Front Cover
 History of the Manuela Ramos...
 The first results
 Quantitative findings
 Analyzing mistakes and defining...
 The Manuela Ramos Movement...
 Lessons learned
 Acknowledgment, references, and...
 Resumen en Espanol
 Resume en Francais
 About the authors
 Back Cover

Group Title: Quality/Calidad
Title: Alone you are nobody, together we float
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088796/00001
 Material Information
Title: Alone you are nobody, together we float the Manuela Ramos movement
Series Title: Quality = Calidad
Physical Description: 32 p. : ill., ports. ; 26 cm.
Language: English
Creator: Rogow, Debbie
Population Council
Publisher: The Population Council
Place of Publication: New York
Publication Date: c2000
Subject: Family Planning Services -- history -- Peru   ( mesh )
Voluntary Health Agencies -- history -- Peru   ( mesh )
Women's Health Services -- history -- Peru   ( mesh )
Women's Rights -- history -- Peru   ( mesh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Spatial Coverage: Peru
Bibliography: Includes bibliographical references (p. 30).
Language: Summary in Spanish.
Statement of Responsibility: by Debbie Rogow ; introduction and afterword by Judith Bruce.
 Record Information
Bibliographic ID: UF00088796
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 45275758
issn - 1097-8194 ;

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
        Page 1
        Page 2
    History of the Manuela Ramos Movement
        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
    The first results
        Page 19
        Page 20
        Page 21
        Page 22
    Quantitative findings
        Page 23
    Analyzing mistakes and defining challenges
        Page 24
        Page 25
    The Manuela Ramos Movement today
        Page 26
    Lessons learned
        Page 27
        Page 28
        Page 29
    Acknowledgment, references, and further reading
        Page 30
    Resumen en Espanol
        Page 31
    Resume en Francais
        Page 32
    About the authors
        Page 33
    Back Cover
        Page 34
Full Text
Alone You Are Nobody,
Together We Float: The
Manuela Ramos Movemrentt



-~1 jF
-r). 0 71
t~ 2.i~U



Quality/Calidad/Qualite, a publication of the Population Council, highlights examples of family
planning and reproductive health programs that are providing unusually high quality care. This
series is part of the Council's Robert H. Ebert Program on Critical Issues in Reproductive
Health which, through scientific and practical efforts, seeks to improve and expand the scope
and quality of reproductive health care. The philosophical foundation of the program, and of
this series, is that women and their partners have a fundamental right to respectful treatment,
information, choice, and follow-up from reproductive health care providers. The pamphlets
reflect one of the four main thrusts of the program: enhancing the quality of family planning
Projects are selected for documentation in the Quality/Calidad/Qualite series by an
Advisory Group made up of individuals who have a broad range of experience within the field of
reproductive health and are committed to improving the quality of services. These projects are
making important strides in one or more of the following ways: broadening the choice of
contraceptive methods and technologies available; providing the information clients need to
make informed choices and better manage their own health care; strengthening the quality of
client/provider interaction and encouraging continued contact between providers and clients;
making innovative efforts to increase the management capacity and broaden the skills of service
providers at all levels; expanding the constellation of services and information provided beyond
those conventionally defined as "family planning"; and reaching underserved and disadvantaged
groups with reproductive health care services.
None of the projects documented in the series is being offered as a model for replication.
Rather, each is presented as an unusually creative example of values, objectives, and
implementation. These are "learning experiences" that demonstrate the self-critical attitude
required to anticipate clients' needs and find affordable means to meet them. This reflective
posture is exemplified by a willingness to respond to changes in clients' needs as well as to the
broader social and economic transformations affecting societies. Documenting the critical choices
these programs have made should help to reinforce, in practical terms, the belief that an
individual's satisfaction with reproductive health care services is strongly related to the
achievement of broader health and population goals.

Publication of this edition of Quality/Calidad/Qualite is made possible by support provided by the Ford
Foundation, the John D. and Catherine T. MacArthur Foundation, and the Population Council.
Statements made and views expressed in this publication are solely the responsibility of the authors and not of
any organization providing support for Quality/Calidad/Qualitd. Any part of this document may be reproduced
without permission of the authors so long as it is not sold for profit.

Number Ten 2000 ISSN 1097-8194 Copyright 2000 The Population Council, Inc.

d Population Council
The Population Council is an international, nonprofit, nongovernmental institution that seeks to improve the
wellbeing and reproductive health of current and future generations around the world and to help achieve a
humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical,
social science, and public health research and helps build research capacities in developing countries.
Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters
supports a global network of regional and country offices.
Population Council, One Dag Hammarskjold Plaza, New York, New York 10017 USA
tel: (212) 339-0500, fax: (212) 755-6052, e-mail: pubinfo@popcouncil.org, http://www.popcouncil.org

Alone You Are Nobody, Together We Float:

The Manuela Ramos Movement

by Debbie Rogow
Introduction and Afterword by Judith Bruce

Since population programs were first articulated in the late 1960s and early 1970s, the empha-
sis has been on the delivery of contraceptive services, with some lesser attention given to safe moth-
erhood and child survival. Almost no programmatic attention has been paid to related reproductive
health issues such as reproductive tract infections (RTIs), sexual violence, and unwanted pregnancy.
In addition, family planning programs have virtually ignored the substantial underlying social barri-
ers that restrict women's access to service and choice, such as limited negotiating power in sexual
relationships, social isolation, domestic violence, and lack of cash resources.
Founded on the premise that access is the key issue, traditional population programs embraced
a "supply-side" paradigm: Make family planning services available and people will use them. Family
planning programs evolved vertically for the distribution of contraceptives through three parallel
systems: clinical outlets, community-based distributors, and commercial/social marketing. This sup-
ply-side approach has also been closely linked to technology, with new program directions often
catalyzed around technological development (e.g., the sudden availability of a new vasectomy tech-
nique). Therefore, the skills providers were thought to need were mainly clinical, and issues of qual-
ity and effectiveness of services rested on fairly standard but limited parameters of provider compe-
tence. The expectation was that after a standard start-up phase of several years, services would be "in
place," and the results (typically measured by number of contraceptives dispensed) would come
quite rapidly.
Several decades later, research has shown that the success of this approach has been uneven in
most countries, including Peru, the setting of this issue of Quality/Calidad/Qualitt For although
contraceptive prevalence has reached over 64 percent among married women in Peru, much (36
percent) of this "use" is of "traditional methods"-such as rhythm and withdrawal-which have not
been given active support by the majority of family planning programs.' In addition, it is estimated
that one-third of all pregnancies in Peru end in abortion (WHO 1998, p. 56). Further, up to 60
percent of all pregnancies may be unwanted, in the sense that the timing is wrong or the pregnancy
takes the individual or couple beyond their desired family size, indicating a significant gap between
desired and achieved family size (having more children than originally envisioned). Thus, among
poor women in particular, there remains substantial unmet need for family planning services.

'Of the 16,885 married women interviewed in the 1996 DHS survey, 10,840 (64 percent) reported contraceptive use.
Among these women using contraceptives, 3,867 (36 percent) reported use of a "traditional" method and 6,974 (64
percent) reported use of a "modern" method (Moyano et al. 1997, p. 63).


The narrow emphasis on contraceptive delivery is also linked to neglect of other essential as-
pects of reproductive health. For example, obstetrical services that were once offered without charge
now require cash payments for supplies, which forces many poor women to forsake a hospital deliv-
ery. Further, only 7 percent of women in Peru have ever had a Pap smear.
During the same period in which the Peruvian population and family planning initiatives were
evolving, the Manuela Ramos Movement was also coming of age and developing its own view of the
reproductive health needs of women. Beginning in the late 1970s as a small, feminist, urban nongov-
ernmental organization (NGO), the Manuelas embraced a very different philosophy that viewed
contraception as only one element within a larger constellation of women's reproductive health needs.
As a result, their clinics routinely offered Pap smears, RTI testing, and counseling. The organization
also advocated for decriminalization of abortion based on its experience and understanding of the
reproductive health needs of poor women.
Over the past two decades, the Manuela Ramos Movement grew from a Lima-based women's
collective into a mature and visionary organization of national standing. It was at this point that its
evolution took an unusual turn: The Manuelas entered into an ambitious collaboration with the United
States Agency for International Development (USAID) to develop a reproductive health approach
appropriate for poor, hard-to-reach women in Peru. This project, to be called ReproSalud, was de-
signed to succeed where traditional programs had failed, by responding to the distinctive social pro-
file of poor women, most of whom reside in remote rural areas. It serves as a natural case study of the
principles set forth at the International Conference on Population and Development (ICPD) held in
Cairo in 1994. The ICPD Plan of Action defined the goal of service delivery as offering reproductive
health and choice to individuals, and identified the empowerment of women as a key strategy for
bringing population and resources into balance. In this issue of Quality/Calidad/Qualite, Debbie
Rogow explores why the Manuelas were uniquely placed to implement this new approach based on
their gender-specific approach to organizing and empowering low-income women.
The task was daunting: The traditional family planning approach had been least successful
precisely where the need was greatest, that is, in the remote rural areas where Peru's poorest inhab-
itants reside. Almost two-thirds of Peru's rural population is defined as living below the poverty line
(61 percent), in contrast to the national average of 37 percent, and educational attainment in rural
areas is only a fraction of what it is in more developed urban areas. Ninety percent of rural Peruvian
women live in communities with low availability of public services, compared to 17 percent of their
urban sisters. Maternal mortality rates in Peru, although listed in the medium range of developing-
country standards, are elevated (265 per 100,000 live births), and are thought to be twice as high in
rural as in urban areas (Moyano et al. 1997, p. 131). Not surprisingly, the urban/rural differentials in
contraceptive use remain significant (70 percent versus 51 percent) (Moyano et al. 1997, p. 66).
While the experiences of poor women throughout Peru are similar in terms of inequality of
male/female relations and family instability (both urban and rural women increasingly report domes-
tic violence, and the rate of female headship in Peru is about 25 percent), by definition the rural poor
are more isolated than their urban counterparts. Few women in rural areas have independent in-
comes or bank accounts, and physical and social spaces where they can meet and interact with other
women are, if not absent, at best poorly developed. While rural women living in less densely populated
areas are limited in their ability to communicate and connect with the outside world, in Peru the prob-
lem is further compounded by the fact that the vast majority of rural inhabitants are Quechua-speaking;
the national language, Spanish, is either a second language or not spoken at all.
The experience of ReproSalud exemplifies how, by combining the resources of a major interna-
tional funding organization and a local grassroots women's organization, it is possible to move away
from vertical family planning programs to more organic, multifaceted approaches and record im-
pressive gains over a range of outcomes, including contraceptive use. ReproSalud is but one chapter,
however, in the fascinating history of the Manuela Ramos Movement, which we share in the follow-
ing pages.

