Women’s Health: An International Comparison

Compared to men, women experience a greater variety of acute physical and mental changes during different life stages. For this reason, many countries have created comprehensive frameworks to support women’s health and active social participation, and health policies anchored in an awareness of gender differences that make the case for the promotion of women’s health and gender equality. Below, we compared the situation in Japan to precedents from the United States and Europe.

• Japan

The fact that the promotion of women’s health contributes to the economy has now been scientifically established. It is hence necessary to formulate health policies that aim for a society where women enjoy good health irrespective of their life stage.³ “Women’s health” was a pillar of the New Health Frontier Strategy announced by the Government of Japan in April 2007. In March 2008, the Ministry of Health, Labour and Welfare (MHLW) designated the first week of March as “Women’s Health Week,” to be observed yearly. During this week, regional municipalities are encouraged to undertake various projects to support women’s health, centering on awareness-raising efforts. The decision by MHLW to create this week was part of a comprehensive set of initiatives aimed at supporting women to achieve good health, become self-reliant, and enjoy bright and fulfilling lives.⁴ In 2009, 3.5 billion yen was allocated to commission projects that benefit women’s health, such as projects for preventing osteoporosis and uterine cancer. Prefectural and city governments were entrusted with the implementation of these projects, and were urged to research effective project development and verification methods. Such activities are assumed to have promoted disease-based health policymaking.⁵

On the other hand, since the psychological and physical conditions of women change greatly depending on their life stage, there has also been active discussion on the shortcomings of disease-based measures and the importance of providing comprehensive support to women’s health throughout their lifetime. Based on these discussions, the “Bill on Comprehensive Support for Women’s Health” was submitted to the Diet in 2014. As of August 2017, the bill has not yet been passed.^6,7 The passage of this bill is expected to help spread awareness of issues related to gender differences, ageing, and life stages. The law is also expected to stimulate research and countermeasures related to female-specific diseases, the large of number of women suffering dementia and osteoporosis, and the difficulties that many women face from their employers when they marry or become pregnant.

“Bill on Comprehensive Support to Women’s Health” (Liberal Democratic Party’s Website) http://www.shugiin.go.jp/internet/itdb_gian.nsf/html/gian/honbun/houan/g18602027.htm

• United States of America

In the U.S, comprehensive support initiatives for women’s health started a long time ago. In 1991, the Office on Women’s Health was established as a government agency with the mission of promoting comprehensive support for women’s health. Among other activities, the Office keeps statistics on increases in women’s life expectancy, improvements in breast cancer screening rates, and female participation in clinical studies.⁸ The Office’s activities center on research, prevention, the provision of healthcare, training of health personnel, and supporting the careers of women in the health and science fields. Based on these activities, the Office provides support to policies and campaigns dealing with different life-stages, trauma care, HIV/AIDS, violence, and health disparities.⁸

In 2010, the Obama Administration passed the Patient Protection and Affordable Care Act (ACA). This Act greatly improved women’s access to healthcare, and reduced out-of-pocket expenditures by extending health insurance coverage. For example, insurance coverage requirements widened to cover preventative measures against diseases generally affecting women, particularly complete psychological and physical care for issues affecting pregnancy such as the prevention of all types of STDs, medical examinations for anemia, smoking and domestic violence related issues, and counseling for contraception.⁹

The effects of the ACA and state legislature were alluded to in a planning report titled “Improving Women’s Health: Health Challenges, Access, and Prevention.” This led to further awareness-raising about issues of health and to policy and policy changes. For example, based on the line of thinking that “Promoting good health among women not only contributes to the wellbeing of women, but also to the wellbeing of their families, and eventually , to the wellbeing of state and national finances,” many states have launched health programs targeting women, including initiatives on early case detection and diagnoses of dementia, the administration of HPV vaccines to adolescent girls, and awareness-raising campaigns on the prevention of non-communicable diseases.¹⁰

• Europe

“Respect for basic and human rights” is one of the fundamental principles upon which the European Union (EU) was established. This principle was behind the creation of the Lisbon Treaty, which came into effect in 2009. This treaty granted legally binding powers to the EU Charter of Fundamental Rights and set out requirements for the prevention of gender discrimination and for gender equality in all sectors.¹¹ That said, since the EU has not developed region-wide policies on health and education systems, variations exist in these sectors among member states at the present time. The EU, however, has previously stated that health differentials between men and women must be considered when creating policies. What’s more, EU-related organizations are active in research on women’s health, and the health disparities that exist between men and women. A report of the European Institute for Gender Equality (EIGE) entitled “Data and Information on Women’s Health in the European Union” laid out the main social and biological determinants of health disparities between men and women.^12,13

In response to this report, in 2006 the Council of the European Union declared that it is imperative to reduce gender-related health disparities. In 2010, the Council called for the creation of policies and action plans on the optimization and collation of data and knowledge related to the reduction of health inequities. The Council also called for further efforts to secure healthcare access for all – including children, youth, and pregnant women – and to implement preventative measures that gave due consideration to the social determinants of health.¹⁴ In 2011, the European Parliament approved a bill that emphasized the extent to which gender inequities and economic reasons contribute to disparities in access to healthcare.

The Council of the European Union report entitled “The Report on Sexual and Reproductive Health and Rights” highlighted existing best practices in member states and pressed for further awareness-raising activities. For example, under “The Equality Act 2006,” all public institutions in the United Kingdom are to introduce the “Gender Equality Duty.” The Duty urges medical institutions to provide services fairly regardless of the recipient’s identity or nation and region, and to ensure that health outcomes do not differ between men and women¹⁵.

