memorandum by Ms Circene, rapporteur
The Council of Europe has already done significant
work in the gender budgeting field. The Parliamentary Assembly adopted Recommendation 1739 (2006)
on gender budgeting in March 2006, on the basis of a
report by our colleague Ms Anna Čurdová (Doc. 10764
). This report included an expert paper by Ms Elizabeth
Villagómez on the role of parliament in promoting and applying gender
Gender budgeting – as a concrete tool in the framework of
gender mainstreaming – has been the focus of several intergovernmental
meetings as well, most recently the Conference on State Budgets:
A Key Factor in Real Equality Between Women and Men, which was organised
by our “sister” committee, the Steering Committee for Equality between
Women and Men (CDEG), in Athens in May 2009.Note
this occasion, a handbook on “Gender budgeting: practical implementation”
was launched, which makes concrete proposals to governmental and
non-governmental actors on how to use gender budgeting as a practical
The Council of Europe’s Informal Network on Gender Mainstreaming
dealt with gender budgeting in September 2005. The same network
focused on gender mainstreaming in health in September 2006. Committee
of Ministers Recommendation CM/Rec(2008)1 on the inclusion of gender
differences in health policy also touched on this subject. However,
I feel that the link between the two subjects remains to be made, which
is why I tabled a motion for a resolution on gender budgeting as
a tool for safeguarding women’s health in February 2009 (Doc. 11836
4. It is my intention to briefly outline gender budgeting principles
in this report, and then to explain how the application of these
principles in the health field could help to save many women’s lives
– and thus make our societies both more cohesive and more prosperous.
2 The principles
of gender budgeting
Even though knowledge on gender budgeting is becoming
more and more widespread, please allow me to briefly cite some paragraphs
of Ms Čurdová’s 2006 report, which explain the gender budgeting
concept in a very exact and succinct way.Note
The Council of Europe’s Steering Committee for Equality
between Women and Men (CDEG) defines gender budgeting as ‘an application
of gender mainstreaming in the budgetary process. It means a gender-based
assessment of budgets, incorporating a gender perspective at all
levels of the budgetary process and restructuring revenues and expenditures
in order to promote gender equality.’
This gender perspective is based on application of the
gender mainstreaming principle in the budgeting procedure. This
entails treating women’s priorities and needs on an equal footing
with men’s and assessing the gender impact of budgetary policies,
while making the budgeting process gender responsive at all levels
and restructuring revenues and expenditures with the ultimate aim
of achieving gender equality.
Public budgets are not neutral in their effects, since
they are used to implement specific policies with implications for
society and the economy. It is through the public budget that the
political authorities shape social and economic development, decide
priorities for action and determine needs-based redistribution criteria
for society. These policies accordingly affect men and women in
different ways, in terms of both revenue and expenditure.
The aim of gender budgeting is not to draw up separate
budgets for women, but to take better account of social realities.
By stepping up the collection and analysis of gender-disaggregated
data and giving an improved insight into the real added value generated
by resources earmarked for women and for men, gender budgeting allows
more equitable distribution of financial costs and benefits, while
fostering more effective use of public funds.
Gender budgeting has three main objectives. First, it
seeks to ensure that budget policies are equitable and to foster
a reduction in inequalities and equality of opportunity, taking
better account of the differing needs of women and men within the
economy and society.
The second objective is to encourage more effective use
of public spending, in keeping with predefined objectives, as regards
the distribution of resources and services targeting men and women.
Gender budgeting accordingly aims to improve the quality and the
efficiency of public services in line with the differing needs of
male and female citizens.
The third objective is to give people a better grasp of
public revenue and expenditure and, hence, ensure greater transparency
of public policies implemented by national, regional and local authorities.”
3 Gender mainstreaming
in the health field
6. In its Recommendation CM/Rec(2008)1 on the inclusion
of gender differences in health policy, the Committee of Ministers
made clear that a key determinant of health is actually gender (which
is a social construct) as opposed to sex (which is a biological
attribute), in that many differences and inequalities between women
and men’s health status stem from social, cultural (including religion)
and political arrangements in society. The Committee of Ministers
noted that gender inequalities can result in problems of access
to health services, including to information, and that the lack
of resources to promote gender sensitivity in health care providers
could constitute structural barriers to quality of health care.
This is why the Committee of Ministers pushed for more gender mainstreaming
in the health field, since the recognition of gender differences
and inequalities would add to the efficiency and effectiveness of
health policies and health care services for both women and men.
