• TABLE OF CONTENTS
HIDE
 Front Cover
 Table of Contents
 Front Matter
 Preface
 Foreword
 Introduction
 Conceptual framework
 Methodology
 Facilitator's guide
 Module 1: Gender and sexual and...
 Module 2: Sexual and reproductive...
 Module 3: Quality in human relations...
 Module 4: Quality in administration...
 Bibliography
 Back Cover














Group Title: Rethinking differences and rights in sexual and reproductive health : a training manual for health care providers
Title: Rethinking differences and rights in sexual and reproductive health
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00080522/00001
 Material Information
Title: Rethinking differences and rights in sexual and reproductive health a training manual for health care providers
Physical Description: 44 p. : ill. ; 28 cm.
Language: English
Creator: Paulson, Susan
Gisbert, María Elena
Quitón, Mery
Publisher: CIDEM
Family Health International
Place of Publication: La Paz Bolivia
Research Triangle Park NC
Publication Date: 1999
Edition: 1st ed.
 Subjects
Subject: Hygiene, Sexual -- Study and teaching -- Handbooks, manuals, etc   ( lcsh )
Reproductive health -- Study and teaching -- Handbooks, manuals, etc   ( lcsh )
Sex role -- Study and teaching -- Handbooks, manuals, etc   ( lcsh )
Human rights -- Study and teaching -- Handbooks, manuals, etc   ( lcsh )
Genre: handbook   ( marcgt )
non-fiction   ( marcgt )
Spatial Coverage: Bolivia
 Notes
Statement of Responsibility: by Susan Paulson, Maria Elena Gisbert, Mary i.e. Mery Quiton.
General Note: Cover title.
 Record Information
Bibliographic ID: UF00080522
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 54036809

Table of Contents
    Front Cover
        Front Cover
    Table of Contents
        Table of Contents
    Front Matter
        Page i
    Preface
        Page ii
    Foreword
        Page iii
    Introduction
        Page 1
        Page 2
    Conceptual framework
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
    Methodology
        Page 20
        Page 21
    Facilitator's guide
        Page 22
        Page 23
        Page 24
        Page 25
    Module 1: Gender and sexual and reproductive health
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
    Module 2: Sexual and reproductive rights
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
    Module 3: Quality in human relations and technical quality
        Page 46
        Page 47
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54-55
    Module 4: Quality in administration and management
        Page 56
        Page 57
        Page 58
        Page 59
        Page 60
        Page 61
        Page 62-63
    Bibliography
        Page 64
        Page 65
        Page 66
    Back Cover
        Page 67
Full Text



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TA]BL E OF CONTENTS

Preface ........................ ...................... ..................... ........... ii

Foreword .............................................................................. iii

Introduction ......................................................................... 1

Conceptual Fram work .................................................. 3

M ethodology ........................................................................ 19

Facilitator's G uide .............................................................. 21

Planning M atrix .................................................................. 25

M odule 1 .............................................................................. 26
Gender and Sexual & Reproductive Health

M odule 2 .............................................................................. 35
Sexual and Reproductive Rights

M odule 3 .............................................................................. 46
Quality Care I: Quality in Human Relations and Technical Quality

M odule 4 ............................................................ ..... ........ 56
Quality Care II: Quality in Administration and Management

Bibliography ........................................................................ 64


























Researchers
Maria Elena Gisberth
Mery Quit6n
Taller de Estudios Sociales-Tes
Mary Marca
Centro de Informaci6n y Desarrollo de la Mujer-CIDEM

Consultants
Susan Paulson
Cecilia Olivares Mansuy
Elena Getino

Technical Advisory Committee
Bertha Pooley, PROCOSI
Alexia Escobar, FCI
Jack Antelo, Prosalud
Carmen Cornejo, SEDES
Susana Rance, Working Group on Unwanted Pregnancy and Abortion
Alfredo Machicao, CIES
Rend Pereira, FHI

General Coordination
Ximena Machicao Barbery

Editor
Cecilia Olivares Mansuy

Design
Sergio Vega C

1 edition 1999
CIDEM-FHI
Copyright: 4-2-144-99
Printing: Trama SRL
La Paz, Bolivia

The authors wish to thank the U.S. Agency for International Development (USAID) for its
generous support. This publication was funded by USAID under Cooperative Agreement
USAID/CCP-A-00-93-00021-05 and USAID/CCP-A-95-00022-02 to Family Health
International (FHI). The conclusions expressed in this report do not necessarily reflect the
policies of FHI or USAID.









PR EFA CE


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 Quit6n, 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.
Ren6 Pereira Morat6
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.

Bolivian rates of Article 1.
fertility and ratios of The state guarantees equality of rights between men and women in political,
maternal mortality economic, social and cultural domains, as well as the incorporation of gender
(MMR) are among the considerations into public policy designed to achieve true equity by promoting
specific actions in the following areas:
highest in Latin 1. Health
America. Between Develop preventive and comprehensive health care services for women,
1991 and 1994, the guaranteeing quality of care and equitable access in all phases of the life cycle,
total fertility rate in with respect to their ethnic and cultural identities, as well as to their sexual and
Bolivia was 4.8 reproductive rights (Government of Bolivia 1997).
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.

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
Some of the sexual and reproductive health care services [in Bolivia] dignity of men and women.
are characterized by compassionate treatment and equality of The package includes a
conditions, a warm environment and emphasis on body-soul relations,
which is so important to reinforce users' own cultural beliefs. In those conceptual framework, a
services with more humanistic treatment, there tends to be more stable guide for training activities,
personnel, and the use of native languages promotes the access and and a set of four educational
acceptability offormal health care services (WHO 1996). videos.












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.









CONCEPTUA L FRAME WORK


This conceptual framework serves as a theoretical basis for the training package and provides
conceptual tools to critically analyze current health care practices and to promote more fruitful
approaches. Interrelated aspects of these new approaches include: equitable interpersonal
relationships within health care teams and between providers and users; the possibility for users
to be informed and choose freely among alternative methods and treatments; recognition and
respect for users' beliefs, practices and experiences in relation to their bodies, sexuality and
reproduction; respect for the population's sexual and reproductive rights; technical competence;
availability of essential supplies; accessibility of services for different groups of users; and
administrative practices that promote equity.

What are the basic concepts that support this type of approach? Here, we emphasize the need to
understand and reflect on four interrelated concepts: gender, sexual and reproductive health,
sexual and reproductive rights, and quality care. While we provide basic definitions for the
training process, it is important to emphasize that these are relatively new and highly contested
concepts for which multiple and sometimes conflicting definitions and applications coexist. Each
individual and health care team needs to develop its own conceptual and philosophical position
through debate, reflection and practice.

* THEORETICAL AND CONCEPTUAL EVOLUTION

Health care practices are constantly being modified and improved by the generation and
introduction of new technology, including medicines, vaccines, diagnostic tools, surgical
equipment and contraceptive methods. Similarly, new methods and techniques for provider-user
interaction and communication are also transforming health care. The approach developed in this
training package is informed by, and contributes to, changes along various philosophical and
conceptual paths, among them:

* Change from a provider-centered approach with indicators of success based on the
achievement of numerically tabulated professional activities and goals (number of patients
seen, number of IUDs inserted, etc.) towards a user-centered approach with criteria for
success based on user satisfaction, solutions for users' health needs and sustained
improvements in the health of the user population.
* Change from an impersonal approach, in which users are treated anonymously and
uniformly, to a more interactive approach, in which both user and provider are respected as
individuals, with their own gender, ethnic, class, and generational experiences and identities.
* Change from a unilateral practice, in which health care providers monopolize information
and decision-making, to a more equitably balanced participatory approach, in which users
and providers share ideas, information, doubts and preferences.
* Change from a narrowly focused approach centered on family planning toward more
comprehensive sexual and reproductive health services ranging from the prevention and
treatment of sexually transmitted diseases (STDs), to pre- and postnatal care and education,
to counseling on sexuality and domestic violence.












* Change from a biomedical focus toward a broader health care model that incorporates social
science, ethics, human rights and respect for the cultural and individual position of each man
and woman.

* GENDER












We understand gender as that which identifies us as women and men within our social life based
on different attitudes and forms of behavior, different roles and responsibilities, opportunities,
spaces and activities. We learn gender values and behaviors as we grow up, and they influence
who we become. These culturally constructed differences are symbolically associated with sex
differences, which are biological characteristics that differentiate males and females, permitting
sexual reproduction of the species.

Teresita de Barbieri writes: "We are born with biologically sexed bodies, to which we attribute
one or another social and cultural meaning. As humans we are historical beings, we are not born
in nature, we are born in societies, in a world culturally construed with laws, norms, values,
symbols, and collective commitments. All cultures have forms of gender training, and all
institutions, governments, schools, churches, families, are pedagogical fields for gender
construction. Thus, in all societies, men and women are raised with life philosophies marked by
gender" (Barbieri 1991).

Marcela Lagarde (1995) Gender beliefs and practices define roles, opportunities and
explains that there are two limitations for women and men, greatly influencing life in all
basic concepts of gender in societies. Aspects of daily life shaped by gender include use of
Latin American societies.
Latin American societies language and means of self-expression, dress and
The first is the traditional
The first is the traditional appearance, education, work opportunities, family structure
gender ideology, which and size, and each individual's health (Paulson 1998).
says that all men and
women's characteristics are natural. It assumes that gender categories and identities were created
by God, or in accordance with Nature's laws, and are thus immutable. This gender ideology is
implemented, guarded and sanctioned by social institutions, which establish parameters for male
and female behavior (here, there are only two gender categories: masculine and feminine, as any
variation is considered unnatural). In Bolivia, this traditional gender ideology foments conditions












of inequality and unequal value of men and women, exemplified by educational practices in
which girls are trained to be self-sacrificing mothers and obedient wives within the domestic
domain, while boys are trained to be strong and brave, to lead in the public domain and be heads
of the household.

The other concept of gender to which Lagarde refers breaks with this traditional scheme. It
defines gender as a category of critical analysis designed to consciously deconstruct the
dominant gender order and to contest conventional assignations of social, psychological and
cultural characteristics. This gender concept reveals that power differences between men and
women are not natural and genetic, but rather historically construed and assigned. This position,
in contrast to the first, facilitates efforts to move towards more equitable conditions and relations
between men and women (Lagarde 1995).

An important aspect of gender is the manner in which certain anatomical differences are
interpreted and managed within each society. Men and women have the same capacity to
produce pleasure in each others' bodies, but only a woman can "produce another body" (Torres
Arias 1989). On the basis of this fact, Barbieri theorizes that every society assigns a special
power to the female body, and establishes the need to keep that body under control: "To assure
an effective control of reproduction, it is necessary to take actions to control sexuality.... In other
words, in order to control reproduction in such a way that one or more men can claim rights over
the product of women's bodies, it is necessary to control access to the female body... Control of
women's bodies means to limit women's work in such a way that they can not escape" (Barbieri
1991).

Sexual and gender identities and relations are not uniform, and we need to consider ways in
which they intersect with other axes of social differentiation. Gender identities vary with the
stages of the life cycle, and the meaning of sex and age varies with socioeconomic and ethnic
factors in the construction of identities and relations. We must also take into account family
structure, economic organization, division of labor, religious beliefs and practices, and other
cultural aspects.

Gender Relations

Gender is a part of all human experience and all social relations, and as such continually
influences the value, power and identity of each participant. In general, Latin American societies
assign certain political and economic values to men and applaud their roles in public leadership,
whereas they assign certain moral values to women and venerate their maternal roles and their
functions as transmitters of cultural and religious traditions in the home. These relations are part
of social fabrics in which men, in general, have more power for decision-making and action than
do women.

Nevertheless, is it crucial to remember that this is not a simple dual hierarchy. Each individual's
class, ethnic group and generation influence his or her experience within the gender structure. In










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Bolivia, white adult women in the middle and upper classes have much more power for decision-
making and action than do adolescent men who are indigenous peasants. While powerful
government, church and economic institutions are dominated by men, it is by an elite group of
men. The majority of Bolivian men (who are poor, indigenous and poorly educated) do not in
any sense "dominate" the society and enjoy very few privileges, even relative to their wives and
sisters.

Because we know that gender systems and relationships change, that they have evolved through
time and differ across societies, we know that the current situation can change. But since
relations of superior power for some and disadvantage for others cross all spheres of life -
personal, public, private, practical, symbolic change must be sought in all of these spheres.

How do we affect such change? Jeanine Anderson (1997) suggests that conflict is inherent in
human life. Within a family, conflict between generations is as inevitable as conflict between
men and women, due to positions that individuals occupy in the family and society, division of
labor and necessary interdependence. Anderson adds, however, that cooperation is also present,
as gender systems both channel and regulate relations of conflict and cooperation. Individuals
and organizations can make a positive impact on these relations by ensuring that gender conflicts
and negotiations are carried out through the democratic processes of dialogue and by refusing to
acquiesce to unjust conventions and situations, thus becoming silent accomplices of oppression.

Gender and Health

Working with sexual and reproductive health from a gender perspective allows us to go beyond a
biological focus on women's bodies to a better understanding of men and women's socially
construed identities and needs, in order to address the social relations that influence each
person's sexual and reproductive health. Services and providers can better respond to user
populations if they recognize that women and men live and perceive sexuality and reproduction
in different ways, and that all of our visions are conditioned by our cultural environments,
ethnicity, age and class position, and our sexual identities.

Cultural symbols and values associated with gender identities influence each person's choice,
use or abandonment of contraceptive methods. In Latin America, many men seek validation of
their masculinity through conquest, the exercise of power and the demonstration of their capacity
to father children. Thus, it is difficult for them to use or collaborate in the use of contraceptives.
For their part, women who see maternity as a principal form of social recognition and value
(because church and family have educated them to believe this; because the gender balance in
education, labor and political and public spaces limit their opportunities; and because they see
little other possibility for personal and professional growth) may choose to prioritize
childbearing at a high cost to their own health and well-being. In addition, we must consider that
using contraceptives implies negotiation between a couple, and that many times gender relations
are such that a woman does not have the power to influence the terms of the discussion, or a man
is denied participation in the decision. These identities and relations are not the only reasons why













many men and women including those who do not want more children do not use
contraceptive methods, but they are factors that should always be taken into account.

Gender also plays a role in relations between providers and users. Numerous studies have
determined that in Bolivia STDs are treated differently in men than in women (Crisosto 1997).
When a woman seeks treatment for gonorrhea, for example, often she will be given a course of
antibiotics and told to refrain from sexual relations for a certain time period. When a man is
treated for the same disease, he is told that his sexual partners probably also have it, and that they
should be treated at the same time. Although he is married, it is not assumed that a man's
relations are limited to his wife, and providers often indicate that he should contact all partners.
Many of the women who are treated alone will become infected again by a partner who was not
included in the cure. This unequal clinical practice only serves to reinforce an unspoken social
norm that says: "Men have a right to multiple sexual partners, and women should only have
relations with their husbands. If women become infected with sexually transmitted diseases, they
must suffer the consequences alone."


STDs cause pain and suffering for women and men in different ways:

1. The risk of contracting gonorrhea from a single sexual act is 25 percent for
men and 50 percent for women.
2. Women's symptoms are less visible. Half of infected women do not know that
they are infected, because they do not notice the symptoms or because women
consider the symptoms normal. Thus, they do not seek treatment until the
infection has reached an advanced stage, causing severe damage.
3. STDs have severe and sometimes fatal consequences for women, including
infertility, cervical/uterine cancer and ectopic pregnancy (Dixon-Mueller et al.
1991; Tinker et al. 1994).



Gender practices and meanings manifest themselves in the religion, science, education,
environment, social and economic conditions of each society. They influence sexuality and
sexual and reproductive health, together with our perceptions and interpretations of what
constitutes health and who is entitled to it. Thus, gender systems may legitimize certain values,
practices and beliefs surrounding the sexual and reproductive lives of different actors in such a
way as to impair the health of specific groups.

