WOMEN'S HEALTH
Maja Korzeniewska, Urszula Nowakowska
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WOMEN'S HEALTH
Maja Korzeniewska, Urszula Nowakowska
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INTRODUCTION
Compared to citizens of Western Europe, Polish people suffer from poorer health and lower
life expectancy. According to a publication issued by the Central
Statistical Office (GUS), entitled Longevity and Causes of
Dying in 1996, the life span for women is 76.5 years and 68.12
for men. Women live slightly longer in rural areas (76.85) than
women living in the cities (76.39). For men, the situation is
the reverse: in the cities, men live longer (68.35 years) than
in rural areas (67.75). In addition, citizens in northeast Poland
live longer than those residing in other parts of the country.
Compared to the Western world, the life span in Poland is five
to eight years shorter.
Particularly alarming
is the increase in the prevalence of cancer and cardiological
diseases in women. This same increase was not found in men.
The need for better health care for women is growing, especially
for the treatment of illnesses that are particular to women, such
as gynecological diseases, sterility, and menopause. Unfortunately,
the level of assistance is very low, especially in small towns
and villages. The percentage of handicapped people is also increasing.
In 1996, handicapped people represented 13.3%. According to
GUS's analysis of economic activity conducted in November 1997,
every third family has a handicapped member. The percentage of
handicapped women and is almost equal to that of men. However,
because women are the caretakers of handicapped men and children,
the prevalence of this condition decreases the percentage of women
in the work force.
Poland's existing system
of medical care is insufficient for its citizens' needs. Those
who receive care in Poland, especially from public medical assistance,
usually give the system a poor evaluation. Although Poland's
financial and personal infrastructure (the number of beds and
doctors in a hospital for 100,000 citizens) does not lag too far
behind selected Western European nations, the effectiveness and
quality of its medical care are very low. The newly introduced
reform of the health care system has failed to improve the situation.
Not only is the price
of health care extremely high in the private sector, patients
must also pay for services, formally and informally, in the public
sector. Many encounter problems when attempting to enter a hospital
of their choice, and must stand in long queues to receive services.
This system causes serious barriers to those who cannot afford
medical assistance. According to GUS (The Living Conditions
in Poland in 1997: An Introductory Analysis of the Data, GUS,
the Signal Information 2/98, Warsaw, March 1998), about
24% of Polish families refuse to visit the doctor, receive medical
services, or undergo rehabilitation, because they cannot afford
these services. Also, 30% of families refuse dental assistance
and 28% refuse to purchase prescribed medicines because of their
financial situations. In Poland, medical statistics do not include
information on preventative measures taken by women. However,
the available data reveals that preventative measures are not
a government objective and the percentage of women undertaking
these measures is very low. Because women live longer than men,
they suffer more health problems that may require medical assistance;
however, because they earn a lower income, it is more difficult
for women to receive this aid.
In Western nations, women's
health problems are an important concern for the government.
The Polish government offers a declaration about the subject,
but no specific agenda. The government, while preparing health
reform, fails to take into consideration the fact that women's
health is influenced by their economic situation, their dependence
on men, their low earnings (as compared to men), domestic violence,
and the limitation of birth control. In addition, international
standards in women's health are not considered in governmental
policy or in daily medical practices. In practice, women's rights
to dignity, to privacy, and to form decisions connected to their
health, are very often infringed.
Legal Guarantees to
Protect Health
The Polish Constitution,
enacted on 2 April 1997, guarantees the right to protect one's
health:
This article omits provisions
regarding equal access to medical assistance for women and men.
However, in the light of the general law establishing the rights
of equality, the constitution undoubtedly prevents discriminatory
practice in this field. Constitutional provisions not only grant
formal guarantees, but also obligate public authorities to ensure
every person equal access to health care, paid for by public funds.
Special attention should be given to children, pregnant women,
the handicapped, and the elderly.
Poland ratified numerous
international conventions, including the UN International Covenant
of Economic, Social, and Cultural Rights and the European Social
Charter. Poland is also a signatory to many other international
documents relating to the protection of health, including the
Final Document from United Nations conference in Cairo, which
focuses special attention on reproductive health and specific
women illnesses.
The Final Document from
the Cairo conference provides that the states-signatories shall:
cancer; and
contraception. Poland has assented to the rights guaranteed by these international documents. Every person has the right to be as mentally and physically fit as possible.
