Gender relations in the field of health care in Ukraine
Introduction
According to modern ideas, public health is a measure of socio-cultural development of society and quality of life. The current stage of socio-economic development of Ukraine is accompanied by difficult conditions for the formation of public health. Crisis in the economy, stratification of society in terms of living standards, social instability, unfavorable environmental situation have led to deteriorating health.
The objective growth of the population's medical problems is taking place against the background of the declining capacity of the health care system. The general economic crisis has had a painful effect on the state of the industry.
The processes related to the transformation of Ukrainian society have affected different groups of the population in different ways - women and men, young and old, rural and urban populations, etc. The most vulnerable categories of the population were in the most difficult situation: children, the elderly, the chronically ill.
Because physiology and biology are two of the few undoubted differences between men and women, the gender perspective in health care seems relevant and logical. However, the analysis of health in general, as a holistic state of well-being with many components and social factors influencing it, should move from analyzing the physical characteristics of women and men to analyzing other aspects - the main players in this field (institutions, institutions), traditions , values, etc.
The purpose of our review is to highlight several issues related to gender relations in the field of health care in Ukraine. We will focus on three key positions:
directly on the state of health in its gender and age aspects;
key health actors, ie health workers and their gender practical and strategic needs, as well as institutional and cultural factors;
strategic directions of development of the health care system in Ukraine and the role of international cooperation projects in the planned changes.
Methods of analysis
The main basis of the analysis is the most relevant literature on the issues under consideration, interviews with experts (both those who provide services and those who use) and their own experience in this area.
Literature contains research, statistics, laws of Ukraine, conference proceedings, plans and reports, etc. The main sources have been collected over the last five years. In total, more than 40 written sources were studied. About 20 experts were interviewed. Among them are two women heads of large district polyclinics in Kyiv, specialists in the field of reproductive health (men and women), medical workers and employees of clinical and inpatient departments, employees of international donor organizations that provide assistance in this field, as well as those who use the services of these institutions and projects.
In the absence of direct data, indirect ones were studied with their subsequent extrapolation, comparison with others that have similar characteristics in terms of the issues considered, and expert survey data.
A significant difficulty for the analysis was that gender-disaggregated data still exist from very few categories, and the data in general are not always correct, as there are many differences both between sources and in one source. In addition, gender-disaggregated health data are mainly related to reproductive health issues.
Modern basic gender theories were taken as a basis, in particular:
gender-based division of labor;
access and control of resources;
the importance of various resources - material, informational, intellectual, temporal - to achieve the level of self-realization in society;
the impact of cultural perceptions and stereotypes on access to and control of resources.
The main gender-disaggregated characteristics
Without providing the main gender-disaggregated characteristics of Ukrainian society, including health, it is impossible to move on to further steps in the analysis.
According to the results of the All-Ukrainian census of 2001, the number of men was 22 million 441 thousand people, or 46.3%, women - 26 million 16 thousand people, or 53.7%.
These data indicate a gradual decrease in gender disparities in the population of Ukraine, if in 1989 there were 1,163 women per 1,000 men, in 2001 - 1,159. This was due to the rural population, in which the same sex ratio changed from 1,205 to 1151 women per 1000 men. In cities, on the contrary, this figure increased from 1143 in 1989 to 1163 in 2001.
Obtaining gender-disaggregated data on the industry faces the same challenges as in other areas of life. They can only be obtained for medical indicators, which are undoubtedly related to biological differences, and therefore are calculated separately. Even according to the information database of medical statistics compiled according to international standards, indicators for other categories (for example, the number of women and men among paramedics) are missing or missing data [26] [38].
As in the polls
According to experts, and according to few printed data, the share of women and men working in the industry is approximately 4: 1 and remains at about the same level in recent years [4] [9].
General characteristics of the current state of demographic development
Characterizing the current demographic development of the country, we can see the following trends.
The fall in the birth rate, which in 2000 was 7.8 people per 1,000 population, is almost 40% lower than in the early 1990s [11].
Ukraine has lost the tradition of having many children. The dynamics of the total fertility rate, or the number of children a woman gives birth to in her lifetime (2002 - 1.13 children per woman, Table 1), shows that the birth rate has long been insufficient to replace the old generations with new ones (why requires 2.2 - 2.3 children per woman) [11] [26]. Despite the fact that in the last 2 years it has risen slightly compared to the previous ones, demographers believe that this is only due to delayed births.