In order to promote sustainable improvements in the sexual and reproductive health of the
population, policies and services need to consider these social conditions and issues. A gender
perspective helps us to analyze and promote changes in organizations, institutions and
communities by moving towards goals of more inclusive, equitable and effective health services.

We must also consider the dynamics of power, knowledge and decision-making in the relations
within each family, between providers and users and within governments and other institutions












and the populations they serve. Health services that have addressed these relations and have
extended their coverage to include comprehensive sexual and reproductive health needs of
women and men, have improved quality care and increased impact on user populations.
Processes of positive change also require analysis of relations of power and knowledge within
health institutions, in order to transform unequal and stereotyped professional relations that
interfere with the provision of equitable quality care.

* SEXUAL AND REPRODUCTIVE HEALTH


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Current ideas of sexual and reproductive health express a change from earlier biomedical
definitions of health and illness toward a more ample concept, which encompasses social science
and ethical considerations and promotes men and women's sexual and reproductive rights,
together with respect for cultural contexts and individual decisions.

Traditionally, health policies and programs have focused on physical functions of the
reproductive system, and especially on fertility control. In recent decades, however, we have
begun to understand that personal and cultural experiences of sexuality are intimately linked to
the biological health of the reproductive system: that these are two inseparable dimensions of
what is experienced as a single phenomenon in human life. Reproductive and sexual health
develop interdependently during the life cycle, and affect each person on multiple levels. For
example, the physical and psychosocial stress of multiple and closely spaced births may impair a
woman's sexual expression, and negatively affect her sexual health (Bassu 1997). In the same
way, certain sexual practices and choices can make individuals vulnerable to diseases that cause
harm, and even infertility, in the reproductive system.

As early as 1974, a committee of experts from WHO defined sexual health as the integration of
physical, emotional and intellectual elements in ways that positively enrich and strengthen
personal identity, communication and love. The comprehensive vision expressed here surpasses
reproductive and pathological aspects to encompass affection, pleasure and communication,
which are important in people's lives (Cerruti Basso 1993) and contribute to improved life and
personal relationships (ICPD 1994; Alcali 1995).

Different definitions and interpretations of sexual and reproductive health coexist. Medical
sciences tend to express them in biological terms, while some NGOs and international












organizations tend to emphasize men and women's rights or the provision of information and
services (WHO 1997). The training guide presented here develops an understanding of sexual
and reproductive health that encompasses these different concerns and takes into account
possible tensions between them. Although the concept of sexual and reproductive health should
definitely include biological factors, it is also fundamental to consider psychosocial and cultural
factors, as well as sexual and reproductive rights. Health is a process that influences and is
influenced by many life factors (WHO 1997).

The International Conference on Population and Development (ICPD) held in Cairo 1994,
established a new vision of reproductive health that explicitly incorporates sexual health:

Reproductive health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity, in all matters relating to the
reproductive system and to its functions and processes. Reproductive health,
therefore, implies that people are able to have a satisfying and safe sex life and
that they have the capability to reproduce and the freedom to decide if, when and
how often to do so. Implicit in this last condition are the rights of men and
women to be informed and to have access to safe, effective, affordable and
acceptable methods of family planning of their choice, as well as other methods of
their choice for regulation of fertility which are not against the law, and the right
of access to appropriate health-care services that will enable women to go safely
through pregnancy and childbirth and provide couples with the best chance of
having a healthy infant. ICPD, Programme of Action, Paragraph 7.2, 1994.

This definition of reproductive health includes a number of points worth considering. First, when
we talk of "a state of complete physical, mental and social well-being" we must ask how many
people do not have good reproductive health because they do not enjoy mental or social well-
being? The phrase "to have a satisfying and safe sex life" should be noted as the first time that an

international document, signed by approximately 180 nations, touched on the theme of sexual
satisfaction. Finally, the "right of men and women to be informed and to have access to safe,
effective, affordable and acceptable methods of family planning of their choice" makes reference
to the quality of health care.

Continuous efforts of NGOs and women's movements have been important forces behind the
broadening of the concept of sexual and reproductive health, especially in the Third World
(Correa and Petchesky 1994). These movements have questioned academic, analytical and
institutional divisions that arbitrarily separate what is lived as an integral experience. While most
services still focus on reproduction, and deal only marginally with sexuality and rights, at the
ICPD, world consensus was generated around the need to forge more comprehensive and user-
focused reproductive health programs.




V


According to this vision, sexual and reproductive health services may include, but are not limited
to: voluntary fertility regulation; prenatal, birth and postpartum care; tetanus vaccines; support
for breastfeeding; infertility treatment; prevention, screening and treatment of STDs, including
HIV-AIDS; gynecological examinations; prevention and treatment of breast and cervical cancer;
treatment of complications from abortion; nutrition programs; production and dissemination of
educational and informational materials; education and counseling about sexuality; protection
against violence; training of extension workers; personal and couple counseling; and diverse
activities that empower users to take greater control and responsibilities for their own health
(Dixon-Mueller 1993; Hardee and Yount 1995).

All men and women, whether or not they have experience with sexual and reproductive health
services, may have their own interpretations of what those terms mean, interpretations informed
by their culture, age, religion, education and personal health experiences. The health of each
population, in turn, is influenced by the quality of care and education available, by the level of
recognition of social sexual and reproductive rights, and by gender meanings and roles within
society.

In many parts of Latin America, the characteristic called machismo emphasizes the sexual
prowess of men, measured by the quantity and daringness of their sexual conquests (Barker and
Lowenstein 1996). This stereotype pushes men to take serious health risks and leads to unwanted
pregnancies, unsafe abortions and STDs (Zeidenstein and Moore 1996).

In Bolivia, women seek health services with much more frequency than do men, due to their
reproductive biology as well as cultural roles that determine women's greater responsibility for
the health of children, parents and sick relatives. There is a growing consensus, however, that a
more balanced participation on the part of men would contribute to health improvements for the
whole population. The ICPD Programme of Action emphasizes the importance of involving men
more fully in spheres from which they have been excluded or marginalized:

Innovative programmes must be developed to make information, counseling and
services for reproductive health accessible to adolescents and adult men. Such
programmes must both educate and enable men to share more equally in family
planning and in domestic and child-rearing responsibilities and to accept the
major responsibility for the prevention of sexually transmitted diseases.
Programmes must reach men in their workplaces, at home and where they gather
for recreation. Boys and adolescents, with the support and guidance of their
parents, and in line with the Convention of the Rights of the Child, should also be
reached through schools, youth organizations and wherever they congregate.
Voluntary and appropriate male methods for contraception, as well as for the
prevention of sexually transmitted diseases, including AIDS, should be promoted
and made accessible with adequate information and counseling. ICPD,
Programme of Action, Paragraph 7.8, 1994.












Thus, working with a gender perspective implies increasing emphasis on men, getting men
involved and recognizing that sexual and reproductive health pertains to men as well as women.
In spite of the above recommendation, services are still predominantly oriented toward women's
needs and the fulfillment of women's rights, and many health centers have not fully accepted that
men also have sexual and reproductive rights. The failure to explicitly include men in sexual and
reproductive health programs clearly limits the chances of achieving greater well-being for men
and women. Services overburden women by reinforcing the idea that women are responsible for
the health of the whole family and for the regulation of fertility and by not promoting
involvement of men. Ormel and P6rez (1997) observe that, although we should continue to
respond to the needs and rights of women and to recognize the inequalities that they suffer, men
also need information, education and access to services in order to participate more actively in
the care of their own health, that of their partners and of their children.

* SEXUAL AND REPRODUCTIVE RIGHTS










The concept of sexual and reproductive rights, together with the declarations that promote
respect for these rights, has a long history. After the Second World War, the Charter of the
United Nations (1945), affirmed faith in fundamental human rights, the dignity and value of
human life, and equality of rights between men and women. In 1948, the Universal Declaration

of Human Rights included Article II, which proclaims the right of all persons to the established
rights and liberties without any distinction based on race, color, sex, language, religion, political
or other opinion, national or social origin, property, birth or any other condition.

Throughout the years, rights were defined with increasing specificity, and the idea of sexual and
reproductive rights was addressed explicitly in the Declaration of the World Conference on
Human Rights in Tehran in 1968, which proclaimed that parents have the basic right to freely
determine the number and spacing of their children, as well as the right to education and
information concerning this issue. Later, at the World Conferences on Population held in
Bucharest (1974) and Mexico (1984), this paragraph was adopted and adjusted so that the term
"parents" be replaced by "couples and individuals."

Other conferences and declarations reinforced the notion that the right to decide about
reproduction, as well as the right to access health services, were basic human rights. In 1979, the
General Assembly of the United Nations approved the Convention on the Elimination of All




V


Forms of Discrimination against Women, and signing countries committed to take measures to
ensure the full development and advancement of women. One of these measures is a
commitment to ensure equal access to health services, including those related to family planning,
and to promote the same rights for men and women to decide the number and spacing of their
children. This measure also highlighted the need to access information, education and the
resources necessary to exercise this right.

Ten years later, the Convention on the Rights of the Child established a set of basic rights for
minors, which affirmed the right of all persons to access services for voluntary regulation of
fertility. The 1993 World Conference on Human Rights in Vienna reiterated the importance of
eliminating all forms of sexual discrimination, together with the need to work to eradicate
gender-based violence.

At the International Conference on Population and Development in Cairo, certain sexual and
reproductive rights were explicitly recognized as basic human rights.

These rights rest on the recognition of the basic right of all couples and
individuals to decide freely and responsibly the number, spacing and timing of
their children and to have the information and means to do so, and the right to
attain the highest standard of sexual and reproductive health. It also includes their
right to make decisions concerning reproduction free of discrimination, coercion
and violence, as expressed in human rights documents. ICPD, Programme of
Action, Paragraph 7.3, 1994.

The United Nations Fourth World Conference on Women in Beijing reaffirmed earlier consensus
on the need to eradicate all forms of discrimination and violence against women and to guarantee

the right to decide freely and responsibly about matters of sexuality and reproduction. The
Beijing Platform for Action mentions factors that influence women's health, which are often
overlooked as circumstantial.

Women's right to the enjoyment of the highest standard of health must be secured
throughout the whole life cycle in equality with men. Women are affected by
many of the same health conditions as men, but women experience them
differently. The prevalence among women of poverty and economic dependence,
their experience of violence, negative attitudes towards women and girls, racial
and other forms of discrimination, the limited power many women have over their
sexual and reproductive lives and lack of influence in decision-making are social
realities which have an adverse impact on their health. Lack of food and
inequitable distribution of food for girls and women in the household, inadequate
access to safe water, sanitation facilities and fuel supplies, particularly in rural and
poor urban areas, and deficient housing conditions, all overburden women and
their families and have a negative effect on their health. Good health is essential













to leading a productive and fulfilling life, and the right of all women to control all
aspects of their health, in particular their own fertility, is basic to their
empowerment. United Nations Beijing Platform for Action, Paragraph 92, 1995.

Today, the exercise of sexual and reproductive rights by men and women is considered a
fundamental basis for a better quality of life. Generally, sexual rights are not distinguished from
reproductive rights, rather they are treated as dimensions of basic human rights, the exercise of
which constitutes a fundamental strategy for human survival and quality of life.

The acceptance of sexual and reproductive health rights has philosophical, ethical and political
implications, as it becomes clear that a large proportion of health problems can be avoided by
respecting basic human rights. A confluence of discourse and emphasis on sexual and

To mark the fiftieth anniversary of the Universal Declaration of Human Rights,
the Latin American and Carribean Committee for the Defense of Women's Rights
(CLADEM), with the support of organizations throughout the region, presented a
gender-focused declaration, including the following text:

Article 10. All human beings have the right to autonomy and self-
determination in the exercise of their sexuality, which includes the right
to physical, sexual and emotional pleasure, the right to freedom of sexual
orientation, the right to information and education concerning sexuality,
and the right to sexual and reproductive health care to maintain physical,
mental and social well-being.
Article 11. Women and men have the right to decide freely and
knowledgably about their reproductive life, and exercise the safe
voluntary control of their fertility, free from discrimination, coercion,
and/or violence, as well as the right to enjoy the highest levels of sexual
and reproductive health (CLADEM, 1998).


reproductive rights and on gender is contributing to changes in health care values and paradigms.
"Within this framework" writes Ladi Londofio, "a gender perspective helps us identify great
shortcomings, unnecessary medical interventions, as well as the importance of emotional and
affective aspects" (Londofio 1996). Quality of life does not only lie in improved infrastructure,
reduced rates of maternal mortality and better resources for health care, it is also based on the
exercise of and respect for individual autonomy in the intimate matters and sexual decisions of
men and women.

Different local and international organizations, as well as individuals, have also created lists of
the sexual and reproductive rights. Here, we present a list of rights taken from IPPF's
Declaration of Sexual and Reproductive Rights (1996), from Mari Ladi Londofio's book, Sexual
and Reproductive Rights (1996), and from the Open Forum for Sexual and Reproductive Rights
in Chile (1996). These rights include but are not limited to:












1. The exercise of sexual independence, as well as the right to enjoy it according to one's own
preferences, and the right to legal protection.
2. Pleasurable and recreational sexuality, independent of reproduction.
3. Adequate information and knowledge about sexuality and reproduction.
4. Love, sensuality and eroticism in sexual relations.
5. Sexual education that is appropriate, comprehensive, secular, scientific and gender-sensitive.
6. Refusal to engage in sexual activity.
7. Freedom from fear, shame, guilt and other imposed beliefs that inhibit a person's sexuality
and diminish his or her sexual relations.
8. Choice of sexual partners, to exercise sexuality without coercion or violence.
9. Nutrition necessary for adequate growth and balanced development of one's body and future
reproductive potential, from childhood.
10. Voluntary motherhood, to decide and live motherhood for one's own choice and not by
obligation.
11. Complete information concerning the benefits, risks and relative effects of all contraceptive
methods.
12. Free or inexpensive contraceptives with current information, follow-up and responsibility on
the part of those who prescribe it.
13. Marriage and family or the choice not to have either.
14. Parenthood and the right to decide when to have children.
15. Good quality services for prenatal care, birth, and postpartum care, guaranteed by appropriate
legislation.
16. Equal participation by women and men in child care, creatively constructing children's
identities beyond traditional gender roles.
17. Effective legal protection against sexual violence.
18. Adoption and right to comprehensive, accessible treatment for infertility.
19. Prevention and treatment of illnesses of the reproductive tract, and the right to make
informed decisions about related interventions.

Many of these rights have been recognized internationally and may take different forms of
expressions within varying national and cultural contexts. In Bolvia, one important universal
right recognized by the Constitution is the right to health. The official document, which Bolivia's
delegation presented at ICPD in 1994, affirms the necessity to "improve coverage and quality of
services in primary health, with special emphasis on reproductive health" (Ministry of Human
Development 1994). The document also emphasizes the importance of respecting women's
decisions about sexuality and fertility, together with the democratization of roles within family
and society.


~ I_ _F Ir












* QUALITY CARE


The term "quality care" is frequently used in health services, where it conveys multiple meanings
because the concept is neither universal nor homogenous. Quality is different not only for men
and women, but for persons of different cultures, ethnic groups, social classes and ages. In other
words, everyone has his or her own definition of quality.

Recognizing that the meaning of quality care can vary from one person to another, it is still
possible to talk of certain principles that help us to achieve quality care. These include: a focus
on the comprehensive well-being and satisfaction of diverse users; the active and equitable
participation of all persons involved in the provision of care; the practice of offering options
from which users may select, such as different contraceptive methods or birthing positions
(Finger and Hardee 1993); the empowerment of users to make free and informed decisions about
their own health; and the equitable treatment of women and men, people of different ages, social
classes and ethnic backgrounds. Quality care has three interrelated dimensions: quality in
administration and management; quality in human interactions, and technical quality.