The realization of constitutional
health protection guarantees is dependent on statutory guarantees.
In this respect, the access and quality of medical services are
of particular importance. The government regulated the conditions
and range of medical services in the Law of 6 February 1997, which
addressed government-provided general health insurance (Official
Journal, 26 March 1997).
According to this Law,
health insurance should be universal, necessary, obligatory, and
based on the rules of social solidarity. It guarantees equal
access to services and the right to choose a doctor or Health
Maintenance Agency (Kasa Chorych). Article 8 of the Law provides
the following groups, now absorbed into the social insurance system,
have the duty to be insured: 1) farmers; 2) those working under
employment contracts; 3) those working under assignment contracts
for a period not shorter than fourteen days; 4) employees on paid
leave; 5) those unemployed and searching for a job or undergoing
training; 6) those on retirement; 7) students and citizens on
welfare; 8) workers preparing to retire, 9) those on disability
pension; and 10) women on maternity leave. Citizens may also
apply for voluntary insurance.
Article 31 of the statute
specifies the services that health insurance provides. Citizens
have the right to receive medical assistance to: 1. maintain good health and prevent illness or injury, 2. detect illness quickly in its initial stages, 3. treat existing illnesses, and
4. prevent or delimit
handicaps.
To realize these rights,
the Health Maintenance Agency (Kasa Chorych) assures the following:
1. medical advice and check-ups; 2. diagnostic examinations; 3. medical treatment (ambulatory service, house calls, hospitalization, medical advice); 4. medical rehabilitation; 5. nursing assistance; 6. prenatal, perinatal and postnatal care for mother and child; 7. preventive care; 8. accessible medication and medical supplies; 9. accessible orthopedic material and support; 10. written accurate diagnosis; and
11. palliative hospital
care.
Another important guarantee
of the right to health care is the Law on Health Management Bureaus
of 30 August 1991, (Official Journal No 91. 91. 408, with later
changes). This statute mandates preventative care: it calls for
medical advice to not only regain one's health, but also to prevent
illnesses (Art. 3). The Law differs from the social health insurance
policy and includes psychological therapy, the care of healthy
children, opinions about health, and dental care in its medical
services.
This statute obligates
public institutions of medical care to grant medical services
paid by public funds to those insured, as well as to others who
are allowed full or partial benefits. If lack of local services
forces a person to seek medical assistance further than sixty
kilometers from his or her domicile, the person has the right
to be compensated for travel (Art. 33.2). This right, however,
is not well known and thus, not utilized. The law also allows
the insured to be charged for some medical services, specified
in additional statutes. The prices of such services are to be
decided by the Ministry of Health; however, the Minister has yet
to determine fees. In practice, the directors of medical institutions
who also determine the prices for medical services rendered to
those who are not insured decide the fees.
Reform of the Health
Insurance System and the Right to Protect Health
Poland's reformed health
care system was established on 1 January 1999. According to the
government, its main goal was to provide more accessible medical
care by restructuring the health care system, improving the conditions
in which patients are treated, reorganizing medical institutions
and their managerial systems, and changing the economic status
and financing system of health care. The government promised
that the reform would place highest priority on the patient. The
medical system's finances and the salaries of practitioners would
depend on the quality of the service and amount of medical treatment
provided by the hospital. Moreover, the reform was to allow every
person the right to choose a doctor, family doctor, specialist,
outpatient clinic, hospital, or Health Maintenance Agency (Kasa
Chorych), as well as the right to withdraw if he or she disapproves
of the service.
Despite the reform's lofty
goals, in practice, the new system evoked many complaints, by
medical practitioners and patients alike. Although the reform
created a mechanism to obligate medical institutions to control
their finances, this change caused more problems than it solved.
