How well are we caring for women? Thinking about gender in evaluating health care

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Despite considerable progress in the past decades, societies continue to fail to meet the health care needs of women at key moments of their lives, particularly in their adolescent years and in older age.

-Women and Health: Today's Evidence, Tomorrow's Agenda
World Health Organization, 2009 


As a growing body of evidence clearly demonstrates, women’s and men’s health issues differ, and their health care needs differ too. This is not only because of differences in biology (sex), but also because of women’s and men’s different roles (gender). Their ability to get these health care needs filled is affected by a wide range of other factors, including racism, and women’s lower socio-economic status in the world.

The need for sex- and gender-based analysis* (SGBA) in health may be self-evident now to those who work in women’s health. But this understanding that sex, gender and many other social determinants are key to health—and health care—has been a long time coming among many others. Over the past several decades, women who were not satisfied with the quality of care they had been receiving began to critique health care, asking: Is it serving women appropriately? And if not, why not? They have been pointing out the gaps and pushing for the need to better understand the importance of sex and gender in health care. In the process, they have been creating and testing models of women-centred care to better serve the health needs of women.

As a result of these gendered critiques and women-centred models, we are beginning to see the development of policies and practice that take women into account, both in Canada and throughout the world. Nevertheless, there are still huge gaps. Below you will find some of the tools that have been developed for evaluating and measuring the gender gaps in health care and health systems. We also provide a selection of the critiques of health care that together strive to answer, How well are we caring for women? Finally, we offer some models of women-centred care whose goal is to offer the best and most appropriate care for women.

*For more information on what SGBA is and how it is being used to further women’s health, see CWHN’s primer: Sex and Gender-Based Analysis (SGBA): Why sex and gender matter in health research, policy-making and practice.

How can we evaluate the quality of our health care, using a gender-based analysis?

The resources below are a selection of tools that have been developed to evaluate whether or not gender and sex are adequately included in health research, policy and care.

Rising to the Challenge: Sex‑ and Gender‑based Analysis for Health Planning, Policy and Research in Canada
By Barbara Clow, Ann Pederson, Margaret Haworth-Brockman, and Jennifer Bernier (Eds.), Atlantic Centre of Excellence for Women's Health, 2009
Provides a comprehensive overview of sex‑ and gender‑based analysis, including both a discussion of core concepts and a number of case studies illustrating the application of SGBA to surveillance data, literature reviews and systematic reviews, health surveys, health policy making, health protection and health program development. Includes a list of resources.

Intersectionality: Moving Women's Health Research and Policy Forward
By Olena Hankivsky, Renée Cormier, with Diego de Merich, Women’s Health Research Network, 2009
Explains intersectionality, a recent paradigm used to study, understand, and respond to how sex and gender intersect with other variables such as ethnicity and class, and how these intersections contribute to unique experiences of health. Explores how health researchers, policy analysts, program and service managers, decision makers, and academics can apply an intersectional perspective to their work. Free registration on this site is required before downloading.

Guidelines for Gender-based Analysis of Health Data for Decision Making
By Margaret Haworth-Brockman and Harpa Isfeld, Pan American Health Organization, 2008
Presents the basic elements needed to carry out a gender-based analysis using health statistics. Highlights the importance of using data disaggregated by sex, age, socioeconomic level, ethnic group, sexual orientation, geographic area, and other factors, in specific contexts, and whenever possible.

SHE Framework: Safety and Health Enhancement for Women Experiencing Abuse: A Toolkit for Healthcare Providers and Planners
By Jill Cory and Linda Dechief, BC Women’s Hospital and Health Centre, 2007
Consists of a tool kit for health care providers and planners to conduct an audit of their practice and/or organization, by looking at the safety of women impacted by abuse. Points to the need to enhance health care for women and includes two contrasting models of care.

Measuring Health Inequalities among Canadian Women: Developing a Basket of Indicators
By Arlene Bierman, Health Canada, 2007
Highlights the importance of incorporating gender and equity into health indicator reporting and describes the process of developing a Women’s Health Indicator Framework for reporting. This Framework was created to serve as a tool to achieve the goals of Canada’s Women’s Health Strategy.

