Abstract
Across the globe the concept of gender mainstreaming is indicative of substantive transformations, and healthcare is a particularly important policy arena. Yet existing research reveals only modest success in the implementation of gender policies in national healthcare systems, despite the availability of complex tools and guidelines. This article introduces an approach that links gender mainstreaming with approaches into policy transfer as dynamic processes of translation involving active players. In a scoping exercise the authors select England and Germany as case studies and draw on document analysis, other secondary sources and additional expert information. The analysis reveals varieties of translation of gender mainstreaming into national healthcare systems – even within the legal framework of the European Union – and the crucial relevance of feminist actors. The study raises more general questions on the nature of international policy-making in relation to national and local healthcare institutions and policy entrepreneurs.
Introduction
Across the globe, the concept of gender mainstreaming is indicative of substantive political and social transformations, and healthcare is a particularly important policy arena. Closing the quality and equality gaps in healthcare now ranks high on the international policy agenda, and improving gender equity and equality is one of the Millennium Development Goals (Abdool et al., 2010; Payne, 2009; Sen et al., 2007). The concept of mainstreaming gender is adopted by all leading international organizations, such as WHO (2002, 2009, 2011) and the United Nations (1999), and is also part of European law and policies (Council of Europe, 1998, 2005; genSet, 2010). Furthermore, the need for gender-sensitive healthcare is increasingly also acknowledged within leading academic journals in the fields of medicine and public health (Nature, 2011; Sim and Mackie, 2011).
Being a ‘world traveller’, gender mainstreaming clearly tells a success story at the level of international organizations but this turns out to be more difficult when tracing policy transfer further down the line towards national governments and health systems. Existing research reveals only little success in the implementation of gender policies in national contexts, despite the availability of gender-sensitive tools and guidelines in healthcare research and practice (Celikab et al., 2011; Ghodsee et al., 2010; Woodward, 2008).
In this article we suggest a fresh approach that moves beyond the debates into success or failure of the international concept of gender mainstreaming in national healthcare systems, to explore how policies are transferred and thereby transformed in order to fit national contexts and actors. We introduce an approach that links gender mainstreaming research with approaches into policy ‘translation’. Understanding policy transfer as translation is interesting for the purpose of our study, because it brings its dynamic nature and the relevance of actors into view (Sahlin and Wedlin, 2008). Furthermore, this approach helps us to unpack activity at the different levels of international, national and local institutions, all of which shape the specific outcome of policy transfer (Burau et al., 2011; Kirkpatrick et al., 2011).
In our scoping exercise we chose England and Germany as case studies. The cases reflect similar developments in two Western European countries which have adopted a legal framework of European gender mainstreaming legislation but have different traditions of welfare states and healthcare systems. England represents a liberal welfare state with a centralized National Health Service (NHS) and Germany a conservative corporatist welfare state with a decentralized Statutory Health Insurance (SHI) system based on partnership governance (Kuhlmann and Allsop, 2008). In terms of method, we apply a context-sensitive comparative approach and a case study design drawing on document analysis and other secondary sources and additional expert information (Burau, 2007; Wrede, 2010).
The article begins by discussing policy transfer as processes of translation and how this approach may be connected to gender mainstreaming. We continue with an overview of the international concept of gender mainstreaming. This is followed by an exploratory assessment of how gender mainstreaming is translated into the institutional configurations of the healthcare systems in England and Germany. We conclude by highlighting key findings that raise more general questions about the tensions between transnational policies and national healthcare states and the significance of feminist actors in the policy process.
Making connections: Gender mainstreaming and the translation of policy
Gender mainstreaming has provoked much scholarly debate but this has mainly been concerned with the outcomes of the new mainstreaming policies, including monitoring, evaluation and overall efforts to improve the quality of statistics. Controversy remains especially around whether and how the critical potential of gender may be able to survive ‘mainstreaming’ attempts (Bacchi and Eveline, 2010; Daly, 2005; Debusscher, 2011). For example, feminism’s critical acuity may be tempered as it is mainstreamed within ‘alliances, coalitions and merged projects’ of civil society institutions and the state (Walby, 2011: 148).
