FHI - Rethinking Differences

Preface

This document was completed in 1998 and was immediately put to use and tested in training sessions in La Paz and Santa Cruz. The training package was well received and the participatory application process generated modifications, primarily in the exercises and examples given in the four modules. The package may undergo minor changes under the supervision of staff at CIDEM, who are eager to continue applying it in a wider scope of training contexts. We believe that the package in its original form serves as a prototype and will be a useful resource to support training efforts in other cultural settings. For this reason we have translated the document from Spanish to English and are making it more widely available.

The specific target audience for this guide and the training it supports have been the men and women working in sexual and reproductive health who are interested in promoting training or reflections designed to improve gender and culturally sensitive care among their provider teams. On a more general level, the conceptual framework and practical modules are designed to target both private and public health professionals and activists working in the field of sexual and reproductive health. The modules include discussions of issues that vary from administrative visions and decisions to details of service provision that will be useful for all staff. The proposal is that the key ideas of the conceptual framework must be applied across the board to create harmonious and long term change.

-- Patricia Bailey
Women's Studies Project
Family Health International

Foreword

The Women's Studies Project, carried out in Bolivia with technical and financial support from Family Health International (FHI), culminates with this important effort to translate knowledge generated through research into training materials for health service providers. The goal of this training is to improve the quality of care in sexual and reproductive health by applying a gender perspective.

This training proposal encourages the practical application of gender considerations advanced in Bolivia by governmental institutions and social movements. We are convinced that by linking these gender considerations with sexual and reproductive health, we will be able to contribute to the improvement of health care programs.

Behind this endeavor lies an important belief that needs to be highlighted: the conviction that the reflection and capacity building activities proposed here will promote profound changes, not only in the performance of providers, but also in the health care model itself. By reorienting health care models toward men and women users, health programs and institutions will have a better chance of responding effectively to the needs of the populations they serve.

It is worth emphasizing that this training manual is the fruit of a collective effort. A select group of persons working in health care services, non-government organizations and reproductive health research have systematically integrated knowledge, research data, intuitions, and professional experiences in a profoundly reflective and creative process. We would like to express our gratitude to all members of the Technical Advisory Committee, and to highlight the efforts of Maria Elena Gisbert and Mery Quit�n, who worked closely with Susan Paulson to develop the conceptual framework and training proposal, and with Cecilia Olivares, who was responsible for the editing and publication of the document. We are pleased to have collaborated with the Center for Information and Development of Women (CIDEM), whose director Ximena Machicao demonstrated praiseworthy leadership and unfailing conviction of the importance of producing this training guide. There were many challenges during this process, and she overcame each of them.

We would like to thank the United States Agency for International Development (USAID) for its decisive financial contribution through FHI, acknowledging that without this support the effort would not have been possible. Thanks also go to the International Planned Parenthood Federation (IPPF) for authorizing the use of the indicators they developed for evaluating quality care from a gender perspective, the Johns Hopkins University, the Flora Tristan Center for Peruvian Women and Ipas for permitting us to use their videos as part of this training package.

Thus, we present this guide in hopes of contributing to the improvement of sexual and reproductive health care services in ways that permit persons of different ethnic backgrounds, ages, social classes and gender identities to know and exercise their rights fully within the context of appropriate health care services.

-- Ren� Pereira Morat�
Representative of Family Health International in Bolivia

Introduction

The Bolivian government established a series of progressive sexual and reproductive health policies and implemented programs in the field throughout the 1990s. In spite of these efforts, many men and women still do not have access to sufficient sexual and reproductive health information, much less basic services. In Bolivian society, women have been assigned the principal responsibility for sexual and reproductive health, but both men and women will benefit significantly from services that are more sensitive to gender and cultural realities.

Article 1.
The state guarantees equality of rights between men and women in political, economic, social and cultural domains, as well as the incorporation of gender considerations into public policy designed to achieve true equity by promoting specific actions in the following areas:
1. Health
Develop preventive and comprehensive health care services for women, guaranteeing quality of care and equitable access in all phases of the life cycle, with respect to their ethnic and cultural identities, as well as to their sexual and reproductive rights (Government of Bolivia 1997).

Bolivian rates of fertility and ratios of maternal mortality (MMR) are among the highest in Latin America. Between 1991 and 1994, the total fertility rate in Bolivia was 4.8 children per woman. Maternal mortality, between 1989 and 1994, was 390 deaths per 100,000 live births. These figures obscure profound differences between regions: in the Eastern Lowlands the MMR falls to 110 deaths, whereas in the Altiplano it is as high as 602 deaths per 100,000 live births per year (INE 1994). These data demonstrate some of the consequences of inadequate sexual and reproductive health care and health education in the country.

Improving the quality of health care is a fundamental step toward achieving significant improvements in the health of the Bolivian population. Yet, the population is characterized by such great ethnic, cultural, socioeconomic and generational diversity that it is impossible to apply a universal model of health care. A gender perspective can be used to better understand the differentiated groups within the society and the dynamics of relations among those groups and their members. This type of understanding needs to be incorporated into sexual and reproductive health policies and programs in order to impact a more significant and more diverse portion of the population.

Some of the sexual and reproductive health care services [in Bolivia] are characterized by compassionate treatment and equality of conditions, a warm environment and emphasis on body-soul relations, which is so important to reinforce users' own cultural beliefs. In those services with more humanistic treatment, there tends to be more stable personnel, and the use of native languages promotes the access and acceptability of formal health care services (WHO 1996).

The training package presented here is designed to promote an approach to sexual and reproductive health care that recognizes different needs and perspectives within a context of respect for the rights and dignity of men and women. The package includes a conceptual framework and a guide for training activities.

The concept of gender-sensitive quality care is gaining importance among numerous health care professionals and centers. Changing social paradigms and new information about the benefits of compassionate and comprehensive health care are motivating a growing interest in this perspective. Nevertheless, there are still many doubts about how to practice quality care with a gender perspective in concrete operational terms. To respond to this need, the training package presents a series of conceptual and methodological advances in a clear and accessible manner in order to facilitate an understanding and the daily use by health care professionals in diverse regions of Bolivia, especially in urban contexts.

The gender perspective advanced here is not presented as a new component or additional activity to add to the already considerable workload of health providers. On the contrary, we wish to facilitate an integrated approach that helps providers carry out their work in a more sensitive and efficient manner, resulting in greater satisfaction and success on the part of providers themselves, as well as users.

Rethinking Differences and Rights in Sexual and Reproductive Health: A Training Manual for Health Care Providers

Table of Contents

Preface

Foreword

Introduction