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

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Presentation on theme: "Gender, Access to Care, and Quality of Care Karen Hardee, GAQ task force (IGWG/MAQ) USAID Global Health Mini University May 12, 2003."— Presentation transcript:

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?

3 SYNERGY OF INTERVENTIONS Creating a Norm of Access and Quality Standards/Guidelines Q Q A A Organization of Work Community Engagement Provider Rewards/Environment Client Engagement Leadership Training Job Aids Supplies/Logistics Supportive Supervision Indicators/Certification Problem Solving

4 Standards/guidelines Organization of work Community Engagement Context Provider rewards/environment Elements of quality for clients: Constellation of services Choice of methods/treatment Information and counseling Client-provider interaction Technical competence Continuity of care Leadership TrainingJob aids Supplies/logistics Supportive supervision Indicators/certification Problem solving Organizational Context Client Engagement Context Societal gender norms RH polices/laws/rights Barriers/opportunities for access Control over resources Maximizing Access to Gender Sensitive, Quality RH Care Gender policy statement Personnel policies

5 GAQ Study 3 countries: India/UP, Kenya, Guatemala 3 types of programs: MOH FP/RH NGO (Sabla, FPAK, APROFAM) Womens 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

6 Organizational Context: Gender Policies for Staff India/UPKenyaGuatemala MOH None Many top staff men None Many top central level staff are women; district leaders male Gender included in national policy; not translated into MOH organizational polices Many top staff men RH NGO Promotes equity. Women leaders; field staff 50:50 Promotes equity 50:50 representation Promotes equity. 50:50 representation W NGO Promotes equity Women given preference at all levels Promotes equity All senior management are women Promotes equity 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/UPKenyaGuatemala MOH Clinics Some outreach (ANMs) Clinics RH NGO Outreach Linked to other clinics 14 clinics Outreach 30 clinics Outreach W NGO Community based CHW in depots Linked to other clinics Part of broader equity activities Community based RH service providers (CBRHSP) Link to other clinics Part of broader equity activities Clinics Outreach Part of broader equity activities

9 Organization and Client Engagement Context: Goals India/UPKenyaGuatemala 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 peoples 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)

10 Community Context India/UPKenyaGuatemala MOH 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.

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 ladys husband is going to give her permission to come. (Guatemala/MOH)

12 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) Is Integrating Gender Important?

13 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 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 ) Is Integrating Gender Important?

15 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) Is Integrating Gender Important?

16 Activities to Integrate Gender Gender policy in organization Workshops and training (information AND skills building) Positioning RH within broader needs in womens lives (womens 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)

17 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 Activities to Integrate Gender

18 Sessions given to youth in schools by program staff that address RH and gender Advocating for gender equity and womens empowerment Addressing gender equity at the policy level Activities to Integrate Gender

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 womens 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)

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 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 Barriers to Gender, Access and Quality

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)

23 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 cant go…that simple. (Guatemala/MOH) The Need to Reach Youth

24 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) The Need to Reach Youth

25 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)

26 Suggestions Link womens 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 womens empowerment programs Provide longer clinic hours Include gender in QOC training Provide more services in rural areas (Kenya) Reduce cost of services Reach couples

27 Next Steps (Discussion) Implications for programs Tools (training curricula, integration manuals, M&E) Where can we go from here?

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