However, little attention has been paid to the processes of policy-making; this is true for the critical junctions between global and local policy in healthcare as well as for the actors involved and the mediations between different institutional actors and interests. This problematic shortcoming of gender mainstreaming research therefore results in a double disconnection: public policy research broadly ignores gender mainstreaming policies, and feminist scholars working in this area rarely look at the healthcare sector.
We suggest closing this gap by connecting gender policies and public (health) policy research; this will enable a better understanding of the opportunities and limitations of implementing new mainstreaming policies in the healthcare sector. Here, recent debates into policy transfer are especially useful. Policy transfer is not a uniform concept; rather it is the host for different approaches that seek to highlight the complexity and procedural nature of policy-making. One strand, for example, has focused on policy learning and policy diffusion; this research has highlighted the many policy hurdles and the overall unevenness of policy processes (Djelic, 2004; Freeman, 2007; James and Lodge, 2003). Others have challenged the assumption of rationality and linearity in policy transfer (Dwyer and Ellison, 2009).
Especially interesting for the purpose of our study of gender mainstreaming in healthcare is the notion of translation in policy transfer (Sahlin and Wedlin, 2008). This approach is interesting for two reasons: it brings the active nature of policy transfer into perspective, thereby opening the door for actor-centred approaches; and it allows for more context-sensitive and dynamic approaches. For example, in their study into medical manager roles in European hospitals, Kirkpatrick et al. (2011: 4) apply the concept of translation to explore ‘local translations of a global template’. In a similar vein, Burau et al. (2011), in their cross-country research into primary care policy transfer, suggest that we distinguish between two phases of policy transfer: the transfer of ideas or knowledge from the international to the national arena; and the transformation of ideas or knowledge into policies within the national arena. Kirkpatrick et al. furthermore argue that the concept of translation can be utilized to link ‘micro-practices – such as the development of medical-manager roles – and institutional contexts’ (2011: 5).
In summary, the new emergent concept of policy translation can help to explore translations between ‘different national contexts as well as different institutional logics’ (Kirkpatrick et al., 2011: 6; see also Burau et al., 2011). This makes it a potentially very useful approach for context-sensitive comparative research into gender mainstreaming policies. To highlight some of the possible connections:
Gender mainstreaming is a ‘global template’ for improving gender equity and equality that may show up in different forms when applied to ‘local institutions’ of healthcare systems. Supranational institutions like the EU act as the most powerful facilitators of gender mainstreaming approaches, while national governments often resist implementation (Council of Europe, 1998; Woodward, 2008). And, to further complicate things, driving forces may also operate beyond formal institutions, for instance in the creation of more gender-sensitive expert knowledge in the context of international and European research agendas (genSet, 2010; Klinge, 2010; Payne, 2009).
Gender mainstreaming meets with new forms of governing the health professions and organizing the healthcare sector through meso-level (organizational) governance practices, especially performance management and target setting. Consequently, governance practices may serve as critical junctions for implementing gender mainstreaming policies in healthcare organizations, such as hospitals. At the same time, there may also be other ‘rationalities’ of organizations that counteract gender policies, including mere ignorance as well as overt conflict of interest with powerful male actors (Özbilgin et al., 2011; Van den Brink, 2011).
In order to achieve transformative potential, gender mainstreaming needs the support of a range of actors. The most obvious actors internationally have been feminists (Zalewski, 2010). However feminist knowledge and action is dynamic and contested. Feminists are increasingly committed to diverse ideas and strategies of gender equality, such as intersectional approaches (see, for instance, Hankivsky and Cormier, 2011), that may have different implications for mainstreaming, including questioning the master status of gender or affecting women’s and men’s healthcare differently (Annandale and Kuhlmann, 2012).