Quality in Administration and Management

This first aspect is directly related to an institution's philosophy, which transmits ideas, values
and attitudes to employees as well as to users (Araujo and Matamala 1995). Quality management
encourages a work and health care environment free from discrimination and abuse of power.
Key here is the existence or absence of mechanisms that promote the participation of personnel
and users in the improvement of services provided. These might include posted policies
promoting users' rights or prohibiting discrimination; the use of suggestion boxes; and the
organization of participatory and democratic meetings between administration and staff, and
between these groups and representatives of the user population.

Therefore, who evaluates quality care? Since the philosophy is oriented toward the satisfaction of
users, it is users themselves who should evaluate the quality of services. To improve quality care,
we must begin with a philosophy that places priority on user satisfaction (Finger and Hardee
1993). An institutional philosophy grounded in user satisfaction will be manifested in a facility's
infrastructure, menu of information and services offered, labor practices and relations, staff
treatment and labor policies, the guarantee of confidentiality and privacy during provider-user
visit and even in the hours of service. If the institution does not take quality care into account as












a matter of policy, it is improbable that staff will be able to provide the kind of services that
satisfy users.

Structural characteristics of a program can promote or prohibit respect for sexual and
reproductive rights and the full exercise of these rights on the part of users. For example, every
institution needs to consider ways to provide access to targeted groups by taking into account
users who need to travel long distances or work long hours, and by adjusting the clinic hours
accordingly. Quality in administration and management also means analyzing the different needs
of men, women, married, single, and adolescents, and building programs in order to respond to
these different expectations and needs.

Each institution expresses its gender perspective in the relations it establishes with the public,
from the assignation of resources among different groups of users and providers, to the
distribution of tasks and responsibilities within the institution. A gender perspective is key to
understanding different groups, to ensuring that services do not favor some and discriminate
against others and making sure that programs do not reinforce existing inequalities. For example,
many maternal-child health and family planning programs could be improved by questioning and
changing their practices of orienting services and information exclusively to women; reinforcing
stereotypes that give women sole responsibility for their families' health; and denying the
fundamental importance of men's participation.

Quality in Human Relationships

This second aspect encompasses the empathy expressed by providers, time dedicated to each
user, sharing of knowledge and respect for each user's opinions and decisions. It also implies
respect for differences between people, e.g., a woman in native dress deserves the same
understanding and respect as a woman in modern dress; a disheveled adolescent boy deserves the
same service as a professional man. Respect is fundamental and should always be first. When I
consider that the patient is a woman like me, I try to treat her the
In addition to changes in attitude on way I would like to be treated. We need to talk in an adequate
the part of workers, quality care way, with a nice tone, and without crude words ... I try to get
requires that users themselves across my point in a clear way. First, we must know how to listen,
and second, know how to communicate, with nice words and a
exercise more responsibility and good tone, just what we want the patient to understand. For me,
initiative. Providers can facilitate this is basic respect. Testimony of a doctor in a family planning
this change by sharing knowledge service in Santiago, Chile. (Araya et al 1997).
about health, offering options for
treatments and methods, and supporting users in their decision-making process. Services should
offer complete information that permits users to care for their own sexual and reproductive
health and to take preventive actions that help achieve a state of physical, mental and emotional
well-being.













Technical Quality


This third aspect concerns adequate equipment and supplies, as well as technical competence on
the part of providers. Technical competence requires that health workers apply current and
appropriate knowledge, skills and technology using a humane scientific perspective. Indicators
for this type of quality include the existence of clear operational norms and procedures, as well
as the skill and accuracy necessary in diagnosis, treatment and follow-up of users.

Technical quality includes having the necessary equipment, supplies and medicines needed to
fulfill standards (Guiezmes 1997), together with maintenance of conditions, the fulfillment of
protocols and the availability of competent personnel (Finger and Hardee 1993). Quality
equipment and supplies also refer to the general infrastructure of the center (water, plumbing,
lighting, garbage disposal) and the conditions, comfort and cleanliness of the waiting and
consulting rooms. A crucial aspect of technical quality is the existence of educational programs,
covering medical techniques as well as techniques for patient care and communication, for
continuous professional improvement for male and female workers.


The
dimensions
quality care
above ar
independent,
rather they i
and interrela
provision of
and repr
health
Advances
three
contribute


three
of
outlined


Maria Jos6 Araujo and Marisa Matamala (1995) identify four fundamental
aspects of quality care:


e not 1. Care and resolution of the problems that motivated the visit. This supposes a
but comprehensive and effective response to the user's health problems, as well
ntersect as the application of interpersonal and technical skills of the health team.
teinthe 2. Satisfaction of the user's expectations. Important here is respect for the
user's self-determination and individuality.
sexual 3. Recognition, promotion and respect for sexual and reproductive rights.
oductive Quality care is grounded in an ethical stance that guarantees human and
care. health rights to all men and women, regardless of class, culture, ethnicity or
in all age.
4. Sharing of information and understanding. Providing users with
appropriate knowledge and information for their own use will improve their
to a abilities and self-determination.


change from a
unilateral practice in which health professionals monopolize knowledge, information and
decision-making toward a more conversational approach in which users participate with their
own ideas, doubts and preferences. This new interaction occurs within an atmosphere of mutual
respect, in which knowledge and responsibility are valued and strengthened in efforts toward
sustainable improvement in the users' health.

Quality Care and Gender

Health providers often reproduce and reinforce gender inequities in their relationships with users
and with co-workers. The provider-patient relationship does not take place in a cultural vacuum;
providers act on their own gender beliefs and assumptions and within institutional frameworks.
In many cases, health professionals tend to overvalue medical knowledge, give privilege to












masculine-scientific discourse and reject other ways of knowing, thinking and talking expressed
by patients. Often the sexual prejudices and values of providers and institutions are expressed
through doubt, criticism, rejection and even sarcasm toward the way patients understand things,
especially female patients, those who come from lower socioeconomic classes, and marginalized
ethnic groups. The Beijing Platform for Action identifies numerous ways to promote women's
access to health care throughout their lives, which will have to be complemented with ways to
promote men's health care in order to build a balanced gender approach:

* Redesign information, services and training for health workers so that they are gender-
sensitive and reflect the user's perspectives with regard to interpersonal and communications
skills and the user's right to privacy and confidentiality; these services, information and
training should be based on a holistic approach.
* Ensure that all health services and workers conform to human rights and to ethical,
professional and gender-sensitive standards in the delivery of women's health services aimed
at ensuring responsible, voluntary and informed consent; encourage the development,
implementation and dissemination of codes of ethics guided by existing international codes
of medical ethics, as well as by ethical principles that govern other health professionals.
* Take all appropriate measures to eliminate harmful, medically unnecessary or coercive
medical interventions, as well as inappropriate medication and over-medication of women,
and ensure that all women are fully informed of their options, including likely benefits and
potential side-effects, by properly trained personnel. United Nations Beijing Platform for
Action, Paragraph 106, 1995.

In social environments in which women assume subordinate positions in most relationships, they
react to providers in the same way, thus, undermining their potential power as health care clients.
In their relationships with health providers, many Bolivian women feel constrained by their
fears, shame and timidity; by guilt and moralistic norms; by insecurities about their own
knowledge; and by their experiences of physical, psychological and sexual violence. These
constraints are coupled by gender related economic and operational difficulties that must be
overcome in order to seek health care. All of these conditions limit women's capacity to take
greater responsibility for their well-being, take actions that favor their health and exercise their
rights.

Men also approach health care from their own gender experiences and are restricted by
normative models of masculinity. In Bolivian contexts, these can include pressure for "real men"
to resist pain, refuse to seek or accept help and appear strong and physically and emotionally
invulnerable. These aspects of "being a man" in Bolivian society impede access to health care.
Pressure to demonstrate stereotyped masculine behaviors is especially strong for young men,
many of whom do not seek medical care until they are extremely ill.

In considering quality care, providers should recognize these gender norms and stereotypes, their
impact on users' health and their influence both on provider-patient interaction and on user
follow-up. Providers must understand that they are capable of forging new gender visions and




T


possibilities, of changing their own behaviors and attitudes through their professional action.
They can, for example, encourage and support women users to make strong decisions in favor of
their own well-being and to assume new responsibilities for their health and sexuality. They can
encourage men to admit that they hurt, seek and accept help and advice and participate in the
health care of their children and partners. Better understanding and respect for others, together
with improved communication among people from different backgrounds, cannot help but
improve relations and processes of diagnosis, treatment and education, and thereby contribute to
improvements in the entire population's health.









METHODOLOGY

* GOAL

This training package promotes gender-sensitive quality care in sexual and reproductive health
services with the goal of contributing to sustained improvements in the health of Bolivia's
population. The conceptual framework and educational activities presented here systematize a
series of theoretical and methodological advances in the area of sexual and reproductive health,
and reinforce the positive experiences and abilities of providers. A gender perspective is applied
to help participants better understand diversity in the Bolivian population and to respond better to
differentiated groups of users and dynamics between them.

* OBJECTIVES

1. Create opportunities for reflection and action in the field of gender-sensitive quality care.
2. Provide basic tools that providers can use in their everyday practice: key concepts,
techniques and practices, criteria for implementing quality care.
3. Develop capacity for critical analysis that permits participants to use key concepts and
criteria to recognize, analyze and respond to users' realities and institutional practices.

* WHO SHOULD PARTICIPATE IN THIS TRAINING?

The present proposal is designed for professionals, technicians and other personnel who work
with sexual and reproductive health in both public and non-governmental services operating in
Bolivian cities. It is important that diverse actors from every institution participate in the training
in order to facilitate comprehensive and consistent efforts towards change, e.g., doctors,
administrators, receptionists, nurses, and other staff. Groups should include less than 25 people
to encourage maximum participation.

* TRAINING METHODOLOGY

Training is a process in which everyone learns something, facilitators as well as participants with
diverse experiences and education. Participants become protagonists of their own learning to the
extent that they commit personally to reflection and change and are willing to share their own
experiences and ideas. This pedagogic philosophy is promoted through the following
considerations:

Active and Participatory Effort

Active and participatory methodologies will permit the group to construct knowledge
collectively, and develop approaches that will be pertinent and significant for the participants.
Active participation is different from mechanic activity in which participants learn by repetition.
In active participation, different strategies are implemented to compare, question, relate,
experiment, analyze, criticize, probe and prove, permitting participants to get integrally involved
in the collective construction of knowledge. This participatory process depends on a democratic












and equitable learning environment in which everyone's knowledge and values are recognized
and respected, and in which the discourse is not dominated by he who talks with greater facility
or she who has the highest position in the institution.

Adapting to the Socio-cultural Context

All people have different ideas, knowledge and experience, organized in different ways. Thus,
facilitators must recognize and use as a point of departure the position and tradition of each
participant. In this manner, learning is context-specific, knowledge is produced in respectful and
equitable ways and the process strengthens the self-esteem of participants whose experiences and
knowledge are publicly valued. Involving participants with their own histories and positions
means responding to their needs, enriching their experiences, skills and knowledge and
appreciating what they do and do not know about the topic.

Education for Change

The training proposed here does not correspond with a traditional transmission of authoritative
knowledge from trainer to participants. On the contrary, it implies creating opportunities for
reflection and analysis of one's own practices, attitudes and abilities, illuminated and enriched by
new perspectives. The goal of this critical reflection is to motivate processes of personal growth
and provide the concepts and tools necessary for each participant to advance in that growth.

* STRUCTURE OF THE GUIDE

The training guide is divided into four sessions, each one with activities relating to a key theme.
The total training involves four sessions, each one lasting approximately four and one half-hours.

Module 1: Gender and Sexual and Reproductive Health
Module 2: Sexual and Reproductive Rights
Module 3: Quality Care I: Quality in Human Relations and Technical Quality
Module 4: Quality Care II: Quality in Administration and Management









FA CIL I TA TOR "S GUIaDE


* HOW TO USE THESE RESOURCES

This guide is designed to support facilitators who will lead training and reflection about gender-
sensitive quality care. It includes general orientation for the proposed approach but by no means
intends to limit the creativity of facilitators. Instead, this section offers ideas for appl1 ing and
adapting the proposal to different learning groups, taking into consideration their specific needs,
expectations and socio-cultural contexts.

* EDUCATIONAL PHILOSOPHY

We suggest a participatory and equitable approach to training activities that reflects the content
of the guide. Among the multiplicity of terms used for educational leader (trainer, monitor,
educator, etc.) we have chosen to use facilitator, which indicates a person who promotes and
supports the process of participatory construction of knowledge through the following means:

* Listen: ask about, listen to and respect the experiences, ideas and opinions that each
participant brings to the training.
* Dialogue: promote sharing and conversation between participants. Discussion will facilitate
the shared interpretation of concepts, and promote the development of critical analysis.
* Motivate: prepare and encourage participants to develop new approaches to act and impact
the situations, in which they live and work.

Each training session is designed to encourage listening, dialogue and motivation throughout
three key processes:

* Reflection: activities that motivate reflection about participants' own experiences and ideas
are designed to lead each individual to evaluate and question his or her everyday practices
and beliefs.
* Comprehension: new concepts and information provided in the conceptual framework and
other materials are presented in ways that relate to prior knowledge and experience of
participants. In each session, the facilitator presents new material through short lectures,
videos and charts in ways that encourage participants to relate it to and contrast it with their
own ideas and practices.
* Motivation: it is crucial to strategize ways in which participants can apply the new materials,
ideas and practices in their daily work and to address the obstacles and challenges that may
impede such innovation.

* THE FACILITATOR'S ROLE

Here we make a few suggestions to help facilitators guide the sessions. The first session begins
with a forum in which all participants introduce themselves; the facilitator may start by
introducing him or herself in a warm and friendly way, and thus, encourage the rest to join in.
We suggest that facilitators participate enthusiastically and from their own subjective standpoint


any












in the introductory activity, and in all following activities in which it is feasible to participate.
Once everyone has introduced him or herself, it is important to give a clear introduction to the
process. At the beginning of each session and each activity, the facilitator must communicate to
the participants:

* the theme of the session or activity on which they will be working;
* the specific objectives of their efforts;
* the methodology for the activities to be carried out; and
* the key concepts and their definitions.

Most activities involve group work. Ideally small groups are self-guided, but facilitators must
visit each group to ensure that they are working on the indicated theme and moving toward the
stated objectives. In addition to guiding the content of the work, facilitators must ensure that the
groups work in a democratic fashion in which the approaches and perspectives of all participants
are heard and respected.

In sessions in which groups present their work, the facilitator must:

* allow groups to express the results of their efforts in their own way, respecting the diversity
of opinions and ways of knowing and expressing knowledge;
* observe carefully, and later discuss, the relation between the indicated themes, directions and
objectives, and the actual results of group efforts;
* intervene to reorient discussions that get off track and do not enrich the topic at hand;
* make a clear synthesis of the ideas and messages presented (often it is useful to discuss the
main points and write them on poster paper).

The four-session training ends with a general synthesis and an evaluation of the learning
experience in which facilitators should participate actively and honestly.

* THE ROLE OF PARTICIPANTS

Each participant is encouraged to take an active part in the learning process. Because many
individuals are hesitant to speak or perform in public and are accustomed to a lecture format,
facilitators must encourage participation in the following ways:

* never forget that participants are adults: regardless of their education and professional
training, they all have rich life experiences that should be recognized and built on;
* make it clear that participation in this learning process is a step toward creating more
participatory and equitable relationships in the work and life of each participant; and
* from the beginning, make it clear that the training is designed to produce new ideas,
approaches and practices, and that participants must prepare to leave behind their old
prejudices, attitudes and fears.












