gender, access to care, and quality of care karen hardee, gaq task force (igwg/maq) usaid global...

Gender, Access to Care, and Quality of Care

Karen Hardee, GAQ task force (IGWG/MAQ)

USAID Global Health Mini UniversityMay 12, 2003

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?

SYNERGY OF INTERVENTIONSSYNERGY OF INTERVENTIONS

Creating a Norm of Access and Quality

Standards/GuidelinesQQAA

Organization of Work

Community Engagement

Provider Rewards/Environment

Client Engagement

Leadership

Training

Job Aids

Supplies/Logistics

Supportive Supervision

Indicators/Certification

Problem Solving

Standards/guidelines

Organization of work

Community EngagementContext

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

Training

Job 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

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

Organizational Context: Gender Policies for Staff

India/UP Kenya Guatemala

MOH NoneMany top staff men

NoneMany top central level staff are women; district leaders male

Gender included in national policy; not translated into MOH organizational policesMany top staff men

RH NGO Promotes equity. Women leaders; field staff 50:50

Promotes equity50:50 representation

Promotes equity.50:50 representation

W NGO Promotes equityWomen given preference at all levels

Promotes equityAll senior management are women

Promotes equityDirector and 90% staff are women

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)

Client Engagement Context: RH Services


MOH ClinicsSome outreach (ANMs)

Clinics Clinics

RH NGO OutreachLinked to other clinics

14 clinicsOutreach

30 clinicsOutreach

W NGO Community based CHW in depotsLinked to other clinicsPart of broader equity activities

Community based RH service providers (CBRHSP)Link to other clinics Part of broader equity activities

ClinicsOutreachPart of broader equity activities

Organization and Client Engagement Context: Goals


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)

Community Context


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

OutreachCommunity engagementFamily orientation

Outreach via volunteers attached to health centers

Outreach to families

W NGO

Microcredit groups, etc.Awareness on rightsGender advocacy

Train women in income generation activities and other topics

An association committed to achieving the development of women. Use community promoters for health.

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)

“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)



“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)

“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)


“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)


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)

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


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


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)

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)

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

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)

“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)

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)



“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)

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

Next Steps (Discussion)

Implications for programs Tools (training curricula, integration manuals,

M&E) Where can we go from here?

gender, access to care, and quality of care karen hardee, gaq task force (igwg/maq) usaid global...

Documents