In our scoping exercise we take on the concept of policy translation but expand the focus to include actors, including policy entrepreneurs, who are only loosely connected to the institutions of the healthcare system. In the next sections we investigate the translation of gender mainstreaming policies by drawing on developments in England and Germany.
The international concept of gender mainstreaming
Based on the 1995 Beijing platform of the fourth International World Conference of Women, the concept of gender mainstreaming serves as a host for new approaches to both gender equality and policy-making. As such it is open to various definitions and political strategies. In international health policy the definition provided by the World Health Organization (WHO) is indicative and adapted in a similar vein by the European Union and individual member states:
. . . the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in any area and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension in the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and social spheres, such that inequality between men and women is not perpetuated. The ultimate goal is to achieve gender equality. (WHO, 2002: 6)
Gender mainstreaming is closely linked with the changing governance of the public sector (Woodward, 2008) and assigned a double role in healthcare: as an approach to reduce social inequalities in health which, at the same time, improves the quality and efficiency of healthcare systems (Kuhlmann, 2009). Also important is that gender mainstreaming operates as a top-down approach, and therefore needs to be tacked to institutions and organizations and must adopt the new managerialist toolset of governance. In healthcare, the major junctions are standardization, target setting and clinical guidelines and evidence-based medicine.
Another important aspect of the international concept of gender mainstreaming is that it expands the scope of action towards men’s healthcare and male actors (Smith et al., 2009; WHO, 2007). This opens up new opportunities for men’s health activists, which include not only much needed improvements in healthcare for men, but also potential competition with feminist approaches and women’s healthcare needs (Annandale and Riska, 2009; Wadham, 2002). At the same time, WHO and other international organizations show an overall strong focus on women’s healthcare, especially in resource-poor countries (WHO, 2009; see also Abdool et al., 2010; Standing, 2006). Within the European context, women’s health is also an important focus, but the mainstreaming concept is more diverse.
In summary, the international mandate for gender mainstreaming provides a flexible ‘toolset’ for the institutions of national healthcare states and local communities, and may therefore be translated differently: as women’s healthcare needs – such as, for instance, in the areas of sexual violence or maternity care – or men’s healthcare needs in areas that counteract traditional masculinities such as mental healthcare, as well as gender-sensitive healthcare that may benefit either men or women, or both, as social groups.
The European Union is a particularly interesting case for exploring policy transfer. It consists of member states with different healthcare systems under the authority of national legislation that, at more or less the same point in time, have adopted common gender mainstreaming legislation. So the international concept of gender mainstreaming is translated into a legal framework relevant for all EU member countries, which, in turn, raises the questions, what was it that created divergent trends in policy transfer? And who are the main actors in the different countries in these processes?
Gender mainstreaming policies in England and Germany
Introduced by the Treaty of Amsterdam, gender mainstreaming came into force in 1999 as a key policy goal and new strategy for equal opportunities in all European member states. Despite the legal commitment and the identification of gender mainstreaming as the most effective strategy to reduce health inequalities between men and women, in 2001 WHO concluded that very few member states ‘have translated this international political commitment into clear policy at the national level’ (WHO Euro, 2001). This situation has not significantly improved since WHO brought these problems into view (Woodward, 2008).
In the next section we will further explore how national healthcare systems may act as a filter for transferring gender mainstreaming into healthcare systems. We focus on new forms of governing through standardization and performance management in the field of primary care for chronic illnesses that have been introduced in both England and Germany over the last decade (Kuhlmann and Allsop, 2008): namely, the National Service Frameworks (NSFs) in England and the Disease Management Programmes (DMPs) in Germany, both of which are (or were) mandatory programmes.
