meeting1

My speech will be developed around three main topics, somehow related to each other: the first point is a brief description of the Italian Health protection system, in a general European frame of reference, and of the role of women's movement; the second point has to do with the role of women in Europe as health professionals and their innovative method of work; the third point refers to new prospects of women's studies in medicine for a women friendly health system.

Every EU country operates facilities designed to protect public health and a number of statutory medical facilities as public hospitals and community health personnel. There are nevertheless significant differences between the various health systems of the EU countries. Two main “models of coverage” can be identified: the “occupational” (or “corporatist”) model and the “universal” (or “statutory”) one. In the "universal" model the main subject of public coverage is the citizen: all citizens are covered in the same way irrespective of their work or family position, while the financial support comes from taxation on general revenues. Where this model is historically rooted, it has engendered national systems of compulsory health insurance or national health services, directly managed by the State. In the "occupational" model the subject of coverage is not the citizen, but the worker paying contributions from earned income to "sickness funds" (or similar "third party" insurers), according to his/her employment category, while the non-active population has eventually acquired the right to coverage either as retired workers or as dependent members of the breadwinner's family.

The "universal" model of coverage prevails in all North European countries: Sweden, Denmark, United Kingdom, Ireland, and Finland; the "occupational" model prevails in all Central European countries: Austria, Germany, France, Belgium, The Netherlands and Luxembourg. The Southern European countries: Greece, Italy, Portugal and Spain, have according to their laws a universal model of coverage, but their national health service “contracts out” to private centres (the Spanish conciertos, the Italian centri convenzionati) the provision of a vast array of services: from diagnostic tests to minor or medium surgery. Moreover, Greece, Portugal and Spain still rely upon a high amount of contributions to finance their systems. For these countries, thus, we may identify a “mixed” model of coverage: this is formally "universal”, but, in fact, it draws an important proportion of its financing from the contributions paid by occupational groups and “sub-contracts” many public care services to private providers.

Another significant institutional feature of the health system is the range of devolution of power to sub-national authorities. In France, despite important recent efforts to decentralise, the health administration remains unitary and centralised: local political authorities have only minor responsibilities in health care matters. On the contrary, in Germany and in Italy the sub-national authorities have their own separate health administration. In Sweden government of health is highly decentralised both functionally and geographically: the county councils, for instance, levy their own health taxes.

Up to 1978 Italy had an "occupational" system of health protection; the National Health Service (Servizio Sanitario Nazionale, SSN) was introduced with the Law 833 of December 1978; since than a single general scheme covers all citizens. The NHS provides all benefits in kind offered free of charge (or with a small fee) to all citizens. The health benefits (prestazioni sanitarie) offered to all citizen free of charge are: general, paediatric and gynaecological assistance; hospital assistance; specialised assistance as prevention or in emergency situations and life saving pharmacological products. Other benefits are offered paying a fee and are free of charge only for older and economically disadvantaged people, this is the case for: some pharmaceutical products; specialised medical assistance; diagnostic tests, radiology, laboratory analysis; special assistance, including rehabilitation measures, appliances etc.

The administrative structure of the NHS is decentralised. At the central level, it is co-ordinated by the Ministry of Health. The Ministry lays down the guidelines of the National Health Plan (Piano Sanitario Nazionale) which must be presented to Parliament every third year. The regions have extensive powers for organising their own health services. They develop their own regional health plans. At local level health services are delivered through main Hospitals and special firms called Local Health Units (Aziende Unità Sanitarie Locali) which provide all health benefits and run small hospitals. The Local Health Units and main Hospitals are run by a "general manager".

An agreement signed by doctors’ unions and the Ministry of Health regulates every three years medical fees and some other aspects of medical practice. Physicians are allowed great margins of freedom to render services on a private basis, even within public hospitals. The NHS itself contracts out to private health centres (“centri convenzionati”) the provision of a vast array of services: from diagnostic tests to minor and medium surgery. Almost 40% of public expenditure on health flows through private centres of provision. This peculiar blend of public/private mix has originated wastes of public money as well as collusive manipulations between private providers/suppliers on the one hand and health administrators/ politicians on the other hand.

3. A peculiar blend of public/private mix for a variety of health services, due to the diffusion of “sub-contracting” to private clinics and health centres.