Over a very long lunch on a sunny after-
noon, I sat with Victoria Villanueva, Susana
Galdos, Frescia Carrasco, and Rosa Espinoza.
At 63, Victoria is the General Coordinator of
Movimiento Manuela Ramos and was one of its
founding members. Susana, also an original
member, is the current director of the
ReproSalud project. Frescia joined the Manuelas
18 years ago, when it was still a young group.
Rosa has been a Manuela for 13 years. The
women have shared so much of the history they
describe that they easily pick up and continue
each other's comments.


The Early Years: Challenging
Assumptions About Everyday Life
The history of Movimiento Manuela Ranos
echoes the growth of feminist organizations in
many countries. In the late 1970s, Peru was
brimming with hopes of restoring democracy
after ten years of military rule. In the exciting
milieu of a new constitution, elections, and dy-
namic workers' movements, a group of seven
women in Lima began to reconsider their as-
sumptions about everyday life. These women,
then in their twenties, thirties, and forties, be-
gan meeting each Tuesday. They spoke of their
lives, their dreams, and their frustrations and
found they shared many feelings.
Sensing the extent to which other women
would appreciate the kind of self-awareness they
were acquiring, the group developed a workshop
format that would allow other women the same
opportunity to reflect upon their personal lives.
Reaching out to low-income mothers' clubs, they
found that, despite class differences, these
women shared similar concerns. Issues of self-
esteem, identity, work, sexuality, and reproduc-
tive health repeatedly surfaced and were often
expressed with great intensity.
By 1980, the group formed a nongovern-
mental organization (NGO), hoping to contrib-
ute to a nascent national women's movement and
believing that low-income women could provide
vital leadership. As a fitting homage to the many
anonymous voices that bubbled up during those

early workshops, the group chose the name
Movimiento Manuela Ramos (the Manuela
Ramos Movement). The name Manuela Ramos
is considered so ordinary and common as to sig-
nify "Everywoman," somewhat akin to Fulana
in Brazil or Jane Doe in the United States
The Manuelas' strategy was to train women
community leaders in Lima's barrios (marginal
urban areas). As Frescia, currently the coordi-
nator of the Manuelas' health program, explains,
"We called it training because we never found a
better name, but they were really reflection
workshops." What they called the "basic course"
was actually quite intensive: almost 40 hours, two
afternoons a week for eight weeks, with three
main themes:
Identity: sexuality, the body, and male/fe-
male relations;
Self-worth: women's rights and history,
emphasizing the "double-shift" (paid work
outside the home plus unpaid labor within
the home) and the fact that most women
have "two bosses"; and
Organization: teaching women skills they
need to advocate for change.

In addition, depending on the interest of
the participants, themes of health and childcare
were explored.
Within three years, the group had com-
pleted nine courses. Seeking greater continuity
with and feedback from participants (who were
also community leaders), the Manuelas began a
follow-up leaders' course, training early partici-
pants to educate others and serve as resources
in their own communities. Upon completion of
this one-month, 60-hour course, the women con-
tinued to attend annual, and in some cases,
monthly meetings; thus the Manuela Ramos
Movement laid the groundwork for ongoing in-
formation exchange and organized a network
among mothers' clubs and leaders of commu-
nity soup kitchens.
The experience challenged the Manuelas
both personally and politically. Frescia explains,
"We had to find a real way to open up an honest
two-way communication with women that al-
lowed them to internalize what they were learn-
ing and express their needs. It took time." Susana
agrees, "We had to learn many things step by
step. We put ourselves into very real interaction
with this group of women. Through this work
we would keep confronting new issues and
would have to reflect on how they affected us in
our own lives." As an example, Victoria describes
a time she was racing home after a workshop:
"One of the women looked at me and asked what
the hurry was. She asked, 'Can't your children
help in the house? Why not stay with us another
half hour?' I remember that moment."
Laughing, they recalled learning about
their bodies, a consciousness-raising experience
women in every corner of the world were hav-
ing at the time. Victoria recalls, "Once, we real-
ized we didn't know the size of the fallopian tube.
Was it as wide as spaghetti? Too small to be seen?
After the workshop, we had a huge argument
about it. We argued for hours before seeking
the answer!"
For several years, the Manuelas continued
this work, primarily with mothers' clubs and
other community groups. They rented a build-
ing in a working-class section of Lima, where
the smell of cocoa wafted through the windows
from the chocolate factory next door. Financial
support came from several European donors,
most notably ICCO (a progressive church-based

organization located in Holland), which has sup-
ported them from 1981 to the present. Victoria
recalls, "We were quietly working away in the
Lima barrios. Friends from the political left wing
told us we were wasting our time on unimpor-
tant issues like sexuality. And nobody else really
knew about us."
In 1983, several of the Manuelas attended
a Latin American regional feminist meeting.
There they encountered other women who were
involved in similar projects that were helping
women to value themselves and better their
lives. The experience was a watershed. As
Victoria explains, "These women had a name for
what we were all doing: feminism."
Expanding Services
As Peru's economic and political crisis
deepened in the 1980s, the Manuela Ramos
Movement soon recognized that women in
Lima's slums were now coping with increasing
problems of diminishing public services.
"Women were also beginning to talk to us about
domestic violence," Victoria says. "In those years,
there was no law against domestic violence. At
the same time, the law required that a woman
had to secure her husband's permission to work.
The Civil Code consolidated women into a com-
pletely subordinate position."
Because the Manuelas had already com-
mitted themselves to the cause of women's em-
powerment, the next steps seemed obvious. Be-
tween 1983 and 1986, they deepened their work
in several marginal neighborhoods. First, they
sought to teach women nontraditional jobs such
as carpentry, but, recalls Frescia:
The women wanted nothing of it! They
wanted to learn sewing and cosmetology, to be
better mothers and wives. We didn't see how to
work it all out, challenging the traditional fe-
male role and reinforcing it at the same time.
When we went to the community of Pamplona
Alta, the women talked about their health needs.
We decided this was a better fit for us.
Reflecting further, Frescia clarifies how
the health program took form: "Really, we had
begun with sexuality. I don't think we even had
heard the term reproductive health back then.
But we saw the need for more comprehensive
services, more respectful care, and far better in-

formation. That's how we started in Pamplona
Pamplona Alta began as a series of
invasiones. An invasion is a squatter settlement
that springs up almost overnight on a previously
abandoned dusty hillside outside Lima. Almost
en masse, squatters appear, each claiming a tiny
space where they erect a makeshift home, often
made out of cardboard. Over time, the lucky or
resourceful manage to rebuild with more durable
materials and the residents organize the networks
and services that give life to a neighborhood.
In Pamplona Alta, the Manuelas created a
women's health clinic, a legal services program,
and, finally, a small income-generating project.
Somehow the project managed to combine sew-
ing and politics: The women of Pamplona Alta
sewed arpilleras, traditional decorative textile
collages, which in this case illustrated their lives
and dreams. Friends and visitors passing through
the Manuelas' headquarters could buy arpilleras
depicting domestic violence or women's health
services as well as those depicting colorful gar-
dens and market days.
To operate the health clinic, the Manuelas
trained 23 local women to be neighborhood
outreach workers, receptionists, and even clini-
cians. Aware that most women in Peru had more

children than they wanted, they offered a wide
range of contraceptive methods-probably the
widest range available in the country. They pro-
vided barrier methods (including diaphragms
when they could get them-usually through
feminists in Brazil)," pills, intrauterine devices
(IUDs), DepoProvera'", and full instruction on
fertility awareness (rhythm methods remain the
most widely used method in the country). They
also provided referrals for sterilization and, later,
for Norplant.
In addition to contraception, the clinic also
provided comprehensive reproductive health
care, including prenatal care and screening for
cancer and sexually transmitted infections
(STIs), although, at the time, Pap smears and
STI testing were almost unheard of as part of
routine care for poor women. Clearly ahead of
their time, the Manuelas believed that counsel-
ing and personal respect were central to pro-
viding quality reproductive health care and that
sexuality was intricately related to almost all as-
pects of such care. Hence, staff training included

SSee Diaz, Margarita and Debbie Rogow. 1995. "The
Coletivo: A Feminist Sexuality and Health Collective in
Brazil," Quality/Calidad/Qualitd, no. 6. New York: Popu-
lation Council.

