Analysis of Women’s Health Strategy for England Public Health Policy

Introduction

According to the World Health Organisation, health is mostly described as a state of complete physical, mental, and social well-being, and does not just imply the absence of infirmity or disease. Health policy on the other hand according to Blank and Burau (2017), can be described as a set of plans, decisions, and actions implemented by institutions, governments, and organisations to improve and protect the health of a population. According to Buse et al, (2012), health policy embraces courses of action (and in some cases inaction) that affect the set of services, funding, institutions, and organisations within the healthcare system. In England, the Women’s Health Strategy for England public health policy is a 10-year policy that has been crafted to protect, improve, and advance health outcomes for girls and women across England. The Women’s Health Strategy for England’s policy is the first ever government-led public health policy that is aimed at improving the healthcare of girls and women in the country. Amongst several other issues, the Women’s Health Strategy for England’s promises significant research on women’s health issues , training doctors to provide specialised care to women, and increase understanding of female-specific health problems that make it hard for girls and women to get the best healthcare. The health policy also promises significant funding of women’s health issues including advanced breast cancer screening.

The purpose of this assessment is to analyse, through an appropriate framework, the Women’s Health Strategy for England’s health policy. According to Collins (2005) and Dunn (1981), health policy analysis focuses on the outcomes of the health policy and how the policy is impacting the people. In conducting such analysis, Dunn (1981) describes five fundamental stages that include definition, prediction, presdescription, description and evaluation. While there are several policy analysis frameworks, Bardach’s (2012) eight-step approach and Bacchi’s (2009) critical policy analysis framework are often used in public health analysis. The current assessment applies Bacchi’s (2009) critical policy analysis framework to analyse the Women’s Health Strategy for England’s health policy. The rationale for choosing to apply Bacchi’s (2009) critical policy analysis framework to analyse the Women’s Health Strategy for England health policy is three-pronged.  First, Bacchi’s (2009) framework uses a robust methodology that is based on multiple theoretical and multidisciplinary perspectives not available in other frameworks. With this robust methodology, the analysis will come up with outcomes that best explain how the problem is represented in the chosen health policy and how such representation impacts girls and women. Next,  Bacchi (2009) focuses on analysing how the problem has been represented in the policy and the underlying assumptions in this problem representation, and this is vital to the chosen policy because it allows the analysis to focus on how women’s health in England has been neglected. With such a problem representation focus, it lays the foundation for demonstrating the anticipated outcome of the policy and how girls and women in England will be involved in such change. Thirdly, Bacchi’s (2009) WPR framework fits the chosen policy because it goes deeper into critically evaluating gaps in the policy debate by asking what remains un-problematised in how some areas have been represented.

Background to Women’s Health Strategy for England

About 51% of the UK population faces barriers when it comes to accessing the care, they need despite the significant progress that has been made towards strengthening the country’s health and care systems (Ekezie et al., 2022 & Carbonell, Navarro‐Pérez, and Mestre, 2020). Sambrook Smith et al. (2019) further demonstrate that women bear a significant burden of the currently existing barriers to care, with the problem being more pronounced for specialised treatment like chronic problems, mental health, and the reproductive system. In areas like maternal health, Grand-Guillaume-Perrenoud, Origlia and Cignacco (2021) demonstrate that women from socially disadvantaged backgrounds face significant barriers that make it extremely difficult to access quality and timely care. A report by the All-Party Parliamentary Group on Women’s Health recently found that 42% of women feel they are not treated with respect and dignity when accessing care, while a worrying proportion of 62% are not satisfied with the information and treatment they get on reproductive health problems like endometriosis and fibroids (All-Party Parliamentary Group on Women’s Health, n.d). While women in the United Kingdom have longer life expectancies than men, they spend more time being ill-health and disabled compared to their male counterparts, and this has been linked to less focus being placed on specific health issues that affect women like menopause and miscarriage (Gulland, 2017). Furthermore, since women’s voices are not heard based on available evidence that informs policies on women’s health, there is an urgent need to bridge these gaps (Ockenden, 2022).

Part of the problems that contributes to the barriers that exist in the healthcare system that make it hard for women to access quality and timely care is male domination of the system (Gulland, 2017). According to Ockenden (2022) and the Department of Health and Social Care, the “male as default” dimension is seen in the healthcare system through research and clinical trials, education, and training for health professionals and how healthcare services and policies have been designed. Because of male domination of the healthcare system, there is scanty research to inform evidence and decision-making regarding specific issues that only affect women, and hence the access gaps are widened. Through analysis of data collected on women’s experiences at varied stages of their interactions with the UK healthcare system, they cited their voices being unheard and getting inadequate information (Department of Health and Social Care, 2022). The negative impacts that certain women’s health issues like menstrual bleeding or fertility treatment have also negatively impacted their participation in the workplace and their daily lives. The policy adopts a six-point plan which aims at boosting the health outcomes for all women and girls in England, and radically improving how the care and health systems listen and engage with women and girls and is set to be implemented within ten years.