Screening rates for cancer in Japan are lower overall compared to other developed countries. The screening rate for diseases specific to females is particularly low. In this section, we compare the reasons behind elevated consultation rates in other counties and discuss efforts to improve rates in Japan.

• Japan

Despite cancer being the leading cause of death for both men and women since 1981, the goal of achieving a 50% cancer screening rate during the 2012 to 2016 period, as set out by the Government in the “Basic Plan to Promote Anti-Cancer Measures,” was not achieved for either men or women.¹⁶ The rates of screening for breast and cervix cancers are low, in the 30% to 40% range according to a survey conducted in 2013.¹⁶ This state of affairs prompted the Government to start the distribution of “free screening” coupons for cancer screenings (for cancers of the cervix, breasts, and colon) and “screening notebooks” containing easy to understand explanations about cancer to people in eligible age groups (cancer screening is undertaken by municipalities and special wards. Information about cancer screenings differs depending on the municipality).¹⁷

According to a survey on promoting the health of working women conducted by HGPI in 2016, the reasons that women listed for not undergoing screening included: “I feel screening is unnecessary because I am healthy” (about 50%), “I have an aversion to hospitals” (about 30%), “I am busy at work and/or home” (about 25%).¹⁸

Further education and awareness-raising activities related to prevention and early case detection are needed. Incidentally, since breast cancer cases are handled by breast cancer oncology departments, while other cancers are handled by gynecology departments, he requirement to visit separate departments can pose a heavy hurdle to women in terms of time and finances. Accordingly, workplaces should offer women financial support and leaves of absence for medical examinations as a way to promote screenings.

• United States of America

In the U.S, the rate of cancer screening is high. According to a 2006 survey conducted by the Organization for Economic Co-operation and Development (OECD), the rate of screening for cancers of the breast and cervix exceeded 80% among the target population.¹⁶ This shows that screening promotion supported by legislation as well as private insurance companies yields results. After the introduction of ACA, the scope of health insurance coverage for breast cancer screening expanded.⁹

• United Kingdom

Screening rates in European countries overall range between 60% and 80%. It is common for many households to encourage girls to visit gynecological departments as early as their teenage years. Sex education is also commonly offered in school. It is thought that these reasons, taken together, contribute to the high screening rates.¹⁶ According to the aforementioned 2006 survey by the OECD, screening rates for cancers of the breast and cervix in the United Kingdom exceeded 70% that year.¹⁶ Following a National Health Service’s (NHS) policy, a notice recommending consultations was sent to everyone with a registered General Practitioners (GP), which pushed screening rates even higher.

• South Korea

Thanks to policy changes, South Korea has successfully improved cancer examination and screening rates in recent years. In 2004, screening rates for breast and cervix cancers hovered around 30% and 50% respectively, which are numbers similar to the low rates seen in Japan. However, in 2011, screening rates for breast and cervix cancers improved to 71% and 67.9% respectively.¹⁹

This trend was not restricted to cancers specific to women. Similar trends have been observed in screening rates for cancers common to men as well. The factors driving the improvement are screening promotion measures that targeted individuals, such as the establishment of the call and recall system (by which multiple calls and letters were sent out to individuals to urge screening), and the dispatch of consultation tickets by insurers to all insured individuals. South Korea stabilized its national finances, and implemented measures that helped to alleviate the burden of medical expenses caused by cancer screenings (the South Korean Government offers financial support for cancer screenings and treatments). It is also thought that the relatively small financial burden of medical screening compared to medical treatment and the limited scope of support for cancer treatment from public health insurance spur people to undergo medical screening.^19,20,21

In Japan, male condoms are the most common method of contraception, accounting for 46.1% of contraceptive use in 2015. On the other hand, the usage rate of low-dose birth control pills stood at a low 1.1%,²² a striking figure when compared to the global average usage rate of 19.2% and Europe’s rate, which hovers around 40%.²²

Low-dose birth control pills were approved for use in Japan in 1999, 25 years later than the United States. At the time of their approval, there were concerns that the pills would encourage the quick spread of HIV/AIDS and other sexual disorders. There was also much apprehension about using drugs for hormone control. These opinions caused a delay in the approval process compared to other developed countries.²³ However, low-dose birth control pills are not only capable of ensuring a nearly 100% rate of contraception, they also provide women with the ability to take independent control of contraception, as well as to control menstrual cramps and the amount of menstrual blood loss. They hence greatly contribute to improving women’s quality of life. Currently, those wishing to use low-dose birth control pills in Japan are required to receive a prescription from a doctor. However, elsewhere, low-dose birth control pills are commonly available as over-the-counter (OTC) medications in about 70% of the world’s 147 countries.²⁴ Because low-dose birth control pills are not covered by insurance, the price of a pack typically costs between 2,500 to 3,500 yen, and must be borne entirely by the user. The high cost of pills in Japan compared to Europe (where the price is about 10 euros, with some variations between countries depending on conditions such as total pill price covered by insurance) is thought to be one of the main factors limiting access to pills.

With regard to emergency contraceptives, such pills can be bought as an OTC medication in over 80% of European countries. In France and the United Kingdom, it is possible to purchase emergency contraceptives starting from a price of around just 7 euros.²⁵ School nurses in France have offered emergency pills since 2001 as a last resort measure to improve access to emergency contraception for the purpose of preventing unwanted underage pregnancies.²⁶