Germany
In Germany gender mainstreaming was introduced in 1999 when the federal government signed the Amsterdam Treaty. In 2000, under the authority of the Federal Ministry of ‘Family, Youth, Women and Elderly’ (Bundesministerium für Familie, Jugend, Frauen und Senioren), a working group was established in order to launch different pilot projects and to coordinate gender activities across the various ministries. This was supported by the establishment of a new Centre for Gender Competence in order to provide scientific advice and evidence on how to introduce gender mainstreaming in all areas of public services. Within this context healthcare was one of the areas where pilot projects were introduced. Characteristically, these initiatives were insufficiently linked to new health policies, such as for instance the Disease Management Programmes (DMPs) or to the restructuring of key regulatory bodies of the Statutory Health Insurance (SHI) care system or to the recent attempts to improve the coordination and collaboration of different provider groups (SVR, 2009).
The government has supported mainstreaming efforts by launching a website on gender mainstreaming which provides useful information on a broad range of areas, including healthcare (www.gender-mainstreaming.net/). Yet in healthcare there is no systematic monitoring and coordination of gender mainstreaming approaches across the various institutions concerned. Different policy authorities and governing bodies are responsible for overseeing the management of various aspects of performance; thus, gender issues may easily get lost in the ‘jungle’ of network-based governance in the healthcare system.
The regulatory structure of corporatist governance (Kuhlmann, 2006) may serve to legitimize that the government does not take comprehensive action towards the implementation and evaluation of gender mainstreaming policies. This is, for instance, obvious in a governmental statement in response to criticism from the Green Party on a lack of gender mainstreaming in DMPs (Deutscher Bundestag, 2007). This statement stresses that, from the viewpoint of the government, there is no need for action because gender mainstreaming has already been introduced in the DMPs. DMPs mark a major effort towards improving standardization and quality of care for chronic conditions (Greß et al., 2006; Kuhlmann, 2006). First, the programme agreements are strongly based on evidence-based policy-making and the Federal Committee regularly reviews available information, including gender-sensitive data, and updates guidelines; second, DMPs attempt to put users first, thus taking account of individual demands. This statement is in line with the network-based governance structure and delegation of power to public law institutions. However, while the government increasingly takes an interventionist stance in health policy, it has not taken over responsibility for gender mainstreaming.
In this situation, the opportunities are shaped by the pillarized configuration of SHI care and negotiations on meso-levels of organizations and self-governing professional bodies. An important weakness of these network-based governance arrangements in Germany is a lack of coordination between different institutional actors and strategies (SVR, 2009), and this may also cause instability of successful mainstreaming practices.
England
In England, by contrast, the concept of gender mainstreaming as applied at the European level is − on first glance − missing from the policy agenda. This may be an effect of an overall stronger resistance against integrated tools of European social policy in England, and more generally in the UK, and not necessarily a sign of missing initiatives. Moreover, attempts to improve gender sensitivity have mainly been submerged within equality laws with increasingly different strategies in England and Wales, Scotland and Northern Ireland. This approach was dominant from the start and increasingly shapes present policy.
The NHS Constitution stipulates that the NHS provides a:
. . . comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population. (DoH, 2010a: 3)
The Government Equalities Office (GEO), a unit within the Home Office, operates across government and takes the lead on issues relating to women and gender equality, sexual orientation and transgender equality matters. Under the Labour government, in April 2007, a new statutory public sector ‘Gender Duty’ was introduced as part of the 2006 Equality Act (EOC, 2006). Defined at the time as the biggest change in sex equality legislation in 30 years, it brought into force new regulatory bodies taking forward a policy of centralized governance and the ‘merging’ of gender into a broader framework of the reduction of social inequalities. However, a recent analysis on behalf of the Equality and Human Rights Commission (EHRC, 2011a: 7) raised ‘serious concerns’ about the performance of the equality duties. The large majority of the Strategic Health Authorities and Primary Care Trusts studied had failed to set clear gender objectives, and inequalities arising from gender differences were unaddressed. The report revealed that very little attention was given to the crucial issue of how the duties were, or were not, achieved in practice, with most engaging in tick-box exercises. Interestingly, there are no signs of systematic linkages between the ‘gender duties’ and other forms of ‘duties’ defined by compulsory health policy programmes, such as for instance the National Service Frameworks (NSFs).