Intensification of mortality - from 1990 to 2000 the mortality rate increased by almost 30%, reaching in 2000 15.3 people per 1,000 population (in 1990 - 12.1%). For men this indicator was 16.6, for women - 14.2. In 2002, these figures were 17.3 and 14.3, respectively. [11] [26]
Leading the list of causes of death for women and men are diseases of the circulatory system, malignant tumors, accidents, injuries, poisoning and respiratory diseases (Table 1). The high mortality rate of men of working age is noteworthy. In 2000, the number of men who died between the ages of 25 and 29 was four times higher than that of women of the same age; 2002 - 6 times. At the age of 30-39 years, this difference is smaller, but also significant and is 3.6 and 2.6 times, respectively, for 2000 and 2002 [26].
Diseases of the circulatory system account for more than half of deaths in men (51.4%). Injuries and poisonings are the second leading cause of death (15.2;), followed by malignant tumors (14.5%) [26]. Most cases of poisoning and injuries, including those in the workplace or in a car accident, are caused by alcohol consumption.
The main cause of female mortality is also circulatory diseases (71.1%), followed by malignant tumors (11.3%) and injuries and poisoning (4.1%) [26].
In women, diseases of the genito-urinary system, malignant tumors, endocrine pathologies are more often registered.
Men are more likely to suffer from mental and behavioral disorders, the main causes of which are again alcohol. Alcoholism is 6.6 times more common in men than in women.
Although biology plays a role in this state of affairs, the impact of differences in the environment in which women and men operate also plays an important role. Due to different socializations, women and men choose different mechanisms for overcoming difficulties and solving problems.
If we classify the causes of death as exogenous and endogenous, it turns out that mortality in different age groups varies as follows: up to 15 years and after 70 predominate endogenous causes, ie genetic and ontogenetic, and exogenous causes of death predominate in working age. For men and women, the level of risk differs in both the type of active factor and the age range. Exogenous risks are much higher for men in almost all working age groups than for women. For men, the full range of peak exogenous risks covers 30 - 54 years, and the greatest exogenous risk occurs at the age of 40 - 44 years. In the dynamics of the mortality rate for exogenous causes for men in recent years has increased by 50%. For women, exogenous risks have a slight peak at 30 - 35 years [8]. Thus, the problem of reducing the impact of exogenous risk factors on the health and mortality of the population of Ukraine is relevant. The gender approach in their analysis should be of paramount importance.
There is another important aspect that is often overlooked. It addresses the different health effects of unemployment. Thus, among unemployed women suffering from chronic diseases, the level of disability increases. This is due to the fact that they are unable to pay for treatment and further complicate the situation, bringing it to a critical level.
Table 1
Causes of mortality of women and men
As a result of the excess of the number of deaths over the number of births since 1991 in Ukraine there is a depopulation, which today is estimated at a loss of more than 2.5 million people [11].
A sharp decline in the matrimonial activity of the population - the marriage rate over the past 10 years has decreased from 9.3 to 5.5 per 1,000 population (ie 41%), while increasing over the same period from 3.7 to 4.0 per 1,000 divorce rates . Thus, the focus on informal marital and family relations is growing in society. The share of childless and single-parent families is increasing, the number of children born out of wedlock, as well as mothers raising children without a husband is growing, which further worsens the demographic prospects of the state
[11].
Population aging - the share of the elderly in 1999 in Ukraine as a whole was over 20%, and in rural areas even 1/3 of the total population, while on an international scale, the "very high level of demographic age" of the country starts at 18.0 %. Accordingly, the demographic burden per 1,000 people of working age averages 409 people in Ukraine, 578 in rural areas and 342 in cities. Further aging of the population will inevitably lead to additional economic and social problems for the maintenance of this group [11].
Table 2
Changing the number of births per woman
Changes in trends in population quality
Negative changes are recorded not only in quantitative but also in qualitative indicators of population development [11].
Deteriorating public health has a negative impact on life expectancy. According to 2000 data, it was 68.1 for the total population and 63.2 and 73.8 for men and women, respectively. In 1990, life expectancy in Ukraine was almost 2.5 years higher - 70.5 years. In 2002, these figures were 62.3 and 73.0, respectively [26]. Ukraine, along with the Baltic states, Belarus, Kazakhstan and Russia, is one of the countries where women live on average longer than 10 years. This leads to the further feminization of poverty, in particular among the retirement age groups.
The morbidity and mortality of the population from infectious and parasitic diseases is growing, the threat of the tuberculosis epidemic has become real - more than 600 thousand citizens of Ukraine are suffering from this disease today. The scale of socially dangerous diseases is growing - in Ukraine there are 1.2 million mentally ill people, 688 thousand alcoholics, 76 thousand drug addicts, 740 thousand cancer patients.