Just the facts, ma’am… A Women’s Guide for Understanding Evidence about Health and Health Care 
Women and Health Care Reform, 2005
Introduces how SGBA may be used to examine evidence in health and health care. Aims to help women make their own decisions by offering them tools to assess arguments and evidence about women, health and health care reforms.

Gender Analysis in Health: A Review of Selected Tools
World Health Organization, 2002
Critically examines seventeen widely used gender tools and their usefulness for gender analysis in health.

Gender Sensitivity and Gender-based Analysis in Women’s Health Development: Historical Outlines and Case Studies of Best Practice
By Dr Jamileh Abu-Duhou, Dr Yuan Liping and Dr Lenore Manderson, World Health Organization, 2003
Offers a historical perspective on the development of GBA, and presents case studies on GBA policy development and programme implementation, and assessments of tools used to evaluate the efficacy of these GBA programmes. Also analyzes the relationship between gen­der, poverty and health.

An Inclusion Lens: Workbook for Looking at Social and Economic Exclusion and Inclusion
By Malcolm Shookner, Public Health Agency of Canada, 2002
Provides a tool for analyzing legislation, policies, programs, and practices to determine whether they promote the social and economic inclusion of individuals, families, and communities.  May also be used in many other contexts, including evaluating gender inclusion or exclusion in health.

Evaluating Programs for Women: A Gender-specific Framework
By Joan McLaren, Prairie Women’s Health Centre of Excellence, 2000
Presents one of the earlier efforts to develop effective evaluation models for gender-specific and woman-centred programs, undertaken when there were very few precedents.

Some examples: evaluating health care using a gender lens

The following resources offer examples where a gender lens has been used to evaluate how well we care for women. These resources offer the big picture—evaluating women’s health status in Canada and in the world. We also provide evaluations of how well health care services are serving women, as well as resources that scrutinize the impacts of health reform on women.

Women and Health: Today's Evidence, Tomorrow's Agenda
World Health Organization, 2009

Describes how, despite considerable progress in the past decades, societies throughout the world continue to fail to meet the health care needs of women at key moments of their lives, particularly in adolescence and in older age.

2009 Spring Report of the Auditor General of Canada
Chapter 1: Gender-based Analysis
Reports on the Auditor-General’s examination of seven federal government departments whose responsibilities can affect men and women differently. Finds that several departments lag behind, and two completely fail to implement GBA. Also describes the history of how GBA policy came to be developed with the federal government’s stated commitment to GBA in 1995.

Explaining the Health Gap Experienced by Girls and Women in Canada: A Social Determinants of Health Perspective
By Cecilia Benoit et al., Sociological Research Online, Volume 14, Issue 5, November 30, 2009
Evaluates how a wide variety of social determinants uniquely shape the health of all Canadians—but especially of girls and women. Shows that the safety net of all Canadians has been eroding, particularly for the most vulnerable.

A Profile of Women's Health in Manitoba
By Lissa Donner, Harpa Isfeld, Margaret Haworth-Brockman and Caitlin Forsey, Prairie Women's Health Centre of Excellence, 2008
Reports on the health, health outcomes and health care use of women in Manitoba, using a broad social determinants of health perspective. Also points to policies and programs which can lead to improvements and change.

Women and Homelessness
The Street Health Report 2007 Research Bulletin #2, June 2008
Documents the brutal impact of homelessness on women’s health and calls homelessness a “life-threatening” condition for women. Reveals staggering rates of sexual assault among homeless women, and describes health effects that significantly reduce their life expectancy.

Bringing Women and Gender Into “Healthy Canadians: A Federal Report on Comparable Health Indicators 2004”
By Kay Willson and Beth E. Jackson, National Coordinating Group on Health Care Reform and Women, 2006
Reports on a workshop where twenty-five women’s health researchers and policy advisors submitted the Healthy Canadians report to a GBA, and found it lacking.

Rural, Remote and Northern Women’s Health: Policy and Research Directions (Summary Report)
By Rebecca Sutherns et al., Centres of Excellence for Women’s Health, 2004
Examines the health of rural, remote and northern women in Canada. Describes how, with the knowledge of women living in those areas combined with that of community organizations and researchers, a policy framework and research agenda on rural and remote women’s health in Canada was developed.

