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Gender, Access to Care, and Quality of Care

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1 Gender, Access to Care, and Quality of Care
Karen Hardee, GAQ task force (IGWG/MAQ) USAID Global Health Mini University May 12, 2003

2 Genesis of the GAQ Task Force
Is there an intersection among gender, QOC, and access in RH programs? How are various programs integrating a gender perspective at the program and service delivery level? How can integrating gender improve services? Post Cairo, many programs have been designed to address access, quality or gender relations; however, the overlap among "gender perspective,” "quality," and "access" has not yet been fully explored.

3 Creating a Norm of Access and Quality
Leadership Problem Solving Client Engagement Indicators/Certification Community Engagement Q A Supportive Supervision Provider Rewards/Environment Supplies/Logistics Standards/Guidelines Creating a norm of easy access and good quality service requires a synergy of interventions. This graphic illustrates the various complementary components to consider in efforts to improve access and quality in our programs. Job Aids Organization of Work Training SYNERGY OF INTERVENTIONS

4 Maximizing Access to Gender Sensitive, Quality RH Care
Organizational Context Gender policy statement Leadership Personnel policies Organization of work Training Job aids Supportive supervision Standards/guidelines Provider rewards/environment Indicators/certification Supplies/logistics Problem solving Client Engagement Context Community Engagement Context Societal gender norms Tried to integrate MAQ and gender perspectives Once a person enters the facility, this increased awareness can be applied to make the service setting and client-provider interaction more sensitive to the gender context of each individual and how it influences his/her decision-making. Elements of quality for clients: Constellation of services Choice of methods/treatment Information and counseling Client-provider interaction Technical competence Continuity of care RH polices/laws/rights Barriers/opportunities for access Control over resources

5 GAQ Study 3 countries: India/UP, Kenya, Guatemala 3 types of programs:
MOH FP/RH NGO (Sabla, FPAK, APROFAM) Women’s NGO (Shramik Bharti, MYWO, AMES) In-depth interviews with 27 program staff and 34 providers FGD with 136 clients (+ 8 non-users in India) Common study guides India: UP – Kanpur and Sultanpur Kenya: Nyanza and Nairobi districts Guatemala: Guatemala city, municipal capital of Esquintla, municipality of Palin Names: Sabla – (“An Empowered Woman”): Set up with funding under SIPSA Shramik Bharti: “Empowering the Poor” MYWO: Maendoleo ya Wanawake Organization AMES: Asociación Mujeres en Solidad (Association of Women’s Solidarity) Program staff: 27 Providers: 26 (+ 1 FGD with 8 midwives in Guatemala) Users: 136 Research organizations: India: India Market Research Bureau (IMRB) Kenya: Own and Associates Guatemala: Red du Mujeres (por la Construccion de la Paz) (Women’s Network to Build Peace) Focusing today on STAFF/PROVIDER responses

6 Organizational Context: Gender Policies for Staff
India/UP Kenya Guatemala MOH None Many top staff men Many top central level staff are women; district leaders male Gender included in national policy; not translated into MOH organizational polices RH NGO Promotes equity. Women leaders; field staff 50:50 Promotes equity 50:50 representation W NGO Women given preference at all levels All senior management are women Director and 90% staff are women

7 Organizational Context: Gender Policies
“I think there is no specific policy like this. I take this job as a government officer… The government does not discriminate against officers at the service provision level.” (MOH/Kenya) “The practice in place is to ensure that men do not take over the organization.” (MYWO/Kenya) “Yes, there is a policy [that promotes gender equity] that not only exists within the structure of the organization, but which also reaches the political level.” (APROFAM/Guatemala) “Sabla means “an empowered woman,” so leadership has to be from women.” (Sabla/UP)

8 Client Engagement Context: RH Services
India/UP Kenya Guatemala MOH Clinics Some outreach (ANMs) RH NGO Outreach Linked to other clinics 14 clinics 30 clinics W NGO Community based CHW in depots Part of broader equity activities Community based RH service providers (CBRHSP) Link to other clinics