The so called first contact doctors, on whom the reform
centered in order to end unnecessary visits to specialists, are,
in fact, seen as a barrier for those in need of specialist. The
doctors are supposed to spend as little money as possible. Because
every visit to a specialist costs a significant amount of money,
doctors limit their patients' referrals to specialists. As a
result, specialists lack clients and their medical equipment remains
unused. Previously, queues existed for these services. Theoretically,
the system was reformed for economic reasons, yet the change may
increase the number of serious illnesses that require expensive
treatment. Access to the first contact doctors is sometimes very
difficult. Occasionally, patients must wait for several weeks
to get an appointment. This often results in delayed diagnosis
and treatment. Moreover, preventive measures, which already were
of poor quality, have worsened. Financial limits threaten to
cause difficulties in getting medical help. In the new system, money is granted for a patient's hospitalization, rather than for treatment, limiting the amount of funding for actual treatment. For example, in the Olsztyn Provincial Hospital's orthopedic ward, out of ninety-nine treated, the cost for forty-four exceeded the expenditure limit. In its laryngological ward, thirty-two out of fifty-six patients exceeded the limit. Olsztyn Hospital Director, Andrzej Kaczmarek claims that Warmiñsko-Mazurska Health Maintenance Agency (Kasa Chorych) gives the hospital less money than needed to provide medical assistance to every patient. Moreover, resources are wasted because the range of refunded medicines is too restricted, causing hospitals to provide cheaper but ineffective alternatives.
No clear treatment standards exist
to repair the system of appraisal used to decide which medicines
should be refunded. The lack of such standards and calculations
from the amount of patients, rather than the results of treatment
may be conducive to abusing the health care system and make it
less effective.
After Kujawsko-Pomorska
Health Maintenance Agency (Kasa Chorych) enforced the new policy,
medical advice and treatment increased by 150-200% in some hospitals.
Mr. Krzysztof Tadrzak, the Director of Kujawsko-Pomorska Health
Maintenance Agency, argues that this number of patients was artificially
increased. For example, some patients who had no clear reason
for staying in the hospital (such as patients with broken limbs
who do not require bed rest) remained in the hospital for two
days. The regional Health Maintenance Agency from
Ma³opolska (Ma³opolska Kasa Chorych) received a list
of patients from one of the District Health Management Bureaus
in Kraków that repeated the names of a few hundred patients
two or three times. The Agency's director believes that these
cases are frequent.
Theoretically, the reform
granted everyone the right to choose his or her outpatient clinic
and doctor. However, in practice, regionalization in Poland prevents
citizens from choosing a doctor. This barrier is especially inconvenient
for women who would like to choose their gynecologist (information
provided by the Federation for Women and Family Planning).
In order to suppress regionalization,
a publication was created to acknowledge the most efficient hospitals
to create public awareness and encourage improvement in the medical
system. Reformers assumed inefficient hospitals would be forced
to close (as in Russia, Slovakia, and the Czech Republic). The
insurance companies (Kasa Chorych), however, decided to limit
the number of patients for each hospital, thus preventing the possibility for a more efficient
hospital to gain additional income. For example, the hospital
in Olsztyn (Olsztyñski Szpital Wojewódzki) wanted
to receive fifteen thousand patients, but the local Health Maintenance
Agency limited
their number to 11, 800, causing some doctors and the medical
equipment not to be utilized. In addition, the cost for one patient
is increased, causing hospitals to fall into debt.
Health Maintenance Agencies
(Kasy Chorych) argue that they do not receive the amount allocated
in the 1999 budget.
Ms. Kamiñska, the president of the Department of the Supervision
of Health Insurance, claims that in the first three months of
the year, the company received 812 million zlotys less then what
was provided in the budget. The money provided by the Health
Maintenance Agencies (Kasy Chorych) is insufficient to finance
the expenses of the Health Management Bureaus (ZOZ). Thus, some
of the ZOZ Departments had to take out credit for their expenditures.
However, it is uncertain if these difficulties stem from limited
funds or mismanagement.
Another problem is the increased dismissal
of nurses and technical staff, a practice that disproportionately
affects women. The Main Council of Nurses and Midwives (Naczelna
Rada Pielêgniarek and Po³o¿nych) expects that
hospitals will dismiss 50,000 people. No clear criteria or guidelines
for nursing care exist, such as the number of patients
each nurse should be assigned. Today, one nurse is responsible
for 179 patients, an amount unacceptable by international standards.
New reforms are aimed at defining nurses' responsibilities and
rights. However, these plans have yet to be implemented. For
the time being, the government ignores the nurses' protests and
postulates. Until the end of May 1999, no dialogue existed between
the government and nurses, despite the nurses' hunger strikes
and other protests. When talks were finally held, they brought
practically no results. When men initiate institutional strikes,
the government usually undergoes negotiations and it is possible
to negotiate larger salaries and dismissal compensation.