A Profile of Women’s Health Indicators in Canada
By Ronald Colman, Bureau of Women’s Health and Gender Analysis, Health Canada, 2003
Presents a big-picture view of how well Canada’s health determinants and health system serve women. Presents a gender-based inventory of indicators that provide a statistical profile of women’s health in Canada.

Women's Health Surveillance Report: A Multidimensional Look at the Health of Canadian Women
Canadian Institute for Health Information, 2003
Looks comprehensively at women’s health in Canada. Provides information and descriptive statistics on determinants of health, health status, and health outcomes. Identifies many gaps in women’s health research, policy and healthcare, and recommends changes needed to improve the health of women.  

Reading Romanow: The Implications of the Final Report of the Commission on the Future of Health Care in Canada for Women
By Pat Armstrong et al., National Coordinating Group on Health Care Reform and Women, 2003
Consists of a chapter-by-chapter gendered analysis of the Final Report of the Royal Commission on the Future of Health Care, Building on Values: The Future of Health Care in Canada (Romanow 2002).

Aboriginal Women’s Health Research Synthesis Project (Final Report)
By Madeleine Dion Stout, Gregory D. Kipling and Roberta Stout, Centres of Excellence for Women’s Health, 2001 
Outlines key health and health-related indicators for Aboriginal women in Canada, reviews CEWH’s Aboriginal women’s health research to date, and makes recommendations for priority-setting in future Aboriginal women’s health research activities.

Advancing Policy and Research Responses to Immigrant and Refugee Women’s Health in Canada
By Mary Ann Mulvihill, Louise Mailloux and Wendy Atkin, Centres of Excellence in Women’s Health, 2001
Includes an overview (to 2001) of Canadian research on immigrant and refugee women's health, as well as preliminary policy issues, research questions and policy implications arising from the research. Suggests next steps for advancing action in research and policy development on immigrant and refugee women’s health.

Evaluating Health Care for Women: Some Examples

Sex and Gender, Hips and Knees: A Sex‑ and Gender‑based Analysis of Total Joint Arthroplasty 
By Beth Jackson, Ann Pederson and Madeline Boscoe, in Rising to the Challenge: Sex‑ and gender‑based analysis for health planning, policy and research in Canada, pp. 68-73, Atlantic Centre of Excellence for Women’s Health, 2009
Critically examines hip and knee replacement surgery to demonstrate the value of SGBA to the wait times issue and to health policy more broadly.

Building Bridges: Linking Woman Abuse, Substance Use and Mental Ill Health (Summary Report)
By Louise Godard, Jill Cory and Alexxa Abi-Jaoudé, BC Women’s Hospital and Health Centre, 2008
Identifies the need for a women-centred framework as part of the solution to improve services that support women’s safety and health. Based on research, practice and women’s narratives confirming that violence is pervasive and central to the development of substance use and mental ill health.

Gender Mainstreaming in Priority Health Programs: The Case of the Diabetes Mellitus Prevention and Control Program in Mexico
Pan American Health Organization, 2008 
Describes a program that won the PAHO 2008 Competition for Best Practices that Incorporate a Gender Equality Perspective in Health.

Engaging Men and Boys in Changing Gender-based Inequity in Health: Evidence from Programme Interventions
By Gary Barker, Christine Ricardo and Marcos Nascimento, World Health Organization, 2007 
Assesses the effectiveness of programmes seeking to engage men and boys in achieving gender equality and equity in health. Finds that, as a result of relatively short-term programmes, men and boys can and do change their attitudes and behaviour related to sexual and reproductive health, their interaction with their children, and their use of violence against women.

A Summary of the 'So What?' Report: A Look at Whether Intergrating a Gender Focus into Programs Makes a Difference to Outcomes
Interagency Gender Working Group, Washington DC, 2005
Shows how taking a gender-based approach to policy and programming has a positive effect on health, particularly on reproductive health outcomes.