Women’s Health Strategy for England Policy and Landscape

The Women’s Health Strategy for England policy aims to boost the health outcomes for all girls and women and radically improve how the healthcare system in the United Kingdom listens to them and engages them. The problem identification in the policy formulation was robustly conducted. To identify the potential problems and barriers that hinder women’s access to quality and timely care in the United Kingdom, a public survey targeted women aged 16 years and above was conducted. At the same time, qualitative evidence was gathered through written submissions by organisations working with women’s health and through focus group discussions with multiple women and women’s groups implemented by the University of York and King’s Fund. The policy centers on women’s access to quality and timely health, and therefore directly linked to access to healthcare and its quality as a social determinant of health. According to Levesque, Harris, and Russell (2013) access to health and its decent quality as a social determinant of health has four main domains (a) coverage, (b) services, (c) timeliness and (d) workforce. The analysis provided by the Department of Health and Social Care regarding the health policy demonstrates that because of a combination of all four dimensions, women are not accessing quality healthcare, hence reinforcing access as the social determinant of care.

Through the feminist social theoretical construction, the health policy has demonstrated that social structures that exist in the United Kingdom have contributed to women’s access to quality care being sufficiently difficult. According to Rose and Hanssen (2010) and Turner and Maschi (2015), the feminist social theoretical approach is built on challenging the existing social structure that is considered to be highly male-dominated and hence limits the participation and engagement of women. The health policy therefore adopts the intersectional approach in highlighting how men have dominated the healthcare system in England and how such domination has created huge bottlenecks and barriers that make it hard for them to access quality and timely care. According to Carastathis (2014), the intersectional dimension of feminist theory is based on how the social identities of individuals can overlap, hence creating compounding experiences of discrimination. Based on how the policy has been constructed, male domination of the UK health system significantly features as a foundational contributor to the barriers that make it difficult for women’s voices to be heard, for them to access healthcare services and for them get high-quality information that complements their treatment. The policy is designed to be implemented under the Health and Care Act of 2022 with significant powers bestowed upon the NHS and the cabinet minister for the department to institute changes elucidated on the policy.

Policy Analysis

Bacchi’s (2009) critical policy analysis framework starts from the position that problems are not given, but rather are social constructions. She focuses on problematisations (instead of problems) and the role they play in the governing processes. Her questioning approach is described as the WPR approach in which a set of six questions guide the practical and critical analysis of the given policy. The six questions are listed as:

1. What is the problem represented to be in a specific policy?
2. What presuppositions or assumptions underline this representation of the problem?
3. How has this representation of the problem come about?
4. What is left unproblematic in this problem representation? What are the silences? Can the problem be thought about differently?
5. What effects are produced by this representation of the problem?
6. How/where has this representation of the problem been produced, disseminated, and defended?

These questions are applied to three policy measures of the Women’s Health Strategy for England policy.

Promoting Mental Health and Well-Being of Women

The WPR framework starts by asking how the problem has been represented in the specific policy or policy measure. The problem is represented as an expensive and inadequate mental healthcare system that fails women from low-income backgrounds, minority ethnic groups and women who have experienced domestic abuse, homelessness, and addiction issues. Such problem representation is underlied by the disparities between mental and physical health access, and this has come about due inadequate providers and professionals in the mental health space who can improve access. Available evidence supports this problem representation and how it comes about since mental health does not receive the same attention as physical health. According to Kmietowicz (2005) and Das, Naylor and Majeed (2016), most healthcare systems, including that in England, do not prioritize mental health as they do physical health. Further, huge disparities exist in accessing mental health care. Women from minority ethnic groups, low-income groups, those with addiction issues, homeless or those experiencing domestic abuse face significant barriers to accessing mental healthcare (Lowther-Payne et al., 2023; Levesque, Harris and Russell, 2013 & Asthana et al., 2016). Asthana et al. (2016) found that only 1 in 3 adults in England can access the quality and timely mental healthcare that they need, and the situation is even worse for women in minority groups or those from low-income neighbourhoods. Further, inadequate government funding and investment in proper mental health services in England underlies how the problem is represented.

