W O R L D H E A L T H O R G A N I Z A T I O N R E G I O N A L O F F I C E F O R E U R O P E
UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Telephone: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eugovernance@who.int Web: http://www.euro.who.int/en/who-we-are/governance
Regional Committee for Europe
70th session
Virtual session, 14−15 September 2020 11 August 2020
200589
Provisional agenda item 6 ORIGINAL: ENGLISH
Joint progress report on implementation of the Strategy on Women’s Health and Well-being in the WHO European Region and the Strategy on the Health and Well-being of
Men in the WHO European Region
This report provides an overview of the progress made in implementation of the Strategy on Women’s Health and Well-being in the WHO European Region and the Strategy on the Health and Well-being of Men in the WHO European Region.
It is submitted to the WHO Regional Committee for Europe at its 70th session in September 2020, in line with resolutions EUR/RC66/R8 and EUR/RC68/R4.
It is important to note that coronavirus disease (COVID-19) outbreak response operations have affected the preparation of this report. A Member State survey to gather information on the implementation of the two strategies has been postponed in order to scale down requirements on Member States, thereby allowing them to focus on the current crisis, as per the Standing Committee’s statement on the COVID-19 situation in Europe issued on 12 March 2020.The next report is due to be submitted to the Regional Committee for consideration at its 73rd session in 2023.
Background
1. The WHO Regional Committee for Europe adopted the Strategy on Women’s Health and Well-being in the WHO European Region at its 66th session in September 2016 (resolution EUR/RC66/R8), and the Strategy on the Health and Well-being of Men in the WHO European Region at its 68th session in September 2018 (resolution EUR/RC68/R4).
2. In resolution EUR/RC68/R4, the Regional Committee requested the WHO Regional Director for Europe to monitor progress and report to the Regional Committee, in an
integrated manner, on implementation of the recommendations contained in both strategies.
3. Together, the two strategies constitute a comprehensive framework for addressing gender and health in the European Region. This sets a firm foundation for stepping up WHO leadership on gender, equity and human rights, under the Thirteenth General Programme of Work, 2019–2023 (GPW 13), and the European Programme of Work, 2020–2025 – “United Action for Better Health in Europe”.
4. The common vision of the two strategies is to improve the health of women and men through evidence-informed, gender-responsive, rights-based and equity-driven approaches.
The strategies align with other guiding frameworks, such as the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs).
Evidence gathering
5. As stipulated in resolution EUR/RC68/R4, this progress report builds on the information already available from existing monitoring and accountability systems. The data used to monitor progress builds on WHO data and the review of voluntary national reviews under the SDGs, the Health 2020 monitoring framework, the Beijing Platform for Action +25 review (Beijing+25 review), the European Institute for Gender Equality indicators and reports, and the concluding observations of the United Nations human rights treaty bodies.
6. A survey to be conducted among Member States, which was intended to identify policy changes, gaps and innovative approaches to gender mainstreaming and was planned for distribution in February 2020, was postponed owing to the coronavirus disease (COVID-19) outbreak response operations. This survey will be conducted at a later stage and the report on its findings will be shared with Member States. Below, there are some highlights on the health of women and men in the region.
7. Although life expectancy in the WHO European Region continues to increase, differences between men and women persist. In 2016, life expectancies ranged from 74.8 years in males to 81.3 years in females. However, the 6.5 years’ difference is reduced to 4.4 years when looking at healthy life expectancy, which is 66.4 years for men and 70.8 years for women.
The gender gap is even smaller within the European Union (EU) where, on average, women live 5.4 more years than men; but only 0.4 of these are healthy life years.