7. The Committee of Ministers put the question in the context
of protection of human rights, and recommended that member states
make gender one of the priority areas of action in health through
policies and strategies which address the specific health needs
of men and women and that incorporate gender mainstreaming. They
recommended the promotion of gender equality in each sector and
function of the health system including actions related to health
care, health promotion and disease prevention in an equitable manner,
and encouraged the development and dissemination of gender sensitive
knowledge that allows evidence-based interventions through systematic
collection of appropriate sex-disaggregated data, promotion of relevant
research studies and gender analysis, as well as the establishment
of monitoring and evaluation frameworks on progress on gender mainstreaming
in health policies.
8. I am aware of the fact that this recommendation is still very
new, and that it is thus premature to expect all of its recommendations
to already have been implemented. However, I feel that one of the
most practical tools of gender mainstreaming, namely gender budgeting,
is missing in the recommendation.
4 The potential benefits
of gender budgeting in the health field: a case study – Cancer
9. The incidence of oncological diseases worldwide is
growing. What is alarming is the fact that among these cases many
are malignant tumours located in sites that are easily accessible
for examination (e.g., cervical cancer, breast cancer, oral cavity
cancer, etc.). They are referred to as visually detectable tumours. The
mortality rate of visually detectable tumours is 3.5 times higher
in women than in men.
10. According to the Eurobarometer survey “Health in the European
Union” conducted by the European Commission in 2006, 29% of inhabitants
answered that they have a long-standing illness or health problem. Each
year 275 000 women develop breast cancer, and 88 000 women die with
this diagnosis. Breast cancer is the main cause of death in women
between 35 and 59 years of age. Increasingly younger women in the
EU are developing mammary gland tumours. Some 35% of women who have
developed breast cancer are younger than 55 years of age, and 12%
have not even reached the age of 45 years.
11. When comparing standardised breast tumour mortality rates
for women up to 64 years of age in the EU and in the Baltic states,
the mortality rate is higher in the Baltic states. These rates might
have been lower if timely diagnostics and adequate treatment had
been provided. Thus it is imperative to draft national strategies for
the prevention and early diagnosis of chronic non-infectious diseases.
12. The second most widespread tumour affecting women up to 45
years of age is cervical cancer. The greatest incidence of cervical
cancer is found in women who are between 35 and 64 years of age.
Main cause of cervical cancer is the human papillomavirus (HPV)
infection, but there are also other factors contributing to development
of this type of tumour. An HPV infection increases the risk of developing
cervical cancer by 20 to 175 times. Cervical screening programmes
are especially important for timely identification of this disease.
13. When comparing indicators in the EU member states, one comes
to the conclusion that in post-communist countries the mortality
rate is higher; that fact can be attributed to delayed diagnosis
and treatment. Controllable
risk factors for malignant tumours are smoking, alcohol use, a sedentary
lifestyle, excess weight, unhealthy food, chronic infections and
delayed diagnosis. This attests to the importance of education and awareness
raising in maintaining good health.
14. One of the reasons for incomplete data on oncological diseases
is insufficient accessibility of health-care services. This can
be attributed to the distance between one’s place of residence and
the health-care service institution (health-care coverage), the
qualification of medical personnel, patient co-payment, queues,
and lack of information. Issues of health care accessibility are
analysed in the EU survey EU SILC (Survey on Income and Living Conditions),
which confirms the importance of these factors.
15. Since health care is regarded as a human right, the principle
of gender equality should be applied to it as well.
16. One measure of society’s health that is used worldwide is
an indicator of premature deaths, or years of potential life lost
(YPLL). It characterises premature mortality and preventable causes
of death; it is also used to evaluate socioeconomic losses sustained
by the state. Such causes of death might have been averted by taking
preventive measures; therefore, these data facilitate prioritising
issues related to the health of society. Years of potential life
lost is an estimate of the average years a person would have lived
if he or she had not died in an accident or from a disease. Years
of potential life lost is an informative fact-based indicator of society’s
17. The number of potential years of life lost due to death from
external causes or acute cardiovascular diseases is five times higher
in men than in women. An analysis of budget use for health care
in member states of the Council of Europe shows that often emergency
care is given priority, and that is easily understandable from the
point of view of saving lives. An emergency situation most often
involves cardiovascular diseases and external causes (traffic accident,
suicide, homicide, drowning, alcohol poisoning, etc.).