* EDUCATIONAL RESOURCES AND SUPPORT MATERIALS

This training package includes the following materials to support and enrich the process:

1. a conceptual framework which provides the theoretical basis of the training;
2. a central matrix which indicates the key content and activities for each session;
3. a guide to the activities and discussions that make up each session;
4. concept cards that summarize the main ideas and key terms;
5. videos to support reflection and learning activities.

* NECESSARY MATERIALS

The materials needed to conduct the training are:

1. photocopies of parts of this guide, including concept cards and activity guidelines;
2. a television and VCR;
3. poster paper and markers and/or whiteboard;
4. colored cards;
5. tape or tacks; and
6. planning matrix.









Planning Matrix

TOPIC OBJECTIVE SPECIFIC OBJECTIVE KEY CONCEPTS ACTIVITIES TIME RESOURCES KEY MESSAGE
Gender, sexual Recognize the concepts of Identify different gender identities Gender. Who are we? 4 hours, 30 Brief texts on gender, and There are different types of users,
and reproductive gender, and sexual and within the social context of the Sexual and reproductive health. Workshop presentation, minutes sexual and reproductive men and women. The quality of
health reproductive health. participant, health; matrix; question service is improved by respecting and
T" How did we become men and women? guidelines, responding to their needs and
Analyze how gender influences the Construction of concept of gender, realities. Gender relations condition all
UI needs and expectations of sexual interpersonal relationships among
and reproductive health. Gender relations within sexual and providers, between couples and
Reproductive health services. providers and users. These
P Recognize gender dynamics in relationships influence the care given
health services, at sexual and reproductive health
O services.
SAnalyze the influence of these
dynamics on quality of care.
Sexual and Recognize sexual and Generate reflection on exercising Sexual and reproductive rights. Defining our sexual and reproductive 4 hours, 30 Question guidelines; brief texts Identifying and valuing sexual and
reproductive reproductive rights, sexual and reproductive rights from rights. minutes on sexual and reproductive reproductive rights allows for the
(C rights the perspective of personal rights; list of sexual and respect and adherence to these rights.
Ijdenir, strategies to experience. Building the concept of sexual and reproductive rights; scripts to
UII promote the exercising of reproductive rights, analyze. Services should socialize information,
These rights. Be respectful and promote these offer options and respect decisions to
Rights in the jaii, routine of sexual The promotion and practice of rights in assist the user in exercising his/her
a and reproductive health services. known situations. rights.
O Create messages that promote sexual Respecting the rights of users as well
and reproductive rights as valuing their opinions improve
quality of care.
Quality of care: Develop attitudes and Identify and reinforce skills and Quality of care in sexual and Valuation of our abilities. 4 hours Brief texts on quality of care; Specific changes in providers'
CO) compassionate learn methods that will methods that promote quality of care. reproductive health services. summaries of techniques to attitudes, practices and techniques
care and high improve relationships with Presentation on the philosophy of improve quality of care with a contribute to more equitable and
LU technical quality users(male and female), Identify attitudes and interpersonal Compassionate care. quality of care. gender perspective; video, effective relationships in improving the
-J respecting their rights, dynamics that promote quality of health of male and female users.
D care. High technical qu.ali, Techniques and practices of quality of
Scare: living examples.
Learn new criteria and techniques. Instruments to improve the quality
0 of care. Conducting consultations with
Compassionate care and high technical
quality.
Quality of care: Analyze the organization Develop the ability to analyze Institutional management for Identify quality of care indicators with a 4 hours IPPF indicators proposal for Providers' personal and professional
institutional and institutional institutional policies, structures and equity and q.ui.ii, gender perspective, sexual and reproductive health practices are developed within an
management administration in sexual dynamics. services with a gender institutional context, which can impede
and reproductive health Quality of care evaluation Apply indicators to evaluate and perspective; FODA analysis; or promote progress in quality of care.
programs to identify Identify evaluation criteria for health indicators from a gender improve our institutions, question guidelines; video,
institutional strategies that services from a gender perspective. perspective, evaluation cards. Quality depends on efforts that range
LU best respond to male and Reflect upon the strengths and from the receptionist's attitude, the
. female users' rights, needs Identify feasible changes at a weaknesses of our institutions(FODA). program's design and administrative
and possible options, personal, interpersonal and management, to national and
P institutional level and explore the Make multiple changes towards better international policies.
O relationships among them. care.
O
SEvaluation of the educational
___experi_________________________________________________________________experience__________________________.___________________________________experience.




f


MODULE 1


GENDER AND SEXUAL & REPRODUCTIVE HEALTH


* SESSION OBJECTIVES:

1. Develop an understanding of two central
concepts: gender and sexual &
reproductive health.
2. Explore relationships between these two
concepts in the field of health care.

* SPECIFIC OBJECTIVES:

1. Identify different gender identities and
experiences in the participants' social
context.
2. Analyze the influence of gender on
people's needs and expectations in
sexual and reproductive health.
3. Identify gender relations and dynamics
within the context of health services.
4. Analyze the influence of these dynamics
on quality care and the satisfaction of
needs and expectations of men and
women users.

* KEY CONCEPTS:

Gender
Sexual and reproductive health

* ACTIVITIES:

1. Who are we?
2. Introduction to the training
3. How do we become men and women?
4. Constructing the concept: gender
5. Relations between gender and
reproductive health

* TIME:

4 hours, 30 minutes


* ACTIVITY 1
WHO ARE WE?

Objectives:
1. Encourage participants to begin to get to
know each other.
2. Generate a context of mutual trust.
3. Introduce the idea of gender difference.

Procedures:
1. Welcome all participants.
2. Ask each participant to choose a card in
a color (pink, blue, yellow or green) with
which s/he identifies, and writes on the
card his/her name, and a salient personal
characteristic.
3. Each participant presents him/herself,
explaining why s/he chose the color and
how it relates to a personal
characteristic.
4. All participants tape their cards on a
board or wall, arranging them as they see
fit (by order of presentation, color of
card, interests and characteristics, sex,
age, etc.). Discuss the role of gender in
personal identities and interpersonal
contact.

Time:
30 minutes

Materials:
Pink, blue, yellow and green cards
Markers
Tape

Discussion:
We choose colors and other identity symbols
to correspond with (and sometimes to reject)
predominant models of feminity and












masculinity. Let us reflect together about the
ways in which we develop personal
preferences and images and how we are
educated with stereotypical gender
expectations. Traditionally, pink is
associated with girls, who are educated to be
dedicated mothers and obedient wives in the
private domain. The color blue is associated
with boys, who are trained to be strong,
manage power and lead in the public
domain. If a man identifies with the color
pink, is he necessarily feminine, or are there
other options for identities?

* ACTIVITY 2
INTRODUCTION TO THE TRAINING

Objective:
Communicate the objectives, content and
methodology of the workshop.

Procedures:
1. Introduce the general objectives and
philosophy of the workshop,
emphasizing the key role of participants
as active agents of change.
2. Explain the objectives, contents and
methods of each session.
3. Briefly present the conceptual
framework and provide a concise
definition of each of the four key
concepts.

Time:
15 minutes

Materials:
Planning matrix
Poster paper with outline of training process
Four concept cards


Discussion:
Reflect on and reinforce the idea that the
success of the workshop depends on the
active participation of all and on the sharing
and appreciation of each participant's
knowledge and experience in the joint
construction of concepts and approaches.

* ACTIVITY 3
HOW DO WE BECOME MEN AND
WOMEN?

Objectives:
1. Describe and analyze the socialization
processes that give shape and meaning to
our physical development during the life
cycle of men and women.
2. Distinguish between biological
characteristics and social identities of
men and women.
3. Recognize that gender identities and
characteristics vary among ethnic and
socioeconomic groups.
4. Recognize and reflect on gender
relations, which range from
complementarity and interdependency to
subordination and exploitation.

Procedures:
1. Describe the method and goals of the
group activity.
2. Form four groups, which may be mixed
or sex-segregated. Two groups will
focus on the life cycle of women, and
two groups will describe the life cycle of
men.
3. Each group chooses a moderator and
presenter.
4. Each group receives poster paper and a
photocopy of the matrix to guide this
activity (included in the support
resources at the end of this session).


~*~~lri~li~*u%-~i ~-~r












5. Participants fill in the columns which
describe the development of physical
characteristics and social education that
contribute to our gender identity at each
life cycle stage.
6. After filling in the matrix, each group
presents their results to the larger group.
7. Based on the descriptions produced by
the groups, analyze and discuss gendered
socialization processes, using the issues
in the question guide provided with this
session, i.e., What are the similarities
and differences in the education of boys
and girls? What are the social and
political implications of this
differentiated socialization?

Activity guide:
Distribute a copy of the matrix "How do we
become men and women?" to each group,
who must fill in the matrix on the basis of
their own experiences and observations. On
one side they will list physical
characteristics of females and males at each
age level, and on the other side they will
describe what families, schools, media and
others tell us, ask us and teach us at each
stage of life to encourage us to act like men
or women. Participants should reflect on
their own experiences and remember. For
example, did anyone ever tell them "big
boys don't cry!" or "nice girls don't get
dirty," or were house keys and late curfews
given to adolescent boys while girls were
carefully watched? They should compare the
expectations placed on a 30-year old woman
(which might include that she should be
married and raising children) versus a man
of the same age (which might include that he
should be earning money or establishing a
career). When groups meet and present their
work, the question guide included with this


session can help to orient the reflection and
synthesis process.

Time:
30 minutes

Materials:
Activity matrix: "How do we become men
and women?"
Copies of the question guide
Poster paper and pens

Discussion:
Small group activities permit each person to
share and apply his or her experience in
order to better understand the relationship
between biological and social characteristics
in his or her own life. The final discussion
among the group as a whole allows for
comparison and contrast of men's and
women's experiences, as well as those of
people from different generations and
varying social, racial and ethnic
backgrounds.

Expected results for participants:
1. Learn to recognize the difference
between aspects of our identities formed
by biological sex and those influenced
by social gender.
2. Analyze different forms of gendered
education and identify implications of
the different values and roles assigned to
men and women.
3. Recognize that gender is not
homogenous; there are many ways of
being men and women.













* ACTIVITY 4
CONSTRUCTING THE CONCEPT:
GENDER

Objectives:
1. Develop an understanding of gender as
an analytical category.
2. Relate the concept of gender to
observations and experiences discussed
in the preceding activity on becoming
men and women.

Procedures:
1. Structure the discussion around the
gender concept card. One participant
reads aloud the first section of the card,
and all can discuss what was read and
relate it to the activity on becoming men
and women. Another participant reads
the next section of the concept card and
the group continues with a discussion of
the ideas raised. The dynamic continues
until the group has heard and discussed
all parts of the concept card.
2. Conclude with a brief discussion about
the different needs and expectations of
health care experienced by people of
different gender groups, ages,
sociocultural, racial and ethnic
backgrounds. Emphasize that health care
which does not respond to gender
differences that affect health, nor to
gender relations which influence and
interfere with service, will always have
limited results.

Activity guide:
Before initiating this session, facilitators
should study the section on gender in the
conceptual framework and prepare to refer
to it during group discussions. Emphasis
should be on relating the theoretical and
analytical concept of gender to the lived


experiences of becoming men and women
that were articulated by participants in the
preceding activity.

Time:
30 minutes

Materials:
Concept card: Gender

Discussion:
Gender is a social, cultural and historical
system that organizes and gives meaning to
many aspects of life in reference to sexual
differences. A gender perspective is a
conceptual tool that allows us to identify the
characteristics, experiences and needs of
men and women and to analyze the
relationships between them, including the
balance of opportunities, power and
decision-making abilities.

Expected results for participants:
1. Relate the concept and the analytical
approach of gender to the gendered
socialization experiences discussed
earlier.
2. Recognize on the basis of own
experience that many "masculine" and
"feminine" characteristics are learned, as
are the power relationships that surround
them.
3. Affirm that the category of gender helps
us to better analyze and address
identities and relations in health care.
4. Be motivated by the possibility of
transforming some gender attitudes and
practices in order to improve health care
for men and women.













* ACTIVITY 5
RELATIONS BETWEEN GENDER AND
REPRODUCTIVE HEALTH

Objectives:
1. Develop an understanding of sexual and
reproductive health as an integrated
concept.
2. Recognize that gender is present in and
influences all relations surrounding
sexual and reproductive health and
health care.

Procedures:
1. Read and discuss together the concept
card about sexual and reproductive
health.
2. Form small working groups.
3. During 15 minutes each group prepares a
brief skit that demonstrates a familiar
situation in sexual and reproductive
health care. The skit should include
diverse individuals involved in the care,
from the time the user enters the center
until s/he leaves. The skits can be based
on participants' experiences in stories
such as the following:
a pregnant 17-year old without a
partner seeks care and advice;
a middle-aged male factory worker
seeks help for STD symptoms;
a 35-year old woman who sells food
in a street market seeks ways to
avoid having more children;
an elderly man seeks a consultation
for prostrate problems.
4. Each group presents its skit for the rest
of the participants. After each skit,
discuss the different identities, attitudes
and characteristics demonstrated by each
actor and analyze the relative power
relations between actors.


5. Identify positive aspects of the identities
and relationships presented and discuss
ways to strengthen and reinforce these in
order to improve service consistently.
Identify negative aspects that impede
improvements in care and seek ways of
changing or overcoming these factors.

Activity guide:
Before leading the session, facilitators
should read the section of the conceptual
framework that addresses sexual and
reproductive health, and refer to it in
presentations and group discussions.

Time:
1 hour, 30 minutes

Material:
Concept card: Sexual and reproductive health






* CONCEPT CARD: GENDER

Gender is a social, cultural and historic
system that assigns certain characteristics
and roles to groups of individuals with
reference to their sex and sexuality. A
gender perspective is a theoretical and
methodological approach that permits us to
recognize and analyze different identities,
perspectives and power balances in the
dynamics of interpersonal relations, and
supports a critical analysis of socio-cultural
institutions and socioeconomic, political and
legal structures.

Teresita de Barbieri (1991) notes that human
bodies are biologically sexed, and that we
attribute social and cultural meaning to these












sexes. Thus, men and women are historical,
not natural, beings; we are born in societies
where we internalize gender roles, norms
and meanings. For Barbieri, sex/gender
systems are constellations of practices,
symbols, representations, norms and social
values that societies elaborate with reference
to anatomic and physiological sex
differences. Institutions such as schools,
governments, churches and families, manage
and transmit gener practices. In fact, whole
life philosophies are marked by gender.

Traditional ideology or new analytical
perspective?
Marcela Lagarde identifies two basic
conceptions of gender in Latin American
societies. One is a traditional gender
ideology that sustains that all feminine and
masculine characteristics are natural, that
gender norms and roles are created by divine
forces (or by biological evolution) and are,
therefore, immutable. This ideology is
reinforced by institutions that supervise and
sanction behavior, guiding the ways in
which people become socially acceptable
men and women.

In contrast to this gender concept, Lagarde
describes another approach to gender that
challenges traditional ways of life as a tool
for critical analysis. This approach to gender
assesses the dominant gender order with the
aim of questioning and deconstructing
predominant social, psychological and
cultural characteristics and relationships. It
reveals that attributes of greater and lesser
power are not natural, nor genetic; they are
socially assigned and, therefore, can be
transformed into more balanced relations
(Lagarde 1995).


Gender relations
Gender is a necessary element of all social
relations -- domestic, labor, political or
economic. Gender organization attributes
different values and powers according to
sexual identity, which influence interactions
and relationships among all persons.
Gender identities are not synonymous with
sexual dimorphism. Factors such as life
cycle, socio-economic and ethnic identity
crosscut gender systems, which include
multiple sexual and gender identities.