8. There are also stark differences between women and men living in the western and the eastern part of the Region. For women, there is a 9-year difference in life expectancy between the 86.1 years in Spain and 77.1 years in Kazakhstan. And among men, the difference in life expectancy is greater, at 11.7 years higher in Iceland (81.2 years) than in the Republic of Moldova (69.5 years). This gap grows when looking at healthy life expectancy. In 2016, male healthy life expectancy was 13.7 years higher in Switzerland (72.4 years) than in
Turkmenistan (58.7 years). Female healthy life expectancy was 11.3 years higher in Spain (75.4 years) than in Turkmenistan (64.1 years).
9. Although the WHO European Region is on track to reach the SDG target on premature mortality from noncommunicable diseases (NCDs) by 2030, significant inequalities remain between men and women as well as between groups of men and women regarding NCD mortality, morbidity and risk factors. In 2016, the probability of dying prematurely between ages 30 and 69 years from four major NCDs was 11.3% for women and nearly twice as high, 21.3%, among men. However, since 2010, male premature mortality is reducing faster and the gap between males and females has reduced from 11.3 to 10.1 percentage points. Regarding risk factors, tobacco use is not reducing fast enough among females to achieve the global target of a 30% reduction by 2025 (1.4 percentage points reduction since 2010 for females, compared to 3.7 percentage points for males). Since 2010, alcohol consumption has reduced by more than 10% for both men and women (11.9% in men and 13.3% in women) due to a reduction in selected countries in the eastern part of the Region, but progress is absent in many countries in the western part. The WHO European Region remains the region with the highest alcohol consumption in the world, with levels being almost four times higher among men (16.0 litres of pure alcohol per capita) than among women (4.2 litres). The gender gap is higher in countries where, due to gender norms, there are high abstention rates among women.
None of the countries are on track to halt the rise in obesity. Although obesity levels were lower among men in 2016 (21.8% of men and 24.5% of women were obese), the increase since 2010 is nearly 50% higher among men (3 and 2 percentage points, respectively).
10. Gender differences in mental health persist and WHO estimates from 2018 show a higher prevalence of depression among women of all ages and in all WHO Regions. It also shows a higher rate of suicide among men and it highlights that men in the WHO European Region have the highest suicide rate in the world: 21.8 per 100 000 population, while the global average is 13.7 per 100 000.
11. In terms of COVID-19, early analysis of available data also shows differences between women and men. As of July 2020, 54% of COVID-19 cases were women, but men have higher rates of hospitalization and intensive-care admissions. Also, as of July 2020, 57% of COVID-19-related deaths in the European Region were men. Latest explanations of the higher infection rates among women and higher mortality rate among men combine biological differences with gendered behaviours and occupations.
12. It remains difficult to assess gender differences in access and use of health services, but Eurostat data on self-reported unmet health care needs in EU Member States show that women consistently report more unmet needs than men, but that these needs are increasingly being met for both. In 2016, 3.2% of women in the EU had unmet health care needs, while in men it was 2.3%. In 2018, fewer women and men (2.1% and 1.5%, respectively) reported unmet needs. There is a wide discrepancy of unmet health care needs between EU countries, ranging in 2018 between 0.1% and 17.8% for women and 0.1% and 14.5% for men.
13. The next sections follow the discussions held with experts in February 2019 to provide guidance on monitoring progress to reduce health inequities between men and women and the impact of gender inequality. It includes examples of WHO activities and cross-office
initiatives to support in-country implementation of the recommendations.
Progress and challenges across priority areas
14. Progress made to date by Member States and the WHO Regional Office for Europe in each of the priority areas under the two strategies is reported below.
Strengthening governance for the health and well-being of women and men
15. Health policies and strategies need to address the impact of gender on health from the perspectives of both efficiency and human rights. A gender analysis of sex-disaggregated data that can be linked with other demographic variables is a prerequisite for understanding both perspectives.
16. Reporting mechanisms and accountability frameworks such as the 2030 Agenda for Sustainable Development and the Beijing+25 review process show that significant progress has been made with respect to the collection, analysis and dissemination of sex-disaggregated data and gender statistics in the European Region. Nevertheless, progress remains uneven between countries.
