihood that health
policy measures alone will be unable to redress the inequalities which
exist in the health status of Australian women from differing socioeconomic
backgrounds. Policy measures initiated from a health perspective may
only be fully effective in redressing these inequalities in health outcomes
when delivered in concert with a range of other measures such as employment
and training programs, income support programs and housing programs.
The central issue of access to health and medical services has largely
been addressed through Medicare with the availability of free (albeit
rationed by waiting list) public hospital services and bulk-billed (at
least in urban areas) general practitioner services. It can be argued
that by maintaining a focus on gender and the social context of health,
gender-specific health programs, together with an increasing presence
of women in the medical profession, have impacted on how these mainstream
health and medical services are delivered. There are, however, other
crucial issues to be addressed, including the question of redirecting
the focus of the health system away from what has been called 'sick'
care and more towards the prevention of illness through the greater
use of adequately funded, appropriately designed and effectively delivered
health promotion and disease prevention strategies.
The 1997-98 Budget provided ongoing funding for the National Women's
Health Program for the next two years, but the nature of this funding
will change. Under the proposed Commonwealth/State Public Health Agreements,
announced in the 1996-97 Budget, the National Women's Health Program,
which has been funded via Specific Purpose Payments, will be broadbanded
with seven other public health programs from 1997-98 and funding provided
to the States and Territories by way of one block grant. It is anticipated
that the proposed Agreements will identify the respective roles and
responsibilities of the different parties as well as performance information
and will contain specific details about financial sanctions to apply
where a State or Territory does not meet its commitments under the Agreement.
Discussions on the implementation of these changes are continuing between
the Commonwealth, States and Territories and it is expected that a Public
Health Agreement will be signed between the Commonwealth and each State
and Territory by 1 July 1997.
Finally, an indication of the Government's position on the future
of women's health programs was provided in a Senate Estimates Committee
hearing in September 1996 by the Minister for Social Security and Minister
Assisting the Prime Minister for the Status of Women, Senator Newman,
who stated that:
the government does have a commitment to women's health and that, while
there are issues relating to future funding and responsibilities and
roles of states and the Commonwealth that are in the process of being
negotiated, there is no walking away from women's health issues by the
Commonwealth.(34)
- For a discussion of several such cases, see the paper Doctors,
Patients and the Courts - Are We On a Dangerous Slippery-Slope?
by Natasha Cica, (Parliamentary Research Service Research Paper No.
7 1995-96), Canberra, Department of the Parliamentary Library, 1995.
- A paper addressing men's health, Testosterone Poisoning or Terminal
Neglect? The Men's Health Issue by Richard Fletcher, was released
in 1996. This paper is also included in the subject collection of Health
Issues Papers.
- Colin Mathers, Health Differentials Among Adult Australians Aged
25-64 Years, Canberra, Australian Institute of Health and Welfare,
1994.
- L. Verbrugge, 'The Twain Meet: empirical explanations of sex differences
in health and mortality', quoted in Colin Mathers, Health Differentials
Among Adult Australians Aged 25-64 Years, Canberra, Australian Institute
of Health and Welfare, 1994.
- Mathers, op. cit.
- ibid.
- Australian Bureau of Statistics, National Health Survey 1995, First
Results, (ABS Cat. No. 4392.0), Canberra, 1996.
- Mathers, op. cit
- Australian Bureau of Statistics, Women's Health, (ABS Cat.
No. 4365.0), Canberra, 1994.
- Australian Bureau of Statistics and Australian Institute of Health
and Welfare, The Health and Welfare of Australia's Aboriginal and
Torres Strait Islander Peoples, (ABS Cat. No. 4704.0), Canberra,
1997.
- Australian Bureau of Statistics, Women's Health, op. cit.
- Australian Bureau of Statistics and Australian Institute of Health
and Welfare, The Health and Welfare of Australia's Aboriginal and
Torres Strait Islander Peoples, op. cit.
- Mathers op. cit.
- ibid.
- Health Insurance Commission, Annual Report 1995-95, Canberra,
AGPS, 1996
- Australian Institute of Health and Welfare, Australia's Health
1996: the Fifth Biennial Health Report of the Australian Institute of
Health and Welfare, Canberra, AIHW, 1996: 124.
- Mann, C., 'Women's Health Research Blossoms', Science, Vol.
269, 11 August 1995: 766-770.
- Mathers, op. cit.
- Kane, P., Women's Health: From Womb to Tomb, Basingstoke, Macmillan,
1991.
- Australian Bureau of Statistics, Women's Health, op. cit.
- Department of Health, Housing, Local Government and Community Services,
National Women's Health Program: evaluation and future directions,
Canberra, AGPS, 1993.
- Department of Community Services and Health, National Women's Health
Policy: advancing women's health in Australia, Canberra, AGPS, 1989.
- Health and Family Services Portfolio Budget Statements 1996-97,
Canberra, AGPS, 1996
- Minister for Health and Family Services (Dr Wooldridge), 'Women's
Health Under the Microscope', Press release, 3 December 1996.
- ibid.
- Australian Medical Workforce Advisory Committee and Australian Institute
of Health and Welfare, Female Participation in the Australian Medical
Workforce, AMWAC Report 1996.7, Sydney, AMWAC, 1996.
- Britt, H., et al , 'The sex of the general practitioner: a
comparison of characteristics, patients and medical conditions managed',
quoted in Australian Medical Workforce Advisory Committee and Australian
Institute of Health and Welfare, Female Participation in the Australian
Medical Workforce, AMWAC Report 1996.7, Sydney, AMWAC, 1996.
- Broom, D., quoted in G. Palmer and S. Short, Health Care &
Public Policy: an Australian analysis, second edition, South Melbourne,
Macmillan, 1994.
- Barrett, A., 'Men's health starting to take centre stage', Australian
Dr, 7 October 1994: 37.
- Dennerstein, L., 'Gendered approach preferred', Australian Dr,
3 February 1997.
- Australian Institute of Health and Welfare, Australia's Health
1996, op. cit.: 124.
- For a discussion of this case and its implications see the paper Testosterone
Poisoning or Terminal Neglect? The Men's Health Issue (Fletcher,
op. cit.).
- Quoted in Richard Fletcher, 'Tackling Men's Health', Arena,
August-September 1995: 10-11.
- Senate Community Services Estimates Committee, Hansard: Department
of Health and Family Services, 18 September 1996: 111.
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