18. In view of the fact that breast cancer ranks first as a cause
of death and YPLL in women, budget allocation benefits improving
the quality of life for men. Considering the use of the health care
budget from the point of view of gender equality, it is important
to discern a link between macroeconomics and effective use of money
spent. As we know, “gender budgeting” does not require two separate
19. In order to improve use of the health-care budget, it is absolutely
necessary to draft a national strategy based on data analysis and
the financial resources of the budget.
20. With regard to improving female health and preventing possible
causes of death in women, a specific programme is needed for women
of reproductive age. The goal is a healthy woman who does not require
a part of the national budget for medical treatment or disability
benefits and who, being healthy, takes an active part in generating
the gross domestic product and in paying taxes.
21. From the point of view of gender equality, it is essential
to involve women themselves as decision makers in the whole process
of drafting the budget. The result is crucial for all decision makers
– for parliamentarians and members of government, for employers
in order to strengthen macroeconomics, and for society as a whole in
the context of the demographic situation.
22. Since the primary causes of female oncological mortality are
breast cancer and cervical cancer, drafting a goal-oriented programme
for preventing these pathologies is a striking example of gender
budgeting. In order to ensure effectiveness of budget contributions,
there are various prerequisites: a precisely formulated goal and
a predicted result that can be statistically demonstrated. To obtain
a scientific basis, there
is a need for precise analysis of data according to a unified methodology
and for sufficient time and factual materials to analyse pilot projects. This is the framework for long-term
planning of effective budget use.
23. In applying this framework to the most dangerous and lethal
oncological diseases in women – breast cancer and cervical cancer
– the European Commission has adopted guidelines for breast and
cervical cancer screening. On the basis of these guidelines, member
states of the Council of Europe should draft concepts and strategies
for ensuring screening programmes for the target group of women,
that is, women of reproductive age. It should be noted that screening
is effective only as a co-ordinated health care policy, not as a decentralised
24. Such screening includes diagnosing cervical cancer by performing
a PAP smear once every three years for women 25-70 years of age;
mammography once every two years for women 50-69 of age; and starting
at 50 years of age, an annual faecal occult blood test. In view
of the fact that the rate of incidence of cervical cancer is increasing,
vaccination against HPV – the most common cause of cervical cancer
– is now being widely introduced.
25. According to data of the European epidemiological surveillance
(Eurosurveillance 2008), the following countries have assessed the
cost efficiency of introducing vaccines against HPV before including
this type of vaccination in their immunisation programmes: Slovenia,
Belgium, France, Canada, the United States, the Netherlands, Denmark,
Great Britain, Germany, Australia, Ireland, Norway and Switzerland.
The most common reasons why countries did not assess cost efficiency
was the lack of financial resources and the confidence that it is
enough to rely on similar research conducted in other countries.
26. The research by Eurosurveillance shows that the main factors
for introducing vaccination against HPV in Europe were a favourable
cost-efficiency ratio and the expected epidemiological influence
upon pre-cancerous lesions and the cervical cancer itself. The European
Centre for Disease Prevention and Control (ECDC) concludes that
vaccination against HPV is a cost-efficient strategy. Several publications
mention that the first benefits of this vaccination will be evident
after a couple of years.
27. In 5 to 10 years’ time, it could be possible to reduce by
30% a high-risk HPV infection, by 40% to 50% pathological changes
in a PAP smear and by 50% to 60% explicit cervical intraepithelial
neoplasia. If vaccination of girls started at the age of 12, the
number of cervical cancer-related cases would decrease by approximately
66%, and the number of deaths would decrease by approximately 67%.
In total, approximately 1 889 years of life per 100 000 women could
be saved. If the average salary is taken into account, the economic effect
in each member state will be different. Nevertheless, it undoubtedly
is a cost-efficient long-term strategy.
28. In view of the fact that the state budget is an instrument
of macroeconomic policy, it is important to find the correct mechanism
and methodology for introducing a gender-based budgeting strategy.
It would help to save considerable costs and would significantly
improve the quality of life not only for women but also for their relatives.
29. Since the 1995 4th World Conference on Women in Beijing, basic
principles of gender equality are being adopted as a strategy and
applied in more than 40 countries all over the world. The government
– specifically the ministry of finance – plays the most important
role in preparing the budget, and in doing so it co-operates with
other ministries. The second most important ministry in planning
health-care expenditures is the ministry of health, which formulates
a national strategy and national policy. It is also very important
to ensure that principles of gender budgeting are understood by
officials at all levels of the civil service.