The law instituting the Italian NHS was necessary because the previous "occupational" system was in a deep economical crisis, fragmented and unequal. The Minister of Health when this law was delivered was a woman, Tina Anselmi. The NHS was the outcome of a twenty years long ideological struggle of the working class and of the left for an egalitarian and universal system of health protection. It was strongly supported by female organisations and by the new emerging professions: psychologists, social workers, sociologists, psychiatrists etc. that is professions with a very large female presence. On the contrary generally physicians were opposed to it because they consider it as a limitation of their professional autonomy. On the other hand, political parties took advantage of the political- partitical control foreseen by the law and of the decentralisation of the system in Local Health Units with its multiplication of political-managerial positions.

During the '80's the liberal parties, their Governments and Ministers of Health and the upper social classes, opposed the implementation of the NHS, trying to limit it trough cuts in expenditures, fees for patients participation to benefits costs: indeed they aimed at an economic regulation of the public Health system and to promote privatisation. Indeed, the liberal ministers of Health of the late '80 early '90's tried to reform the system in direction of a partial privatisation and of leaving the well to be citizen the choice between the public system and a private insurance. In this direction moved the measures taken in 1992 by the Minister of Health (DL 502 Amato), however these measures were never implemented because the following Minister of Health (a woman: Maria Pia Garavaglia) modified them in 1993 (DL 517). The main innovation of these years has been the devolution of managerial power (previously demanded to politicians) to professional managers and the competition among Local Health Units.

In any case the most innovative goals of the NHS, such as participation, prevention, health education and integration of social and health services, were never completely achieved. Therefore the same non-medical health professions which had strongly supported the reform were feeling an increasing unease, because the lack of resources and of co-operation from the medical staff made it difficult to implement the goals of the NHS and the out-patient clinics they had supported. They therefore asked for a revision of the system to make it more efficient, autonomous from political parties and to find a new professional identity.

This is the frame in which the present central-left Government and the Minister of Health - another woman, Rosi Bindi - is strongly trying to rationalise the system making it more efficient from a qualitative point of view, while strengthening its public nature and setting the citizen-patient at the centre. In the guidelines for the new National Health Plan this woman Minister underlines the importance of principles such as prevention, integration between social and health services, diminishing inequalities, strengthening the decisional autonomy of patients. Another important point for this Minister is the attempt to overcome the peculiar Italian public/private mix particularly with norms about the incompatibility between private and public professional activity for physicians asking them to choose between work in the public system or in the private sphere.

To sum up, it seems that the implementation of innovative aspects of the Italian NHS: prevention social-health integration, development of out-patient clinics, have been strongly supported from the beginning by women's movement, by women in health professions as well as by the three women who have reached the role of ministers of health.

Lets us come, now to the role of the women's movement in the implementation of more democratic and more women's friendly laws and services.

The Italian women's movement started from the idea of "self" and the wish for liberty, for a new social and familial agreement. The theme of health and well being was a logical consequence of female emancipation; the practice experimented on the "self" and with other women started out from the conscience of their own body. From this took strength the female political movement demanding laws for a new (more woman friendly) family legislation, sexual liberty, contraceptives, abortion, divorce, social services, family consulting clinics etc.

- The law for family consulting clinics where to have information on contraceptives (mid '70s);

- The law on divorce of 1974, confirmed later on by a Referendum voted also by catholic women;

- The law for Equal Opportunities and the promotion of Positive Actions of 1991;

- More recently, in 1998, after a long struggle started in 1977, finally was delivered the law against rape and sexual violence: it took 20 years to cancel a fascist law and to assert that sexual violence is not a crime against morals, but it is a crime against the person! It must be said that the law by itself does not solve all problems: what is needed indeed, is a deep cultural change in society and in particular in the magistracy as some recent sentences show (requests of proof of violence! The idea that jeans cannot be taken out without the woman's consent!).

Italian women have long reasoned on their own body and on taking care of themselves (this has been a big revolution for a woman used to take care of other people). With the same practice used in the "self awareness" groups they promote, both as health professionals and volunteers, "self help" and "mutual aid" groups for women with mental unease, with food problems, with cancer and for women who had suffered the surgical removal of the breast etc. In medical practice women are bringing new strategies for health promotion not based on traditional instruments and pharmacology. Several women's groups and professionals promote de-medicalisation, natural birth and re-appropriation of feminine positive energy: on this field are particularly active some associations, women gynaecologist and midwives. Now women are present in different fields and health professions and in all these fields they are bringing innovative inputs. In medical and scientific research they are bringing a new perspective, underlining gender prejudices and bringing to the attention of the scientific world the importance of taking into account gender difference.