Even in the eyes of the
Ministry of Health and Social Policy, the new reform is far from
perfect. According to the Ministry's analysis on 25 May 1999
to assess the realization of the reform's main goals, the most
dangerous phenomenon is that the collection of money for health
insurance is not performed correctly. In the first three months
of 1999, 12.5% of the collection was not received by the Health
Maintenance Agency. The Ministry agrees that patients face several
problems when trying to visit the co called first-contact doctor
to receive a recommendation to visit a specialist. However, the
Ministry claims that the problems are not connected to reform,
but to the incompetent work of administrative and medical staff.
A danger also exists for district hospitals because patients
have the right to choose their hospitals. They choose the larger
clinics, causing the smaller hospitals to become bankrupt. The
Ministry agrees that there is a need to multiply the number of
specialized procedures financed from government funds, as well
as to develop the list of chronic illness.
The Ministry is preparing to initiate
a project on the privatization of health care services and to
update the health insurance statute. However, the Ministry has
frowned upon the introduction of equality between adults, children,
and youth. As a result, the quality of medical treatment at schools
and childcare institutions has declined. As money for preventative
care is lacking, fewer nurses are hired to work in these establishments.
By the decision of the Government Plenipotentiary for Enacting
Health Insurance, until a new law is written to change the situation,
the practitioners should refer to the law previous to one equalizing
the rights between adults and minors.
Shortcomings in the functioning
of public health institutions combined with the incomplete and
slow reform may cause difficulty in the realization of the patient's
right to protect his or her health. Many people have no possibility
to get free medical aid. No analyses have been completed, but
women seem to face greater difficulty in receiving medical assistance
than men receive. Women constitute the majority of the unemployed
deprived of the right to unemployment benefits. They often accept
unfavorable terms of employment including low salaries and thus,
cannot afford to buy private health insurance. This problem is
common for young women who often disregard health insurance to
increase their net income.
Pharmaceutical Marketing
- A Threat to Women
The financial situation
of the Health Management Bureaus (ZOZ) causes doctors to be concerned
more with finances than therapy. Another danger is connected
with the marketing activities of pharmaceutical companies, especially
from the West because these companies have generous promotional
budgets. The sales representatives of these companies often operate
at the margins of the law, using all kinds of baits to encourage
doctors to prescribe their products.
The prices of medicines
have increased dramatically and subsidies for a patient's medication
are now limited. Thus, as doctors often prescribe the more expensive
medicine, patients frequently decide not to purchase the medication
and end their treatment. The Ministry of Health has prepared the
catalogue of diseases, diagnostic pharmaceuticals and appropriate
medicines, which, if prescribed, can be purchased free or at a
reduced price. The catalogue omits approximately 200 diseases;
it does not include, among others, sclerosis multiplex, liver
inflammation, cirrhosis and some forms of cancer. It only includes
31 specialized treatment procedures. According to the ministry,
that is all Poland can afford. Those mostly life-saving procedures
were selected on the basis of morbidity rates and the cost and
effectiveness of treatment. The catalogue of refunded medicines
and treatment procedures has been strongly criticized by both
doctors and patients. It restricts equal access to free health
care, particularly for those who suffer from less common diseases
or do not respond to commonly applied medicines. Moreover, the
catalogue does not include modern drugs used in the treatment
of glaucoma, calcium preparations for the treatment of osteoporosis
and some important medicines used in the treatment of rheumatism.
Inappropriate treatment of glaucoma may result in total blindness,
while arthritis (most common rheumatic disease) may cause full
immovability of joints. All these diseases are particularly common
among women. Ministerial policy towards serious chronic diseases
seriously limits the access of less wealthy patients to health
care. The Polish Ombudsman claims (in the Information by the Ombudsman
for the period 1 January - 31 December 1998) that this situation
has destroyed the social right to equal access to health care
financed by public money. In the cases of children, pregnant
women, the handicapped and elderly, it is also contradictory to
the constitutional duty of public authorities to ensure special
medical care (art. 68, 2.3 of the Polish Constitution). It also
contradicts the patient's right to receive medical advice and
causes many problems for the poorest segment of society by preventing
them from joining special programs to promote health (Art. 19
1.1, regarding the Law on Health Management Bureaus of 30 August
1991 - Official Journal No 91.408, with later changes).