17. While several European countries now have major national statistical surveys that provide disaggregation by sex, age, education and geographical location, challenges remain.
Although most indicators in the European Health for All database are disaggregated by sex, this is still not the case under the GPW 13 Impact Framework.
18. Representatives of academia and civil society have made a clear call to countries to report sex-disaggregated data during the COVID-19 response. A mapping of publicly
available data shows that, as of July 2020, 21 WHO European Member States (39.6%) report sex-disaggregated data on both number of cases and number of deaths, 20 countries (37.7%) report on at least one or the other, and 12 countries (22.6%) do not report sex-disaggregated data at all.
19. At the local level, the Healthy Cities Gender and Health Survey conducted by the Regional Office, covering 40 cities in 21 Member States, showed good overall availability of disaggregated data with 70% of cities reporting sex-disaggregated data on health and 60%
presenting data with further levels of disaggregation, such as age, location and socioeconomic status. Important data for gender-responsive health policies and programmes, such as data on child care and parental leave, unemployment, sexuality, education and violence against women, were also provided (by some countries). The use of data across sectors at a national level remains a challenge for gender-responsive health policy and programmes. Concerted efforts to use data, such as in the State of Men’s Health in Leeds and the State of Women’s Health in Leeds reports, by Leeds Beckett University, have driven attention and funding to the high risk of suicide among men.
20. A Regional Office desk review of the extent to which national health policy and strategy documents address women’s and men’s health differences and integrate gender-responsive approaches has shown a variety of approaches. Sex-disaggregated data are presented in most of the policies (42 policies) in connection with main disease burden, exposure to risk factors, and/or health outcomes, although only seven policies present a gender analysis of this data, and 14 provide some kind of gender-responsive health action. The word “gender” is
mentioned in 36 policies but the concept of “gender mainstreaming” appears only in six health policies (Cyprus, Czechia, Finland, Germany, North Macedonia and San Marino). Only
four national health policies (Azerbaijan, Sweden, Tajikistan, the United Kingdom of Great Britain and Northern Ireland) promote actions considering women’s and men’s specific needs and, at the same time, address the causes of gender-based health inequities. Gender equality commitments are made in the national health policy of Turkey, while in Azerbaijan’s policy, gender is mentioned as a determinant of risk factors for NCDs. In some countries, specific gender inequalities are identified, such as gender-based violence in the Republic of Moldova, and in others the focus is predominantly on sexual and reproductive health. Only in a small number of cases is gender mentioned as a determinant of men’s health, for example in
Tajikistan, in the context of access to services. Austria and Ireland are the only countries with specific men’s and women’s health action plans although the Austrian process to develop the men’s health strategy based on the WHO strategy has been postponed due to COVID-19 priorities.
21. As many European health policies have an end date of 2020, there is an important opportunity to strengthen the integration of gender in the next phase of European health policy-making, adapting it to national and subnational contexts. WHO is preparing policy guidance based on the gender component of the interview guide for health planning tested with the WHO Barcelona Office for Health Systems Strengthening.
22. Gender-responsive budgeting in south-eastern European countries offers good
experience that could be used by the health sector. Almost half of all member countries of the Organisation for Economic Co-operation and Development have undertaken gender-
responsive budgeting training.
23. WHO has partnered with civil society to raise awareness and use the strategies as the basis for advocacy work. Global Action on Men’s Health has disseminated information via social media, in reports and other publications, and held a webinar specifically on the strategy in September 2019. The Danish Men’s Health Forum made the WHO strategy a central part of its activities for Men’s Health Week in June 2019 with WHO participation. The European Institute of Women’s Health built the European Action Plan for Women’s Health on the WHO strategy.
Making gender equality a priority for women’s and men’s health
24. Although considerable advances have been made, gender equality has not been fully achieved in any Member State in the European Region. In fact, in many countries, progress over the past decade has been slow.