A Call to Action: Women’s Health at Work & Gender-based Analysis
By Stephanie Premji with members and associates of CINBIOSE, 2003
Describes how women’s and men’s health issues in the workplace differ, even when they are doing the same work, and argues that occupational health should be examined using GBA. Sets out recommendations for researchers, government, organizations, unions and others to follow so that women can move toward equity in workplace health.

Evaluation Report of the Sheway Project for High-risk Pregnant and Parenting Women
By Nancy Poole, British Columbia Centre of Excellence for Women’s Health, 2000
Reports on a unique outreach program located in the Downtown Eastside (DTES) of Vancouver, providing holistic services to pregnant women with substance use problems, and support to mothers and their families until their children are 18 months of age. Shows the benefits of a woman-centred, harm-reduction, culturally focused approach to providing services.

Health Care Reform: How Does It Affect Women?

Women and Water in Canada - The Significance of Privatization and Commercialization: Trends for Women’s Health
Women and Health Care Reform and National Network on Environments and Women’s Health, 2009
Discusses why access to clean, safe drinking water is a central determinant of health. Examines the pressures to move towards the privatization and commercialization of water services and delivery in Canada and evaluates the gendered health implications for women.

Gender Equity and Health Indicators in the Context of Health Reforms
By Hilary Standing, International Journal of Public Health, 52: S5–S6, 2007
Identifies the significant challenges facing those who evaluate health reform using a gender lens.

Is There a Method to This Madness? Studying Health Care Reform As If Women Mattered
By Karen R. Grant, National Network on Environments and Women’s Health, 2006
Examines several key issues about researching health care reform, and proposes ways to research health care reform as if women mattered.

What Evidence is there about the Effects of Health Care Reforms on Gender Equity, Particularly in Health?
By Dr. Piroska Östli, World Health Organization Regional Office for Europe, 2005
Finds that health reform may affect women and men differently—with worse impacts on women—due to the different positions they occupy in society, the different roles they perform, and the variety of social and cultural expectations and constraints placed on them.

Health Care Reform and Women Series
Presents, in plain language, analyses of health care reform using a gender lens, by the Women and Health Care Reform group in Canada.

Models of women-centred care

The goal of women-centred care is to ensure that all girls and women receive evidence-based care that respects their social, economic, physical, cultural and spiritual realities. The following resources describe some of the models of women-centred care that have been developed in recent years.

Women-Centred Care: A Curriculum for Health Care Providers
By Jill Cory with Robin Barnett, Shelley Rivkin, Gayla Reid, and Laurie Hasiuk, BC Women’s Hospital and Health Centre, 2007
Presents a curriculum (based on the Framework for Women-Centred Health) to support health care providers in developing and sharing knowledge and practice related to women-centred care.

Doing It All: Developing Integrated Support for Women Experiencing Mental Health, Trauma-related and Substance Use Problems
By Nancy Poole, Centres of Excellence for Women's Health Research Bulletin, Spring 2006, Volume 5, Number 1
Describes the need for integrated and women-centred approaches to treatment and support for women who experience mental health, trauma-related and substance use problems, as found in a meeting of nine women-serving agencies in BC who have delivered or are delivering such integrated programming.

Voices from the Front Lines: Models of Women-Centred Care in Manitoba and Saskatchewan
By Robin Barnett, Susan White and Tammy Horne, Prairie Women’s Health Centre of Excellence, 2002
Highlights the most effective models of women-centred care, by examining such care within Saskatchewan and Manitoba and comparing findings with other women-centred models. Presents a special focus on Aboriginal-centred models.

Fetal Alcohol Syndrome and Women's Health: Setting a Women-Centred Research Agenda - Final Report
By Lorraine Greaves et al., British Columbia Centre of Excellence for Women’s Health, 2002
Summarizes discussions and recommendations arising from a workshop to help define a preventative approach to FAS using an evolving model of women-centred care. Points to the importance of prevention by focussing on the health of substance-addicted mothers.

A Framework for Women-Centred Health
Vancouver / Richmond Health Board, 2001
Provides a resource that has been and continues to be used to develop policies, procedures and initiatives across the spectrum of health services that affect women. Provides tools and strategies to improve responses to the health needs of individual women and specific populations of women.