Gender and health
Gender organization and meanings manifest
themselves in science, religion, education,
politics, economics and the environment and
influence sexual and reproductive health, as
well as the ways in which we perceive it.
This organization legitimizes values, beliefs
and practices in relation to the sexual and
reproductive lives of individuals in ways
that can strengthen or hamper the health of
certain groups.

Applying a gender approach to sexual and
reproductive health allows us to go beyond a
biological focus on women's bodies. It
allows us to better understand the socially
constructed identities of men and women,
and thereby approach the social
relationships, which influence the sexual and
reproductive health of each person. Health
services and providers can better respond to
user needs if they recognize that women and
men live and perceive sexuality and
reproduction in different ways and that the
visions with which we approach our work as
health professionals are also conditioned by
gender factors embedded in our cultures and
related to our own sexual identities.


V













In Bolivia, for example, gender symbols
associated with masculinity and femininity
influence the choice, use and discontinuation
of contraceptive methods and practices on
the part of each man and women. Gender
relations influence negotiation, decision-
making and contraceptive use. Gender roles
also play an important part in the
relationships between providers and users
and affect health outcomes for men and
women. Finally, analysis of power and
knowledge relationships within health
programs and institutions allows us to
identify and transform unequal and
stereotypical relations that interfere with
quality care.

A gender perspective helps us to recognize
and respect differences within populations
of providers and users and helps us analyze
the dynamics of power, knowledge and
decision-making within couples and
families, between providers and users, and
between governments and health institutions
and the populations they serve. Health
services that consider and respond to these
realities, and that broaden their focus to
encompass multiple dimensions of sexual
and reproductive health of all gender groups,
achieve greater success in the goal of
improving the sexual and reproductive
health of the entire population.

M CONCEPT CARD: SEXUAL AND
REPRODUCTIVE HEALTH

The concept of sexual and reproductive
health expresses a change from a biomedical
focus on health and illness toward a more
comprehensive approach to well-being that
incorporates the social sciences and the
ethical bases of human rights. In this
concept, biological, psychosocial, cultural


and legal aspects of sexual and reproductive
health are intimately interrelated, and sexual
and reproductive health is understood as a
life process which influences and is
influenced by a variety of other factors
(WHO 1997).

Traditionally, health policies and programs
have centered on biomedical aspects of
reproductive health and, especially, on
fertility control. In recent decades, however,
we have begun to understand that personal
and cultural experiences of sexuality are
intimately linked with the health of the
reproductive system. The two dimensions
develop interdependently during each
person's life cycle and affect each other in
multiple ways. For example, the physical
and psychosocial stress of closely spaced
births can limit a woman's sexual expression
and have negative affects on her sexual
health (Bassu 1997). Similarly, a sexually
transmitted disease can lead to problems in
the reproductive system, including
infertility.

The Cairo definition
The International Conference on Population
and Development held in Cairo in 1994
established a new vision of reproductive
health that explicitly incorporates sexual
health:
Reproductive health is a state of complete physical,
mental and social well-being and not merely the absence
of disease or infirmity, in all matters relating to the
reproductive system and to its functions and processes.
Reproductive health therefore implies that people are
able to have a satisfying and safe sex life and that they
have the capability to reproduce and the freedom to
decide if, when and how often to do so. Implicit in this
last condition are the rights of men and women to be
informed and to have access to safe, effective, affordable
and acceptable methods of family planning of their
choice, as well as other methods of their choice for
regulation of fertility which are not against the law, and
the right of access to appropriate health care services
that will enable women to go safely through pregnancy
and childbirth and provide couples with the best chance
of having a healthy infant. ICPD, Programme of
Action, Paragraph 7.2, 1994.













Sexual and reproductive health services
According to this vision, sexual and
reproductive health services can include, but
are not limited to: voluntary fertility
regulation; prenatal, birth and postpartum
care; tetanus vaccines; support for
breastfeeding; infertility treatment;
prevention, screening and treatment of
STDs, including HIV-AIDS; gynecological
examinations; prevention and treatment of
breast and cervical cancer; treatment of
complications from abortion; nutrition
programs; production and dissemination of
educational and informative materials;
education and counseling about sexuality;
protection against violence; training of
extension workers; personal and couple
counseling; and diverse activities that
empower users to take greater control and
responsibilities for their own health (Dixon-
Mueller 1993; Hardee and Yount 1995).

Gender and sexual and reproductive
health
The gender roles played out by men and
women in our societies have significant
influence on their health. In many parts of
Latin America, values associated with
machismo emphasize men's sexual prowess,
measured by the daringness of their sexual
conquests and the number of sexual relations
(Barker and Loewenstein 1996). This type
of symbolic system motivates men to take
risks with their own health and sets the stage
for unwanted pregnancies, abortions, and the
spread of STDs (Zeidenstein and Moore
1996).

In Bolivia, women seek and obtain health
services with greater frequency than men
due to their reproductive biology, as well as
gender norms that discourage men from
seeking health care and assign women social


responsibility for the health of others,
including children, parents, sick friends and
relatives. There is a growing consensus that
a more balanced participation, including
both men and women, would contribute to
improved health for all. One of the Cairo
recommendations highlights the importance
of involving men more fully in sexual and
reproductive health issues. "Innovative
programmes must be developed to make
information, counselling and services for
reproductive health accessible to adolescents
and adult men. Such programmes must both
educate and enable men to share more
equally in family planning and in domestic
and child-rearing responsibilities and to
accept the major responsibility for the
prevention of sexually transmitted diseases"
ICPD, Programme of Action, Paragraph 7.8,
1994.

Thus, working from a gender perspective
means putting more emphasis on men as
well as on women. To date, there is still a
predominant emphasis on care and treatment
for women and on advocacy for women's
health rights and services. Many of those
who design health policies and provide
health care have not yet accepted the idea
that sexual and reproductive health takes
two; that men as well as women have sexual
and reproductive health needs, expectations
and rights.


,7













* ACTIVITY MATRIX: HOW DO WE
BECOME MEN AND WOMEN?

HOW DO WE BECOME MEN?
Life stage Physical What they tell
characteristics us, ask of us
and experiences and teach us so
that mark us as that we
men become men
0-5 years old
5-10 years
10-15 years
15-20 years
20-45 years
45-80 years

HOW DO WE BECOME WOMEN?
Life stage Physical What they tell
characteristics us, ask of us
and experiences and teach us so
that mark us as that we
women become women
0-5 years old
5-10 years
10-15 years
15-20 years
20-45 years
45-80 years

* QUESTION GUIDE FOR GROUP
DISCUSSION

* Are the education and socialization that
we receive at each life cycle stage the
same for men and women? How are they
different? Why are they different?
* What effects do the differentiated
education and socialization have on the
health of boys and girls, adolescents,
men and women?
* How does this differentiated education
affect women and men's sexuality and
reproductive practices? In their
adolescence? In midlife? In later years?
* Do men and women participate equally
in decision-making processes at home, in


the workplace, in communities and
nations?
* Do men and women of Aymara,
Quechua and other indigenous
populations receive the same kind of
gender education and the same kind of
gendered opportunities as men and
women of European descent?
* Do girls and boys in rural Andean and
Amazonian communities receive the
same type of gender education as boys
and girls in large cities?
* Do the sons and daughters of
professional families receive the same
gendered training as the sons and
daughters of maids and wage earners?









Af MOD U[LI E 2


SEXUAL AND REPRODUCTIVE RIGHTS


* SESSION OBJECTIVES:

1. Develop awareness of and respect for
sexual and reproductive rights.
2. Identify strategies for promoting the
exercise of these rights.

* SPECIFIC OBJECTIVES:

1. Generate reflection about the exercise of
sexual and reproductive rights in
participants' personal and professional
experiences.
2. Motivate commitment to the promotion
of rights in daily practices of health
services.

* KEY CONCEPT:

Sexual and reproductive rights

* ACTIVITIES:

1. Defining our sexual and reproductive
rights
2. Constructing the concept: sexual and
reproductive rights
3. Promoting and exercising sexual and
reproductive rights in familiar situations
and contexts
4. Developing messages to promote sexual
and reproductive rights in the workplace

* TIME:

4 hours, 30 minutes


* ACTIVITY 1
DEFINING OUR SEXUAL AND
REPRODUCTIVE RIGHTS

Objective:
Reflect on the exercise of sexual and
reproductive rights in our own professional
and personal experience.

Procedures:
1. Each participant writes on several cards
the sexual and reproductive rights that
s/he exercises or would like to exercise
(5 minutes).
2. Everyone deposits cards in a box.
3. Each person pulls cards out of the box
and reads them, deciding as a group how
to organize them into several themes or
categories.
4. Participants form groups. Each reads the
cards grouped under one theme and uses
the discussion guide provided with this
session to direct reflection and analysis
(25 minutes).
5. The whole group unites. Each thematic
group presents its analysis of the rights
that they can exercise, the rights that
people want to exercise and the obstacles
that impede the latter (30 minutes).

Discussion guide:
1. What conditions are necessary to
exercise these rights (consider social,
economic, cultural conditions)?
2. Do different groups in our society enjoy
the conditions necessary to exercise
these rights?
3. What obstacles must be overcome before
each group can fully exercise its rights?












4. How can we work to guarantee these
rights in our work and private lives?
5. How can we promote and guarantee
these rights within health services and
institutions?
6. Compose a declaration which addresses
the specific rights and conditions
discussed here.


Time:
1 hour


Materials:
Index cards
Photocopies of discussion guide

Discussion:
All people have sexual and reproductive
rights. The specific details of these rights
and the exercise of them are expressed
differently in different cultural groups,
genders, generations and religions. Yet for
all people, sexual and reproductive rights are
based on the principles of human dignity,
liberty and equality.

The promotion and full exercise of sexual
and reproductive rights contribute to the
improvement of health services and the
quality of health care, thereby, causing a
positive impact on the health of user
populations. It is not possible to isolate
sexual health rights from reproductive health
rights, i.e., the kind of quality care that
improves a population's health depends on
addressing both these rights in a
comprehensive way.

Expected results for participants:
1. Learn to identify and express sexual and
reproductive rights in our own words
and in reference to our own lives.


2. Identify actions and attitudes that
promote the respect for and exercise of
these rights.
3. Identify political and institutional actions
that guarantee these rights and promote
the exercise of these rights on the part of
men and women health care users.

* ACTIVITY 2
CONSTRUCTING THE CONCEPT:
SEXUAL AND REPRODUCTIVE
RIGHTS

Objectives:
1. Develop a clear understanding of sexual
and reproductive rights.
2. Share information and basic guidelines
for promoting sexual and reproductive
rights in health services.

Procedures:
1. Using the concept card on sexual and
reproductive rights, participants can take
turns reading aloud one paragraph each
about the history of international
declarations concerning sexual and
reproductive rights. The group should
discuss both the symbolic importance
and the real impact of these declarations
on the guarantee of and exercise of
sexual and reproductive health by men
and women in Bolivia.
2. A participant reads aloud the second
section of the concept card, dealing with
the promotion of sexual and
reproductive rights in health services.
The group discusses each participant's
possibilities of advancing these rights in
his or her own work and the
opportunities (or lack thereof) that male
and female users have to exercise their
rights.












3. The facilitator can display a poster with
the list of sexual and reproductive rights
provided as a resource for this session.
Each participant reads aloud one of the
rights on the list. After discussing each
of these rights, participants should
articulate and add to the list other rights
that they feel are important in the
context in which they live and work.

Activity guide:
1. Before presenting the section on rights,
facilitators should read the section of the
conceptual framework on sexual and
reproductive rights and be able to refer
to the information provided there.
2. Facilitate connections between the
specific rights that participants identified
in Activity 1 as enjoyed or desired and
the international declarations and
published definitions of sexual and
reproductive rights presented on the
concept card.

Time:
30 minutes

Materials:
Concept card: Sexual and reproductive
rights
List of sexual and reproductive health rights,
printed on poster paper or white board

Discussion:
In order for women and men to take
responsibility for their sexual and
reproductive health, and to make decisions
favorable to their own health and that of
their families, both users and providers must
know, respect and exercise basic sexual and
reproductive health rights.


* ACTIVITY 3
PROMOTING AND EXERCISING
SEXUAL AND REPRODUCTIVE
RIGHTS

Objective:
Identify ways to promote sexual and
reproductive rights in the daily work of
health services and commit to these
practices.

Procedures:

Part 1
Form four groups, with each receiving a
story that represents different experiences of
health care (the complete texts of these
stories are included in the support resources
at the end of this section). After taking five
minutes to prepare, assign roles and read
through the scripts, each group presents its
story, reading and/or performing the
interactions in front of the other groups. The
stories include:

1. A woman in indigenous dress seeks
fertility control and is demeaned for her
traditional practices and beliefs.
2. An adolescent seeks care for
complications from an abortion induced
at home and receives compassionate and
thorough care.
3. A man with an STD seeks care in a
health clinic oriented toward women.
4. A young unmarried couple seeks birth
control methods and is chastised by the
physician who does not provide
complete information or promote
informed choice.

Time:
25 minutes












Part 2
After all the stories are presented, distribute
to each group a discussion guide which will
guide reflection and analysis of the stories
just performed.

Discussion guide:
In the story we just enacted, in what way do
the providers:

1. recognize and respect users' different
identities and needs?
2. share information and knowledge?
3. share decision-making and power in
efforts to improve the user's sustained
well-being?
4. promote the exercise of specific sexual
and reproductive rights?
5. impede the exercise of these rights?
6. show sensitivity and respond to users'
expectations?
7. consider users' fears and other feelings?
8. facilitate dialogue and communication?
9. explain clearly the importance of
treatments and outline preventive actions
that the user can take?
10. respect the sexual behavior and cultural
practices of users?

Time:
20 minutes

Part 3
1. Once the groups have discussed the
above issues, we ask, "What changes in
attitude and interaction will help
promote the sexual and reproductive
rights of these different users?"


2. Each group develops a new script in
which the institution and the providers
are more successful at recognizing and
respecting users' differences and at
promoting the exercise of their rights.

Time:
30 minutes

Part 4
1. Each group presents its "improved
story" skit and explains the reasons
behind modifications.
2. Finish with discussion about ways to
promote sexual and reproductive rights
in health care services, including rights
and issues not considered in the skits.

Time:
45 minutes

Total time for four-part activity:
2 hours

Materials:
Copies of the scripts
Poster paper, markers
Copies of the discussion guide

Expected results for participants:
1. Appreciate and value attitudes that
facilitate the exercise of rights.
2. Identify attitudes that are barriers to the
exercising of sexual and reproductive
rights.
3. Develop practical strategies to modify
services in order to better respect users'
differences and promote their rights.












* ACTIVITY 4
DEVELOPING MESSAGES TO
PROMOTE SEXUAL AND
REPRODUCTIVE RIGHTS IN THE
WORKPLACE

Objective:
Help participants to formulate
communication strategies to promote the
respect for and guarantee of sexual and
reproductive rights in their own institutions
and activities.

Procedures:
1. Participants form groups to work on
proposals to promote sexual and
reproductive rights through
communication media.
2. Each group decides what type of media
they want to use: posters, pamphlets,
radio messages, television spots, etc.
3. Groups develop simulated media
campaigns that express key messages
about rights and advance strategies to
promote them.
4. Each group presents the poster,
advertisement or other message that it
has prepared.





* DISCUSSION GUIDE FOR GROUP
REFLECTION
1. What conditions are necessary to
exercise reproductive and sexual rights
(consider social, economic, cultural
conditions)?
2. Do different groups in our society enjoy
the conditions necessary to exercise
these rights?


3. What obstacles must be overcome before
each group can exercise its rights?
4. How can we work to guarantee these
rights in our work and private lives?
5. How can we promote and guarantee
these rights within health services and
institutions?
6. How can we compose a declaration
which addresses the specific rights and
conditions discussed here?