basic information and skills for sexuality educa-
tion and counseling, including listening skills,
aspects of human sexuality, gender dynamics and
the right to say no, sexual pleasure, masturba-
tion, and cultural aspects of human sexuality.
Dominga Florian Pachas and Cristina
Yachachon Verasteguo were among the original
residents hired in 1989 to staff the Pamplona
Alta clinic. Today they still welcome neighbors
into the clinic, now housed in a terra cotta-col-
ored building erected by the Manuelas last year.
Dominga describes how she came to work with
the Manuelas:
I am 53 years old, so I was 44 then. Of my
seven living children, I still had five at home. I
was the head of the Vaso de Leche [a commu-
nity food program, literally "Glass of Milk"] here
in Panplona Alta. The Manuelas advertised for
health promoters and I was one of the women
picked. We went through a six-month training.
It was not at all what I expected! I thought it
would be a narrow health topic, but it covered
so much. What I remember most, even today,
was the part on self-esteem. This point was new
for all of us, but so important. Also the unit on
helping the community; we have so many prob-
lems here, with illness and with social conditions.
I have learned so much here. Now I pre-
scribe drugs and do breast exams, Pap smears,
and pelvic exams. We always offer the woman a
mirror so she can see what her cervix looks like.
I don't do the wet smears to test for infections,
but a few of the other promoters do. I can also
remove IUDs, treat cuts, and provide education
about family planning. We provide pills,
DepoProvera, foaming tablets, condoms, and
IUDs. We explain rhythm and fertility aware-
ness. And we make referrals for Norplant, tubal
ligation, and vasectomy.
In 1989, I went to Peru as part of an inter-
national evaluation of family planning counsel-
ing services, where we visited the most presti-
gious family planning service sites in the country
and observed client-provider interactions. Later,
we paid an informal visit to the Manuela Ramos
clinic in dusty Pamplona Alta. My colleague sat
stunned, watching Dominga and her colleagues
at work. My colleague described the services we
saw there as "the best thing going on in the coun-
try, and nobody knows about it." But the local

women appreciated it. Dominga recalled one
woman who complained of discharge and ab-
dominal pain:
Upon examination, her cervix was found
to be inflamed. The physician gave her a pre-
scription for treatment and told her to abstain
from intercourse for several weeks. Five days
later, she came back and asked to talk to me. She
was worried because her husband was insisting
on sexual relations. He was claiming that she
looked fine and he didn't see any wound. I told
her to bring in her husband, and two days later
we (lid afollow-up visit with him present. Again,
he claimed she had no wound. With her eager
consent, I offered to show it to him. (She had
seen her own inflamed cervix earlier) We did
an exam. Looking at the cervix, he asked, "What's
this hole?" He couldn't believe that is where the
baby came through.
I even told him I had once had such an
infection before. For a while, he just couldn't take
his eyes off that cervix. Then he said, "Take out
that iron thing [the speculum], so my wife can
be more comfortable. Now I understand." He
told her to rest. We congratulated him for hav-
ing accompanied her She got better They are still
very friendly when I see them in the market.
Her colleague Cristina agrees that educa-
tion and counseling are critical:
The men are so machista. They think
women are the source of all the infections. So I
show them the plastic penis I have. I ask them
what they know about a particular infection.
They tell me that they shower daily to avoid in-
fection themselves. But I explain it to them. I
even teach them to pull back the foreskin and
Other cases are more painful. Cristina
speaks of a local paraplegic washerwoman:
Last month, she was coming back from
delivering clothes at 7:00 p. in. when a young man
raped her. Robbed her, too. He left her in a ditch
and she had no way to get out until someone
came along. This week she came here crying. It
is always hard to understand her speech, but I
really tried. She was so worried, because her
period had not come. We did a pregnancy test
and it was positive. She cried. She had con-
tracted an infection, too. She came back in this

morning, but I wasn't here. She will be back later
today. We still don't know what will happen.
By the end of the 1980s, the movement was
growing more visible, both through its services
and by participating in public protests. Still, the
Manuelas were often ridiculed or marginalized
by critics. Victoria reflects back on that time:
We talked about gender relations and that
made men nervous. And at that time most people
had a naive and caricatured view of feminism.
They characterized us as divorced women, hat-
ing men, not caring about the family. The funny
thing was that we were almost all married women
raising our own small children!

The Policy Stage
As happens with many dynamic NGOs, the
Manuela Ramos Movement began to evolve as
it recognized that its ability to effect change by
providing services was constrained by the social
structure and laws in Peru. The legal program,
which had been providing assistance to women
suffering domestic violence, now began organiz-
ing protest marches. I observed one such march
in the slum of Villa El Salvador in the early 1990s.
Close to 1,000 women-a solid majority of the
female residents not at work-marched. Bands
played! Stilt-walkers were transformed into 30-
foot-high marionettes! Virtually the entire town-

ship was either in the march or watching it.
Surely, there wasn't a household in Villa El Sal-
vador that lacked for conversation that evening.
Subsequently, the legal program began working
with judges and the police and helped promote
legislation to expand women's legal protection
and recourse against physical and sexual abuse.
Soon the health program was moving along
a similar trajectory. Susi Chavez, the midwife
who ran the Malnielas' clinics both in Pamplona
Alta and at their urban headquarters, recalls this
stage vividly. One day, a new invasion had ap-
peared in the Pamplona Alta area. Word came
to Susi that one of the squatters, a woman, was
feverish and bleeding vaginally. Apparently, the
woman had just had an illegal abortion but re-
fused to give up the little plot upon which she
was squatting for fear of losing it. Eventually,
with Susi's support, the woman got antibiotics
and was able to seek further medical help.
As the Manuelas met woman after woman
seeking abortions, they became leading advo-
cates for increased awareness of abortion as a
public health problem in Peru. Abortion is ille-
gal in Peru in all instances, except when the
mother's life is proven to be in danger. Police
have sometimes been posted at emergency
wards to ensure that physicians report all women
with suspicious miscarriages. Because the
Manuelas had always worked openly and within

the law, and did not want to jeopardize their
ongoing work, they decided to keep their activi-
ties within the Peruvian legal framework, draw-
ing attention to the health consequences for
women, sponsoring Maternal Mortality Day
events, calling for humane treatment of women
with complications from unsafe abortion, and
otherwise raising consciousness about the real-
ity of abortion in Peru.
Because they knew that the reproductive
health care available to most women was gener-
ally inadequate, often more for lack of attention
to women's needs than for lack of funding, the
Manuela Ramos Movement declared itself a
stakeholder in Peru's family planning commu-
nity. Their 1998 20-year anniversary document
describes that period:
At that stage (the late 198os), we priori-
tized the creation and strengthening of high-
quality services. Hence, we formed women con-
sortia, networks, and collectives to enable women's
organizations to influence political processes and
decisions. This new challenge required that we
analyze, systematize, and publish the experience
we had developed in human rights, sexual and
reproductive health, training, and income gen-
eration. A second priority was the development
of our own channels of communication as well as
building relationships with the mass media to in-

fluence public opinion regarding equitable gen-
der relations.
Suddenly, the Manuelas seemed to be ev-
erywhere: They published magazines, organized
meetings, and attended congressional sessions;
members appeared on radio and television. They
continually promoted quality care, abortion re-
form, comprehensive reproductive health ser-
vices, and greater awareness of and attention to
sexuality and gender equity. Yet, during this pe-
riod, the full-time staff of their health program
numbered only five or six.
One of their first experiences in the broad
policy arena came when the United States
Agency for International Development (US-
AID) mission in Peru developed a new five-year
country population strategy. The main focus was
on long-term, provider-dependent methods that,
at the time, consisted of the IUD and steriliza-
tion. The Manuelas were outraged and called
upon both the family planning and nascent femi-
nist communities to publicly criticize the strat-
egy. They published a paid editorial in the news-
paper and sponsored a multisectoral public
forum. As it turned out, the strategy was only
partially implemented before being replaced by
one with broader vision.
Gradually, the Manuelas began to be in-
vited to collaborate in local family planning ac-

tivities, albeit sometimes only in a symbolic fash-
ion. By 1990, with significant experience in both
service delivery and reform behind them, tlhe
Manuelas entered the political arena as full
stakeholders. They were backing selected po-
litical candidates, demanding position state-
ments on women's rights from all national po-
litical candidates, and continuing to nurture a
growing network of women's organizations
across the country.
It was not an easy time to construct a
women's movement in Peru. Between the mili-
tary and the terrorist movement, there was little
room for democratic activism. Shining Path,
Peru's largest terrorist group, also began mov-
ing into new, unorganized slums; providing a few
vital-but until then absent-services; and thus
becoming the de fact local government. Shin-
ing Path found it difficult to accomplish its goals,
however, when local communities were already
autonomously organized-usually by groups of
women leaders such as those who had been in-
volved in the Manelas' early workshops. There-
fore Shining Path decided that periurban women's
popular organizations were a hindrance and at-
tempted to intimidate local activists. One soup-
kitchen leader was assassinated during this pe-
riod and the Manuelas also received death threats.

For a long time, women's health activists
and reproductive health professionals have rec-
ognized that their efforts to provide contracep-
tion and to treat STIs are significantly hindered
by women's restricted social mobility, limited ne-
gotiating power with partners and service pro-
viders, and even by their own low self-esteem.
But the practicality of groups like the Manuela
Ramos Movement had begun demonstrating
effective ways to successfully address such sen-
sitive issues as gender and self-esteem.
Just as the Cairo' era approached, Susan
Brems was named by USAID to head its Health,
Population, and Nutrition Division in Peru.
Trained in public health and social and cultural
anthropology, she has devoted her career to inter-
national development.
In Peru, Susan decided to develop a repro-
ductive health project that would go beyond the
traditional contraceptive distribution approach,
focusing instead on reproductive health and
women's empowerment. With assistance from

' The International Conference on Population and De-
velopiment (ICPD) was held in Cairo, Egypt, in 1994.

Barbara Feringa, a population fellow providing
technical assistance to USAID's Office of Popu-
lation, she designed a request for applications
(RFA) for a project aimed to succeed where pre-
vious efforts had failed-in the poorest regions
in Peru. This new, five-year project, with a $25
million budget, would account for almost one-
third of the population program portfolio of
USAID's mission in Peru. The remaining funds
would continue to support government and pri-
vate-sector family planning efforts, with an em-
phasis on improving the quality of existing services.

