Gender, Access to Care, and Quality of Care

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

6. Organizational Context: Gender Policies for Staff

7. “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 theservice 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) Organizational Context: Gender Policies

8. Client Engagement Context: RH Services

9. Organization and Client Engagement Context: Goals

10. Community Context

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)

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)

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

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

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)

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. “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) The Need to Reach Men

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)

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

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