The new and most recent Equality Duty, brought into force in April 2011 (under the Equality Act of 2010) by the Coalition government, which came into office in May 2010, replaced the existing specific race, disability and gender equality duties (EHRC, 2010). Those subject to the Duty, such as the NHS, are, among other things, in the exercise of their functions, expected to have due regard to advance equality of opportunity between people who share a ‘protected characteristic’ and those who do not. Although, within this Act, sex is a ‘protected characteristic’ (EHRC, 2011b: 43), the potential visibility accorded to gender under the old Gender Duty disappears. Moreover, government equality strategy turns attention away from potential discrimination based on group characteristics, towards individuals. Thus, the recent equality strategy ‘sets out a new approach to equalities, moving away from identity politics of the past to an approach recognising people’s individuality’; rather than ‘treating people as “equality strands”’, emphasis is given to ‘recognising that we are a nation of 62 million individuals’ (Equalities Office, 2010: 6, 8).
When comparing the gender policies in our two countries, different policy discourses of ‘mainstreaming’ in Germany and ‘equality/diversity’ in England come into view. Interestingly, however, in both cases, a discourse of ‘individualization’ and user demand serves the government to outflank more systematic and complex gender mainstreaming efforts. In the next section we further explore how these policy discourses translate into practice.
Tracing the translation of gender mainstreaming in healthcare systems
One of the key characteristics of the gender mainstreaming concept is the close linkage with sector-specific developments and policy reform. Over recent years, both countries have faced significant transformations in their governance arrangements (Table 1). In the centralized NHS, hierarchical governance is increasingly complemented with more plural stakeholder arrangements, mixed forms of public–private funding and an overall extension of governance practices towards the level of local organizations (for example, healthcare trusts). This will be taken further, if the Coalition reforms proposed currently going through parliament (DoH, 2010b) become law. In Germany, we can observe opposite trends with an increasingly more interventionist state and direct steering efforts in a decentralized system of public law institutions (Kuhlmann and Allsop, 2008).
Governance arrangements in the UKa and Germany.
For the UK this characterizes the overall regulatory framework but takes devolution into account. Note that the focus of our empirical analysis in on England.
Source: Modified from Kuhlmann and Allsop (2008).
Our case study material reveals that the institutional arrangements of the two healthcare systems do not easily predict the outcome of policy transfers when it comes to mainstreaming gender. As mentioned previously, we have chosen from among the most comprehensive policy programmes in the two countries aiming at standardization of services for an in-depth exploration: the implementation of National Service Frameworks (NSFs) which ran between 2000 and 2010 in England, and Disease Management Programmes (DMPs) in Germany. Specifically, our focus is on healthcare services for people with coronary heart disease (CHD) because this area has been the subject of considerable interest regarding the relevance of gender. Both NSFs and DMPs introduced a number of new managerial procedures that can easily be connected with the implementation of gender mainstreaming approaches, as outlined, for instance, in numerous guidelines provided by the European Union and WHO (Abdool et al., 2010; Klinge, 2010; Lin and L’Orange, 2010). The two country examples allow for a comparative approach because they follow similar goals, the monitoring procedures were introduced at a similar time and a gender assessment report exists also for both countries (Doyal et al., 2003; Kuhlmann, 2004). Looking at ‘most similar cases’ helps us to better understand the factors that further divergent trends.
The limitations of policy transfer: The case of coronary heart disease care
Across countries CHD care is one of the most dramatic examples of the negative impact of ‘male-bias’ in healthcare systems (Nature, 2010). ‘Masculinities’ shape all areas of care from CHD prevention to clinical care and rehabilitation, and also medical and public health research and the attitudes of patients and citizens. This mainly neglects women’s healthcare needs but may also impact negatively on men who do not seem to fit the model of ‘hegemonic masculinity’ (Riska, 2010). Although age differences between men and women suffering from CHD are important, they do not explain gender differences in outcomes.