If implemented correctly, the policy measure is likely to benefit all women in England from both the medical and psychological perspectives, but more so those from low-income groups, from minority ethnic backgrounds, and other vulnerable groups like those going through domestic abuse, battling addictions and homelessness. There are significant actions directed at improving access to mental healthcare for women in England. For example, the planned expansion and transformation of NHS mental health services by £2.3 billion in the current fiscal year will make mental health services easily accessible to women. Furthermore, the Women’s Mental Health Taskforce has helped in reducing disparities, providing safer and gender-focused inpatient care and training health professionals on gender and trauma-informed care. From the financial dimension, the implementation of this policy change is based on how the problem has been represented mostly around boosting the lives of those from low-income neighbourhoods. The significant financial investment of £2.3 billion to the NHS brings more and better mental health services to women from low-income backgrounds. With more victims of domestic abuse and those with housing problems accessing quality mental health care, their quality of life overall improves, hence better socially and hence can contribute to society.

Healthy Aging and Long-Term Conditions

In this policy measure, the problem is represented as England having a healthcare system that does not focus adequately on the healthcare needs and experiences of older women. Because of this specific problem, the healthcare system does not fully understand the differences in the long-term chronic problems that affect men and women, and therefore a generalised approach to solving has always been adopted, something that needs to rapidly change.  This assumption is supported by the existing evidence that shows that men have dominated hospitals and healthcare facilities as researchers, workers, and consultants (Jefferson, Bloor and Spilsbury, 2015 & Regenold and Vindrola-Padros, 2021). For example, Jefferson, Bloor, and Spilsbury (2015) demonstrate that more men are employed in the UK health system than women, reinforcing the concept of male domination in the system and therefore the voices of women are not heard as was found in the call for evidence in the construction of the policy. Further, how this problem is represented impacts the level to which women can get information on healthcare problems that plague them.

Significant milestones have been achieved towards promoting healthy ageing in women based on the policy. Working with different organisations like Women’s Health Ambassador, there has been significant awareness creation of risk factors for cancers and long-term conditions. Evidence shows that cancers and long-term conditions like cardiovascular disease and diabetes reduce women’s quality of life and life expectancy, and therefore channelled efforts in these areas are yielding fruits (Li et al., 2020 & Wang et al., 2023). Milestones in promoting healthy lifestyles aimed at addressing long-term conditions include 5 million downloads of the Couch to 5K application aimed at promoting physical activity, £30.5 million invested in adult weight management, reduction of smoking in pregnant mothers by 1.8% since 2020 and the NHS Health Check that will see prevention of 150,000 heart attacks in England (Department of Health and Social Care, 2022). According to the study conducted by Li et al. (2020), promoting healthy lifestyles like reduced alcohol consumption and smoking, physical activity and better dieting reduces the risk of long-term and chronic conditions that make it hard for women to enjoy quality life in old age. Socially, the investments being made in healthy ageing and the management of chronic health problems imply that women can participate in social activities and keep meaningful relationships that improve their quality of life overall. Holmes and Joseph (2011) demonstrate that the management of chronic problems in old age for both men and women improves social participation, hence healthy ageing, and better quality of life. The focus on managing these conditions and promoting healthy ageing also promotes the mental and emotional well-being of these women.

Reducing Health Impacts of Violence Against Women

Under this thematic area, applying the WPR framework represents the problem as a lack of awareness and adequate information regarding specialist services offered to women who experience different forms of violence.  The public survey conducted as part of evidence collection revealed that only 9% of women respondents indicated that they were aware and had adequate information concerning specialist services like female genital mutilation and sexual assault referral centres (Department of Health and Social Care, 2022). The policy highlights that the health impacts of abuse and violence like domestic abuse are wide and expansive and have monumental physical and mental health impacts on the affected girls and women. The way this problem is represented can be supported by available research that shows fewer women have information on specialist services when they experience abuse and violence (Colombini et al., 2013 & Panovska-Griffiths et al., 2020). In two London boroughs, for example, Panovska-Griffiths et al. (2020) found that women delay seeking care for domestic abuse-related cases because they lack adequate information or awareness on where to get help. Silva et al. (2022) also found that women’s lack of knowledge and perceptions on the role of HCPs are barriers towards seeking care after IPV.

The assumptions underlying the representation of this problem are three-pronged. First, healthcare professionals do not understand and spot signs of domestic abuse to offer the best support for girls and women. Next, women are not aware of and have minimal access to trauma-informed services, and lastly, the design of the healthcare system does not motivate or encourage women to report incidences of abuse. McKinlay et al. (2023) reinforce that unavailable services like were experienced during the pandemic make it extremely hard for victims of abuse and violence to seek care. The net effects of the problem representation can be examined from medical, financial, psychological, and social dimensions. Medically, if this policy measure is implemented appropriately, victims of abuse and violence will receive appropriate health care. More specifically, the policy will focus on preventing and early identification of victims of abuse, and at the sample time, social care is provided to victims of violence.  The social and psychological impacts are monumental. For example, the department is working with NHS England to create safer and more effective processes that support staff affected by violence against girls and women. Further, there is a focus on exploring how victim support services for victims of sexual abuse and domestic abuse can be promoted and enhanced.