The most important women's groups and organisations have been in the beginning two organisations linked to the two main political parties, particularly relevant up to the mid seventies:

- CIF the organisation of catholic women of the former Christian Democratic party; it had a role in supporting the poor, the week and in organising catholic kindergartens (nursery schools); Federcasalinghe, an organisation of housewives quite powerful today, derived from CIF;

- UDI organisation of women of the former Communist party; it had an important role of information and for women's organisation; its importance declined after the rise of feminist groups and as a consequence of the debate on usefulness of party based forms of organisation.

- The Feminist groups of "self awareness rearing" were particularly active in the '70s-'80s.

Other groups are particularly active on specific health related themes, among them I shall mention:

- "Il Melograno", an Association, active since the mid seventies, which promotes natural birth, informs and prepares pregnant women and their partners to the experience of birth, motherhood and fatherhood; there are four "Melograno" centers: in Ancona, Roma, Verona and Varese;

- METIS - Medicina e Memoria - Women Health International Centre Research and Therapy, is a group of Milan based on an idea of cure and scientific research which brings to the centre the relationship between the persons (health worker and patient) involved in the therapeutic action;

- Finally, last September was founded "Obiettivo 2001: per una salute a misura di donna" - "Objective 2001: for a health made to measure (to fit) women's needs; this is a group of women medical and scientific researchers who have underlined, each-one in her specific field, gender differences. This group of women recently constituted a study group at the Ministry of Equal Opportunities with the aim to denounce the actual gender prejudices and to work out guidelines for a women friendly health. The main aims of this group will be described in the third point of my speech.

Let us come now to the second point of my speech: the role of women in health and their method of work. What I am going to say in this point refers to the results of a research on the access of women to high level decision-making positions in the health institutions of the 15 European Union member states[1] and to the documentation of “good practices” in health insofar collected for the European Action Project: “Hannah Arendt School of Politics: women involvement in the public spheres”, a project that we are now carrying out with other Italian and European Associations.

Women are today two thirds of the health employment in all European Member States and are present in all health professions. Nevertheless their participation in health decision-making is by no means adequate in most European countries. However, we found considerable differences among the three "major European regions". As a matter of fact, the participation of women at top decision-making levels is higher in the five North European countries (Sweden, Finland, Denmark, Ireland, Great Britain); it is lower in the six Central (Netherlands, Belgium, Luxembourg, France, Germany and Austria) and in the four South European countries (Italy, Spain, Portugal and Greece).

The presence of women seems to be particularly low in those professional groups which hold decisional power. In most European countries the percentage of women as head physicians and administrative top managers is low. For instance, in Germany, in 1993, women were 35% of all practising physicians, but only 5% of chief physicians. In Italy, within the 208 Local Health Units of the National Health Service, only 2.9% of the general managers are women and similar percentages are reported for the main hospitals (3.6% ).

Women are present in all health professions, however they are concentrated in some of them; that is among: biologists, psychologists, physiotherapists, and they are everywhere the large majority of nurses and other non-medical health professionals[2]. Within the medical professions, there seems to be a precise hierarchy of prestige and power among the different specialisation and women doctors have less opportunities of access to some medical specialities (in primis, surgery).

In synthesis, in health women are still under represented at decisional levels also because the professions in which they are more present (general practitioners, paediatricians, psychologists nurses, technicians, midwives) are given low prestige and decisional power, in spite of the fact that these professions develop a more direct knowledge of reality, of patients and a better ability in communicating with them[3]. It should be mentioned on this matter that the value and prestige granted to the different professions is defined by culture and power relations, thus today's professional hierarchy may be vitiated by the unequal representation of men and women and by a power relationship which up to now has been in favour of men[4].

The question now is why should an adequate participation of women in health decision-making be important and whether they contribute in a new and valuable way in this field.

I would like to point out, first of all, that their participation in the decisional process is important not only for a principle of equity, but above all for the different way women have of confronting health problems: thanks to their specific professionalities, they have developed an approach to health problems which makes them particularly sensitive to prevention and better meets the needs of the population, and of women. As a matter of fact, our research underlined that women have on their agenda of health policies, different priorities from men. They seem to give more importance to prevention; health promotion; integration between social and health services; caring of the elderly and of chronic diseases. They pay more attention to problems related with the maternity-infant sector and to all areas concerning specific female problems: pregnancy, childbirth, caring of the new-born child, prevention of breast and womb cancer, menopause and osteoporosis[5]. In other words, while men seem to be more inclined to medicalisation, to resort to advanced technologies, to intervene on serious pathologies - heart attacks, brain surgery, etc. - which have more prestige in the medical hierarchy, women seem to have a wider view, seeking long term results, giving relevance also to low prestige areas.