* CONCEPT CARD: SEXUAL AND
REPRODUCTIVE RIGHTS

Sexual and reproductive rights are
inalienable human rights, inseparable from
other basic rights such as the right to food,
housing, health, security, education and
political participation. Sexual and
reproductive rights can be defined in terms
of power and resources: the power to make
informed decisions over one's own fertility,
procreation and child care, gynecological
health and sexual activity, as well as the
resources to carry out those decisions safely
and effectively (Correa and Petchesky
1994).

History of sexual and reproductive rights
The concept of sexual and reproductive
rights, together with the declarations that
promote respect for these rights, have a long
history. After the Second World War, the
Charter of the United Nations (1945)
affirmed faith in fundamental human rights,
the dignity and value of human persons, and
equality of rights between men and women.
In 1948, the Universal Declaration of
Human Rights included Article II which
proclaims the right of all persons to the
established rights and liberties without any
distinction based on race, color, sex,
language, religion, political or other opinion,


V










',~l~eJ ~I~AI e~~


national or social origin, property, birth or
any other condition.

Other conferences and declarations
reinforced the notion that the right to decide
about reproduction, as well as the right to
access to health services, were basic human
rights. In 1979, the General Assembly of the
United Nations approved a Convention on
the Elimination of All Forms of
Discrimination against Women, and
countries that signed the treaty committed to
take measures to "ensure the full
development and advancement of women."
One of these measures is a commitment to
ensure equal access to health services,
including those related to family planning,
and to promote the same right for men and
women to decide the number and spacing of
their children. This measure also highlights
the need to access the information,
education and resources necessary to
exercise this right.

The International Conference on Population
and Development in Cairo recognized
certain sexual and reproductive rights as
basic human rights. "These rights rest on the
recognition of the basic right of all couples
and individuals to decide freely and
responsibly the number, spacing and timing
of their children and to have the information
and means to do so, and the right to attain
the highest standard of sexual and
reproductive health. It also includes their
right to make decisions concerning
reproduction free of discrimination, coercion
and violence, as expressed in human rights
documents" (ICPD, Programme of Action,
Paragraph 7.3, 1994). The Fourth World
Conference on Women in Beijing reaffirmed
earlier consensus on the need to eradicate all
forms of discrimination and violence against


women and to guarantee the right to decide
freely and responsibly about matters of
sexuality and reproduction.

The promotion of sexual and
reproductive rights in health care services
Today, the exercise of sexual and
reproductive rights by men and women is
considered a fundamental basis for a better
quality of life (UNFPA 1997). Generally,
sexual rights are not distinguished from
reproductive rights; they are treated as
dimensions of a set of basic human rights,
the exercise of which constitutes a
fundamental strategy for human survival and
quality of life.

Increasing emphasis on sexual and
reproductive rights is contributing to
changes in health care values and
paradigms. "Within this framework" writes
Ladi Londofio, "a gender perspective helps
us identify great shortcomings, unnecessary
medical interventions, as well as the
importance of emotional and affective
aspects" (1996). Quality of care doesn't only
lie in improved infrastructure, reduced rates
of maternal mortality and better resources
for health care, it is also based on the
exercise of and respect for individual
autonomy in intimate matters and sexual
decisions of men and women.

* LIST OF SEXUAL AND
REPRODUCTIVE RIGHTS

These rights include but are not limited to:

1. The exercise of sexual independence, as
well as the right to enjoy it according to
one's own preferences, and the right to
legal protection.












2. Pleasurable and recreational sexuality,
independent of reproduction.
3. Adequate information and knowledge
about sexuality and reproduction.
4. Love, sensuality and eroticism in sexual
relations.
5. Sexual education that is appropriate,
comprehensive, secular, scientific and
gender-sensitive.
6. Refusal to engage in sexual activity.
7. Freedom from fear, shame, guilt and
other imposed beliefs that inhibit a
person's sexuality and diminish his or
her sexual relations.
8. Choice of sexual partners, to exercise
sexuality without coercion or violence.
9. Nutrition necessary for adequate growth
and balanced development of one's body
and future reproductive potential, from
childhood.
10. Voluntary motherhood, to decide and
live motherhood for one's own choice
and not by obligation.
11. Complete information concerning the
benefits, risks and relative effects of all
contraceptive methods.
12. Free or inexpensive contraceptives with
current information, follow-up and
responsibility on the part of those who
prescribe it.
13. Marriage and family or the choice not to
have either.
14. Parenthood and the right to decide when
to have children.
15. Good quality services for prenatal care,
birth, and postpartum care, guaranteed
by appropriate legislation.
16. Equal participation by women and men
in child care, creatively constructing
children's identities beyond traditional
gender roles.
17. Effective legal protection against sexual
violence.


18. Adoption and right to comprehensive,
accessible treatment for infertility.
19. Prevention and treatment of illnesses of
the reproductive tract, and the right to
make informed decisions about related
interventions.

This list of rights is compiled from IPPF's
Declaration of Sexual and Reproductive
Rights (1996), from Mari Ladi Londofio's
book, Sexual and Reproductive Rights
(1996) and from the Open Forum for Sexual
and Reproductive Rights in Chile (1996).

* STORY #1
"I DON'T UNDERSTAND ABOUT
METHODS"

Rosalia is a 21-year old indigenous woman
who met Pedro a year ago. They fell in love
and decided to move in together. Pedro
works as a mason, and Rosalia left her job as
a maid and began to sell food in the
marketplace, which gives her more time and
freedom to build a relationship with Pedro.
In the house where Rosalia worked, her
employer and her friends would say that "a
woman should take care to not have children
too soon" and "men just make babies and
disappear." Remembering these warnings,
she decided to visit a health center.

When Rosalia arrives at the center, she is
impressed by the number of women in the
waiting room with babies and toddlers. She
timidly approaches the receptionist and asks
for a visit with the doctor. She thinks to
herself that she would be less frightened if
the doctor were a woman but is afraid to say
this to the receptionist, who is busy asking
her a series of questions about her personal
life and noting the answers on a chart.
Rosalia answers in a low voice, not wanting












other patients to hear. When the questions
are finished, she receives a number and is
told to wait her turn.

After an hour and a half, her number is
called. Rosalia walks quickly to the
consulting room, where she is relieved to
find a woman doctor. Her brave "Good
morning, doctor" is answered by a kind
"How are you, child? Take a seat." The
doctor reads the chart that the receptionist
filled out and says, "So this is your first
visit? How can I help you?"

Rosalia explains that she has recently moved
in with her boyfriend and does not want to
have children yet because they are saving to
buy a house. The doctor answers "Very
well, child, it's good that you think ahead,
but you must remember that children are
always welcome, and that you are young and
can care for them well now when you are
older it will be more difficult. Tell me what
method you have been using." Rosalia
explains that she is using the rhythm
method, but is afraid it will fail.

The doctor explains to her that there are
several ways of protecting herself, and
rapidly lists IUDs, condoms, pills and
injections before asking her which one she
wants. Rosalia is confused, and has not
understood many of the words the doctor
has used, but is afraid to tell her so. "Which
one do you suggest, Doctor?" she asks, and
the doctor says she would like to examine
her before making a suggestion.

Rosalia takes off some of her clothing, and
when the doctor moves to check her heart,
she says, "So much clothing, child. Skirt on
top of skirt on top of skirt. Why don't you
use western clothing? That way you can


save money your traditional clothing must
be very expensive and uncomfortable."
Rosalia does not answer but feels
increasingly uncomfortable and eager to
leave.

Upon completing the examination, the
doctor says that Rosalia can use any method
and asks her which she prefers. At that point
she is nervous and confused and only says,
"I'll talk to Pedro. Perhaps he will get mad
at what I choose. Then I'll come back."
"Very good," answers the doctor, "I'll be
waiting for you to come back, and it would
be good if you bring Pedro along so that we
can discuss this with him."

Rosalia leaves quickly, feeling that she
never wants to come back. She has a bad
feeling about the visit. It seemed to her as if
the doctor mistreated her and ridiculed her
about her clothes, and she didn't understand
a thing the doctor said about methods. When
she gets home she doesn't share her
experience with anyone, nor does she return
to the doctor. Three months later Rosalia is
pregnant, and plans to travel back to the
countryside to have her baby where her
mother and sisters can attend to her.

* STORY #2
"I'M PARALYZED WITH ANGUISH"
Ana is in a difficult situation: Her period is a
month late, and she is worried that she is
pregnant. Last week she went to the
pharmacy to get an injection to "regulate her
menstruation," but nothing happened. She
then followed the advice of a friend, whose
aunt had given her some pills to take,
together with strong, very hot oregano tea.
Ana also made great efforts to carry heavy












things, and run up and down the stairs of
their apartment building.

Six days after taking the pills and oregano,
and after several days of intense physical
effort, Ana wakes up feeling terrible. Her
mother, seeing that she is pale, depressed
and overcome with anguish, sits on the bed
and asks Ana what is the matter. Ana
explodes in tears, and finally tells her what
happened, and admits that she is pregnant.
Her mother also starts to cry, and asks why
Ana didn't trust her enough to confide in
her. "The thing to do now, Ana, is get you to
the doctor. I'll help you get dressed and
take you to the clinic where I go each year
for my Pap test."

The wait is not long, but Ana can barely
walk when she is called into the consulting
room. Ana hardly answers when the doctor
asks what is troubling her, but he grasps the
situation quickly and has her lie on the table
so that he can examine her. When the
doctor announces that she is suffering from
an incomplete abortion, Ana starts crying
again, and her mother tries to calm her while
the doctor prepares the anesthesia and
equipment for a D&C.

When the procedure is finished and Ana is
resting, the doctor invites Ana's mother to
sit down and talk. He explains that the
methods used by Ana are very dangerous,
and that it is important for her to overcome
this frightening experience, understand what
happened, and to be better prepared in the
future. He makes a date for an appointment
with Ana the following week. Ana's mother
agrees that the doctor should explain
"everything" to Ana.


When the girl wakes up crying, the doctor
takes her hand and assures her that she will
be fine, that she must go home and rest, and
that he looks forward to meeting with her
the following week.

* STORY #3
"HOW CAN I TELL THEM WHAT I
HAVE?"

In his 34 years, Martin has almost never
been in a clinic. His work as a mason did not
leave him much free time. His wife has
always gone with her sister to prenatal visits
and the births of their three children, and it
was she who took the children to get
vaccinated. When he enters the health
center, Martin sees a series of doors marked
with signs: Vaccines, Laboratory,
Administration, Maternity, etc. He decides
to ask at administration, although he is very
worried about what exactly to ask for.
Martin greets the woman behind the
administration desk and asks her where he
can find the office that deals with
"infections." Without greeting him, the
administrator says, "The visit is twelve
dollars." Without having received any
clarification, Martin pays the fee, receives a
number and sits on a nearby bench. The
whole time he is thinking frantically about
how he can explain what is wrong with him,
and hoping that he will be doing the
explaining to a man, and not a woman nurse
or doctor.

A woman in native dress leaves the
consulting room and nods to Martin who,
like herself, is Aymara. Soon his number is
called and he enters the room, where a
doctor and nurse, both women, are talking
about the prior patient, commenting on her
poor hygiene and ignorance and expressing












their doubts that she will follow through
with the treatment they prescribed. They
finish their conversation, and the doctor
invites Martin to sit down and she asks,
"What is your problem?" Martin fights his
embarrassment and starts describing his
symptoms, when he sees the doctor and
nurse exchange a knowing look. When he
has finished talking, the doctor explains that
in order to know exactly what kind of
infection he has, he must leave a urine
sample at the laboratory for analysis. She
writes out a lab order, explains that he must
give the sample before eating the following
morning, and makes an appointment for
Martin to return a few days later for the
results. Martin doesn't dare say anything -
he simply nods and leaves.

When he returns with his lab results, Martin
must wait over an hour for his turn, and
suffers an increasingly urgent need to
urinate. He looks around the whole clinic,
but only sees doors that say "Women," and
is embarrassed to ask for the men's rest
room. When he finally gets called into the
consulting room, the doctor studies the lab
results and writes out a prescription,
explaining that Martin, as well as all his
sexual partners, must take an entire course
of this medicine. She also explains that he
must not engage in sexual relationships for
the next 15 days.

When he arrives home, Martin tells his wife
that the doctor has said that they both might
be infected and that they both need to take
the medicine. She gets very angry, accusing
him of ruining the family with his infidelity
and complaining about the high cost of the
doctor visit and the medicine.


* STORY #4
"PLAYING WITH FIRE"

Stella and Marcos are university students. A
couple of months ago, Stella had a
clandestine abortion and, luckily, recovered
without complications. After this
frightening experience, they both want to
prevent another pregnancy, but are not sure
what method is right for them. On a friend's
advice, they go to a health center that offers
numerous types of methods.

When the young couple arrives at the clinic,
Stella and Marcos approach the receptionist,
who smiles, greets them and asks them to fill
out the medical chart. When they finish, she
apologizes for lack of space: two women and
another couple are occupying all the chairs.
The clinic is in an old house, and the reception
area hardly has space for a desk in the corner.
Several old magazines lie on an end table, but
the lighting is too poor to read them.

After a 50-minute wait, they call Stella's
name. When Stella and Marcos enter the
consulting room, the doctor is talking on the
phone and gestures for them to take a seat.
The consulting room is bigger and nicer than
the waiting room; it has its own bathroom
and several posters about AIDS. After a
couple minutes the doctor hangs up and,
smiling at them both, asks the motive of
their visit. Stella takes the initiative and
explains in a low voice that she recently had
an abortion and does not wish to repeat it, so
they want to get a sure method of birth
control. She explains that they want to
finish their studies and get married before
having children.

The smile disappears from the doctor's face
and he responds intensely, "I am glad that


7r












you have come to the clinic, because a
clandestine abortion is gambling with a
woman's life, especially when it is poorly
done. But it is even worse to play at being
married and have relations when you know
what can happen. You two, who seem like
well-bred individuals, make mistakes as if
you were uneducated. Young people today
dedicate themselves to pleasure and don't
think about tomorrow, or about the parents
who have invested their trust in you.
Returning to the point of your visit, I
suggest that you choose a very secure and
popular method, the Copper-T IUD. Of
course there are other methods, but this is
the best one for you. Stella, when was your
last period?" Stella answers that she just
began that day, and the doctor responds
enthusiastically, "Perfect, that is the best day
to introduce the IUD, because we are sure
that you are not pregnant. Good, are you
decided?"

Stella and Marcos do not reply and the
doctor suggests that they take five minutes
to talk it over in the waiting room while he
makes a call. The young couple walks
silently to the waiting room, where Stella
whispers, "It seems right that today is the
day to put in the IUD, but doesn't it have
side effects?" Marcos suggests, "Let's go to
another doctor. This one made me feel bad
- but you decide." "He made me feel bad,
too," answers Stella, "but another doctor
will just be the same. We've already been
through the worst here, let's just get the IUD
inserted."

While they are whispering, the nurse walks
into the small room and overhears part of the
conversation. "It's a difficult decision," she
whispers to them, "but I would advise the
Copper-T. I've had one in for four years


with no problems." Stella asks her "what
problems might I have with the Copper-T?"
and she answers "None at all, dear, it's
totally safe as long as you get a checkup
every six months."

Stella turns to Marcos with a more assured
tone and says, "She's right, I will get it
inserted today." The receptionist indicates
that the doctor is waiting for them, and when
they enter the consulting room he announces
with a smile, "You've come to a decision,
have you? Well let's get to it."