Patients' rights
Patients' rights are not
discussed in a single document, but are described in a number
of acts, making a rights dialogue difficult. Patients' rights
are set forth, among others, in the Health Management Bureaus
(ZOZ) Act of 30 August 1991 (Official Journal 91.91.408 with later
changes). It ensures the following rights:
4. the right to privacy and dignity while under treatment;
5. the right to die calmly
and with dignity. In the hospital or in clinic, patients needing twenty-four hour or a full day medical assistance have the right to: 1. additional care by that not connected with the hospital; 2. personal, phone, or written contact with others outside the hospital; and
3. religious services.
The patients also have
the guaranteed right to read all medical documents about their
condition (Art. 18). If their rights are infringed, they have
the right to receive financial compensation for the wrong.
A large number of patients'
rights are not publicly known, preventing citizens from taking
advantage of them or doctors and nurses from complying with them.
No one is responsible for informing patients about their rights.
Although in 1992, the World Health Organization (WHO) took the
initiative to create the position in the office of Ombudsman,
no spokesperson for patients' rights exists in Poland. It is a
paradox that every institution agreed that such a position be
created, but only one took the initiative to do so.
According to the Federation
of Women and Family Planning and other women's organizations,
there is a problem of gynecologists often imposing their own moral
values on their patients. They refuse to advice women on contraceptive
pills or they make judgments about whether a woman is too young
to be having sex. Women's rights are infringed in their discussions
with their doctors about such an important and delicate part of
their lives. In the maternity wards, women are treated as objects
and both doctors and nurses ignore their concerns and opinions.
The medical care of
pregnant women and women giving birth
All pregnant women have
the right to receive periodic check ups and medical care. Many
women, though, especially from villages, do not have access to
this care and often never consult with a doctor. This lack of
medical care corresponds to low education levels and lack of knowledge
of birth control or prenatal care.
The quality of medical
care for women and children can be measured by the infant mortality
rate, the number of stillborn children and the rate of children
delivered with low birth weight. Although this percentage is
decreasing, it is still very high compared to Western Europe.
The infant mortality rate in 1996 was 12.2 (out of
every 1000 live deliveries), which is twice as large than in most
Western countries. The highest percentage was in regions with
a highly polluted environment (Katowice, Wroc³aw and Jelenia
Góra regions). The percentage of children delivered with
a low birth weight
is also very high in Poland. In 1996, it grew to 6.9% (7.3% in
the cities).
In Poland, there is still
a large percentage of complicated pregnancies and deliveries (12%
of hospitalizations in public hospitals). The perinatal mortality
rate is 13.6 (out of 1000), which is higher in cities (14) than
in the villages (13.7). In some regions of Poland, this percentage
is much higher than the mean (the Jelenia Góra district
has 18.6, while the Opole district 16.3).
Even though Polish law
and the Constitution (Articles 18 and 68.3) expressly protect
pregnant women, those giving birth fail to receive the proper
medical care, especially in villages. Frequent infringement of
women's rights occurs in maternity wards. Women are told which
position the babies should be delivered. They are not informed
of the state of delivery, they have no privacy, and they receive
no help in caring for or nursing the child. In addition, a woman
must pay a fee if her husband joins her in the delivery room (150
zlotys to 500 zlotys) and for anesthetics, because the price is
not refunded. These common practices infringe upon the
right to dignity, information, privacy, and the right to best
possible medical care (Art. 19, 1.4, of the Law on Medical Institutions
of 20 June 1997), creating painful situations for women. Although
the campaign launched by the largest Polish daily, Gazeta Wyborcza,
"To Deliver with Dignity" caused medical staff to become
more empathetic with the subjects, the situation still needs much
improvement.
The health of Polish women
is poorer than women in Western countries. Because of the inaccessibility
of data, only a few illnesses that women fall victim to, such
as venereal diseases, breast cancer, hypertension, heart disease,
and diabetes, can be analyzed. Most of the data does not differentiate
between the sexes or the patient's demographics (village or city).
A representative study
conducted in 1996 by the Central Statistical Office (GUS), in
cooperation with the National Fund for the Rehabilitation of the
Disabled, of how Polish people evaluate their own health showed
that more women than men assess their health as poor. More than
50% of adults assessed their health as "less than good."
