Gender-specific medicine, healthcare system and citizens’ rights

Domenico Mantoan

National Agency for Regional Health Services

Received 18 March 2021


“The clinical approach characterizing gender medicine is not only interdisciplinary and transversal, covering every branch and specialty, but above all multidimensional. According to a global vision of the concept of health, the provision of appropriate care implies taking charge of the sick ‘person’, evaluated not only with regard to the biological and clinical characteristics of the disease, but also based on all the personal, cultural and social factors that characterize their past experiences, exploring which it is possible to grasp the aspects that distinguish and define the gender, from the management of everyday life, in relation to therapeutic treatments, to the impact of the disease on the relationship between the individual person and their social context”.1 The Plan for the application and dissemination of gender medicine drawn up by the Ministry of Health, envisaged by Law 3/2018 and signed on June 13, 2019, clearly states that the new legislation aims to guarantee the quality and appropriateness of the services to be uniformly provided by the Italian National Health Service (NHS) throughout the national territory. Quality and appropriateness are also the keywords that guide the daily activities of the National Agency for Regional Health Services (Agenas, Agenzia nazionale per i servizi sanitari regionali), which was established in 1993 as a technical-scientific body of the NHS and that, over time, has consolidated in Italy its mission as a point of connection between the central and the regional levels, carrying out research and support activities for the Minister of Health, the Regions and the Autonomous Provinces of Trento and Bolzano in areas concerning the effectiveness of health interventions, as well as the quality, safety and humanization of healthcare.

The work of the Agency deals both with the governance of what already exists and with the research activity. The latter cannot focus only on the development of innovative therapies, but must also take into the utmost account the development of more efficient and equitable organizational models; an activity that, on the one hand, should involve all the regional situations of our Country and, on the other, cannot avoid being compared and related with the healthcare systems of other nations, since in most cases the issues and uncertainties affecting the development and implementation of the healthcare programs of comparable Countries are similar. From these interactions, different solutions often arise, in line with the peculiarities of cultures and organizational structures. One of the main missions of Agenas is to be able to interpret, measure and define the best organizational models and, if possible, anticipate problems.

Looking at a more sensitive, precise and relevant healthcare research, there is a growing focus on gender-oriented medicine. In recent years, extraordinary advances have been made in gender-specific clinical research, and the design and subsequent analyses of the data aimed at investigating gender peculiarities are now part of the cultural background of both methodologists and researchers. Although much has been done, however, there are still many obstacles to overcome, such as, for example, a still perfectible attention to gender in the training of healthcare professionals: the key to highlighting the values expressed by a gender-specific approach in health policies implies the acceleration of a process which, as previously mentioned, can no longer be stopped.

As we know – and as also underlined at the opening of the Plan for the application and dissemination of gender medicine – some areas of clinical medicine have developed a greater knowledge and familiarity with this approach than others. In fact, we cannot forget that – while gender has been a leading dimension in the social sciences for many years and has long influenced research – only relatively recently it has begun to enter the lexicon of biomedical and public health researchers. In the latter context, the prospects offered by greater attention to gender are extremely promising. Gender-related experiences are firmly linked to social, political and economic contexts: gender is part of all human interactions, and can also prove to be a determining and “stable” form of inequality.2 Gender-related experiences – and the cultural values connected to them – often translate into socially pre-established gender roles that determine different behaviors, interests, expectations and professional consequences for women and men, with a direct impact on health. Health policies attentive to gender-specific effects can be an instrument to reduce – if not to eliminate – inequalities, to promote equity and to truly restore centrality to the citizen, to the patient and their families.

In this regard, I would like to recall some activities carried out by Agenas in the context of a growing attention to the individual experiences of citizens. I am thinking, first of all, of the progressive expansion of the analysis and monitoring of the performance of healthcare services in support of the Ministry of Health, the Regions and the various bodies of the NHS, with particular attention to the process of requalification of hospitals and the updating of the National Outcome Program (PNE, Programma Nazionale Esiti); but also the collaboration in verifying the provision of essential levels of care, which cannot fail to take into account the particular expectations of patient populations characterized by gender-specific needs; the promotion of the dissemination of good practices for the empowerment of patients, citizens, professionals, organizations and communities; the analysis of the organizational models and care networks within the process of reorganization of the healthcare system. These are all areas in which attention to gender issues can integrate and enrich the activities aimed at improving the quality and humanization of healthcare and the improvement of the organizational paths. These are all activities that fall within the Agenas research lines, both the ‘epidemiological-descriptive and inferential’ ones – based on observational data from current healthcare flows – and the ‘organizational-managerial’ ones, aimed at the transfer of models, instruments and methodologies in the governance and in the management of organizations, healthcare activities and their underlying processes.

While underlining how gender-specific medicine cannot be reductively reduced to the mere attention to women’s health, I recall that in recent months the first versions of the checklists for the assessment of the counseling centers and birth points have been developed among the activities for the participatory evaluation of the services of the Birth Pathway. The checklists were built on the basis of the indications of the literature, of national and international experiences and of the proposals made by the members of the “YOUman LAB Humanization” (healthcare professionals and members of associations advocating the rights of women/pregnant women). Similarly, as regards the issue of the prevention of complications related to pregnancy, an in-depth work was carried out, together with the Ministry of Health and the representatives of the Regions and Autonomous Provinces, on the document Clinical-organizational guidelines for the prevention of complications related to pregnancy, childbirth and puerperium. Agenas also played an active role in the activities of the Coordination Center on Neonatal Screening (CCSN, Centro di coordinamento sugli Screening Neonatali), established at the Italian National Institute of Health, as well as in the drafting of the document aimed at describing the state of the art regarding the standards and the dissemination of the best practices relating to the different stages of implementation of the Extended Neonatal Screening (SNE, Screening Neonatale Esteso) programs in each Region/Autonomous Province as of June 30, 2019, in application of Law 167/2016.

The key phrase that connotes the sustainable development goals, which all Countries have endorsed through the United Nations, is “leave no one behind”.3 The goals for 2030 concern health and well-being for all, and the UN global strategy Every Woman Every Child (EWEC), for the health of women, children and adolescents (2016-2030), is the unifying roadmap to achieve this goal for each of them.4 A careful approach to the gender dimension and related experiences, needs and skills is one of the conditions for “leaving no one behind”, and creating a value-based healthcare system, respectful of the citizens’ rights.

References

1. Ministero della Salute. Piano per l’applicazione e la diffusione della medicina di genere (in attuazione dell’articolo 3, comma 1, legge 3/2018) [Ministry of Health. Plan for the application and dissemination of gender medicine (in implementation of article 3, paragraph 1, law 3/2018)]. Published on June 21, 2019; last update June 21, 2019.

2. George AS, Amin A, de Abreu Lopes CM, Ravindran TKS. Structural determinants of gender inequality: why they matter for adolescent girls’ sexual and reproductive health. BMJ. 2020;368:l6985.

3. Every woman every child [Internet]. The global strategy for women’s, children’s and adolescents’ health. (2016-2030). Available from: https://www.globalstrategy. everywomaneverychild.org

4. Boerma T, Victora CG, Sabin ML, Simpson PJ. Reaching all women, children, and adolescents with essential health interventions by 2030. BMJ. 2020; Jan 27;l6986.

Conflict of interest statement: the Author is Director General of the National Agency for Regional Health Services

Correspondence to:

Domenico Mantoan

Agenzia Nazionale per i Servizi Sanitari Regionali

Via Puglie 23

00187 Rome, Italy

email: dir@agenas.it