Since 1995, the number of HIV / AIDS cases in Ukraine has been growing rapidly. Between 1995 and 1998, the number of people infected with HIV increased almost 17 times [27], [28]. Ukraine has the highest rate of HIV / AIDS in Europe. The majority of those infected are young people, 15% of whom are children and adolescents. If from 1987 to 1996 the ratio of men and women living with HIV / AIDS was 4: 1, in 2001 it has already reached a ratio of 2: 1 [26]. The number of infected women is growing every year. Two thirds of registered HIV-positive women are between the ages of 20 and 29, which is the peak of their reproductive activity. In fact, 60% of pregnant HIV-positive women are under 25 years old. Not surprisingly, since 1999, the number of HIV-positive children has increased significantly due to the increase in the number of infected pregnant women [8].
Table 3
Proportion of women and children among HIV / AIDS patients (%, 1996 - 2002)
Source: Ukrainian AIDS Center, 2003, unpublished, taken from [8]
Women and men suffer differently from the HIV / AIDS epidemic. Here is an approximate list of influencing factors [39]:
biological vulnerabilities;
violence;
coercion;
economic barriers;
education;
the burden of domestic worries.
One of the obvious harms of the HIV / AIDS epidemic is that women are biologically easier to contract than men. The probability of transmission of the infection by a man to a woman is much higher than the probability of its transmission by a woman to a man. Moreover, studies show that women are twice as likely to be infected with HIV as men [40]. Physiologically, women are more vulnerable to HIV infection because they are more likely to have microdamages during sexual intercourse, and laboratory tests show that the specific concentration of the virus is higher in male semen than in female secretions. In addition, because the reproductive system in young girls is underdeveloped, it is more vulnerable to microdamages, especially when sex is forced. As with all sexually transmitted diseases (STDs), women are about twice as vulnerable as men, and the presence of untreated STDs is an additional risk factor for HIV.
In addition to the biological aspects of HIV and its rampant spread, women face a number of social, economic and cultural factors that are equally problematic and detrimental to them. One of the most important factors is violence, which violates women's universal rights and increases their vulnerability to HIV. Although there is no real picture of violence in Ukraine, the 2002 Law on Prevention of Domestic Violence, adopted in 2002, gives reason to hope that both the statistics and the level of violence will improve.
The high incidence of involuntary sexual intercourse and the inability to agree to make sex safe also contribute to the rapid spread of HIV among women. It is not uncommon for women to become infected with HIV from men or intimate partners who, in turn, have multiple sexual partners. Therefore, a woman's risk of HIV infection depends not so much on her lifestyle, moral principles or number of sexual partners, but on her ability to insist on condom use and
opportunities to have intimate relationships without coercion.
Another factor contributing to the AIDS crisis among women is their economic and financial dependence on men. These difficulties are increasing for women with HIV / AIDS. Given that women's incomes in Ukraine as a whole are lower than men's, they may face additional barriers to treatment.
Education is an effective way to fight HIV / AIDS and drug use. It also prevents the spread of misconceptions that are particularly harmful to girls, such as the myth that "HIV can be cured by sex with a virgin" and similar misconceptions [40]. However, the quality of education in Ukraine has generally deteriorated, and many programs related to HIV / AIDS and drug prevention are under development or initial implementation. In addition, the overburdened education system has virtually no "gap" for the introduction of such programs in the curriculum.
Women everywhere are the main worries about doing housework and caring for family members. The term "home care economy" is sometimes used to describe the many household chores that are performed primarily by women and girls. The AIDS pandemic has led to a significant increase in many women's concerns. Poverty, as well as the inadequacy of public services, make this burden unbearable for many women, with all the social, medical and economic consequences. According to the HIV / AIDS hotline, only women call for care.
Women IDUs (injecting drug users) are more vulnerable to HIV than their male compatriots, in part because men try to buy raw materials and prepare their own drugs, while women are more likely to inject with a syringe from a drug dealer or partner [ 8].
More than 35% of HIV-positive women in the sex industry inject drugs, which is typical of most European and North American countries. In other countries, a sharp increase in the number of HIV-positive sex workers and an increase in the prevalence of the virus in this group to 50-80% is considered a warning signal of the spread of the epidemic among the general population.
Reproductive health status of the population
According to the World Health Organization, reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease in all aspects of the reproductive system, its functions and processes at all stages of life. Therefore, reproductive health is one of the most important components of the general state of health of the population and the basis for shaping the prospects for further demographic development of the country.
Maternal mortality has been declining in recent years, but remains quite high compared to other European countries. Its average level in Ukraine reaches 25.2 per 100,000 births, ranging from 5.6 to 87.4 per 100,000 births, depending on the region [11]. The most common causes of death are bleeding, preeclampsia and septic complications due to general weakness.
One of the determinants of high mortality and morbidity among women is the large number of abortions, which still remain the main method of birth control. The number of abortions is 1.2 times higher than the number of births. For comparison, in Germany and France this figure is 0.25, and in Japan - 0.06.