Moreover, women have different ways of dealing with health problems and a different method of work from men: that is, in health services they resort to a method of work based on confrontation, on group or équipe work and on listening to patients and colleagues; they give great relevance to interpersonal relations both with patients and with colleagues. The result is a more effective health care due to a more global knowledge of health-care problems and a better way of communicating.

Compared to men, the style of leadership women resort to appear to be more co-operation and consensus oriented. They tend to recognise authority to all professions, to respect the different roles, to entertain clear, direct, but informal relations with colleagues and the people working under their direction. When conflicts occur in the decisional process, they take their time to discuss, to focus the main objective of the service, to reach collegiality. When conflicts occur between the different institutions they are able to start a tenacious work of mediation, connections building, and networking, without forgetting the main aim of the public service, and the general benefit. Of course, some women in top management positions have an authoritarian style of leadership, but this occurs more frequently if they are few; when there are more women in top positions it is more likely that they assume a more democratic approach to work and leadership.

To sum up, our researches have clearly shown that women bring with them new ideas, different priorities, different methods of work and a different style of leadership from men. They look for collaboration in the decisional process; because they believe that, when decisions are shared, they are also more effectively carried out, and result, in the end, in a more effective health care.

As an example of the innovative practices women bring in public health, I will briefly describe the method of work developed in the public Mental Health service of Naples by Elvira Reale and her group of health professionals. In their work practice they verified that traditional mental health services do not fit the needs of women, because they do not take into consideration their private lives and living conditions, therefore they decided to set up a new service, unique in Italy, addressed to women to prevent their mental illness: the Woman's Mental Health Prevention Centre, "Centro per la Prevenzione della Salute Mentale della Donna".

The main aim of this Centre is to increase self awareness in the woman seeking help; the working hypothesis is that the woman's suffering derives from an incorrect understanding of her personal interests (while assuming other people point of view) and from the over load of work and responsibilities she is charged of, without an adequate recognition of her fatigue as a result of this over load. The woman suffering from depression does not attribute her malaise to her life conditions, to the over load of work, but to herself. She adapts to requests made on her, gives up her personal point of view, looses all her energy, interests and drive for life; thus having given up satisfaction of her own needs, she has no longer any energy to satisfy those of others. In illness she expresses at the same time both the impossibility of being as she wishes (not adhering to her role) and the impossibility of being as she ought to be (adhering the her role). In order for the woman to understand the hidden meaning of the symptoms she needs to go over all the phases of her life and to uncover the concentration of requests which overburden her.

Elvira's group, therefore, has considered women's mental unease as a subjective perception, as changes in how she adapts to her role, rather than as hormonal changes in the various stages of her life as in the psychiatric tradition. As a consequence the methodology of work assumed starts out from a careful listening to the woman seeking help, and to the links between her unease and her life conditions. This is done with a woman to woman therapy, the group being made of only women professionals (psychologists, sociologists, physicians, nurses); two work instruments have been adopted: the register of daily life analysis and the register of illness perception. When talking to patients the groups adopts a language easily understandable to them and, overcoming the traditional asymmetric patient/therapist relationship, they try to make the woman protagonist of her recovery, of her acquiring self awareness and of a radical change in her life.

3. The status of the Italian research and the project at the Ministry of Equal Opportunities.

Let us come now to the last point: the new prospects of women's studies in health; this refers mainly to the work group formally constituted in September at the Italian Ministry of Equal Opportunities: the group "Objective 2001: for a health made to measure women's needs" (a women friendly health).

Before describing the aims of the group it is necessary to spend a few words on the inadequacy of health information and research in Italy.

- In our country are lacking health data systematically collected and distinguished by sex and results presented according to this distinction;

- there are no data on violence as a cause of women's ill health; often these data are hidden on the voice "domestic accident";

- in Italian health research there are no rules demanding to include gender difference in the population samples; this fact penalises women primarily with reference to the research on the causes and main risk factors of the pathologies prevalent on female population;

- in particular this is true for pharmaceutical research: there are no rules demanding samples of population divided by gender, separate data collection and processing, in spite of the evidence of gender differences in efficacy and in side effects of pharmaceutical products;

- there are no adequate inputs to make research on risk factor of the female population and on new frontiers for prevention in order to grant better life and health conditions for women.