To give only some examples: with reference to the UK, women are under-represented in cardiac rehabilitation. The British Heart Foundation (2010) reports that, if men and women were taking part in rehabilitation in proportion to the case rates for heart attack, we would expect there to be 63% men and 37% women. However, women made up 32% of referrals but only 26% of participants. The report estimates that if the uptake rate for rehabilitation had been equal, another 3500 women would have benefited from rehabilitation in 2008–2009 (see Kuhlmann, 2004, for similar results in Germany). There is now accumulated evidence that physicians are less likely to recognize the clinical signs of CHD in women; standard diagnostic procedures and drug therapies are less effective in the group of women compared to men; and women may receive angiographs and cardiac surgery less seldom than men, although such interventions vary significantly between countries and there is no uniform pattern of gender differences (Bönte et al., 2008; Kuhlmann, 2004).
In establishing standardized programmes, such as the NSF and DMPs for CHD, both countries intended to provide clear guidance and standards, thereby reducing unwarranted variation in services, among other things. However, they broadly neglected existing research into gender-based bias in healthcare, thus failing in the goal of providing guidance for professional performance. The NSF on CHD (DoH, 2000) in its opening pages recognized that rates of CHD vary by social circumstances, gender and race, but as Doyal et al. conclude ‘there is no discussion of how these variations should be reflected in preventive or curative care’ (2003: 27). These authors were able to demonstrate evidence of gender differences and a need for sensitive indicators for each of the 12 standards comprising the NSF.
With respect to the German DMP for CHD, in its first version, even the category ‘sex’ was missing from the key documentation form; this was altered in 2003/2004 and the sex category included in all forms. By contrast to gender-blind policies, in both the German SHI funds and the medical associations there was some interest in gender-sensitive care for CHD and an overall call for more evidence-based information; also, a survey of office-based doctors revealed some support for gender-specific information and care (Kuhlmann, 2004).
Following these early reports and other criticism of gender-blind policies for CHD care and an overall growing body of gender-sensitive research and data, we can observe some transformations in both countries. In England, the need for gender-sensitive CHD care was mentioned and some guidance was provided in the ‘Sectoral Guidance for Health’ from the then Equal Opportunities Commission (now Equality and Human Rights Commission; EOC, 2007). A preliminary review of the annual progress reports on the NSF for CHD by the Healthcare Commission (2007) (since superseded by the Care Quality Commission) did show some signs of improved gender sensitivity, while at the same time the ‘gender-blind’ approach seems to persist. For example, the progress report for 2007 (DoH, 2008) failed to provide male/female breakdowns for most key data. Further, a particularly dramatic decline in premature mortality from CHD for men is mentioned, while a steady and less significant decline for women occasions no comment. The most recent progress report (DoH, 2009) pays no attention to gender at all. This underlines a general trend in the UK, namely that ‘gender inequalities in healthcare’ come second to, or are subsumed under, socioeconomic inequalities which have been considerably higher on the political agenda. Results also point towards insufficient policy coordination and knowledge exchange between different regulatory bodies that must be explored in further research.
In Germany, information on CHD risks for women and prevention has significantly improved in all stakeholder groups. Indeed, there are a number of ‘good practice’ examples, such as, for instance, the development of a gender-sensitive evidence-based guideline for CHD rehabilitation by the medical profession (Rauch et al., 2007) and gender-sensitive health reports (RKI, 2007). At the same time, there are also clear signs of resistance and continuing ignorance. Thus is, for example, obvious in the assessment of the DMP for CHD and recommendations for change by the Institute of Quality and Efficiency in Healthcare (IQWiG, 2008). Despite the growing body of literature that reveals ‘evidence’ of gender differences in CHD care, IQWiG has not adopted a clear gender mainstreaming policy and, much like the NSF progress reports, this report demonstrates gender blindness and male-bias in CHD care.