Infertility, miscarriage, and high incidence of genital inflammatory diseases are negative consequences of high abortions, low levels of health care, and awareness of reproductive health issues. For example, secondary infertility (ie, infertility after abortion) occurs in 60 to 80% of women. In 5 cases out of 10,000 abortions end in the death of a woman, which is a high figure by any standards [11].
On August 17, 1998, the Cabinet of Ministers adopted a Resolution "On the regulation of the provision of free and discounted medicines on prescription." According to this decree, adolescent girls, as well as women who have contraindications to pregnancy and / or women who belong to the categories affected by the Chernobyl disaster, are entitled to free contraceptives. However, this decision remains little known among women.
According to the State Statistics Committee, 40,631 cases of infertility were registered in Ukraine in 2002, of which 89.3% were women. The level of female infertility in recent years has increased from 2.9 to 3.1 per 1,000 women, which is significantly higher than in Western Europe [26]. Low statistics on infertility among men do not reflect the real situation, but only indicate that they do not turn to medical institutions with similar problems, which is a cultural feature of Ukraine. There is a myth that infertility depends only on the woman. In addition, the sign of male infertility, according to traditional beliefs, speaks of his male "inferiority" and is less tolerated by
society.
The social and legal protection of working conditions and the extremely unsatisfactory implementation of existing legislation in this area remain unsatisfactory. According to various estimates, today about half a million Ukrainian women work in conditions that do not meet sanitary and hygienic and safety standards. There are no data on men.
The infant mortality rate in Ukraine under 1 year of age, an indicator adopted by the Program of Action of the International Conference on Population and Development (Cairo, 1994), is also a matter of concern, as it remains high at 12.8 per 1,000 live births in 1998. About 47% of newborns who die in the neonatal period are premature [11].
Another problem is the state of health of adolescent girls - almost every 10th of them between the ages of 15 and 17 have chronic diseases of the genitourinary system, menstrual disorders or iron deficiency anemia. The health of teenage boys is also a matter of concern. This is especially evident during the conscription campaign, when only one tenth of conscripts join the army. Apart from health, there are other reasons for dropping out, but health is one of the influencing factors.
Forecast of the situation
The project of the Intersectoral Comprehensive Program "Health of the Nation", in particular, the work "Strategic Directions of Health Care Development in Ukraine" (edited by Professor Valeria Lehan) forecast the development of the situation is determined by the following components [11].
Birth rate forecast. The birth rate forecast is based on the hypothesis of differences in the reproductive attitudes of rural and urban populations. The latter type of disagreement is also related to belonging to a certain nationality. One of the options now envisages a compensatory increase in the birth rate to 1.35 in 2010. There is already a significant increase in the birth rate. After 2010, we can expect a steady increase in the intensity of childbearing, to 1.55 at the end of the second decade of the XXI century. Alternatively, the increase in the total ratio will occur after 2012-2015.
Mortality forecast. In the coming years, only a gradual slow decline in infant and child mortality rates to 5 years is likely. Contrary to the traditionally more favorable dynamics of female mortality, the mortality of women is expected to stabilize over the next decade and the corresponding indicators calculated for men of working age to be gradually improved. Unfortunately, there is no reason to expect the same positive dynamics among older age groups. Modern psychological overload, forced work in several workplaces, irrational nutrition will inevitably show signs when the natural immune reserves come to an end. Accordingly, mortality among the oldest age groups will continue to rise. Average life expectancy, according to forecasts, will be:
2005: for men - from 62.7 to 63.0 years; for women - from 73.4 to 73.6 years;
2010: for men - from 64.0 to 65.0 years; for women - from 74.6 to 75.2 years;
2015: for men - from 66.2 to 67.1 years; for women - from 74.8 to 75.9 years;
2020: for men - from 68.2 to 69.1 years; for women - from 75.6 to 77.1 years.
Table 4
Average life expectancy
Forecast of the influence of gender and age composition. Even with the likely improvement in trends in births, deaths and depopulation, Ukraine's aging population will continue to have a negative impact on the country's demographic prospects.
Gender aspects of employment in the industry
Ukraine's healthcare has a strong potential. As of the end of 2000, 200,111 doctors and almost half a million paramedics (498,845 people) were registered under the Ministry of Health. There is an extensive network of health care facilities: 6,456 outpatient clinics, more than 16,000 medical and obstetric facilities, 3,059 hospitals with 434,139 beds [11].
31% of women and 18% of men with higher education among all employed work in the health sector [4]. Among them, the number of women who perform research in medicine and pharmacology, more than men (5590 and 4859) [4]. 370 women and 986 men have a doctorate, 2984 and 1744 have a candidate, respectively [4]. 5 women academicians of the National Academy of Sciences represent medicine and biology, out of 6 female corresponding members - 4 are also physicians.