25. The Beijing+25 review includes reports from 49 Member States in the Region on progress made for women and girls over the past five years (2015–2019) and on priorities until 2025. The WHO Secretariat analysed all national reviews from a health perspective and submitted a report to the Beijing+25 Regional Review Meeting, which was organized by the United Nations Economic Commission for Europe on 29–30 October 2019. The analysis showed that few connections are made between gender equality goals and health outcomes, and that sexual and reproductive health and rights are now less frequently prioritized than they were previously.
26. The analysis was also based on the policy brief on health and SDG 5 prepared by the Regional Office in 2018 to strengthen coherence between policies on health and on gender equality. At the time, 34 Member States in the European Region had national gender equality strategies and only 24 included a health focus. It is worth noting that benefits of gender
equality for men’s health are invisible in these policies and references to men are often limited to their engagement in preventing gender-based violence and improving sexual and
reproductive health.
27. It is also relevant that only one strategy mentions collaboration with the health sector agencies in those countries with an institutional mechanism to coordinate the intersectoral implementation of their gender equality strategy. Moreover, the Beijing+25 review concludes that in European countries, gender equality machineries are often weak and underfunded.
28. Gender equality continues to be addressed under human rights frameworks. As part of the 2017 joint framework for collaboration between WHO and the Office of the United Nations High Commissioner for Human Rights, the Secretariat of the Regional Office is producing European country profiles on gender equality and health, based on the concluding observations of international human rights treaty bodies, with a view to supporting
governments in advancing progress. A review of all recommendations issued by the Committee on the Elimination of Discrimination against Women to European countries highlights the need to: adopt a national gender equality action plan with a strong intersectoral mandate and ensuring the necessary human, technical and financial resources; intensify intersectoral efforts to eliminate violence against women, including ratifying the Council of Europe Istanbul Convention; and repeal discriminatory provisions governing access to safe abortion, marriage and divorce.
29. Few gender equality strategies include actions that engage men in achieving gender equality. The Secretariat has initiated a process for noting innovative practices at the
subnational level, such as the Redefining masculinity programme from the Swedish Association of Local Authorities and Regions, which addresses matters relating to the sexual and mental health of young men, and the Gizonduz Initiative led by the Emakunde, the Basque Institute for Women, which provides free gender equality training for workers in key public institutions and community associations, and for political representatives.
30. Estimates from the Region show that one in four women have experienced intimate partner violence at least once in their lifetime. National estimates for all countries will soon be published under the GPW 13 Impact Framework. A baseline assessment of how violence against women is addressed in national health systems in the Region, which was published in 2019, concluded that nearly 83% of the surveyed countries addressed violence against women in health policies and strategies, and 71% had developed protocols for their health system response. Significant room for improvement remains, however, with regard to the allocation of human and financial resources, and better integration of the health system response into national multisectoral plans, with regard to violence against women.
31. The Secretariat is intensifying partnerships to support countries in strengthening their health systems’ response to violence against women, through joint action with other United Nations agencies, including the Spotlight Initiative in Kyrgyzstan and Tajikistan.
A memorandum of understanding was recently signed between WHO and the Union for the Mediterranean on women’s health priorities and a cross-regional initiative has been set up between the Regional Office for Europe and the Regional Office for the Eastern
Mediterranean. A Health Evidence Network synthesis report on what health systems can do to prevent and respond to human trafficking will be launched later in 2020.
32. At the EU level, it is important to highlight the European Commission’s new Gender Equality Strategy 2020–2025 launched in March 2020 with WHO’s contributions on health perspectives.
Making health systems gender responsive
33. Health systems can improve universal health coverage by better integrating gender and human rights perspectives into health care throughout the life course.