Taken together, neither NSFs in England nor Germany’s DMPs have systematically integrated gender mainstreaming approaches. Neither country has developed any systematic policy and monitoring approach of the implementation of gender equality in the major regulatory bodies and the new agencies of public control.
The case study material points towards similar weaknesses in policy transfer of an international model of gender mainstreaming in the more centralized NHS system in England as well as in the decentralized, corporatist German system. Both healthcare systems have failed to adequately link their new managerial tools with the goals of gender equality, as the concept of mainstreaming would require (WHO, 2002, 2011). Furthermore, women, in general, are heavily under-represented in the key regulatory bodies and this reduces the chances that feminist players are directly involved in the macro-level of health policy-making.
Exploring gender mainstreaming through the lens of policy transfer has serious limitations, however. Our case study material illustrates that from this perspective we can explore macro-level mainstreaming and policy outcomes but easily lose sight of the wider translations of an international concept that may happen further down the lines of the policy process, and that may even transform the concept itself.
How policy translation matters
The top-down approach of mainstreaming may face various different forms of translation on its way into practice. Here, the institutional arrangements of the two healthcare systems and the position of feminist and other actors come into play.
To begin with, corporatist governance is usually identified as a barrier towards innovation and the main reason for the overall ‘slow motion’ in Germany’s healthcare system (for an overview, see SVR, 2009). However, there are also some interesting examples of ‘good practice’: for instance, the Robert Koch Institut − a quasi-governmental institution responsible for health statistics and reports in Germany − has introduced clear gender mainstreaming policies and developed standards for gender-sensitive data collection and reports (RKI, 2007).
Furthermore, within the context of a major merger of hospitals, gender mainstreaming approaches were introduced as a means of competition for both qualified staff and high quality care for patients (www.klinikum-muenchen.de/unternehmen/chancengleichheit/gleichbehandlung/). Overall, hospitals increasingly present themselves as ‘women-friendly’ and ‘family-friendly’ employers in order to attract qualified staff, especially women doctors, and this is supported by governmental action (BMFSFJ, 2009). In a similar vein, a large sickness fund has adopted mainstreaming policies; this includes gender-sensitive patient information and specific actions for women as well as attempts towards improving gender equality within the organization. Thus, in a competitive climate of healthcare systems different corporatist actors may refer to gender mainstreaming, using certain elements of this concept as a ‘market tool’ to attract women as both clients and staff members.
A further example is the inclusion of gender research in the development of a clinical guideline for cardiac rehabilitation (Rauch et al., 2007); here, too, change in the wider healthcare system, like the introduction of new measures of performance, served as an avenue of gender mainstreaming into the practice of healthcare. Added to this, within the medical profession mainstreaming is also supported by various efforts by the Women’s Physician Association. Importantly, in all these cases, feminist actors (either women or men supportive of feminist approaches and gender-sensitive healthcare) played a major role in the policy process and were in leadership positions.
In England, the spur to increased visibility of gender issues within healthcare held out by the Gender Duty (Zalewski, 2010) has dissipated with the new more ‘inclusive’ and individualized approach to equality embodied in the Equality Act of 2010. The relative lack of direct interest by centralized regulatory bodies in gender leads to missing connections between the different levels of governance, and the various stakeholders involved seem to be the major hurdles for the diffusion of the new gender policies and monitoring of their implementation. However, the recent emphasis on third sector engagement, shared by the prior Labour government and present Coalition government, provides at least a potential open door to influence and hence policy translation. The charity Men’s Health Forum, formed in 2001, became a national voluntary sector partner to the Department of Health for three years in 2009/10; and the Women’s Health and Equality Consortium (WHEC) (a network of six partners), which formed in 2008 expressly in response to the Department of Health’s call for strategic third sector partners, became a partner in 2010/11.