If we take into account that according to 1997 data, about one million (994,300) women worked in the health sector, which was 82% of the total number employed in the industry [16], small estimates based on preliminary data show that the share men in medical positions, in scientific institutions, and, accordingly, at higher levels of decision-making are much higher than women, who are more in the middle and lower positions. That is, there are signs of vertical segregation, when men and women play roles for character
erom posadi. This problem is also called "glass ceiling".
Yes, a male health minister has 4 to 3 deputies and 1 female deputy. In the Kyiv City Department of Health, the male head has 8 deputies and 1 deputy. However, if women do appear in Ukraine from time to time, medicine is one such field. The same applies to the Committee on Health, Motherhood and Childhood of the Verkhovna Rada of Ukraine.
According to a poll, 74 percent of Ukrainian men and women are in favor of family medicine. Even more - in the countryside. And what do we have in this direction? There are still very few family medicine institutions, and the staff is a tenth of the need. But even with the minimum number of staff graduated from medical schools, only 14 percent of graduates work in family medicine. The reasons are known: the lack of the same motivation to work, domestic insecurity, blurring, uncertainty about the status of family doctors, the lack of a clear legal framework that would socially protect them. Although gender-disaggregated data are also lacking here, it can be assumed that under such conditions, the share of women here is also high.
This problem is also evident in the Sanitary and Epidemiological Service of Ukraine. According to the Chief State Sanitary Doctor of Ukraine Olga Lapushenko, over the past ten years the number of employees in this service has decreased by 10 thousand people. Four thousand vacancies - and this against the background of natural aging, with the rapid onset of infectious diseases.
The level of wages in the industry remains traditionally low. But if, according to 1997, women in the industry received 93.89% of men's salaries [4], in 2002 this share decreased to 86.17% [26]. If this trend continues, then, with effective health care reform and a significant increase in wages, women are at risk of being gradually "washed out" of high-paying jobs into lower-skilled and lower-paid jobs.
Table 5
Comparison of women's and men's salaries and industry with the average in Ukraine
The performance of reproductive roles, which in Ukraine is predominantly left to women [4], [9], does not encourage women who, in particular, work in the field of health care, to seek high positions. Thus, the head of one of the largest district clinics in Kyiv, a deputy of the district council, said that it would be good if women held middle management, because they can better handle difficult situations with clients and clients, on the one hand, and senior management, with another. At the same time, it is better for men to occupy higher levels, because "a woman loses everything feminine in this position." Similar thoughts could be heard from others. But to the question, "What would help you not to be torn between family and work?" many women called homework and the lack of modern home appliances "difficult to buy with the money we get." A vicious circle is being created.
Productive health roles have both clear gender boundaries and more neutral positions.
The inversely proportional ratio of women to men (high proportion of women as nurses, nurses and lower in administrative positions and the opposite for men) in various positions has already been mentioned above.
Among the areas within the industry are also larger "women's" and "men's". Thus, surgery, especially some of its areas (neurosurgery), still remain segregated and virtually inaccessible to women. At the same time, pharmacology is predominantly a female field. Here, for example, is where men mostly work in one of the largest polyclinics in Kyiv. Among the paramedics are masseurs, X-ray technicians, paramedics, emergency nurses. Among the doctors are surgeons, gynecologists, several therapists. These facts indicate the existence of horizontal segregation, when there is a tendency to provide employment for men and women in different specializations.
It is also interesting to note that in the same clinic, the ratio of working women to men is 9: 1. The share of women is higher than in the industry as a whole. Accordingly, there is reason to believe that in traditionally "male" specializations (hospitals, specialized clinics) the ratio will be different.
The influence of cultural features on the gender distribution of specialties is small. Thus, if in many cultures there are taboos on women receiving gynecological services from men, in the Ukrainian ethnic group there is no such taboo. However, this can create some problems for women of other ethnicities. Thus, in the Roma community, where the above-mentioned taboos are very strong and health problems are generally more severe than the average in Ukraine, these factors can play a significant role. There are also certain cultural peculiarities in terms of the propensity to receive medical services in certain areas from women or men. They are almost the same as the percentage of men and women in these areas.
Despite the fact that the legislation of Ukraine (Constitution, Labor Code (Labor Code), etc.) does not provide for
There are a number of institutional factors that affect the gender aspects of employment. Thus, the provisions concerning the protection of women's labor (Constitution of Ukraine, Article 43 and the Labor Code, Chapter XII) are protectionist in nature and may be a reason for denial of employment if a woman has a child under 3 years of age and her work in a medical institution associated with work at night.
There are no official data on obstacles to employment, promotion, and early dismissal of women, but these phenomena apply to one degree or another to all areas of employment in Ukraine.
Health care reform in Ukraine and the role of international cooperation projects
Reform in the health sector concerns the restructuring of both the financing of the industry as a whole and specific services. The reform of the sector should be aimed at ensuring equal access to health services, as well as improving the quality of treatment.