30. When drafting a research-based plan and calculating its efficiency,
it is very important to keep in mind the need to achieve a “measurable
result” and to assess its suitability for a given strategy. Usually,
when the budget is prepared, officials give lip service to “gender
neutrality”, but in practice the budget tends to discriminate against
women’s interests. This is because “gender neutrality” is not the
same as “gender equality” or “gender sensitivity”. The government’s
duty is to protect the weakest and to prevent any form of discrimination.
This can be done successfully by involving the NGO sector. A good
example is the United Kingdom Women’s Budget Group, which regularly
conducts analysis of the United Kingdom budget and actively lobbies
the parliament for higher allocations for women’s health care.
The report of the Task Force on International Innovative Financing
for Health Systems, co-chaired by United Kingdom Prime Minister
Gordon Brown and World Bank President Robert Zoellick, was completed
on 29 May 2009 at the 3rd task force meeting held in Paris. All
task force members agreed to the final report and a set of recommendations
that includes a range of innovative financing options which countries
and other stakeholders can choose to support. One of the main recommendations
of the task force report is Recommendation
: “Strengthen the capacity of governments to secure better
performance and investment from private, faith-based, community,
NGO and other non-state actors in the health sector”.
32. The World Health Organization, the United Nations and the
World Bank also emphasise the importance of gender budgeting and
point out that by investing in women’s health, governments significantly
promote social development. Back in 1994, the Vienna Statement on
Investing in Women’s Health in the Countries of Central and Eastern
Europe recognised the introduction of screening for breast and cervical
cancer as a priority.
33. An audit of the observance of the gender equality principles
should be applied not only to specific ministries but to all social
services, and it should include issues such as the accessibility
of specific services, safety, the school system, foodstuffs and
sports activities. These principles should be incorporated into
national legislation, and the law should define the audit methodology,
the system for data compilation, analysis and monitoring. Such streamlining
of national legislation has begun in Belgium, Austria and Spain.
34. In 2001, the Organisation for Economic Co-operation and Development
(OECD), the United Nations Development Fund for Women (UNIFEM) and
the Nordic Council of Ministers held a Conference in Belgium on
Strengthening Economic and Financial Governance through Gender-Responsive
Budgeting. In March 2005, the Council of Europe’s Committee of Ministers
approved the Plan for Gender Equality (Order APV/526/2005) with
regard to informative and statistical systems and introducing gender-responsive
fiscal and budgetary policies.
35. Pursuant to the strategy for preventing the incidence of breast
and cervical cancer and reducing the death rate from these diseases,
all Council of Europe’s member states should conduct data analysis
in accordance with a uniform methodology and by following the existing
WHO guidelines. They should develop and implement national strategies
which include organised screening for tumours; early diagnosis of
cancer would improve the effectiveness of treatment and the quality
36. One of the main requirements is to raise public awareness
by introducing health education in schools and promoting a healthy
lifestyle; it is also important to raise awareness about the importance
of self-examination. Comprehensive informative and educational campaigns,
as well as health promotion measures, are vitally significant. The
quality of services and their accessibility should be the cornerstone
of these strategies. In drawing up national health care budgets,
national anti-cancer strategies should be regarded as priorities.
37. As we have seen from the above, there is increasing
evidence from all fields of health research that risk factors, clinical
manifestation, causes, consequences and treatment of disease may
differ between men and women. This means that, in turn, prevention,
treatment, rehabilitation, care-delivery and health promotion need to
be adapted according to women’s and men’s differing needs. Gender
budgeting can make a crucial contribution to the actual delivery
of health care which responds to these needs.
38. As in all fields of gender budgeting, it is essential that
gender-disaggregated data be collected in member states in the health
field, and that gender impact assessments be made. With these two
tools in hand it is then possible to effectively move on to the
step of gender budgeting, that is allocating the budgetary resources
in the health field in a way which is fairer to women and men –
and more efficient.
39. I believe that gender budgeting should be an essential element
in member states’ health policies, and that the Committee of Ministers
should promote gender budgeting also in the health field.
The Assembly should thus recommend that the Committee of Ministers:
- ensure that member states apply
Recommendation CM/Rec(2008)1 on the inclusion of gender differences
in health policy, in particular the recommendations relating to
the incorporation of gender mainstreaming into national health policies
and strategies, including the collection of gender-disaggregated
data and the use of gender impact assessments;
- encourage member states to go further and to apply gender
budgeting to the national health policies and strategies in order
to allocate the budgetary resources in the health field in a fair
and efficient way for both women and men;
- instruct the competent committees to consider following
up Recommendation CM/Rec(2008)1 with a recommendation on gender
budgeting in the health field.