These responses were more common in rural areas (57,8%) than
in urban areas (54,3%). The results of this study are an important
indicator of the state of the health of the population of Poland.
Table 1. Health self-evaluation by sex and age in the population aged 15 and more, in 1996
Health evaluation is closely
related to the incidence of chronic diseases. In the adult population
only 32% of women and 44,5% of men do not suffer from any chronic
disease. Morbidity of chronic diseases is closely related to age.
People from the youngest group (15 - 24 years of age) in most
cases don't have serious health problems, however, 22,8% of young
women suffer from one, and 12% from two or more chronic conditions.
In the age group of 25 - 44, only four in ten women are not chronically
ill, and one in ten women suffers from four or more diseases.
Most women age 45 and older are chronically ill and almost 50%
of women who are 65 or older suffer from four or more chronic
diseases. Studies show that many relatively young women have serious
health problems. Men are healthier than women in every age group,
including age 65 and older. If they are ill, the number of diseases
they suffer from is lower than in the case women.
The list of the most common
women's chronic diseases include:
41,8% of women who are
80 and older suffer from atherosclerosis, and 29,9 from eyeball
diseases (including glaucoma and cataract). Chronic gynecological
diseases are prevalent among women between 50 - 59 years.
The study documented women's
preventative health care. Women were asked whether, in the previous
year, they had a cytological examination and whether they had
a mammogram. Less than one fourth of the women questioned replied
"yes" to the first question. Married and divorced women
have cytological examinations more than twice as often. The number
of women who have had mammograms is even lower. Only 9.3% of women
have ever had this kind of examination: 11% in urban and 6,4%
in rural areas.
Table 2. Women who
have had mammograms and cytological examinations.
The Prevalence of Illnesses
of the Circulatory System
Illnesses of the circulatory
system are the leading cause of death in Poland (50.4% in 1996,
compared to 1990, where it decreased roughly by 2%). The greatest
number of deaths occur in women: in 1996, for 100 000 deaths from
circulatory illnesses, 51,080 were women and 49,520 were
men.
According to Central Statistical
Office (Statistical Yearbook of the Republic of Poland, Warsaw1998),
women do not utilize hospital services as often as men, although
the number of women receiving medical treatment for illness of
the circulatory system are increasing more quickly than for men.
The percentage for 100,000
people of each sex
Illnesses of the circulatory system
are the main reason for the hospitalization of women. The number
of women hospitalized increased between 1980 and 1992 by 47.2%
(Data from Ministry of Health and Social Care for 1996).
In addition to causes
connected to everyday life, such as preferred lifestyles, stress,
high workload, excessive outside duties, and lack of physical
activity, health problems are also caused by natural physiological
process related to aging. Heart attacks are a significant danger
for every second woman after menopause, cerebral hemorrhages for
every tenth women, and arteriosclerosis is the cause of 35% of
premature deaths. The percentage of women suffering from hypertension
in 1995-96 in Poland was 19.2%; a number that varies within the
following age groups: 15-24: 0.7% 25-34: 3.4% 35-44: 9.3% 45-54: 25.2% 55-64: 41.1% 65-74: 46.7%
75 and above: 41.2%
The percentage of women
suffering from chronic heart disease was 15.5% between 1995 and
96, occurring in each of the following age groups: 0-14: 1.0% 15-24: 1.9% 25-34: 4.7% 35-44: 9.6% 45-54: 24.8% 55-64: 40.3% 65-74: 54.1%
75 and above: 43.1%
Women's deaths resulting
from the diseases of circulatory system
(1996) Total 510.8 (per 100 000 population)
and capillaries 227,8 .
The cancer morbidity
rate
Cancer-related illnesses
constitute the second highest cause of death in Poland (20% of
all deaths) and the rate is increasing in both men and women.
In women, however, the increase is currently greater, although
more men are dying from it. In 1996, 243.2 men for every 100
000 died and 172.3 women for every 100 000 (Yearly Statistics
GUS, 1998).