If in the developed countries the priority (as well as the lion's share of budget revenues for health care financing - compared to specialized and highly qualified medical care) is given to the primary health care system, in Ukraine the opposite: funding for specialized and highly qualified medical care significantly exceeds that for the primary level, in which the medical care of the majority of the population. If in countries with well-organized health care systems the share of expenditures on primary health care is 20 - 30%, in Ukraine - 4 - 5% [11]. In order to eliminate this dissonance, active work is being done today, and this year the situation is expected to change. These changes can affect men and women in different ways. For example, studies in many countries have shown that men are less likely to seek preventive services and begin to worry about their own health only when "something is wrong" [14], ie there are significant disease syndromes. Thus, in the day hospital of one of the largest polyclinics in Kyiv, designed to provide non-urgent medical services, as well as those that do not provide round-the-clock supervision of patients, the percentage of men who use its services does not exceed 20%. There is a danger that men will fall even more out of the prevention-oriented system. An important cultural factor that affects both women and men is the "culture of self-love." In Ukraine, there is often an indifferent indifference to oneself, especially in rural areas. Thus, to the question "how can we fix the situation with high payment for medical services and in particular operations?", The answer was: "We will put our hands on our chests, lie down and die" [6].
On the other hand, choosing a family doctor may not be easy, as women may not like the fact that the family doctor will know "all the secrets" about family health and will be the mediator between the woman and the gynecologist.
Today in Ukraine the frequency of referrals of patients by primary care physicians to specialists is 6-15 times higher than in countries with well-organized health care systems. Increasing the role of doctors and general practitioners can create a "surplus" of specialists. It is important to keep in mind that reform can change the proportion of men and women. At the same time, in each of the sub-sectors the changes will be individual.
Today, health care funding is focused mainly on the maintenance of the industry (although it should be - on patient care): according to the Chairman of the Committee on Health, Maternity and Childhood of the Verkhovna Rada of Ukraine Mykola Polishchuk, about 60-70% of budget funding is directed for the salaries of medical workers, 20-30% - for utilities and only 2-8% - for the treatment of patients. Against the background of the constant reduction of the bed stock in Ukraine, no medical institution has closed, ie the disproportion continues to increase. Thus, the situation needs to be radically changed, and health care financing needs to be accelerated (accelerated by the Ministry of Health): first of all, it is necessary to finance patients by enabling health workers to earn a decent living.
Funding for the industry was still insufficient, but it increased by 23 percent from the previous year. Wages are a painful issue, but even here there have been some small, but still some changes, although a decent level of wages is still far away. Health care reform should seek ways to increase the prestige and salaries of physicians, rather than simply transferring control of the profession to men, as mentioned above. This may simply lead to increased vertical segregation, which is still significant in the industry.
For the same reasons, the role of nurses in the new system should be analyzed from a gender perspective. Today, the majority of nurses are women. Wages of this category of medical workers
and workers are low. It should be borne in mind that changing the role of nurses in the new system, the requirements for their qualifications, salary increases will inevitably have different effects on women and men who work or can work in this capacity.
The decision to reform the health care system has been made by the state, and the Ministry of Health has been working consistently in this direction. The general state of the health care sector can now be described by the following factors [11]:
devaluation of individual and public health;
raising public expectations about health care opportunities;
uncritical assessment of the state and role of public health by political forces;
supercritical health care system;
structural imperfections of health systems;
deformed health care management;
unbalanced vertical control system;
uncertainty of the role and functions of regional governance;
lack of new management technologies;
lack of information;
financial and economic uncertainty;
lack of ideology of health and technology of its protection.
At least half of them could improve the overall situation through a consistent and convincing gender approach.
Thus, the attitude to one's own health (individual and public) as an unimportant "female" value has led to corresponding distortions in macro policy. The deformity of health care management and the imbalance of the vertical management system are not least related to vertical gender segregation in the industry.
Despite the consistent initiatives of the Ukrainian government to achieve gender equality in various areas of public life, in the field of health care, these initiatives are mainly focused on aspects of the excellent biology and physiology of women and men, rather than social factors. Thus, the National Program "Reproductive Health 2001-2005" in the sections "Education" and "Research" contains provisions that carry protectionism or, at most, the approach "Women in Development", which aims to increase the role of women's contribution in the field of social development, but can not see the picture of the impact of policies on the lives of women and men in general.
International humanitarian and technical assistance provided under international agreements, as well as contracts with government agencies, foreign NGOs, through cooperation with non-governmental organizations in Ukraine, is an important factor in improving public health and improving the quality of health services. . Although there is no national data on the cost of assistance from all such sources, it can be argued that the amount of technical assistance is significant.