9 Organization and Client Engagement Context: Goals
India/UP Kenya Guatemala MOH Providing QOC for community at clinics. Remove access barriers through outreach/camps Reducing unmet need for FP by making quality and sustainable services available to all. Eliminate discrimination against women and increase male participation Govt. policy to integrate gender perspective into services. Focus on providing quality clinical care. RH NGO To reach both women and men to improve FP provision and address related gender issues To make RH services available to the underprivileged. Focus on quality and gender issues To provide SRH focusing on gender and quality, to the poor W NGO Enlarge people’s choices and increase economic participation, improve access to employment, credit, health, education. Focus on gender Increase status and condition of lives of community members by increasing access to quality RH services. Focus on gender Focus on gender equity in the economic, social and cultural development of women through human, labor and health rights. Provision of RH care. Access for maquilas (garment workers) This shows that all of the organizations are using quality of care language and that all are interested in expanding access. Gender is included in the language of the RH and women’s NGOs and also in the MOH in Guatemala.

10 Community Context MOH RH NGO W NGO India/UP Kenya Guatemala
Outreach workers focus on RH Promotes gender and RR but works through health centers Guatemala laws stress gender equity; MOH has no community-based program to promote equity RH NGO Outreach Community engagement Family orientation Outreach via volunteers attached to health centers Outreach to families W NGO Microcredit groups, etc. Awareness on rights Gender advocacy Train women in income generation activities and other topics An association committed to achieving the development of women. Use community promoters for health. RH as a means of promoting gender equity Imbedding RH in a wider developmental approach to promoting gender equity

11 Is Integrating Gender Important?
“Just the fact of providing good-quality services is not going to make them [husbands and wives] equal. Because…providing good services does not mean that the lady’s husband is going to give her permission to come.” (Guatemala/MOH)

12 Is Integrating Gender Important?
“We are receiving special training from a different NGO to strengthen [AMES]… personnel to be able to speak the same language and to give more warmth, when needed… At the beginning, not all of them knew much about the gender approach that is to be applied mainly in health care. That is something hard to communicate… I think that when we can all handle this, the quality of the service will be better.” (AMES/Guatemala)

13 Is Integrating Gender Important?
“As concerns this particular community, decision-making is too much in the hands of men. I say this because many women when they come here they would like to insist on the kind of FP the husband has told them to have….sometimes it is very hard to convince the mother to take anything else apart from what she has been told by the husband.” (MOH/Kenya)

14 Is Integrating Gender Important?
“We try to empower women with information and skills so that they can make informed decisions, they can be prepared to change the situation they are in in terms of socio-economic…by making them identify the potentials they have in them and trying to make them feel as equal partners with men in development and RH. We also empower them so that they can negotiate for safer sex practices. Because….you should be able to discuss the condom use and why it is important. If they man does not want to use the condom you should be assertive enough to say that it is even for the married. We also empower the young people to say no to advances in unsafe sex.” (FPAK/Kenya) “For most of them, you’ll find it’s just impossible for the women to start negotiating so they just submit. But of late because of this failure, women have also requested for the use of the female condom so that they can insert it themselves.” (FPAK program officer).

15 Is Integrating Gender Important?
“We realized that women were facing a lot of problems both at the home front as well as at the community level. So we thought there was a need for a program to deal with these problems of women.” (Shramik Bharti/UP)

16 Activities to Integrate Gender
Gender policy in organization Workshops and training (information AND skills building) Positioning RH within broader needs in women’s lives (women’s NGOs) Couple outreach workers -- UP (access to both females and males in the community) Participatory learning approach (PLA) in the community (Sabla/UP) Annual program review of QOC from a gender perspective (FPAs) Gender policy in organization Workshops and training (information AND skills building) Couple outreach workers (access to both females and males in the community) (Sabla/India) Getting male outreach workers difficult unless you pay them Annual program review of QOC from a gender perspective (FPAs/Guatemala)

17 Activities to Integrate Gender
Awareness raising -- need to “filter it through the skin” for staff and clients Creation of awareness of rights Counseling that includes a gender perspective: “Particularly because of this era of HIV, we have to know whether they are faithful to each other.” (MYWO/Kenya) Addressing violence Awareness raising - need to “filter it through the skin” (Guatemala) Creation of awareness of rights – women’ s NGOs particularly Violence: RH and women’s NGOs more likely to address. Done in MOH in Guatemala, mixed in UP and Kenya.