Malignant Cancer Illnesses
(Data of Oncology Institute)
Currently, the most common
form of cancer for women is breast cancer. Previously, the most
prevalent was uterus and urethra cancer, which is now the second
most common. The recognition of the importance of early detection
of cancer created preventative programs. Even though many women
do not take preventative measures (28% of women have never received
pap smears, according to the Public Opinion Research Center (CBOS),
October, 1998: "Preventative Measures Undertaken by Women
Against Breast and Uterus Cancer"), these programs educated
many women about the necessity of regular pap smears and mammograms.
The percentage of women with breast cancer is still very high,
especially among women above the age of thirty. Each year 10,
000 women suffer from this form of cancer, most of whom die because
their cancers were diagnosed too late. In Poland breast cancer
is detected early in 20% of cases, while early detection rate
in Europe approaches 80%. Unfortunately, no common global program
promotes prophylactic care. Women are not taught self-breast
examinations nor do they attend regular gynecological exams, although
early detection is the only way to survive the cancer. Popular
women's magazines do their best to disseminate the information
regarding self breast exams, to organize educational material
on cancer prophylactics, to promote a healthy lifestyle, and to
inform the readers that regular gynecological exams are necessary.
Unfortunately, these efforts are not enough. Moreover, gynecologists
do not take enough care to inform women of their health needs.
For example, if not asked, the doctor will not perform a breast
exam. 33% of women claim that a doctor has never given them
a breast examination. Cancer illnesses are the second cause of
death for women in Poland.
Apart from the low level
of health education and limited access to mammography facilities,
there is also a problem of the quality of these devices. They
are rarely controlled, so the results of a screening are not always
reliable. According to the authors of the report on the state
of repair of mammography facilities, probably one third of those
devices are not fit for the early detection of breast cancer and
should be out of use. On the other hand, more than a half of
these devices are not fully used, which shows that the system
of examinations is poorly organized, and neither women nor health
authorities are interested in providing this examination. Another
reason that the mammography facilities are under-used is that
Health Maintenance Agencies refuse to finance mammography examinations.
Malignant cancer is the second most common cause of women's deaths
in Poland. The Prevalence of Malignant Cancer for Women in Poland (from the Ministry of Health and Social policy, 1996 - per 100,000 women):
The number of women suffering
from malignant cancer per 100 000 women in 1995, for each of the
following age groups: 0-9: 11.4 10-19: 11.1 20-29: 23.3 30-39: 81.5 40-49: 246.0 50-59: 439.2 60-69: 680.7 70-79: 992.3
80 and above: 1077.9
Deaths Among Women
from Malignant Cancer (per 100 000 people):
Other illnesses
In 1994, illnesses related
to pregnancy and childbirth caused 11.8% of illness-related absences
from work among women. Together with gynecological diseases,
these maladies constitute the second most prevalent reasons for
missing work (17.1%). Among miscarried pregnancies, spontaneous
abortions are the cause of 50.3% of absences, their number doubled
in the last five years. The number of absences resulting from
missed abortions (12% of miscarriages) increased three times.
The greatest problem connected to pregnancy, however, is premature
delivery (3.8%). The medical assistance for pregnant women is
still inadequate. According to the government statistics, in
1997, during the first three months of pregnancy, only 60.4% of
women living in the city were given medical advice and 44.3 women
in the country. Women are also hospitalized from illnesses of
the urinary and reproductive systems (13%), and complications
with pregnancy and childbirth (14%).
The percentage of chronic
illnesses among adults (15 years and above) in 1996 was 62.1%,
the majority of which were women (68% as compared to 55,5% of
men) (Parliamentary Research and Expertise Office, "Current
Statistics on Women," 28 April, 1999). The following is the
breakdown of the data on chronic illnesses, showing the rates
for men and women in urban and rural areas: In urban areas: 63.2%,
In rural areas: 60.2%,
The main work-related
injuries among women in 1995 were:
Health problems of
elderly women
Another serious problem
is a limited accessibility to hormonal treatment for women during
menopause and to the examinations needed to prescribe the use
of hormonal pills. In addition, even though Polish society is
aging, the medical system lacks preventive programs in geriatrics.
This problem is more significant for women because they have
longer average life spans. Women account for 68.8% of retired
people. (Current Statistics on Women, 20 April 1999). Another
common problem in developed countries is the quick growth of osteoporosis.
The breakage of fragile bones indicates that the disease has
deeply penetrated the individual and 30% of the bone has disintegrated.