Susan is straightforward in her explanation
of the origins of the ReproSalud project:
There is nothing new here in terms of re-
productive health. What is new is that we are,
with the mandate of Cairo, actually implement-
ing what has been learned from the field of de-
velopment. Decades of work and research in
development have generated the same basic les-
sons: community participation and working
from the ground up. These essential principles
are talked about all the time, but they get short
shrift in implementation. Community participa-
tion often turns into getting local folks to do the
work without giving them real ownership. It's easy
to have a town meeting, but building actual ca-
pacity at the local level is a different process.
[With Cairo] we have had to erase tradi-
tional assumptions about what improves people's
lives. We have had to acknowledge how many of
our activities are socially constructed, for ex-
ample, by gender and power We needed a dif-
ferent framework.
ReproSalud would invest not in traditional
avenues such as a new technology or expanded
service delivery but in the social and economic
development of women to enable them to exert
control over their own lives. Susan comments,
"Problems like schistosomiasis [a disease caused
by parasites] can be controlled with a single tech-
nical input. But family planning and reproduc-
tive health are one-to-one services."
ReproSalud would go into communities in
areas of Peru where government and private
family planning programs had largely failed to
find an audience. Through individual surveys
and participatory, day-long, group "self-diagnos-

tic workshops" in each community, staff would
gather information about women's social pat-
terns, belief systems, and primary needs and
concerns, with a focus on reproductive health.
As part of this process, local women would pri-
oritize the reproductive health issue of most con-
cern to them. One of the mothers' clubs or food
programs would then work as a subgrantee, or
partner, in addressing the identified problem,
with technical assistance and funding coming
from the central project staff.
Three principles would be served in this
Knowledge is power. Local group repre-
sentatives would go to a training session to learn
about their bodies and about the identified
health issue. These elected leaders would then
go back and teach their neighbors.
Collective action is power. Project staff
would work with local organizations to enable
them to advocate more effectively for improved
care from their local government health post,
particularly with regard to the identified health
Money is power. In selected areas, the
project would work with local organizations to
promote income-generating schemes and estab-
lish communal credit programs in cooperation
with banks across the country. Unique among
USAID's population projects, 16 percent of the
project budget was allocated for this non-repro-
ductive health component. Cash inputs would
enable women not only to pay for the medicines
they said they could not afford, but also, per-
haps, to renegotiate matters of daily life with
their husbands.
If all worked as planned, women's lives
would change in quiet but profound ways. Their
reproductive health would improve, their social
mobility would increase, and their sense of self-
esteem and agency in their own lives would be
enhanced. The theory underlying this project
was that women's reproductive health is closely
linked to their social and economic situation;
therefore, without engaging in a dialogue about
the social context of their lives, they would have
little ability to gain access to available health ser-
vices. For this reason, approaches focusing solely
on the supply side fall short of reaching their
full potential. ReproSalud would begin by do-
ing the longer, slower work of gender-sensitive

development, which would enable women to
promote their own reproductive choice and
health both through changed personal behavior
and greater capacity to shape local health services.
Duff Gillespie, director of the Health,
Population, and Nutrition Division for USAID
in Washington, DC, sums up his view of the
agency's approach:
ReproSalud does not represent any funda-
mental shift in the agency worldwide position
on Cairo. It reflects a change in climate. The
greater openness allows for new ways of doing
things that are conducive to going outside the
traditional approach to family planning and re-
productive health. Officially, we encourage look-
ing at different ways of going beyond narrow
service-delivery approaches to respond to de-
mand, to have a more holistic approach.

Susan Brems knew she would need a
unique partner to implement this project: "We
wanted an organization willing and able to do
work that was time-intensive, locally specific,
and inductive; that is, without a blueprint. [We
wanted an organization with] experience in all
major aspects of the project, from health advo-
cacy to self-help education to income genera-

tion, all through the lens of gender and empow-
erment." This was a daunting challenge, one well
suited to the Manuela Ramos Movement.
Despite criticism from some quarters of
the feminist health movement (for collaborat-
ing with USAID, for risking likely failure, and
for courting organizational catastrophe), the
Manuelas decided to submit a proposal. They
believed that, as challenging as the project would
be, they could carry it out. Not surprisingly, the
awarding of the project to the Manuela Ramos
Movement also raised doubts, particularly
among traditional family planning organizations
that wondered whether a feminist organization
based in the capital city could pull off this enor-
mous and ambitious project in the Quechua-
speaking mountains and Amazonian jungles of
Having no experience dealing with the in-
tricacies of USAID contracts, the organization
spent much of the first year finding its way in-
stitutionally. Susana Galdos, who was named
ReproSalud's director, gives a few examples:
We had to hire a huge number ofstaff. We
had been such a stable staff for so many years,
with such unity. Now we had to set up regional
offices around the country and find people who
lived in the area and spoke the local language,
had the technical skills to carry out their func-


tions, and also shared our perspective on gender.
This was very hard. We hired some great people
but also some people who were not a good match.
Also, we had to buy a fleet of heavy ve-
hicles, capable of going across roads that are not
quite roads. Because the project is funded by the
United States, we have to buy vehicles made in
the United States. You won't believe the amount
of paperwork and time and expense involved in
getting those vehicles here. And getting parts is
even harder.

The USAID mission provided ongoing
support by placing senior technical advisor Bar-
bara Feringa at ReproSalud on a part-time ba-
sis. Barbara helped the Manuelas tackle many
administrative and bureaucratic challenges;
without her support, it is certain that the sparkle
in Susana Galdos's eyes would have dimmed long
ago. For her part, Barbara says that while the
Manuelas had inadequate management systems,
their strong management sense brought them
through the period of rapid expansion.
The Manuelas decided that the leaders of
ReproSalud would have to come from the ranks
of their own organization, which would greatly
diminish the staff of their existing health pro-
gram. In addition to Susana Galdos, Susi Chavez,
Susana Moscoso, and several other Manuelas
were shifted over to the ReproSalud project,
leaving only Frescia Carrasco to coordinate the

Manuelas' non-USAID clinical and health ad-
vocacy activities.
A problem that has recently emerged for
the Manuelas as a result of their collaboration
with USAID is that the U.S. government-in
response to antichoice politicians-has rein-
stated a policy that denies funding to any project
that provides abortions, refers for abortion, or
even advocates for abortion reform. Therefore,
to avoid abandoning the thousands of women
being empowered by the ReproSalud project,
the Manuelas have had to pay an enormous ran-
som in terms of their right to free speech and
their institutional effort to reduce a major cause
of humiliation, illness, and death among the en-
tire female population of Peru.
Moving Out into the Field
The Manuelas set up offices in nine regions
that were selected for their high poverty, low con-
traceptive prevalence, and lack of terrorism. They
hired regional coordinators, who in turn hired
local promoters and administrative support staff.
The promoters went out to selected villages, con-
tacted mothers' clubs and Vaso de Leche groups,
and told them an organization named Manuela
Ramos wanted to help them improve their health
and make their lives better.
I visited women working with ReproSalud
through mothers' clubs in various parts of the
country. All of them remarked on their first con-

tact with the project. Women from one
Quechua-speaking village told me, "Here was a
group that said they were here for us. We
couldn't believe it, that they didn't want any-
thing. Usually, people come and say they are
doing something for us. But then later, we are
supposed to pay for it." This sentiment echoed
the response the Manuelas received in Lima
when they began their work there: As a moth-
ers' club leader in Lima recalled: "My neighbor
said, 'Why go? You know they don't really care
about us.' But I had read about this Dr. Manuela
Ramos in the newspaper and heard about her
on the television. She was pretty famous and
here she was, coming to our neighborhood. So
I wanted to see her. I didn't know she is an or-
ganization!" And a woman in the Amazonian
town of Pucallpa said simply, "They listened to
me and said they wanted to support me in what
I cared about. Nobody ever said that before."
The next step was to invite all the local
women's groups from a cluster of towns and vil-
lages to submit a simple application giving their
history and noting a specific reproductive health
concern. Typically, about 15 clubs in each area
responded, and regional staff then selected five
finalists, inviting them to "compete" for the
partnership; the competition consisted of pre-
senting a skit about the problem they had identi-
I attended one of these sociodrama com-
petitions in a Quechua village in the Andes. One
by one, each group, consisting of about 20
women and half a dozen children (several hus-
bands had also accompanied a group that had
walked eight hours to get to the event) stood up
to present its skit. Some of the skits were pre-

Autodiagn6sticos are a participatory
research process using games and group
exercises designed to help women analyze
their lives, identify their health needs, and
reflect on how they view their health care.
They are led by a ReproSalud promoter
using the community's first language
(Quechua or Spanish). Using the image of
a tree, the group analyzes the selected
problem:The tree trunk represents the
problem; the branches, the consequences;
the roots, the underlying causes. Carried
out in three to five sessions, each lasting
four hours, the autodiagndsticos are tape
recorded and transcribed in such a way
that the information can be analyzed and
systematized as part of the project's
ethnographic research component. In this
sense the autodiagndstico seeks to
develop new knowledge based on women
gaining a fundamental understanding of
their own lives.

sented in Spanish, others in Quechua. Some
dealt with the lack of adequate prenatal care,
others with the need for contraception. Some
were extremely well prepared and enacted, oth-
ers a bit sloppy. But all were lively; soft-spoken
women were transformed into drunken husbands,
mothers giving birth, and nagging neighbors. Af-
ter the presentations, lunch was served and par-
ticipants were informed that they would be no-
tified of the final decision by letter within a week.

Susana Moscoso, associate director of
ReproSalud, explains how the sociodramas re-
veal the level of social organization within a
group: "Did it seem that the group had taken
time to think about the issue, to rehearse, to get
everyone there? Did they plan for costumes? We
don't care whether they are good actors, what
we are assessing is whether they are able to iden-
tify a problem and work cooperatively and ef-
fectively to try and address it. With the
sociodramas, you can see this very easily."
Once the winning group was identified,
ReproSalud staff collected quantitative data by
surveying both men and women in the commu-
nity about employment, income, reproductive
health history and status, utilization of health ser-
vices, contraceptive practice, and sexuality.
Qualitative data were gathered through
autodiagndsticos (participatory diagnostic work-
shops) that identified the reproductive health
and gender issues local women cared about the
most (see box "Autodiagn6sticos").
The most common problem identified was
descensos, which translates roughly as vaginal dis-
charge. "Too many children" was a commonly
cited concern in a number of villages, followed
by childbirth complications, abortion, and teen-

age pregnancy. Two issues that emerged as press-
ing concerns in virtually every workshop across
the country were domestic violence and disre-
spectful and inadequate treatment by the local
health post.
Because the Manuelas believe in listening
to women and involving them creatively in their
own "diagnosis," the diagnostic workshops have
proven to be more than a research tool; they are
also an intervention in and of themselves. Indeed,
the workshops proved so revolutionary for some
women that staff realized that any surveys taken
after the workshop could no longer be consid-
ered baseline data because, by the time the work-
shops were over, ReproSalud had already started
to make a difference in women's lives.
During the next stage, local ReproSalud
promoters helped their local partner organiza-
tions develop a work plan. Picture a dozen
women and a few babies sitting on benches and
swatting flies while articulating general goals,
specific measurable objectives, and concrete ac-
tivities, as well as the personnel, supplies, and
time frame needed for each activity. All this in-
formation went onto big sheets of paper.
ReproSalud staff then calculated the budget and
transferred funds to the organization.