34. WHO’s support focuses on gender analysis of NCD risk factor surveys such as the WHO STEPwise approach to surveillance (STEPS), Childhood Obesity Surveillance Initiative (COSI); Health Behaviour in School-aged Children (HBSC), Global Adult Tobacco Survey (GATS) and Global Youth Tobacco Survey (GYTS). Men’s higher exposure to behavioural risk factors, the increased vulnerability and biological risk among women in later life and the prevalence of tobacco use in women (highest of all WHO Regions) are some of the priorities.
Country support activities have prioritized those countries with less capacity on gender and NCDs analysis.
35. Gender was integrated into the country assessments on the health systems barriers to NCD responses in Kazakhstan (2018) and Turkmenistan (2019). The gender perspective was also addressed in the 2018 good practice briefs on men and cardiovascular diseases from Ireland and Uzbekistan, and highlighted in the high-level regional meeting, Health Systems Respond to NCDs: Experience in the European Region, which was held in Sitges, Spain, on 16–18 April 2018.
36. The policy brief, Why using a gender approach can accelerate noncommunicable disease prevention and control in the WHO European Region, prepared for the WHO
European High-level Conference on Noncommunicable Diseases, which took place on 9–10 April 2019 in Turkmenistan, sparked initiatives in several countries. Armenia, Belarus, Georgia, Kyrgyzstan, the Republic of Moldova and Turkey have developed gender and NCD country profiles based on data collected through STEPS. National focal points discussed the results in Copenhagen, Denmark, in November 2019 and in Tbilisi, Georgia, in January 2020.
The preliminary findings were presented in March in a webinar organized by the George Institute for Global Health in collaboration with the WHO Global Coordination Mechanism on the Prevention and Control of Noncommunicable Diseases. Gender analysis of GYTS and GATS was done for Romania and is planned for three other countries.
37. Specific support for capacity-building was provided to countries including Kyrgyzstan, through a capacity-building workshop on gender for teams preparing the HBSC survey, and a session on men and cardiovascular disease during the Annual Congress of the Kyrgyz Society of Cardiology, held in June 2019. A workshop on gender and physical activity was held during the Asian Games 2017: Sports, Nutrition and Physical Activity – Promoting a Healthy Lifestyle conference, which took place on 6 April 2017 in Turkmenistan, and a training session on gender and NCDs was held during the International Conference on
Noncommunicable Diseases: lessons learned from international experience, held in Kyiv, Ukraine, in October 2018.
38. In strengthening primary health care services, the Regional Office has provided gender and rights guidance for sexual and reproductive health country assessments and reports, for example in 2019 in Romania, during the preparation of its new strategy on sexual and reproductive health. Disseminating good practices, such as the Irish national men’s health training programme ENGAGE and work on gender and cardiovascular diseases from Spain, shows how a gender-focused approach enables primary health care practitioners to engage more effectively with men and how to address gender in cardiovascular disease outcomes.
39. Given the importance of considering the health of older persons both from demographic and gender perspectives, the Regional Office launched an initiative on gender and integrated long-term care at the end of 2018. A conceptual framework and a policy brief on gender and long-term care services is being prepared with input from the WHO Collaborating Centre on Social Welfare Policy and Research, based in Austria, and gender has been mainstreamed in country case studies on integrated long-term care in Denmark, Germany, Portugal and Romania.
40. Access to mental health services is a priority; the Regional Office is publishing a Health Evidence Network report on men, masculinities and mental health help-seeking behaviour. A webinar to present the preliminary findings of the report was held in April 2019.
41. Gender transformative health promotion will be addressed under the WHO European roadmap for implementation of health literacy initiatives through the life course, which was discussed and noted by the Regional Committee at its 69th session in resolution
EUR/RC69/R9. Initiatives in this regard at the subnational level include a capacity-building workshop, held at the Youth Health Summit organized by Public Health Wales in December 2019.
42. The importance of applying gender-focused approaches to digital health is recognized in the WHO European Programme of Work and the WHO European roadmap for the
digitalization of national health systems. WHO’s participation in the fifth Men’s Health Conference dedicated to the health and well-being of men in the digital area, organized by the German Federal Centre for Health Education, highlighted the importance of bringing gender and digitalization together for health.