* DISCUSSION GUIDE:
In the story just enacted, in what way do the
providers:

1. recognize and respect users' different
identities and needs?
2. share information and knowledge?
3. share decision-making and power in
efforts to improve the user's well-being?
4. promote the exercise of specific sexual
and reproductive rights?
5. impede the exercise of these rights?
6. show sensitivity and response to users'
expectations?
7. consider users' fears and other feelings?
8. facilitate dialogue and communication?
9. explain clearly the importance of
treatments and outline preventative
actions that the user her/himself may
take?
10. respect the sexual behavior and cultural
practices of users?


:T








MAOD ULIE



QUALITY CARE I
QUALITY IN HUMAN RELATIONS AND TECHNICAL
QUALITY


* SESSION OBJECTIVE:

Learn methods and develop attitudes that
help to improve interpersonal relations
between providers and users, and to respect
users' rights and identities in sexual and
reproductive health services.

* SPECIFIC OBJECTIVES:

1. Identify and reinforce skills and
practices that promote quality care in
health services.
2. Become familiar with personal attitudes
and interpersonal dynamics that promote
quality care.
3. Learn new criteria and techniques for
more effective and efficient services.

* KEY CONCEPTS:

Quality care in sexual and reproductive
health services
Quality in human relationships
Technical quality
Tools for improving health services

* ACTIVITIES:

1. Appreciating our abilities
2. The quality care philosophy
3. Practices and techniques of quality care
4. Human and technical quality in health
care interactions


* TIME:

4 hours

* ACTIVITY 1
APPRECIATING OUR ABILITIES

Objective:
Identify and reinforce skills, abilities and
practices that promote quality care in sexual
and reproductive health.

Procedures:
1. Each participant identifies three abilities,
skills or practices that make a positive
contribution in his/her work. Try to
focus on abilities that help us to
recognize and respect differences,
establish equitable and constructive
work relationships, share knowledge and
power, and strengthen users and
colleagues' skills.
2. Participants write each ability on a card,
providing a concrete example of each.
Deposit all cards in a box.
3. When all the cards are in the box, each
participant draws three, which s/he reads
aloud and writes on the poster paper.
4. Participants have a group discussion and
analyze the different practices and
abilities that promote compassionate
quality health care and gender
sensitivity.

Time:
30 minutes












Materials:
Index cards
Poster paper
Markers

* ACTIVITY 2
THE QUALITY CARE PHILOSOPHY

Objectives:
1. Introduce the philosophy of quality care.
2. Relate the abilities and skills identified
in the preceding activity to the practice
of gender-sensitive quality care.

Procedures:
1. Guide a discussion using the concept
card on quality care. Different
participants can read consecutive
sections of the concept card, pausing to
discuss alternative interpretations and
applications of the ideas presented in
each section.
2. Conclude with a discussion about
tangible attitudes and actions that
participants can take to offer better
quality care in their work. Refer to the
poster paper that records the positive
abilities identified in Activity 1 to see
how these can be strengthened and
institutionalized to guarantee quality
care.

Activity guide:
Facilitators should have read beforehand the
section on the conceptual framework that
presents quality care, and be prepared to
refer to it in discussion. Invite the
participants to relate their own abilities
presented in Activity 1 to the goal of
developing and implementing quality care at
an institutional level.


Time:
45 minutes


Materials:
Concept card: Quality care

* ACTIVITY 3
PRACTICES AND TECHNIQUES OF
QUALITY CARE

Objectives:
1. Observe the practice of key techniques
for quality care in sexual and
reproductive health.
2. Analyze cases in which different
methods that contribute to quality care
are practiced.

Procedures:
1. One at a time, watch each of the three
cases presented in the video "Hablemos
con Confianza," produced by The Johns
Hopkins University, plus the case
presented in the video "Quality Care in
Reproductive Health," produced by the
Flora Tristan Center for Peruvian
Women.
2. After each case, stop the video and
spend 10 minutes discussing what was
seen using the discussion guides
provided below. Facilitators can enrich
the discussions with the summary of
techniques for improving gender-
sensitive quality care included in the
support resources for this session.

First Case: "We were all 18..."
This case emphasizes the importance of
respecting the user's age, culture and way of
thinking in health care interactions.












Discussion guide:
1. What message does this story convey?
2. What challenges did the provider face in
her efforts to put herself in the user's
place?
3. How well did the provider carry out her
role? Which aspects did she handle well,
and where could her approach be
improved?
4. What sexual and reproductive rights
come into play in this case?
5. What obstacles impede the user from
making her own informed decision?

Second Case: "Step by step"
The GATHER method lays out steps to
follow that help to ensure better
communication with users. This method is
not rigid and can be adapted to the needs of
each situation and each user (Rhinehart et al.
1998).

Discussion guide:
1. What message does this story convey?
2. How is the couple's relationship
presented? What rights does the woman
exercise? What rights does the man
exercise?
3. What sexual and reproductive rights
does the provider promote?
4. What did the provider do well? What
could we have done differently?
5. Use poster paper to write out the steps of
the GATHER method.
6. Discuss each step of the method in light
of participants' experiences.
7. How can we apply each of these steps in
our own work?
8. What are the advantages and the
drawbacks of the GATHER method?


Third Case: "We all have doubts"
This case demonstrates techniques for
listening, respecting users' silences and
respecting the users' perspectives as a means
of improving communication.

Discussion guide:
1. What is this case about?
2. What is the personal situation of the
user? Of the provider?
3. What feelings and fears does each
experience?
4. What expectations does the user bring to
the consultation?
5. Identify positive attitudes and practices
manifested by the provider.
6. How would we act in this situation?
7. In this consultation, was the right to
obtain comprehensive information
respected?
8. On poster paper note the non-verbal
techniques (gestures, looks, facial
expressions) and the verbal techniques
(phrases of interest, listening, open
questions, closed questions, reflection
questions) that are employed. Identify
an example of each of these techniques
in the video.

Fourth Case: "Quality care in
reproductive health"
This video demonstrates a user's fears about
negative power relations with health
providers, revealing numerous tensions and
anxieties that need to be discussed and dealt
with to obtain quality care.

Discussion Guide:
1. What is this story about?
2. What aspects of interpersonal relations
in health care are brought into question
here?












3. How can one describe the first contact
that the user has with the health care
center?
4. What type of power relations are
manifested in the different provider-user
interactions depicted during the video?
5. Do the imagined stories have any basis
in reality? Have participants observed or
heard of any similar experiences?
6. What rights are not respected in the
imaginary visits?

Time:
2 hours

Materials:
Videos
Summary of techniques to improve gender-
sensitive quality care
Poster paper

Discussion:
It is important to emphasize that the
techniques presented here do not dictate
uniform approaches to all interactions with
users. The methods and techniques reflect a
range of possibilities that should be selected
and applied according to the personal style
of each provider and the needs and identities
of each user.

Expected results for participants:
1. Learn how to apply for personal use
certain techniques that help to improve
the quality of human interactions in
health care.
2. Understand that gender identities,
relations and considerations constantly
influence health care interactions, among
men, among women, or between men
and women.


3. Embrace analytical approaches that
promote reflection, critique and
improvement of one's own daily work.

* ACTIVITY 4
HUMAN AND TECHNICAL QUALITY
IN HEALTH CARE INTERACITONS

Objectives:
1. Identify concrete strategies to improve
our daily work.
2. Apply methods to improve the quality of
care in sexual and reproductive health
services and make those services more
sensitive to gender realities and
relations.

Procedures:
1. Form groups. Each group selects one
technique or method for gender-sensitive
quality care, as presented in the videos.
2. Develop skits that demonstrate the
application of the chosen technique in a
familiar health care setting and situation.
3. Members of each group prepare to act
out the skit.
4. Each group presents its simulation of a
health service situation in which gender
sensitivity and quality care techniques
are used.
5. In open debate, discuss the following
questions:
What advantages does the use of this
technique or method provide?
What difficulties might interfere with
our attempts to practice this method?
In what contexts will this method
help to improve care?
In what contexts will this method be
inappropriate?


Time:
45 minutes


mV












Discussion:
The methods and techniques presented in the
videos help providers put themselves in the
place of users and, thereby, empathize with
their health situations and decisions. This
effort requires sensitivity to the cultural,
gender and generational identity of the user,
as well as sensitivity to his or her unique
feelings, fears, doubts and needs.






* CONCEPT CARD: QUALITY CARE

Quality care is a philosophy of
comprehensive and compassionate health
care oriented toward the satisfaction of
users. It facilitates improvements in services
offered to men and women through changes
in personal communication and interaction,
as well as through changes in administrative
and technical practices. Quality care
strengthens users' responsibility, knowledge
and autonomy, self-esteem and dignity and
the exercise of their rights.

Quality is different not only for men and
women, but also for persons of different
cultures, ethnic groups, social classes and
ages. In other words, everyone has his or her
own definition of quality. So then, who
evaluates quality care? Since the philosophy
of quality care is oriented toward the
satisfaction of users, it is they who should
evaluate the quality of services.

Basic principles help us to obtain quality
care: a focus on the comprehensive well-
being and satisfaction of diverse users; the
active and equitable participation of all
personas involved in health care; the


practice of offering options from which
users may select, such as different
contraceptive methods or birthing positions
(Finger and Hardee 1993); the
empowerment of users to make free and
informed decisions about their own health;
and the equitable treatment of women and
men, people of different ages, social classes
and ethnic backgrounds.

Quality care has three interrelated
dimensions: quality in administration and
management; quality in human interactions
and technical quality.

Quality in administration and
management
An institution's philosophy transmits ideas,
values and attitudes to employees as well as
to users (Araujo and Matamala 1995).
Quality management encourages a work
environment and a health care environment
free from discrimination and abuse of
power. The key here is the existence or
absence of mechanisms that promote the
participation of personnel and users in the
improvement of the service. These might
include posted policies promoting users'
rights or prohibiting discrimination; the use
of suggestion boxes; and the organization of
participatory and democratic meetings
between administration and staff, and
between the latter two representatives of the
user population.

To improve quality of care, we must begin
with a philosophy that places priority on
user satisfaction (Finger and Hardee 1993).
This philosophy will then be manifested in a
facility's infrastructure, menu of information
and services offered, labor practices and
relations, staff treatment and labor policies,
guarantee of confidentiality and privacy












during provider-user visits and even in the
hours of service. If the institution does not
take quality care into account as a matter of
policy, it is improbable that staff will be able
to provide the kind of services that satisfy
users.

Each institution expresses its gender
perspective in the relations it establishes
with the public, from the assignation of
resources to different groups of users to the
distribution of tasks and responsibilities
within that institution. A gender perspective
is key to understanding different groups,
ensuring that services do not favor some and
discriminate against others and making sure
that programs do not reinforce existing
inequalities. For example, better gender
balance and more equitable participation
could improve the quality of many maternal-
child health and family planning programs
by questioning and changing current
services and information that are oriented
exclusively to women; reinforcing
stereotypes that give women sole
responsibility for their families' health; and
denying the fundamental importance of
men's participation.

Quality in human relationships
Quality of interactions encompasses the
empathy expressed by providers, time
dedicated to each user, sharing of
knowledge and respect for each user's
opinions and decisions. It also implies
respect for differences among people: A
woman in native dress deserves the same
understanding and respect as a woman in
modern dress; a disheveled adolescent boy
deserves the same service as a professional
man.


In addition to changes in attitude on the part
of personnel, quality care requires that users
themselves exercise more responsibility and
initiative. Providers can facilitate this
change by sharing knowledge about health,
offering options for treatments and methods
and supporting users in their decision-
making process. Services should offer
complete information that permits users to
care for their own sexual and reproductive
health, and to take preventative actions that
help them to achieve a sustained state of
physical, mental and emotional well-being.

Technical quality
Technical competence concerns adequate
equipment and supplies and requires that
providers apply current and appropriate
knowledge, skills and technology. Indicators
for this type of quality include the existence
of clear operational norms and procedures
and demonstration of the skill and accuracy
necessary in diagnosis, treatment and
follow-up of users.

Technical quality includes having the
necessary equipment, supplies and
medicines needed to fulfill standards
(Giiezmes 1997), together with maintenance
of conditions, fulfillment of protocols and
availability of competent personnel (Finger
and Hardee 1993). Quality equipment and
supplies also refer to the general
infrastructure of the center (water,
plumbing, lighting, garbage disposal) and
the conditions, comfort and cleanliness of
the waiting and consulting rooms. A crucial
aspect of technical quality is the existence of
programs for continuous professional
improvement for men and women personnel,
which cover medical techniques as well as
techniques for patient care and
communication.












Quality care and gender
Health providers often reproduce and
reinforce gender inequities in the
relationships that they develop with users
and with co-workers. In many cases, health
professionals tend to overvalue medical
knowledge, give privilege to masculine-
scientific discourse and reject other ways of
knowing, thinking and talking as expressed
by patients. Often the prejudices and values
of providers and institutions are expressed
through doubt, criticism, rejection and even
sarcasm toward the way patients understand
things, especially female patients and those
who come from lower socioeconomic
classes and marginalized ethnic groups.

In social environments in which certain
groups of women assume subordinate
positions in most of the relationships in
which they engage, these women tend to
relate to providers in the same way, thus,
undermining their potential power as health
care clients. In their relationships with
health providers, many Bolivian women feel
constrained by their fears, shame and
timidity; by guilt and moralistic norms; by
insecurities about their own knowledge; and
by their experiences of physical,
psychological and sexual violence. These
constraints are coupled by gender-related
economic and operational difficulties that
must be overcome in order to seek health
care.

Men also approach health care from their
own gender experiences and are restricted
by normative models of masculinity. In
Bolivian contexts, these can include pressure
for "real men" to resist pain, refuse to seek
or accept help and appear strong, physically
and emotionally invulnerable. These aspects
of "being a man" in Bolivian society impede


men's access to health care. Pressure to
demonstrate stereotyped masculine
behaviors is especially strong for young
men, many of whom do not take
preventative measures, nor seek medical
care until they are extremely ill.

In considering quality care, providers should
recognize these gender norms and
stereotypes, their impact on users' health
and their influence both on provider-patient
interaction and on user follow-up. Providers
are capable of forging new gender visions
and possibilities, and of changing their own
behaviors and attitudes, through their
professional action. They can, for example,
encourage and support women users to make
strong decisions in favor of their own well-
being and to assume new responsibilities for
their health and sexuality. They can
encourage men to admit that they hurt, to
seek and accept help and advice, and to
participate in the health care of their
children and partners. Better understanding
and respect for others, together with
improved communication between people
from different backgrounds, cannot help but
improve relations and processes of
diagnosis, treatment and education, and
thereby contribute to improvements in the
population's health.

* SUMMARY OF TECHNIQUES TO
IMPROVE GENDER-SENSITIVE
QUALITY CARE

The video "Hablemos con Confianza," from
The Johns Hopkins University, presents
three health service stories, and the video
"Calidad de Atenci6n en Salud
Reproductiva," from the Flora Tristan
Center for Peruvian Women presents
another health care story. Each of these 10-












minute stories presents a series of gender-
sensitive techniques and methods designed
to improve interaction and communication
between providers and users. Watching and
discussing these videos motivates us to
reflect on our everyday practices and think
about ways in which we can improve. Here
we provide a brief discussion of each video.

"Hablemos con Confianza"
1. "We were all 18 ..."
This story explores the difficulties that a
provider faces in putting herself in the place
of a young user. It makes clear that the
provider brings to her patient her own
personal biases, and that her fears, doubts
and opinions influence interactions. The
video deals with the provider's personal
history on two levels: how the situation
affects the provider's own beliefs and
feelings, and how it affects her interactions
with the user. The reflection leads us to
consider differences between provider and
user and to understand the role that these
differences play in the provision of health
service. The story emphasizes the
importance of empathy as a key element that
enables the provider to listen to and respect
the position and decisions of the user.