Gender and Health Workshops for Men

Most men are surprised by the workshop.They
expect more technical training, but encounter
instead a process of looking more critically at
themselves and their culture. One of the initial
exercises is called "The Male Body." It is a
technique that fosters discovery of the relation-
ship between the dominant characteristics of
masculinity and the consequences or costs to
the body and health.The group explores the
relationship between the traditional male role
and health problems, for example:
The relationship between being "the boss,
responsible, a worker (or workaholic), and
strong" and loneliness, tension, stress,
heart disease, gastritis, and alcohol abuse;
The association between being a "lady's
man" and having STIs and AIDS; and
The link between being macho and defen-
siveness, alcohol abuse, cirrhosis, and
Another exercise is called "TheTunnel of
Time." By way of a directed fantasy, partici-
pants go back in time over their own history,
visualizing the moments, people, and mes-
sages that had the greatest influence over
who they have become.This experience is
expressed artistically, with participants
creating a collage with drawings, cutouts,
and text.These collages are shared with the

Each women's group then elected an ad-
ministrative team and a teaching team that were
trained together with their counterparts from
other communities. The administrative team
learned basic bookkeeping, financial reporting,
general management, and leadership. The
teaching team learned about reproductive tract
infections (RTIs), contraception, or whatever
topic the group identified as its first priority,
along with basic pedagogic techniques such as
participatory learning. Both training programs
lasted about a week. The administrative team
then began to manage the project, while the
newly trained teachers went back and, with as-
sistance from ReproSalud promoters, taught
their neighbors all they learned. At this point,
the project was up and running.

group. For most of the men, this is the first
time they have systematically thought about
gender dynamics in their own lives and
shared experiences with other men in a
noncompetitive, alcohol-free environment.
From this point of departure, the group is
ready to delve more deeply into the involve-
ment of men in violence, alcoholism, sexuality,
and fatherhood. Subsequent units focus on
reproductive and sexual anatomy and physiol-
ogy, women's rights, gender roles, contracep-
tion, the particular reproductive health issues
that the women in their community identified
as their priorities in the self-diagnostic work-
shops (e.g., RTIs), and the role of men in
familial abuse. In this last topic, which is
difficult for men to contend with, the goal is to
sensitize them in terms of the experiences of
mistreatment or abuse that they themselves
may have suffered or witnessed, and from
there touch on the violence that they inflict on
others. According to Benno de Keijzer:

It is key to touch their own emotionality and
the cultural ideas that serve as a base for
violence toward the family. In the experience
of ReproSalud, we have seen the same thing
that has emerged in other countries: There are
growing contingents of men willing to reflect
and to live in a different way.

During the first two years in the field,
ReproSalud identified 79 mothers' clubs as part-
ners and began the subgrantee process. Several
clubs have now completed their first project and
begun a second cycle of activities.
ReproSalud's plan was based entirely on
working with women. However, early on, the
women questioned this plan, because they wanted
to involve their husbands in the educational work-
shops. In some cases, women were attempting to
erode male opposition. But more often, women
were going home excited about what they were
learning and experiencing, and their husbands
wanted to know more about the workshops.
Initially there was concern about shifting
resources away from women's activities, but
ReproSalud soon modified the project's design

in response to the women's requests. Project staff
contracted an expert in the area of men and gen-
der-Benno de Keijzer, a male anthropologist/
physician from Mexico-to head this effort, but
soon realized they would have to recruit and ori-
ent men who knew the local culture and language
to serve as trainers. They also needed to develop
separate materials for the men's sessions. Once
a group of men from the various regions were
selected, they attended a national training-of-
trainers workshop. The key objective of the work-
shop was to create an opportunity for participants
to reflect about their masculinity so that they
could help other men think about sexual and re-
productive health. As with the women's work-
shops, it was the reflective process that allowed
the material to influence participants' lives. These
trainers then trained male peer educators/pro-
moters from the villages; generally, these men's
wives were also involved in ReproSalld. Finally,
following the ReproSalud model, local male pro-
moters offered the workshop (with support from
trainers) to the men in their communities.
The workshops were an enormous success.
Men valued the opportunity to learn about their
bodies and about sexuality, and they were also
eager to explore ways to promote harmony in the
family. This latter objective led to intense discus-
sions about alcoholism and violence, forced sex,

and communication. Ultimately, training men to
work as educators of other men in their own com-
nunities would become one of the most salient
facets of ReproSalud's work. (See box "Gender and
Health Workshops for Men" for a description of
some of the exercises in the workshop.)

Income-generating Program
The income-generating program comprises
two types of activities: a village bank/credit pro-
gram and product development/narketing.
Originally ReproSalud planned to work with es-
tablished microcredit institutions, but, ultimately,
it proved more practical to work through exist-
ing banks. Currently, the program works with 20
banks in four regions. Establishing a working
relationship between banks and grassroots
women's organizations was quite a challenge.
None of the women had ever been inside a bank
before; they worried that because they were from
rural areas they were not dressed properly or that
not speaking Spanish would hinder them. To
overcome these hurdles, ReproSalud staff accom-
panied them on their first visits to show them
how the system worked.
Although the credit system was intended to
help women establish microenterprises and meet
their own health expenditures, many women have
taken out loans for a wide range of needs, such as

family transportation costs or buying medicine
for sick husbands. The program works on the
assumption that it is not the role of the lending
institution (in this case ReproSalud) to determine
the viability of a woman's request. If a woman
feels that the best investment is to help her hus-
band get well, and thus begin earning income
again, that is her choice. To date the vast major-
ity of loans have been used to support commer-
cial activities or pay off existing loans. All loans
are guaranteed by the local women's groups and
the repayment rate is 97.8 percent. As of Febru-
ary 2000, 183 banks are participating, and the
microcredit program is expected to reach sustain-
ability by the end of the year-well ahead of the
accepted time frame for most microcredit pro-

Market-led Product Development
One of the larger enterprises supported
through the credit program is in the Amazon
town of Pucallpa. After a study of locally avail-
able resources and market export opportunities,
the group decided to begin producing decora-
tive brooms made from palm fibers and hand-
made paper from banana trees. Marilena Da
Souza was elected project leader because, al-
though new to the group, she had completed
high school and had worked for a few months as
a nurse. Marilena recounted her story:

I married at seventeen, just after I had
started working. My husband didn't want me to
work, so I kept house and had four sons. Stay-
ing home alone, I got lonely and discouraged.
Last year, I started coming to the mothers' club,
even though my husband didn't want me to. On
my first visit, they made me secretary! Being
with the other women, you don'tfeel as lonely;
you get motivated, you can get more confidence.
Then the people from ReproSalud came to talk
to us about the project. The group named me
coordinator. It's a lot of responsibility. The
women had to learn that you have to come to
work. Every day. You have to be responsible.
The group has just sold its first shipment
of brooms for export. They will use the money
to buy "things we can't pay for now-school fees,
medical attention. We are going to have a big
Overall, ReproSalud's product develop-
ment activities are beginning to bear fruit, with
some projects already getting orders from in-
ternational retailers. However, the investment of
time and money required to build these initia-
tives into sustainable, profitable enterprises is
enormous, particularly as microenterprise is not
the area of Manuelas' greatest expertise. For these
reasons, ReproSalud has decided not to expand
product development activities beyond the five
regions where they have already begun this work.

Because ReproSalud is a population
project, one of its goals is to contribute toward
greater utilization of family planning services.
However, as long as women find the quality of
local reproductive health services unacceptable,
they will not use them. Hence, a key project
component is to enable the mothers' clubs and
Vaso de Leche groups to become effective ad-
vocates for improved local health care.
In the Huaraz region, where there were
many complaints about local health posts, a
Quechua mothers' group has been pressing for
better services. A young ReproSalud promoter
described the women's growing confidence:
They go right up to the [public health]
authority. At first, you can see he thinks they
don't know anything about family planning.
They tell him about their analysis of their prob-
lems, the causes, their needs, and their plans.
And then he sees how much they do know! For
me, this is the best moment.
Nydia Villavicencio Rios, the ReproSalud
coordinator for the Ucayali Amazon region, ex-
The women say the nurses insult them and
tell them, 'This will hurt. You should have
thought about it before!' They would never speak
this way to a middle-class woman. So the women
stay in their own homes to give birth -70 per-
cent of the city-dwellers and 90 percent of those
in the rural areas. When Ifirst met these women
they were afraid to go to the health center and
speak up to the doctor Now they go straight to
the mayor! They knock on his door, step firmly,
go up the stairs, and air their concerns. They
inform him of their work and tell him what they
need, 'A school, Mr. Mayor!' I have a proud little
place in my heart when I see that.

The launching of ReproSalud raised an-
other important question regarding how such a
project could be evaluated. Despite the
commonsense wisdom of ReproSalud's design,
the complexities of studying its impact have been
the biggest challenge. As Susan Brems explains:
At USAID, we manage for results, and this
is a two-edged sword. On the one hand, we are

spending taxpayers' money and we have to show
something for this. On the other hand, the pro-
cess of development is as important as the prod-
uct. When we take shortcuts, as has happened
with many projects-including USAID-funded
ones -there is no long-term sustainability. The
process that leads to sustainable development is
a slow one. We have to temper one approach with
the other
Questions of both philosophy and meth-
odology loom large. What is a realistic time
frame in which to anticipate an increase in con-
traceptive use? Who may properly be consid-
ered a beneficiary? If no increase in contracep-
tive use is found, will improvements in women's
overall reproductive health and status justify the
project? What are the best indicators of women's
empowerment? What is the appropriate mix of
qualitative and quantitative research for assess-
ing the impact of such a project?
Liz Maguire, former director of USAID's
Office of Population in Washington, was aware
of the pioneering role the Manuelas needed to
undertake in developing effective evaluation
measures: "This is a different program. We need
quantitative aspects of the evaluation, but also
qualitative ones. We must document the pro-
cess, letting the women speak and letting us hear
them. The concern for us is how we can learn
from this wonderful opportunity."
Duff Gillespie remains more focused on
the quantitative outcomes:
There's a tendency for different interna-
tional groups to identify "worthy" outcomes as
markers of a successful project, without show-
ing a link to the underlying mission, which for
population is still, basically, changes infertility

Yet while the number of direct beneficia-
ries of this $25 million project may be limited,
the long-term benefits of large-scale, top-down
projects are also questionable. As Judith Bruce
discusses in the introduction to this issue, tradi-
tional family planning models have often led to
failure and wasted resources. Even when they
reap some success, says Susan Brems, "top-down
projects eat a lot of money on travel, cars, and
top-level salaries."
Certainly a project such as ReproSalud is
more difficult to evaluate than one that counts

bodies or the number of contraceptives that have
moved through a warehouse. Susan points out,
"Measures such as CYP [couple years of protec-
tion] are used precisely because it is hard to mea-
sure things that indicate deep, sustainable
change." It is clear that, while as a scholar and
donor she cares deeply about assessing the im-
pact of ReproSalud, she does not think that the
challenges posed by evaluation should under-
mine a commitment to doing the right kind of


When the Maneulas decided to request an
extension of the project for an additional five
years, the demand for some preliminary docu-
mentation was increased and they embarked on
ReproSalud's first field-level or impact evaluation
activity: case studies in three Andean regions
where ReproSalud had been working for at least
one year. This qualitative effort was complemented
by quantitative studies of knowledge before and
after participation in the community-level work-
shops, as well as service utilization statistics over
time, based on the logs at the health posts serv-
ing these villages. All of the findings-summarized
below-were striking, given the short period of
time the ReproSalud project has been active.