Both organizations have responded to the proposed changes to the NHS (DoH, 2010b) from a gender perspective (MHF, 2010; WHEC, 2011). Each expresses general support for the emphasis on greater patient choice in the provision of care, but emphasizes that more attention needs to be given to the health of men (MHF) and women (WHEC). WHEC (2011) points out that patient choice alone will not reduce the gap in health inequalities due to the barriers to access faced by women such as those associated with inequality in power and resources, knowledge of their rights and caring responsibilities. Thus WHEC argues for attention to be directed to barriers as well as choices. MHF takes as its starting point the ‘disadvantage’ of men in relation to women which, it is argued, is reflected in their less frequent use of health services and taking of preventative actions. This reflects the common approach by men’s health activists of advancing the cause of men’s health by comparisons to women, who, more often than not, are presented as better off (Wadham, 2002).
Thus, in comparison to Germany, ‘mainstreaming’ is far less evident in England. Central government equality policies bestow certain equality duties on NHS institutions, but provide minimal steer on how they should be met or the approach that should be taken towards progress monitoring. Recent evidence raises serious concerns about equality performance (EHRC, 2011a; see also Annandale et al., 2007).
Conclusions
This article has attempted to explore gender mainstreaming policies through the lens of policy transfer. We have introduced the concept of policy translation and have suggested ways for how this concept might be applied to empirical research. Some conclusions drawn from our scoping review suggest several different things. Our study highlights the relevance of institutional configurations and governance arrangements of healthcare systems that create varieties of a global template of gender mainstreaming, even if the concept itself is not common currency, as in England.
In the German case, gender policies unfold within the decentralized, network-based framework of Statutory Health Insurance (SHI) care. In this situation, bottom-up alliances between different policy players and certain organizational interests are more likely to activate the transformative potential of gender mainstreaming than is top-down governmental action. Consequently, strong feminist or women-friendly actors in leadership positions of the respective institutions, organizations and medical associations are crucial. Here, the corporatist governance arrangements embody opportunities for policy entrepreneurs acting beyond the macro-level of politics. These lower levels of policy-making in organizations and associations may be more permeable for women and/or feminist actors in leadership positions who then make a difference in the translation of gender policies, as illustrated by the examples of ‘good practice’.
By contrast, in England regulatory frameworks generally are becoming more plural with the state acting as a ‘navigator’ of the organization and delivery of care. However, hierarchical governance remains strong but does not appear to be adequately linked to the more plural subordinate tiers. In this situation, to have transformative potential, gender equality policy, such that exists, needs strong policy players in governmental bodies and increasingly competes with other groups also claiming public support for their interests. The emphasis of recent governments on third sector engagement provides a potential route of influence for policy translation on the part of voluntary sector groups at national level, though a division into men’s and women’s health lobbies may inhibit the development of shared policy objectives. Such competition is overall weaker in Germany and activities are more focused on gender inequality and specific issues of women’s health, while in England men’s health is increasingly promoted and, beyond specific issues such as maternity care and maternal child health, women’s healthcare issues are less evident on the policy agenda.
A comparative approach helps us to better understand how the governance arrangements of healthcare systems create (or block) specific ‘windows of opportunity’ for feminist and other actors, thereby modelling policy translation. Consequently, there is a need for context-sensitive approaches into gender mainstreaming that take the importance of actors into account and that connect macro- and meso-/micro-levels of gender policies in healthcare (Annandale and Kuhlmann, 2012). Our analysis furthermore reveals more general problems of ‘global’ policy-making that challenge the assumption of policy convergence and, instead, turn the spotlight onto the complexity of policy transfer and the various forms of translating ‘global’ policy into ‘local’ action.
Footnotes
Acknowledgements
Earlier versions of this article were presented at various conferences, including the 2010 ISA Conference in Sweden. We wish to thank our colleagues for discussions and comments, especially Ivy Bourgeault, Viola Burau and Sirpa Wrede. We are also very grateful to our key informants in both countries.
Funding
Funding support was provided by the Department of Sociology, University of Leicester seed grant scheme.