According to an analysis by the Polish Osteoporosis Foundation,
the breakage of the femoral neck, which occurs to women above
the age of sixty. It is the most serious effect of osteoporosis
and the third cause of death - after circulatory illnesses and
cancer - among seventy year-old patients. The deaths are caused
mainly by illnesses connected with extensive bed rest, such as
problems with the lungs. Special preventative osteoporosis examinations
allow for the detection of this disease in its early stages, when
only a small percent of the bone disintegrates. To prevent osteoporosis,
women should take hormones pills, calcium supplements, and vitamin
D (Annals of Internal Medicine 1999). This cure strengthens bones
and protects women from the effects of menopause. Unfortunately,
the situation of elderly women is especially difficult because
they are usually in a poor financial situation: they earn less
than men, retire earlier, and receive smaller pensions. In addition,
elderly women often live alone which makes their situation even
more difficult.
Disabilities among
the elderly
In the 1990s, the number of the disabled
has grown considerably. In 1988, disabled people constituted
9,6% of the population. In 1996, their percentage grew to 14,3%
(i.e. 5, 430, 600 persons). The number of disabilities grows with
age, particularly among people 50 - 59 years of age. The growth
of the number of the disabled in older age groups is slower. Disabilities
are mainly the result of diseases unrelated with ones occupation,
and less frequently of occupational diseases, accidents or other
injuries.
Table 3. The disabled
aged 60 and more, by sex and cause of disability, in 1996.
Numerous studies show
that Polish women suffer from poorer health than men. Because
of their longer life span and biological functions, women more
often use the services of the health care system. Moreover, they
often must seek medical assistance, as the victims of domestic
violence. Therefore, compared to men, they more often face the
problems resulting from the growing costs and other deficiencies
of the health care system. Women's right to health protection
is seriously endangered as a result of numerous paid services
introduced to the public health care system and because of the
high prices of medicines which have not been included in the catalogue
of subsidized remedies. Because women's earnings and pensions
are lower, the growing cost of medical assistance seriously affects
their access to health care.
Another reason for serious
concern is the rapid increase in the number of women who die from
cancer and heart disease. The government ignores the situation
and does not pursue an active policy aimed at preventing and combating
these diseases.
In Poland, despite the
social and economic transformation, the value of health has not
yet been recognized in terms of practical advantages and quality
of life. Low funds allocated to health protection combined with
the low levels of health education and limited preventive measures
are the reasons that, compared with the citizens of Western Europe,
Polish people, including Polish women, suffer from poorer health.
A government strategic health protection program "Health
for All in the year 2000" was prepared in 1985, and endorsed
in 1990. Today, however, it exists only on paper. The so called
reform of the health care and health insurance system, which was
introduced in January 1999, turned out to be ineptly devised and
incompetently implemented. It has dramatically limited access
to public health care and deteriorated the quality of health services.
The reform and its consequences should be brought under proper
public control.
Women's health - selected recommendations
Objective 1. Develop national
strategies and policies regarding women's health and elaborate
appropriate documents.
Actions to be taken:
-reduce negative effects on women's health resulting from violence against women;
-address reproductive health and family
planning problems;
Objective 2. Devise and implement
preventive programs regarding women's health.
Actions to be taken:
Objective 3. Develop and implement
social welfare and health insurance systems to ensure sufficient
funding for women's health care services.
Actions to be taken:
Objective 4. Improve access to
specialist and women-friendly (as defined by WHO) medical treatment
and other services with particular attention given to women in
rural areas and in small towns.
Actions to be taken:
decrease payment for hormone drugs for the treatment of menstruation; fertility, pregnancy, puberty and menopausal problems and as
contraceptives to 30% - 50%; introduce free distribution of hormone drugs for the treatment of cancer and
recancerous conditions;
-provide sexual and reproductive health care, which includes family planning
information and services,
-provide health education, promote
healthy life style and sexual education,
-disseminate information on such
centers.
Objective 5. Improve quality
of life and health of menopausal and older women.
Actions to be taken:
Objective 6. Identify and eliminate
women's health hazards resulting from accidents at home and at
work, from occupational diseases as well as those leading to disability.
Actions to be taken:
Objective 7. Support women's
role as health care providers within the family and in the environment
by organizing modern educational programs.
Actions to be taken:
References
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