Qualitative Impact Studies
Using a semistructured interview guide,
researchers interviewed women, men, youth,
village leaders, health officials, and municipal
authorities about the progress and preliminary
impact of the project in promoting: (1) women's
empowerment and (2) contraceptive use. To
measure women's empowerment, researchers
identified indicators at levels of the individual,
family, and community (ReproSalud 1998). Be-
cause this project seeks to empower women to
promote their own reproductive health, health-
promoting behavior was included as an addi-
tional indicator of empowerment. Data collected
on family planning outcomes included changes
in contraceptive knowledge, attitudes, and use.

Empowerment Outcomes
Individual-level empowerment. The in-
dicators of women's empowerment at the indi-
vidual level included:

Increase in self-esteem;
Female control of cash;
Knowledge of rights; and
Knowledge of and comfort with one's body
and reproductive system.
Aside from their association with general
wellbeing, these indicators are also generally
linked to positive reproductive health outcomes
and family planning use. The following are ex-
cerpts from women's testimonies:
Once a month we come by foot and bus to
the town of Huaraz to take some of our money
from the bank. The first time we went in, we
were frightened. We are not dressed like the
people in the bank. We speak Quechua. And we
were not used to working with cash. (Pause) But
we're not nervous anymore. (A big smile lights
up her face) Now we like it.
Aurelia, project coordinator
in Canchabamba
I tell you, my pridefollows me home.
Marilena, young coordinator at the
Pucallpa broom factory
Before, we were like burros, not knowing
anything. Now Ifeel useful for what I know, that
I can know something too. Before, we knew noth-
ing, we were forgetful, we were crying, crying.
Now, we know the parts of the body and how
they function, contraceptive method, how a baby
is produced, how to care and eat to have a
healthy baby. How to teach other women and to
determine if a woman needs to go to the health

center. The rights of a woman, that nobody can
mistreat us, not even our husbands, to learn to
respect ourselves.
Paula, age 43, seven children,
promoter in Huaripampa Bajo
I didn't know the rights: That our husbands
not hit us, notforce us to have sex. To decide the
number of children. To know the parts of our
bodies, inside and outside. To use the [contra-
ceptive] method we want.
Cirila, age 53, 12 children born,
president of Organizaci6n de
Comunidad Basada (OCB)4 in Chuyo
If there is a single observation one can im-
mediately make upon speaking with the women
who are working with ReproSalud through their
clubs, it is their expanded sense of negotiating
skills and their heightened self-esteem.
Empowerment in the family. Empow-
erment at the level of the family was assessed
by changes in the realms of:
Domestic violence;
Satisfaction regarding sexuality;

S"OCB" refers to community-based organizations gener-
ally. ReproSalud considers all mothers' clubs and Vaso
de Leche groups OCBs once they have become involved
with ReproSalud.

Overall family life, including more open
and equal decisionmaking and communi-
cation; and
Social and geographic mobility among
Domestic violence. In what is perhaps the
most impressive finding of the entire study,
ReproSalud's intervention, which began approxi-
mately one year ago, has apparently resulted in
dramatic decreases in alcohol consumption, do-
mestic violence, and forced sex in all of the vil-
lages we visited. While a small minority of re-
spondents (whose husbands had not attended
the men's training) reported no change in vio-
lent behavior, the vast majority of respondents
(both female and male) spoke openly and at
great length about this change.
Thirty men were trained. About ioo more
are in the community. The husbands who have
been trained understand better Before, they bru-
tally forced sex. They hit, especially when they
were drunk. Now, no more. I see this change in
my cousins. They tell me, "Thank God this help
came, so my husband understands and we have
left that life aside and he knows how to ask." I
am so proud.
Eusebia, age 32,
subproject treasurer in Acopalca
Before, when our husbands hit us, we sat
quietly and cried. Now we are not afraid. We can
file a complaint; some women are doing that. Be-
fore, no. We were just cooking and crying. My
husband was very difficult before. Now he went to
the men's training. And he is more affectionate.
Rosa Maria, age 35, seven children,
attended workshop in Huarimayo
At first I had to think about it. I had to
talk about it with the other men in the training.
More or less, we decided together Those of us
who changed are more respected by the women.
I don't miss alcohol. My feet hurt when I drink;
now I work better, too.
Alberto, age 55, 11 children,
municipal official in Huaripampa Bajo
I think it's true that the men are drinking
less and mistreating the women less because now
they understand. Even in my own family and
my relatives'families. I saw it a lot. And now I
don't see it anymore. This makes me feel happy.

When I was younger, I saw my father hurt my
mother and I was very anxious. I was always
very frightened when my father drank. I would
like to teach young people about abuse, so there
won't be any anymore.
Crispin, age 20,
youth promoter in Canchabamba
Sexuality and family life. Knowledge, atti-
tudes, and experiences related to sexuality and fam-
ily life are also changing.
The training opened the subject of how to
have relations, to have... pleasure. He learned
about the clitoris (smiling). It is a big change.
Juana, age 49, coordinator in Acopalca
Marilena, coordinator of the broom fac-
tory, describes how her husband felt threatened
by her working:
He said, "You have more education than I
do. Now you're going to earn more money than
I do. You are wearing the pants in the family."
But now he's running for mayor of the district
and I am helping him in his campaign. My sons
have learned to do more. They help cook and
clean. And now my husband wants to learn how
to make the brooms, too!
Ucayali regional coordinator Nydia
Villavicencio Rios describes how contact with
the ReproSalud project affects gender relations
in the women's marriages: "The women say, 'Be-
fore, when my husband came home drunk I had
to serve him [sexually]. Now I know he can't take
me by force, because I have the right.' And when
we talk with the men, we are finding an open-
ness to change."

Community-level empowerment. The
study of women's empowerment at the commu-
nity level found increases in:
Internal unity of the mothers' groups;
Status and activity of the groups and their
members throughout the village;
Level of influence of the group in advocat-
ing in the larger municipal government; and
Activity and effectiveness of the group in
advocating for improvements in quality of
care in local health services.
At the village meetings, more women give their

opinion, whatever opinion. Before, the men would
say, "Why do the women have to get mixed up in
this?" Now the men don't say a thing about it.
Angelica, age 37, three children,
past president of OCB in Huarimayo
Our community has never had a woman
president. Yes, I could be president. I would im-
prove many things here.
Domitila, age 33, four children,
president of OCB in Huaripampa Bajo
ReproSalud is working in Huarimayo. The
women are taking a great role. Their work is to-
tally practical. They are tired of working and
then being dominated by the men. They came
here for help with building their house [head-
quarters] and we are helping them. The leaders
are here all the time, and they are demanding!
(smiling). The leaders are very good; despite all
the machismo, they get things done. I have con-
fidence in the women.
Mayor Garcia,
Head of Chavin Municipality
Even within the same community, respon-
dents' opinions differed about the degree of
positive change in local health services. Many
women felt that services had improved, while
others did not think anything had changed.
Leaders at the hospitals and health centers ap-
pear to appreciate the contribution and support
ReproSalud is providing.
Before, the people at the hospital threatened
us, that we should usefamily planning. They treated
us like that, they put us down. Now it is better
Primitiva, age 32, three children,
subproject treasurer in Huarimayo
Before, they didn't take good care of us at
the hospital they said we were bothering
them. We told the director that we had rights,
that they needed to take care of us. Now they
attend to us well; they take care of us quickly.
Angelica, age 37, three children,
past president of OCB in Huarimayo
At first, we were afraid of addressing the
director of the hospital. We were trembling. But
he received us well. The director told us that he
didn't want the people from the country to be
treated badly. Now we are not afraid. But it
hasn't changed. They haven't done anything. The
receptionists treat us worse. The nurses are bad,

too. The doctors are better, once you see the doc-
tor I think we will keep making an effort and
that it will change. Little by little.
Eusebia, age 32,
subproject treasurer in Acopalca
The women were complaining that they
were not treated respectfully and that they had
to wait too long we are improving patient
flow. Now they get a card and start moving
through; before we had a longer process with
their records. So the waiting time is less. We have
also done some training with all levels of staff
about how to treat patients. We check for im-
provements through a suggestion box. The forms
have drawings for the illiterate women.
Lucy Ribera, nurse in charge of
women's health at Huari Hospital

Empowerment to promote reproductive
health. The last component of empowerment the
case study assessed was women's ability to pro-
mote their own reproductive health through:

Home-based health-promoting behaviors;
Actual utilization of services (also assessed
separately in quantitative analyses); and
Effective interaction with individual health
Positive changes were found for all three