2. "Step by step"
This story presents the method GATHER,
designed to encourage and improve
communication between provider and user
through the following steps: greet the user;
ask the user about him or herself; tell the
user about his or her choices; help him or
her to make an informed choice; explain
fully how to use the chosen treatment or
method; and return visits should be
welcomed and encouraged. This method is
not rigid and there is no need to follow the
steps in order. It is a general guideline that


allows for a comprehensive and systematic
interaction with users, ensuring respect for
their rights and decisions, which can easily
be adapted to different cases.

3. "We all have doubts"
This story demonstrates verbal and non-
verbal techniques for achieving better
communication with users. It encourages
providers to pay more attention to the
messages they are sending and to the
messages expressed by the user. The
following examples demonstrate the type of
techniques presented in this video.

Communication Example
Technique
Open-ended question "What brings you here
today?"
Specific question "How old are you?"
Directed question "Are you interested in
changing your method?"
Reflection question "How has it been for you
using this method?"
Invitation for clarification "Do you have any doubts
about this?"
Silence Wait patiently for user to
gather his/her thoughts and
bring up his/her issues
Smile or nod Nonverbal message that
expresses encouragement,
confidence

4. "Quality care in reproductive health"
This video demonstrates a whole series of
stories depicting different relationships that
might develop during a user's visit. These
relationships are influenced by the life
experiences and beliefs of each participant,
especially their experiences in relation to
sexual and reproductive health. In some of
the imagined stories, the providers feel they
know everything and have no need to listen
to or respect the user's opinion. The various
imagined stories contrast with the final visit,












in which the provider shares knowledge and
power in a respectful and equitable way,
setting the scene for a gender-sensitive
quality consultation.









MO D IUILE 4



QUALITY CARE II
QUALITY IN ADMINISTRATION AND MANAGEMENT


* SESSION OBJECTIVES:

1. Analyze the organization and
administration of sexual and
reproductive health programs.
2. Identify institutional strategies that
facilitate more effective responses to the
identities, needs, rights and possibilities
of different users.

* SPECIFIC OBJECTIVES:

1. Develop capacity for critical analysis of
sexual and reproductive health policies,
institutional structures and management
practices.
2. Learn criteria for evaluating health
services from a gender perspective.
3. Identify feasible and possible changes
that we can make on personal,
interpersonal and institutional levels.

* KEY CONCEPTS:

Institutional administration and management
for equity and quality
Criteria for institutional assessments of
gender-sensitive quality

* ACTIVITIES:

1. Criteria for evaluating gender sensitivity
and quality care
2. Assess and improve institutions in which
we participate
3. Reflect on institutional strengths and
weaknesses
4. Multiple changes towards better care
5. Evaluation of the learning experience


TIME:
4 hours

* ACTIVITY 1
CRITERIA FOR EVALUATING
GENDER SENSITIVYAND QUALITY
CARE

Objectives:
1. Become familiar with IPPF criteria for
gender-sensitive quality care in sexual
and reproductive health, and understand
how these criteria are applied.
2. Identify factors in institutional
organization and function that promote
or impede quality care.

Procedures:
1. Introduce the background and basic
concepts of the IPPF evaluation criteria
(included in session resources). If
possible, circulate copies of IPPF
literature concerning gender-sensitive
quality care.
2. Present the list of quality criteria, written
on poster paper. Distribute photocopies
of the list to each individual.
3. Ask each participant to read one
criterion aloud.
4. Discuss and comment on the IPPF
proposal for institutional assessment.

Time:
30 minutes

Materials:
IPPF'S proposal for institutional evaluation
List of IPPF criteria on poster paper













Photocopies of IPPF criteria
Copies of IPPF publications concerning
gender-sensitive quality care

* ACTIVITY 2
ASSESS AND IMPROVE
INSTITUTIONS IN WHICH WE
PARTICIPATE

Objective:
Apply gender-sensitive quality criteria in a
simulated institutional assessment.

Procedures:
1. Participants divide in groups; preferably,
each group will gather participants who
work in or know one particular
institution.
2. Each group identifies one health project
or institution to assess. It is not
necessary for participants to have exact
knowledge of all aspects of the
institution, as they will simulate an
assessment based on the familiarity that
they have, and on approximations
concerning information they lack.
3. Each group uses the IPPF evaluation
criteria as a basis for assessing the
chosen institution. In many cases
participants will have to invent details;
they should feel free to imagine missing
data in order to construct a complete
institution for the simulated assessment.
4. Once the criteria have been applied, the
group carries out the most important
stage of the assessment, which is to
interpret the results, identify the
strengths and weakness of the institution
and make recommendations for
improvement.
5. Participants join together so that each
group can present the most interesting


and important aspects of its assessment
and conclusions.

Activity guide:
The desired result of this activity is NOT to
produce an authentic evaluation of a real
institution; it is to provide skills and
experiences that will prepare participants to
participate in such an evaluation in the
future. We choose to focus on projects and
institutions with which we are familiar
because it facilitates a more meaningful
learning process. It is not necessary that
each group stick to exact and verifiable
details; what is important is that participants
learn to identify and evaluate pertinent
criteria and most importantly to reflect
on, discuss and interpret the profile which
emerges from the evaluation and to make
recommendations based on this
interpretation.

Time:
1 hour, 30 minutes

Materials:
Photocopy of sheet explaining the IPPF
proposal
Photocopy of list of IPPF criteria
Poster paper
Markers

Expected results for participants:
1. Get to know criteria for evaluating
gender sensitivity and quality care, as
proposed by IPPF.
2. Gain experience through simulated
assessment of a health care project or
institution.
3. Develop capacity for critical analysis of
aspects of the institutions and programs
in which we work.














* ACTIVITY 3
REFLECT ON INSTITUTIONAL
STRENGTHS AND WEAKNESSES

Objective:
Identify and reflect on opportunities and
strengths for improving gender-sensitive
quality care in specific sexual and
reproductive health projects and institutions,
as well as weaknesses and threats to be
overcome.

Procedures:
1. Form the same groups that worked
together in the preceding activity.
2. Distribute copies of the sheet explaining
SWOT, which is a method for analyzing
the strengths, weaknesses, opportunities
and threats in an institution and its
context.
3. Ask each group to carry out the SWOT
analysis on the basis of the institutional
profile developed during the prior
assessment. Seek strengths and
opportunities that will enable the
institution to develop respect for gender
differences and identities and to develop
a comprehensive and compassionate
approach to sexual and reproductive
health care.
4. Join together so that each group can
comment on the process and share the
most interesting things that they learned
in the application of SWOT.

Time:
1 hour

Materials:
Sheet describing the SWOT method
Poster paper
Markers


* ACTIVITY 4
MULTIPLE CHANGES TOWARD
BETTER CARE

Objectives:
1. Reflect upon across-the-board changes
that are necessary and/or possible in
health services.
2. Apply ideas generated in sessions on
gender, sexual and reproductive health,
rights, and quality care to the problem of
incomplete abortions in Bolivia.

Procedures:
1. Watch the video El aborto: Un problema
de salud piblica, produced by Ipas and
the Bolivian Ministry of Health.
2. Form groups to discuss the video,
oriented by questions in the discussion
guide.
3. Bring the entire group together to
continue the discussion.

Discussion guide:
1. How do the gender identities and
relations predominant in Bolivia
influence the situation of the user in this
video?
2. Considering this reality, what gender
considerations need to be taken in the
response to and treatment for this case?
3. What role do men play in this situation
(sexual partner, father, persons who help
women get medical help or accompanies
them to the clinic, provider)?
4. What special attention does a woman
need to recover from this type of
experience?
5. What does the idea of comprehensive
sexual and reproductive health care have
to do with this case?


* .*-;P;ssseiii~ev^-i-"- -*"












6. What is the policy of the institution
depicted in the video concerning sexual
and reproductive rights of men and
women?
7. What rights do women have when they
suffer an incomplete, illegal abortion?
8. How can we characterize the human
relationships within the institution
depicted in the video? Among personnel
in that institution?
9. Do these relationships have anything to
do with the kind of care that is provided
to the woman suffering an incomplete
abortion?
10. What changes can be made by all kinds
of actors within the health care center in
order to provide more compassionate
quality care for women who arrive
needing help for incomplete abortions?

Activity Guide:
The video fosters a critical analysis of
institutional policies and providers' attitudes
and practices. Training in earlier sessions
about gender analysis and sexual and
reproductive rights allows participants to
address the problem of incomplete abortions
in a new light.

Time:
45 minutes

Materials:
Video
Discussion guide

Discussion:
Women who have decided to interrupt a
pregnancy and end up with an unsafe and
incomplete abortion have suffered trying
experiences. Even though providers may
not approve of the woman's decision or
action, it is their duty to provide her with


quality care and treat her with compassion.
Each woman has her own unique story,
identity and situation, but they all deserve
quality care.

Quality in human relationships, technical
skills and institutional administration are
interdependent. To better address any health
issue, such as incomplete abortion, we need
to work on all levels in an integrated
manner.

* ACTIVITY 5
EVALUATION OF THE LEARNING
EXPERIENCE

Objectives:
1. Evaluate the development of knowledge
and understanding among participants.
2. Appreciate the diversity of
understandings and approaches
generated on the basis of individual
experiences and education.
3. Verify the level of motivation that has
been generated to initiate the process of
personal, professional and institutional
change.
4. Identify advances in participants'
analytical capacity and ability to develop
strategies for applying gender-sensitive
quality care.

Procedures:
1. Each participant, including facilitators,
fills out an evaluation form without
identifying themselves. Place
evaluations in a box.
2. As a group, discuss the seven questions
on the evaluation form, and any other
questions or issues that arise.
Facilitators may read and share some of
the written evaluations as part of the
discussion.













Time:
15 minutes

Materials:
Photocopies of evaluation sheets






* IPPF'S PROPOSAL FOR
INSTITUTIONAL EVALAUTION

IPPF developed a guide to assess the
relationship between a focus on gender and
improvements in quality care and
management within institutions that provide
sexual and reproductive health services
(Cardich et al. 1998).

Recognizing the need to bring together work
carried out on gender-focused quality care,
IPPF organized a conference on the theme in
Lima in 1995, which brought together
professionals with a great deal of experience
in reproductive health, women's health,
human rights and gender. The objective of
the conference was to develop a set of
criteria for gender-sensitive quality care. On
the basis of existing studies and documents,
and together with the experience of those
participating, the group came up with a long
list of criteria. They also worked on ways to
carry out institutional analysis based on
these criteria and formulate
recommendations and corrective measures
to help institutions improve their quality and
gender focus.

Proposal for evaluation and improvement
Quality care and gender sensitivity require
changes in focus and in attitude within the


institution, which naturally requires political
and personal commitment, dedication and
time. The evaluation proposal is designed as
an instrument to support and accompany this
process.

The proposal includes evaluation criteria,
methodological orientation, a review of
existing practices and materials and the
formulation of recommendations within an
integrated plan that requires the participation
of diverse actors within the institution and
an external consultant specialized in the
field.

* CRITERIA LISTED IN THE IPPF
PROPOSAL FOR EVALUATING
GENDER SENSITIVITY AND
QUALITY CARE

1. The existence of policies that prohibit
sex discrimination in hiring, salaries,
benefits and promotions.
2. The existence of policies that prohibit
abuse of power and sexual harassment
within the institution.
3. The existence of policies and procedures
that promote the development of all
staff, independent of sex.
4. Percent of users who find the service
hours convenient.
5. Mechanisms that do away with the
requirement of spousal consent before a
woman can be treated.
6. Presence of a declaration that promotes
the empowerment of women within the
mission statement of the institution.
7. Mechanisms through which users'
opinions can be known, including
evaluation sheets and studies to evaluate
user satisfactoin.













8. Mechanisms to promote programmatic
changes in response to users' requests,
complaints and suggestions.
9. Percent of administrative positions held
by women.
10. Percent of users who were addressed
with respectful titles and not called by
diminuitive or pejorative names (little
mother, dear, my child, my queen, etc.).
11. Percent of users who note that providers
greeted them.
12. Percent of users who note that providers
looked them in the eye during
conversation.
13. Presence of educational activities in the
waiting room (educational talks, videos,
group discussions led by personnel).
14. Existence of sufficient number of chairs
in waiting room.
15. Percent of user visits in which the
provider discussed reproductive health
issues, such as prevention of STDs and
AIDS, breast and cervical cancer or
unwanted pregnancy.
16. Percent of user visits in which the
provider discussed sexual heath issues,
such as satisfaction with sex life,
presence of sexual abuse or
mistreatment, risks and ways of
contracting STDs and AIDS, feelings of
guilt or low self worth in sexual
relations, partner's attitudes about
fertility control, advantages and
drawbacks of different methods.
17. Use of educational materials in provider
explanations.
18. Percent of staff who feels that the
workplace is equitable.
19. Percent of providers who report that they
provide advice and information to users
who ask about abortion.


20. Provision of Pap tests, breast exams,
analysis of vaginal secretion and STD
tests.
21. Percent of personnel that promote the
practice of double protection, regular
Pap tests and self breast exams.

* SWOT ANALYSIS

SWOT is a tool for conceptual analysis that
permits us to explore and address the
underlying structural causes that generate
institutional situations. It also enables an
analysis of the dynamics between what goes
on within and outside of an institution or
program in question. In order to carry out
this analysis, we need to examine the
dynamics inside the institution, as well as
external factors that condition institutional
change. The analysis is carried out through
group discussion and characterization of
each of the following four elements,
followed by group interpretation and
analysis of the dynamic relationships across
the four elements (Wolff et al. 1991).

What does SWOT mean?
S: Strengths. What strengths exist within the
institution? What positive aspects, abilities,
qualities make the institution in question
stand out? These may include: unity and
solidarity; human, technological or financial
resources; good organization; threshold
ideas; infrastructure or equipment, etc.
W: Weaknesses. What weak points exist
within the institution and how can they be
addressed? These may include: lack of
knowledge; inadequate infrastructure or
resources; hierarchical and non-democratic
organization; etc.
O: Opportunities. What positive situations
outside the institution support its growth and
help it achieve its goals? These may












include: financial support; changing values
and paradigms in the social context;
favorable political or historical situations;
innovative methods and ideas; etc.
T: Threats. What external situations
threaten to impede the progress of the
institution? These may include:
politicization of certain aspects of the work;
economic or political instability;
conservative social pressure against change;
conflicts concerning resources; etc.

* DISCUSSION GUIDE
VIDEO ON POSTABORTION CARE

1. How do the gender identities and
relationships predominant in Bolivia
influence the situation of the user in this
video?
2. Considering this reality, what gender
considerations need to be taken in the
response and treatment of this case?
3. What role do men play in this situation
(sexual partner, father, persons who help
women get medical help or accompanies
them to the clinic, provider)?
4. What special attention does a woman
need to recover from this type of
experience?
5. What does the idea of comprehensive
sexual and reproductive health care have
to do with this case?
6. What is the policy of the institution
depicted in the video concerning sexual
and reproductive rights of men and
women?
7. What rights do women have when they
suffer an incomplete, illegal abortion?
8. How can we characterize the human
relationships within the institution
depicted in the video? Among personnel
in that institution?


9. Do these relationships have anything to
do with the kind of care that is provided
to the woman suffering an incomplete
abortion?
10. What changes can be made by all kinds
of actors within the health care center in
order to provide more compassionate
quality care for women who arrive
needing help for incomplete abortions?

* EVALUATION FORM

Date & Place of workshop

1. Describe an idea that developed during
the training that affected you personally.
2. Comment on a concept or proposal that
caused confusion, raised doubts, or that
you rejected for whatever reasons.
3. What topics and methods explored in the
sessions are related in some way to your
own work?
4. What topics or methods have nothing to
do with your work, or were irrelevant to
you?
5. In which topic or method were you most
interested? Why?
6. Did the workshop satisfy your
expectations for learning? Why or why
not?
7. What suggestions do you have to
improve the workshop?


F









BIBLIOGRAPHY


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