Alternative Strategies

First, the choice of actions detailed in the policy does not adequately address governance and leadership as being valuable in improving women’s voices and representation in the healthcare system. According to Yuan et al. (2017), systems of governance and leadership play a vital role in the performance and operationalisation of effective health systems. For example, strong government commitment and will and clear policy goals were found to be at the centre of effective health systems in China. Smith et al. (2012) demonstrate that governance and leadership systems that focus on setting priorities, monitoring performance and accountability are more effective in yielding positive health outcomes. The Department of Health and Social Care is responsible for the implementation of this policy, but clear governance and leadership directions that will guide such a process have not been adequately called out. According to a study conducted by the King’s Fund, the key problem facing all NHS organisations is that they lack cultures that ensure the delivery of high-quality, safe and compassionate healthcare, and this is attributed to a lack of appropriate leadership and governance structures in place (The King’s Fund, 2015). With proper leadership and governance structures in place, there will be direction, alignment and commitment within the teams and organisations that are charged with implementing the policy which leads to effectiveness and efficiency in the achievement of outcomes. Figueroa et al. (2019) further state that since health systems are complex and continuously changing, there is a need to invest in dynamic, flexible, and transformational leadership that will ensure that potential changes likely to be encountered in women’s health needs are countered with proper solutions that are customised and targeted.

The other alternative strategy is to expand universal health coverage in the United Kingdom to bring more people towards receiving care, especially women from disadvantaged communities and groups, or those experiencing inherent problems in their quest to access quality and timely medical care. According to Khan (2023) and Ham (2020), some of the challenges that have affected the NHS include staff shortages, financial inadequacies, patient care backlog, healthcare inequalities and the growing and evolving healthcare needs which cannot be addressed by the existing coverage. During the Covid-19 pandemic, the inadequacies of the NHS were greatly exposed, with the UK experiencing a cute hospital bed crisis due to the underfunding of the NHS. Many patients, especially those from low-income and minority communities have seen their quality of life go down and their life expectancies reduce because the NHS is grossly underfunded (Ham, 2020). Compared to other developed countries like France, Sweden and Germany, the UK’s universal healthcare coverage system is inferior due to underfunding and staffing problems that make it extremely difficult for women to get better health and social care. Robust improvement of the NHS from staff to funding and even adopting a more transformational leadership approach that will end discrimination and bring more people under coverage will ensure that the policy’s desired outcomes are achieved. For example, for women from low-income neighbourhoods and ethnic minorities, ending the discrimination in the NHS and increasing funding will ensure that they access both the physical and mental healthcare that they need.

Summary

The Women’s Health Strategy for England policy is aimed at promoting health outcomes for girls and women in the next ten years with a significant focus on improving the existing healthcare system to be responsive to women’s healthcare needs. Multiple dimensions have been adopted by the policy, all geared towards ensuring that women experience better medical, social, and psychological experiences and outcomes from the improved healthcare system in England. There are massive human, financial and system resources that are being pumped into this 10-year policy to ensure its implementation is successful and that it leads to the desired outcomes. With the strategy implemented well, more women will be brought on board for research and development, be included in offering healthcare services and be consulted on issues that affect women. The biggest problem that this policy seeks to address is the underrepresentation of women and their voices in England’s healthcare system. With its implementation, women’s voices will be heard with healthcare professionals empowered and women’s representation increased to listen to women more. Next, the policy will improve access to services especially those that meet their reproductive health needs. The policy’s approach is also aimed at addressing disparities in outcomes among women, ensuring that factors like sexuality, disabilities, age, ethnicity, and age do not affect their ability to access services and treatment. The other dimensions likely to be positively impacted include information and education, understanding of women’s health and more research and evidence base for women’s health problems. The way this policy is constructed is heavily built on significant evidence gathering on women’s thoughts, opinions, and representations. The public surveys conducted showed that women feel underrepresented in the healthcare system and their voices unheard. With more and better information and education provided to women in England, they will be enabled to get accurate information about their health and increase their understanding of how women’s health affects their experience in the workplace.

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Appendices

Table 1: WPR Framework

Question 1: What’s the problem represented to be in a specific policy or policies?

Question 2: What deep-seated presuppositions or assumptions (conceptual logics) underlie this representation of the problem?

Question 3: How has this representation of the problem come about?

Question 4: What is left unproblematic in this problem representation? What are the silences? Can the problem be conceptualised differently?

Question 5: What effects (discursive, subjectification, lived) are produced by this representation of the problem?

Question 6: How and where has this representation of the problem been produced, disseminated, and defended?