18 Activities to Integrate Gender
Sessions given to youth in schools by program staff that address RH and gender Advocating for gender equity and women’s empowerment Addressing gender equity at the policy level Sessions in schools: Guatemala and Kenya

19 Barriers to Gender, Access and Quality
Gender is not just women “The main blunder of the gender approach is that it is linked to women.” (MOH/Guatemala) “Many people confuse gender mainstreaming to be a women’s issue.” (FPAK/Kenya) Lack of awareness of rights “The greatest challenge [to integrating gender] would be to [get women to] start thinking that they also have rights… women are not looking for any kind of empowerment, at least, not here.” (APROFAM/Guatemala) Gender does not = women: Lack of awareness of rights

20 Barriers to Gender, Access and Quality
Attitudes of providers (particularly doctors) “The truth is that because you are a doctor, you think that you are a god from Olympus. But men think they are a little bit higher than Zeus. But because one is a professional….at least in this environment, we have been able to show how much we know and everything. We have achieved equity, at least to the point that they respect us, and that they leave us two [female doctors] alone.” (Guatemala/MOH)

21 Barriers to Gender, Access and Quality
Cost of services (economic barrier for women) Clandestine use by women; limits communication and choice of methods Lack of privacy inhibits asking questions on clients’ lives during counseling

22 The Need to Reach Men “If we cannot explain it to the man, then not much is achieved by just explaining it to the women…so we try to take the whole family.” (Sabla, India/UP) “Remember that we live in a macho society, so we would have to get men to understand that their wives have obligations as well as rights. So we would have to educate men in the same direction as women.” (Guatemala/APROFAM) “So as much as we promote women and we promote gender equity then it seems we will be going back to the same problems where we are targeting women and forgetting about men and therefore we shall be having some imbalances.” (FPAK/Kenya) “We should have some policy for the males as well… Our policy, at present, does not deal with them at all.” (MOH/UP) Men come for condoms when they are “moving around” (Kenya)

23 The Need to Reach Youth “Something is very clear here….if the girl is pregnant, or already has a partner…she has a little more access, or a little more freedom to come to the health services…but if she is home, she just can’t go…that simple.” (Guatemala/MOH)

24 The Need to Reach Youth “Only when she has become pregnant or is having irregular periods, her parents will talk to us about her….They want to know where they can have a safe abortion without the society knowing about it.” (MOH/UP) “These boys at times ask about AIDS when we are passing in the fields… We have the label of a pill-condom supplier, so talking can land them in big trouble.” (Shramik Bharti/UP)

25 The Need to Reach Youth “There are policy guidelines…[that] have removed all the obstacles to the provision particularly on RP to the adolescents and men… But we have not effectively updated our service providers and because they have their own attitudes, they are still part of the community.” (MOH/Kenya) “The policy on the youth on services provision, it is vague. It does not say yes or no.” (MYWO/Kenya) “We know some CBD who do not believe. The service providers themselves are a barrier to the youth.” (MYWO/Kenya) “Talk to them about condoms, talk to them about sexuality then they will become free.” (Kenya/MOH) India: Get to adolescents by: sewing classes, sports meets, encouraging girls to go to school, talking first about hygienic products (India)

26 Suggestions Link women’s and RH NGOs with government services
Develop policy on linking QOC with gender Need a policy for men Better access by young people Address GBV Community based approaches promoting gender equity and RH Develop women’s empowerment programs Provide longer clinic hours Include gender in QOC training Provide more services in rural areas (Kenya) Reduce cost of services Reach couples GBV (related to contraceptive use, dual method use/protection, and other household or family issues). “OK, the question [of GBV] does not really come in because the women do not expose it and it is very difficult to find a women who will tell you that my husband abused me or sexually harassed me. I think they have accepted that as part of the norm, unless somebody is physically hurt is when you can. But I still think they may hide. I think the women are over protective over their husbands and would not like to consider an outside to know what is happening in their homes.” (FPAK/program officer) Women’s empowerment programs to help enable women to negotiate safer sex practices and to give women life skills that will enable them to make informed decisions about their bodies and their families (Kenya).

27 Next Steps (Discussion)
Implications for programs Tools (training curricula, integration manuals, M&E) Where can we go from here? Mention the IGWG ” So What” Paper –- evidence that integrating a gender perspective does make a difference to RH outcomes (and to gender outcomes). Will be out in Summer 2003. Tools: training curricula (WHO, IPPF, IGWG)


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