Assessing international activities in the field of health care, we can note the following main areas of activity of international and foreign organizations.
Reforming the health care system (for example, supporting the development of Ukraine's medical standards system by the Delegation of the European Commission to Ukraine).
Development of national programs in the field of health care (for example, development of the National Program "Reproductive Health 2001-2005" with the support of the POLICE project (subcontractor USAID).
Training of health workers and methodological assistance (for example, training of employees of the Family Planning Service by the United Nations Population Fund).
Improving health services (eg improving the quality and access to perinatal services with the support of the Swiss Cooperation Office in Kyiv).
Chernobyl programs and projects.
Overcoming the TB and HIV / AIDS epidemic (for example, a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria).
The main players in terms of providing international humanitarian and technical assistance are the following:
Agencies for International Development and Cooperation (British Council, Swiss Cooperation Office in Kyiv, USAID and others);
Global Fund to Fight AIDS, Tuberculosis and Malaria;
International Renaissance Foundation;
Representation of the European Commission in Ukraine;
UN Office in Ukraine;
World Bank Office in Ukraine.
Despite the fact that almost all of the above institutions in one way or another declare gender as a "mainstream" in their activities, a comprehensive balanced consistent approach is rare.
Both in government programs and in the activities of international organizations, this is due to several reasons:
the absence or small number of people with a “gender vision” of problems at the decision-making level;
high level of gender bias and stereotypes on the part of workers of state and international organizations working in / for the health care system;
lack of a gender-sensitive approach to sectoral strategies and programs.
The level of gender sensitivity of performers often varies between non-recognition of the importance of denying the need for gender justice in society. Yes, the coordinator of the "Health" program of one of the foundations after participating in the training on gender
He said that "gender equality may be a threat to Ukraine's national security." Another common attitude to the problem is that "today it is a fashionable concept that needs to be incorporated into all projects that don't really need it." Such an attitude cannot promote the proper implementation of gender programs and components.
The current state of affairs is sometimes explained by the activities of women's and other organizations working in this field - shallow awareness of the concept of gender, accusatory tactics in the implementation of gender justice, lack of consistent strategies for gender equality, and so on.
One of the examples of a comprehensive approach to the problem is the activity of the UN Office in Ukraine. For example, the UNDP Gender in Development project has been working for many years to implement gender issues in various spheres of life. “Human Development Report in Ukraine 2003. Special Edition. Ukraine and HIV / AIDS: Time to Act ”contains provisions on the gender dimension of the epidemic in Ukraine. One of the latest initiatives is the creation of a Coalition of Women Leaders in response to the HIV / AIDS epidemic. The combination of all available resources in terms of cooperation with different players (both government and public) can give a synergistic effect.
However, this example is rather an exception. In other donors, the consistent implementation of steps to implement a gender perspective is more sporadic and sometimes marginal.
Almost everywhere there are no responsible strategies for donor exit in terms of implementing gender programs, which would include the definition and publication of long-term plans with at least three phases - accession, sustainable development, exit. Thus, the International Renaissance Foundation, which has played a leading role in supporting programs and projects related to women's and gender issues since 1998, abruptly closed the Women's Program in late 2002 without any justification, and immediately reduced funding for Ukrainian NGO projects. an already narrow field for fundraising. For the unstable young public sector of Ukraine, such and similar steps are dangerous in terms of their disadvantage to the sustainable development of civil society, and for such a controversial topic as gender.
Conclusions
The current demographic situation, the state of health of the population of Ukraine and the prospects for their development, even under favorable conditions, are of concern. Gender imbalance has already reached a critical level in some situations.
Indicators such as mortality, life expectancy, birth rate, reproductive health, and HIV / AIDS, along with biological ones, have strong socio-gender factors.
Employment in the health care system carries all the hallmarks of vertical and horizontal segregation, which, to some extent, "translates values" into the realm of health care.
The level of wages in the industry remains traditionally one of the lowest in Ukraine, and the industry itself is traditionally "female" in terms of employees.
There is an influence of culture and traditions on the gender characteristics of employment in the industry, but it is not rigid, and differences are generally tolerated by society.
State steps to reform the health care system in Ukraine today do not consider gender as an important concept and do not take into account the impact of gender on the implementation of the reform.
International foundations and cooperation agencies do not always have comprehensive gender-responsive strategies, as well as human and other resources for their implementation.
General recommendations
Health analysis must go beyond the body of men and women and take into account the institutions, traditions and views that play a crucial role in determining the quality of health care and the root causes of ill health. As these institutions and factors reflect the different roles of women and men in society, the introduction of a gender perspective in this area is crucial. If gender equality is declared as one of the national priorities, then efforts should be directed to all segments of the population and to all spheres of public life.