The first task of our work group is to document and denounce all these deficiencies; the group - in which Elvira Reale and I take part - is made of 11 women from different medical, health and social professions who in their practice and research work have contributed to detect specific gender aspects of health. Take part to this group: 2 psychologists, a psychiatrist, an oncologist, a cardiologist, a gastroenterologist, an epidemiologist, a pharmacologist, en expert of labour medicine and 2 sociologist. The aims of the group are:

- to create a unified observation field over the main pathologies prevalent on women and over different areas of medicine;

- to point out the biases of research on women and the under-evaluation or over- evaluation in medical research of some factors influencing women's health;

- to work out guide lines of intervention for a women's friendly health in every field of medicine.

1 - The first problem is the lack of or inadequate consideration of gender difference. For instance, all biological differences have been reduced to the reproductive sphere without a global consideration of biological differences between sexes, and this is due to the ideological over evaluation of women's reproductive function. In fact it has been underlined that, man and his biology has been constantly taken as the sole reference point for clinical studies; this has favoured the exclusion of women from clinical studies in fields different from gynaecology (indeed, there are always few women in clinical trials). In fields such as cardiology, oncology, pharmacology, and labour medicine we find a clear homologation of the female body to the male one; moreover, the efficacy of diagnostic tests and of treatment is essentially measured on men.

This exclusion of the female body from medical observation causes several problems:

- with pharmacological experimentation in determining the dosage and the collateral effects in most medical fields and particularly with reference to cardiology and psychiatry;

- in the analysis of social risk factors because the reference model of work is the male productive model with the exclusion of plural work model of women in professional and family work.

The final aim of the group is to find out operative instruments to modify the actual medical practice and define technical-scientific guidelines to be experimented in some health unit and to propose for adoption by the National Health Service in order to reach a health system more women friendly, "made to fit women's needs".

This area of study - I believe - could constitute an important field of research, comparison and common action with EWHNET for the future; I think it is a very interesting and innovative field which is also apt to strengthen the action of women in health. If we want a women friendly health system we must be able to apply pressure on political and health institutions, make our presence felt in every country and institutions as health professionals, researchers and users of services; therefore we should build together a strong self-supporting network not only lasting the time of a contingent project, but to last and to widen its net with other groups and countries and in the end to increase our power, our ability to promote health for women and for all.

Fig. 1 - Distribution of the health systems of the EU Member States according to the model of coverage and the range of devolution of power to sub-national authorities

[1] Paola Vinay - Prospecta, “Gender, Power and Change in Health Institutions of the European Union” "Genre, Pouvoir et Changements dans le Secteur de la Santé dans l’Union Européenne” - Geschlecht, Macht und Veranderung in Institutionen des Gesundheitswesens der Europaischen Union”), in Employment & Social Affairs, Equal Opportunities and Family Policy, European Commission, 1997.

[2] In France, women are about 75% of psychologists, 85% of chief nurses and almost 100% of midwives, but 28% of general practitioners. In the United Kingdom, women constitute 89% of the non-medical staff; about 50% of paediatricians, but only 7% of surgeons (1994); the percentage of women surgeons in Ireland is only 3%.

[3] Other obstacles are a minor access to "informal networks" and to "“influential people” and their supposed lesser “aptitudes for management”. Other important obstacles depend on the difficulty of combining professional and family life. Where this is concerned a large number of women in top positions is “single” or “divorced” and has no children. On this matter there are significant differences among the European Member States: compared to the ones in the North, a much higher number of women in Centre and South of Europe who have reached top decisional roles are “single” or "separated" and without children: among the women of the South 47% (but only 9% of men) doesn’t live as a couple, double the number of those in the North; 39% has no children, while two thirds of the women in the North have at least two children.

[4] Beccalli B., “Comparable Works”, in Pari e Dispari, giugno 1994.

[5] Several surveys have shown a correlation between a wide representation of women at the political-administrative level and the development of social services, in particular those for children; moreover, they have shown that, wherever female problems are taken in consideration, there are women bringing them up in the political agenda. See: Eduards M., “Participation des femmes et changement politique: le cas de la Suède”, in Ephesia, La place des femmes. Les enjeux de l’identité et de l’égalité au regard des sciences sociales, Paris, 1996 and cited bibliography.