43. The WHO report, Delivered by women, led by men: a gender and equity analysis of the global health and social workforce,1 raised awareness of the barriers female health workers still face in achieving leadership positions. As of March 2020, only 19% of health ministers in the European Region are women (down from 34% in 2019). The need to pay attention to women’s roles, rights and conditions as frontline workers during the COVID-19 pandemic has been highlighted by civil society and international organizations.
Tackling the impact of gender and social, economic, cultural and environmental determinants on women’s and men’s health and well- being
44. The WHO European Health Equity Status Report Initiative, launched in 2019, provided further evidence on how gender-based health inequities combined with age, disability,
migrant background, ethnicity, sexual orientation, gender identity or socioeconomic background have different impacts on women and men.
45. The Beijing+25 review shows persistent gender differences in labour market
participation, pay and pensions. The European Foundation for the Improvement of Living and Working Conditions has noted that reductions in the gender employment gap in the EU stagnated between 2015 and 2018, and that there are indications that it may be starting to grow again. Valuing and recognizing unpaid care work remains a challenge and addressing the gender imbalance in the sharing of unpaid work and caring responsibilities remains a priority, as recognized in the SDG target 5.4. Policy change incentives, such the Directive
1 See: https://www.who.int/hrh/resources/health-observer24/en/.
(EU) 2019/1158 of the European Parliament and of the Council of 20 June 2019 on work-life balance for parents and carers, are an important step forward in improving the gender care balance and supporting men’s role as fathers and carers.
46. The impact of environmental determinants of health was raised during the United Nations Climate Change Conference COP25 in December 2019, where a workshop organized by the Ministry of Health of Spain with the participation of the Regional Office focused on tackling gender inequalities in health and climate change. The five-year Gender Action Plan adopted at COP25 presents an opportunity to address the health impacts of gender-just climate solutions.
47. There is increased recognition that gender intersects with other forms of discrimination such as migration status, ethnicity, and sexual orientation and gender identity. The Report on the health of refugees and migrants in the WHO European Region, published in 2018,
recognizes gender as an important determinant of migrants’ and refugees’ health; although not widely available, sex-disaggregated data highlight important differences in vaccination rates, diabetes and risk factors relating to NCDs, among others. An EU-wide survey from 2019 conducted by the European Union Agency for Fundamental Rights confirms that 9% to 12%
of lesbian, gay, bisexual, transgender, queer and intersex people have experienced
discrimination by health and social services. The higher COVID-19 death rate reported among BAME (Black, Asian and Minority Ethnic groups) men in the UK is another example of the need to understand and address multiple vulnerabilities.
Future perspectives
48. In the coming years, in collaboration with and under the guidance of Member States, the Regional Office will refocus its work under the two strategies to support countries in implementing the European Programme of Work, 2020–2025 – “United Action for Better Health in Europe”.
49. Future perspectives will build on the lessons learned from the impact on gender and human rights of COVID-19 outbreak response operations, strengthen the gender focus of digital health systems and promote gender-responsive health with a focus on mental health and youth engagement.
50. Focus will remain on supporting countries, regions and cities in developing gender- responsive NCD prevention and control initiatives, as well as on gender equality action for strengthening health systems to address violence against women and ensuring access to sexual and reproductive health and rights.
51. The strategies have triggered mainstreaming gender initiatives across technical programmes that need to be further developed, such as the advocacy brief on gender and antimicrobial resistance published in 2019.
52. The analysis of policy documents is being complemented by a review of good practices that will be presented in the 2023 report.
53. Current partnerships under the United Nations Issue-based Coalition on Gender Equality and with the European Institute for Gender Equality will be strengthened.
54. Finally, engagement with civil society will continue to be at the centre of the Regional Office’s work on gender and health.
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