Before, we didn't know anything about tak-
ing care of ourselves. Keeping our vaginas clean.
Now we all know. We wash with clean water,
we don't put anything inside, not even soap. Be-
fore, I used to put soap inside.
Eusebia, age 32,
subproject treasurer in Acopalca
The doctor told me the discharge is from
anxiety. I told him I went to a training and I
know it's not from that! He remained silent.
Victoria, age 32, five children, Acopalca
Last week a woman came in to talk about
agua blanca [white water5]. She proceeded to
describe her problem to me. She asked for her
treatment. This surprised me! With the other
women, we have to ask, to draw them out. They
don't want to tell us. The women who have been
trained by ReproSalud talk openly about their
bodies. They are not inhibited.
Lucy Ribera, nurse in charge of
women's health at Huari Hospital

Contraceptive Outcomes
The second component of the case study
sought to assess changes related to contracep-
tive knowledge, attitudes, and use. The results
indicated an undeniable sea change: the idea of
family planning has gained enormous legitimacy

The term "white water" is used by local women to refer
to vaginal discharge.

over the past year in all of the communities stud-
ied. There is a continuum from those who have
initiated method use to those who are now con-
sidering the idea for the first time.
After my first child, I controlled with the
period. I got pregnant, and then after the second
pregnancy, I used herbs. When my period didn't
come, I would take the herb and the next day, my
period would come. Listening to the training about
taking care, my husband decided the injection
would be best. Since my last child, two months ago,
we are controlling [with the injection].
Primitiva, age 32, three children,
subproject treasurer in Huarimayo
In the ReproSalud training, they talked
about protecting ourselves with calendar, with
pills, condom, the operation on the arm [Nor-
plant], the Copper T, the operation [steriliza-
tion]for the man and for the woman. What they
told me was different from what the health cen-
ter people told me ReproSalud speaks
Quechua to us, they spend more time with us,
they tell us more details.
Elda, age 34, pregnant with fifth child,
attended workshop in Huaripampa Bajo
Since the talks, my wife and I take care. I
prefer natural ways, according to her period,
well, from time to time, the condom. Before, we
knew nothing. We didn't take care at all.
Sabino, age 52, four children,
village official, attended workshop in Chuyo

The men have changed. Before, we were all
like animals. Now, they have changed and I have
changed. We know all about our bodies. He says
there is not enough work to feed the children. Now
I know what it is to control, with the injection. If
not that, I will use Copper T If that's not good,
then with the pill. Any one of them.
Aurea, age 33, seven children,
attended workshop in Chuyo
ReproSalud has helped these women to
trust in family planning, to want to learn, to feel
valued. Even if ReproSalud left the community
by next year, the number of women using family
planning will continue to rise. Because some-
thing has changed, and with that change, there
is no going back.
Rosa Manrique,
technical nurse in Canchabamba

The lessons learned from the case study
closely parallel those that emerged from a
multicountry evaluation, by the Global Fund for
Women, of efforts to promote empowerment
and family planning among women's organiza-
tions. That evaluation also found that women
tended to see building self-worth and confidence
as prerequisites to effecting changes in family
and community life, and that participation in
women's organizations promotes such individual
growth. The authors of that evaluation argue
that, in neglecting these personal markers, de-
velopment experts fail to understand the com-
plex processes by which women and their orga-
nizations can effect positive change.
These findings join a growing body of lit-
erature that is overthrowing the conventional
wisdom that it is folly to tinker with deeply in-
grained intangibles such as gender dynamics and
self-worth. Heightened self-esteem and an ex-
panded sense of what is possible are now the
signature of the women-and men-whose lives
have been touched by ReproSalud.

Early quantitative data were generated
from pre- and posttests among a sample of par-
ticipants in the community workshops. Re-
sponses showed increased knowledge of how
methods work and striking increases in knowl-
edge of the fertile phase of the menstrual cycle
(from 29 percent to 50 percent); recent experi-
ence discussing family planning (from 60 per-
cent to 98 percent); and stated intention to be-
gin using a method within the next year (from
40 percent to 68 percent).
At the time of the case study-eight months
to one year after the workshops-studies were
undertaken to measure impact on service utiliza-
tion. Analyses of patient logs at family planning
service sites, generated by comparing the logs
from a two-month period before ReproSalud
began working in the area to the same two-month
period a year later, corroborated the qualitative
findings. While the patient logs were not of the
best quality and absolute numbers remain small,
dramatic increases in utilization of contraceptive
services were documented among residents of the
villages where ReproSalud is working. At one hos-
pital, there was a 400 percent increase in family

planning visits by residents of the local
ReproSalud community, as compared with a 51
percent increase by residents of nearby
"nonexperimental" villages and a drop in the num-
ber of visits made by residents of the urban cen-
ter where the hospital is located.
The patient log at a second hospital indi-
cated a 100 percent increase in family planning
visits from the residents of the local ReproSalud
community, compared with a 39 percent in-
crease among residents of nearby villages and a
26 percent increase among local urban residents
(Rogow and Diaz 1999). The Manuelas are con-
ducting further data collection and analysis to
corroborate and supplement the case study.
They will also repeat the same surveys done for
the baseline at the end of the project. Still, the
early results clearly support the use of holistic
models that seek to enable women to control
their fertility in the context of their overall em-
powerment. If the results from this preliminary
study are confirmed by assessments in other re-
gions of Peru and over time, they will suggest
important lessons for researchers about "hard-
to-reach" populations that have shown low de-
mand for contraception.

Although they experienced considerable
success, the ReproSalud team also made plenty
of mistakes in implementing the project, which
they readily acknowledge. According to Susana
Moscoso, "The most serious error was taking
on too much at once." Susana suggests they
should not have tried to establish the repro-
ductive health and income-generating compo-
nents of the project at the same time they were
trying to establish themselves institutionally.
She adds that they also tried to work in too
many geographic regions right from the out-
set, especially given the difficulties in finding
appropriate local staff. Susan Brems agrees,
adding that working in fewer regions would
have allowed the Manuelas to understand the
infrastructural needs of the regional offices
before they opened so many.
There were technical problems as well. As
noted above, the participatory diagnostic work-
shops initially preceded the baseline surveys. How-

ever, because the workshops themselves were an
intervention of sorts, it became unclear how reli-
able subsequent survey data were as a preproject
baseline. Eventually ReproSalud decided to carry
out surveys prior to the workshops.
The idea behind the baseline surveys was
to be able to repeat the survey several years later
in order to identify whether any change had
taken place. It was unclear, however, what sorts
of changes would be realistic and measurable at
the end of the project. At first contraceptive use,
health-seeking behaviors, and economic data
were to be the key indicators. However, the
Manuelas soon realized the need to add inter-
mediate markers measuring greater social mo-
bility and decisionmaking.
Another problem was the length of time
required for the women to move from wanting
to learn about a specific problem to actually gain-
ing the knowledge needed to address the prob-
lem. The process of teaching women to become
self-confident community educators, program
planners, money managers, and advocates could
take as long as six or seven months. ReproSalud
was not only "teaching the hungry womann how
to fish," but how to make a fishing pole and how
to find a river!
In addition, ReproSalud staff assumed that
the project would work exclusively with women.
The case studies verified that including men was
a powerful force for promoting change in gen-
der dynamics; men who attended the workshops
reported profound personal changes that were
corroborated by interviews with their wives.
Another problem is that establishment of
advocacy activities is proving to be slower and
less susceptible to direct programmatic inputs
than educational or employment activities. As
Susana Moscoso says, "Our advocacy work is
slower than the other work. After all, we are
constructing democracy."
Finally, the Manuela Ramos Movement suf-
fered from the process of establishing ReproSalud.
Tripling the staff created severe institutional shock,
and the enormous financial growth of only one
program in the organization (which quintupled its
overall budget) resulted in administrative confu-
sion. For example, it was unclear whether or not
the newly hired ReproSalud staff were members
of the Manuela Ramos Movement. Over time, not
only have most of the regional staff come to iden-

tify themselves as Manuelas, but they are also not
afraid to say that they are feminists.
Gradually, the Manuelas' own health, le-
gal, and income-generating programs have be-
gun to interact with ReproSalud. For example,
the Pamplona Alta clinic has become a
ReproSalud site; the legal program has set up
services in a ReproSalud office in the Puno re-
gion; and the income-generating program is still
exploring ways to dovetail with ReproSalud
microenterprise activities.
Yet another difficulty is the isolation of the
regional staff. Charged with nurturing a self-
health movement and overseeing credit and en-
terprise programs, regional pronwtoras have only
each other and their supervisor, the regional co-
ordinator, for support. In addition, the regional
coordinators meet as a group only quarterly. "At
these times," explains Ucayali coordinator Nydia
Villavicencio Rios, "we tend to focus on the prob-
lems, and don't stop to talk about the successes. I
feel the need for my colleagues to come see what
we are doing. Sometimes I feel lonely."
There has also been occasional political
opposition. ReproSalud staff met some resis-
tance in parts of the Andes where there has been
acute controversy over the government's tubal
ligation program; one mothers' club, not partici-
pating in the program, spread the rumor that
the ReproSalud staff were part of the steriliza-
tion campaign. In other settings, leaders of the
Catholic Church initially tried to dissuade the

mothers' clubs from participating in the project.
However, when priests and nuns found out that
the women themselves chose the problems they
wanted to work on, they could no longer say that
the program was being imposed by outside
groups. Finally, the Manuelas had to cope with
envy and resentment among some agencies that
had not been invited to participate and health
ministry personnel who had expected more di-
rect influence over project activities. In each
case, ReproSalud staff sat down and talked
openly with their critics and, over time, were
able, at least partially, to win them over.
Ultimately, however, the success of
ReproSalud rests largely on a factor that the
project cannot control: the responsiveness of
government to improve the quality of services.
Advocate as they may, women will only increase
their use of local public health services if those
services actually improve in response to their
needs. Such change is slow at best. As Nydia
Villavicencio Rios explains, standing by a banana
tree that will soon be stripped to produce pa-
per, "Even with all we are achieving, this is a
slow process. We are changing people. We are
changing institutions." Susana Galdos expects
that ReproSalud will help create communities
of healthier and happier families. She anticipates
inroads into problems that have seemed intrac-
table for decades-problems such as high lev-
els of unwanted fertility and domestic violence.
Further, she knows ReproSalud will leave be-

hind a group of experienced community lead-
ers-women with skills, courage, and a track
record of working for change.
Everyone seems to agree that ReproSalud
has blazed new paths in just a few years and also
that it will not be possible to accomplish all it
has set out to do in the five years initially allot-
ted for the project. Therefore USAID has now
extended the project for another five years. Al-
though the departure of both Susan Brems and
Barbara Feringa from USAID/Peru may reduce
the degree of technical support they get from
USAID, the Manuelas are confident in their abil-
ity to carry on-the final story on ReproSalud is
far from written.