It is important to monitor the gender impact of health care reform on both the health and economic aspects of women's and men's lives. Gender-disaggregated data is one of the most important resources for such monitoring.
As the health care system is partly funded by social taxes, health policy development should ensure that both women and men have equal access to all health services. One of the specific research initiatives is to analyze the costs of households to pay for health services. It is important to remember that not all households operate on the principle of a "common pot", when resources are equally available to all its members.
Implementation of gender research, etc.
conducting gender sensitivity trainings in this area remains a necessary component of the implementation of gender justice in society.
A balanced and responsible gender policy by international foundations and development and cooperation agencies can be an important factor in stabilizing both health care reform and the development of a modern democratic society as a whole.
Literary sources used
Alekseeva G., Balakireva O., etc., Gender parity in the conditions of development of modern Ukrainian society. - Ukrainian Institute for Social Research, 2002
Bogatyreva R., Ventskovsky B., Vovk I., etc., Reproductive and sexual health of adolescents in Ukraine (Situation analysis). - United Nations Population Fund, 1999
Gender statistics for monitoring the achievement of equality between women and men. Ukraine. K .: Institute of State and Law of Ukraine, 2000
Gender analysis of Ukrainian society. UNDP, 1999
Gender budget, gender expertise. - Moscow, 2001
Donald Allen VA, Goncharuk O., Perrotta L. Ukrainian village at the turn of the century: sociological and anthropological section / Edited by Yu. Saenko. - Kyiv: Institute of Sociology of the National Academy of Sciences of Ukraine, 2001
Zhilka N., Irkina T., Steshenko V. - The state of reproductive health in Ukraine (medical and demographic review). - Kyiv: Ministry of Health, National Academy of Sciences: Institute of Economics, 2001
Human Development Report in Ukraine 2003. Special edition. Ukraine and HIV / AIDS: time to act. - K., 2003
Lavrinenko N. Woman: self-realization in the family and society (gender aspect). - К .: ВИПОЛ, 1999
Lekhan V., Health care system in Ukraine: results, problems, prospects. - К .: Сфера, 2002
Lekhan V., Lakiza-Sachuk N., Wojciechowski V. and others, Strategic directions of health care development in Ukraine / Under the general ed. W. Lehan. - К .: Сфера, 2001
Proceedings of the scientific-practical conference "Promoting Gender Equality in Volyn". - Lutsk, 2003
Niemanis A., A Practical Guide to Gender Mainstreaming. UNDP RBEC from http://www.undp.sk/genderlibrary
Survey of representatives of various branches of government: awareness and attitude of representatives of the highest echelons of power to the issues of reproductive health in Ukraine. - POLICE, 1999
A practical guide to implementing gender approaches. UNDP RBEC. http://www.undp.sk/genderlibrary
Work in Ukraine: Stat. coll. - K., 1997
On the National Action Plan for the Advancement of Women and the Promotion of Gender Equality in Society for 2001-2005, Resolution of the Cabinet of Ministers of Ukraine of May 6, 2001 № 479
On the situation of families in Ukraine: Report on the results of 1999. - Kyiv: Ukrainian Institute for Social Research, 2000
Reproductive Health of Ukrainian Women - 1999. - Kyiv International Institute of Sociology, Centers for Disease Control and Prevention, USA. - K., 2000
Statistics stingy language… Newsletter №4. - Kyiv, 2000
Public organizations working in the field of reproductive health in Ukraine. Directory. Kirovograd, 2003
Modern approaches to the prevention of smoking, alcoholism, drug addiction and AIDS. - Proceedings of the conference, 2003
UNAIDS / Ministry of Health of Ukraine (2000). HIV / AIDS in Ukraine: situation analysis
UNAIDS / Ministry of Health of Ukraine (2000). HIV / AIDS in Ukraine: report analysis
UNAIDS. Global HIV / AIDS Epidemic Report 2002, Geneva
Gender Issues in Ukraine. Challenges and Opportunities. - UNDP, 2003
Kohut M., Lakiza-Sachuk N. - National-Level Decision Making on Reproductive Health Policy in Ukraine. - K .: The Futures Group Int., RTI, CEDRA., 1999
Kohut M., Lakiza-Sachuk N. - Key Informant Study: Policymakers ’Knowledge of and Attitudes towards Reproductive Health in Ukraine. - K .: The Futures Group Int., RTI, CEDRA., 1999
www.moz.gov.ua
www.ozu.com.ua
www.who.int
www.health.gov.ua
www.intellect.org.ua
www.apteka.ua Weekly "Pharmacy"
www.vz.kiev.ua Newspaper "Your Health"
www.zdorovja.org.ua
www.health-ua.com Health of Ukraine newspaper
www.medstat.com.ua
www.icw.org
www.un.org/womenwatch/daw
www.eldis.org/gender
www.ilo.org