Today the Manuela Ramos Movement has a
beautiful three-floor building in Lima, painted
blue, ochre, and rust and surrounded by a sunny
patio. In one corner is the Manuelas' crafts store;
on the patio, two women are meeting with a ce-
ramist, explaining how the store can work with her.
The Manuelas' general offices are on the second
floor; the third floor is devoted to ReproSalud.
While the Manuelas have hired some 100 people
to work on the ReproSalud project, the original
Manuelas rely on a staff of 40, three of whom were
part of the original Tuesday-night group from 20
years ago. Rosa Espinoza comments, "People al-
ways wonder about the stability of the staff. But
we are not working for a salary [salaries at the or-
ganization are low]; we work for an idea. We value
the chance to implement our ideas through this
work. And we have done it all collectively."
The original founders of the organization
recall with pride their rise to prominence. Victoria
Villanueva laughs, "The organizations that criti-
cized our concern with personal life issues-well,
20 years later they're no longer around, and we
continue to thrive." The Manuelas are mentioned
in the press almost daily and are invited by the
medical community to speak, advise, and collabo-
rate on a range of health initiatives. They also have
very high credibility in Congress, where their
word on reproductive health issues carries enor-
mous weight. During a national crisis over poor
technical quality and inadequate informed-con-
sent practices of the government's tubal ligation

program, one legislator grandly called for "testi-
mony about this crisis from Dr. Manuela Ramos."
The entire Congress laughed as all but the unfor-
tunate speaker knew that Manuela Ramos is not
an individual, but an organization-and
Everywoman at that. Indeed, at the organization's
20-year anniversary last year, Congress awarded
the Manuela Ramos Movement a Medal of Rec-
ognition for its contribution to health.
The Manuelas' nonhealth activities also
continue to grow. Aside from the roughly $4 mil-
lion annual budget for ReproSalud, the organi-
zation spends $1 million every year to support
its ongoing service and advocacy projects. As
Victoria explains:
We have succeeded in helping get some pro-
gressive legislation passed. But implementation
of these laws is still a problem. In some cases,
people in the rural areas have not even heard of
the laws. In other cases, the powers-that-be are
dragging their heels. So we are devoting energy to
promote and monitor enforcement ofthe new laws.
For example, until 1997 Peruvian law
stated that a man could not be arrested for rape
of a female 14 years or older if he later married
the victim. In the case of gang rape, all the rap-
ists could be let go as long as one of them mar-
ried the victim. In some cases, the perpetrator
was let go just for offering to marry his victim,
even if she refused. Rosa explains, "Many legis-
lators and journalists view domestic violence as
normal in the indigenous communities. From
our work with these women, we can assure you
they do not feel this way."
Another example is Peru's new law requir-
ing that political parties include women as 25
percent of their slate of candidates. To help imple-
ment and monitor this law, the Manuelas have
formed a broad, nonpartisan coalition of women's
organizations that are working to identify strong
women candidates and mobilizing women to vote.
The Manuelas are also concerned about devel-
oping leaders from the next generation. Susana
reflects, "We haven't really had a strategy to in-
corporate youth. We are just now figuring out how
to become a resource for young people. After all,
we're getting old!" Victoria adds, "We want to see
young women involved in politics."
It seems the Manuelas are not at risk of
running out of work or energy.

The ReproSalud project is unique in many
ways, but, in particular, it is one of the rare times
when a feminist NGO has joined forces with a
major international donor such as USAID to
implement a large-scale program intervention.
The experience of the Manuela Ramos Move-
ment/USAID collaboration demonstrates not
only that it can be done successfully, but also pro-
vides important lessons for donors, international
institutions, and women's NGOs when large-scale
efforts are undertaken to promote improved
women's reproductive health and increase their
sense of empowerment. The first three lessons
are institutional; the last three are substantive.
1. Although the Manuela Ramos Move-
ment was a small NGO, it had previous ex-
perience in almost every aspect in the
project's scope of work.
2. The Manuelas were able to staff the
leadership of the ReproSalud project from
within their own highly stable ranks, thus
ensuring cohesiveness as a team and soli-
darity with the rest of the organization.
3. USAID provided active technical
and professional support to the Manuelas-
something that was tremendously important
given that the organization had no experi-
ence managing such a large and complex
cooperative agreement. This allowed for a
gradual process of learning administrative pro-
cedures without inhibiting the on-the-ground
development of the program. Barbara Feringa

emphasizes this point: "Providing institutional
support to foster feminist organizations' success
was a necessary part of the trust-building pro-
cess" between the two organizations.
4. Clarity of purpose was essential to
the success of this project. As Susana Moscoso
says, "We approached this work with the right
philosophy: the direct participation of women
in improving their own lives." Susan Brems
agrees: "Look how important RTIs are to Peru-
vian women. It's their number one concern in
this project. Yet RTIs have not been deemed im-
portant in many public health and population
5. Listening to women demands project
flexibility. Women suggested parallel work with
men; it was not part of the original program de-
sign. This add-on component, however, is now
seen as a critical element in achieving the
project's goals. The fact that the project was able
to make this significant program shift is a credit
to both the Manuelas and USAID and the will-
ingness of both to be responsive to needs ex-
pressed by project participants.
6. A number of programmatic elements
have proven essential to the program's suc-
cess. Along with reaching out to men, build-
ing self-esteem and collective action appear
to be particularly important. According to
Marilena, the coordinator of the broom factory
in the Amazon: "Alone you are nothing. If you
think you're nobody, you are nobody. Together,
we have courage, we have new ideas. Together
we float."

With ReproSalud, the Manuela Ramos Movement is implementing perhaps the first large-
scale, gender-sensitive project specifically designed to grapple with the social and service-based bar-
riers that impede the achievement of reproductive health among the most disadvantaged women-
the vast majority of whom live in rural areas. But it will take some time for the population field to
learn from and refine the elements that are key to the successful development of such a program. In
the late 1960s Reimert (Rei) Ravenholt, director of the USAID Office of Population at the time,
outlined five steps in the development of family planning programs: (1) building facilities (the "bricks-
and-mortar" stage); (2) delivering contraceptives (including substantial investments in new contra-
ceptives throughout the late 1960s into the 1970s); (3) training workers (often, but not always, single-
purpose family planning workers); (4) offering services; and (5) evaluating results. He then posited a
five-year time frame before one would begin to see results from such conventionally configured
family planning programs (Ravenholt and Chao 1974).
It is important that the same longer-term view be applied to ReproSalud, which has outlined
steps for the development of the project but is using some very different markers and internal pro-
cesses. A key difference is that the early stages of its program approach require building a social
(rather than physical) infrastructure that can reach and mobilize women. A major challenge has been
to find ways to give voice to women by creating safe spaces for them away from their homes where
they can spend time together and, with structured support, begin to discuss and analyze their own
experiences and establish their own priorities. Through this process it has been possible to consoli-
date a new social environment for women, and local women's organizations (some preexisting and
some that are being nurtured in this new open environment) have begun to elaborate programs
aimed at giving women increased economic and social authority (such as savings clubs, provision of
loans, and functional education).
To work in such a new way and in places where previous efforts have failed or have not been
undertaken at all requires a distinct learning phase. It is unfortunate that the "diagnostic phase," so
honored in the development literature, has rarely been given its due when programs are actually
implemented in the field. In the case of ReproSalud, however, the project was specifically designed
to allow for this learning period to take place. As described in its USAID project document,
"ReproSalud undertakes the time-intensive, locality-specific activities that are required to make re-
productive health services meaningful to local, hard-to-reach women" (USAID 1995). ReproSalud's
objectives and mode of operation are, therefore, seeking to address deficits-both in the service-
giving system (with regard to quality and content) and the social system-that constrain women from
acting in their own best interests. It is impressive that a USAID-supported population initiative re-
served 16 percent of ReproSalud's budget for non-reproductive health interventions. The availability
of these monies has meant that as the diagnostic phase identified women's needs outside the health
sector, there was a capacity within the project to respond.
The fledgling women's infrastructure the Manuelas have created has now begun to interact
with Peru's established health system, with the result that an increasingly articulate community of
women has begun to make demands on the existing health services to meet their own needs for safer
pregnancy and childbearing, voluntary fertility regulation, diagnosis and treatment of RTIs, and more
equitable and open communication between sexual and marital partners. And last but not least,
women have demanded to be treated respectfully.
Through ReproSalud, the Manuela Ramos Movement has fostered a parallel process of interac-
tion with rural women's male partners, based on the women's demands that their partners be in-
volved in the project. This is of particular significance, given that male methods or methods requiring
some degree of male participation (e.g., periodic abstinence, condoms, withdrawal, and vasectomies)
account for more than one-third of all contraceptive use in Peru. Listening to and learning from
women, ReproSalud has established dialogue with men at the community level aimed at changing
their social perceptions of their female partners and of their responsibility for creating greater har-
mony in the home.

Seven years after its initiation, ReproSalud is poised to look critically at the results of its work so
far. There are marked improvements in women's knowledge and health-seeking behavior, more sup-
portive behaviors from the men in their lives, an increase in women's social and economic opportuni-
ties, and the development of accountability links between health services and their clientele.
Many of the debates prefiguring the ICPD in 1994 centered on whether contraceptives alone
or development alone was the best approach to achieving voluntary fertility reduction in poor com-
munities. Poor women, however, should not be asked to choose between reproductive health ser-
vices and social and economic development-they need both. The Manuela Ramos Movement has
shown us how to forge synergistic links between women's reproductive health and the social and
economic domains of women's lives on a large scale. Support of large-scale projects such as ReproSalud
and building capacity in organizations such as the Manuela Ramos Movement around the world can
result in long-awaited and impressive gains in reducing unwanted fertility, along with achieving mea-
surable outcomes in the health and social wellbeing of poor women.

The author is indebted to Benno de
Keijzer for providing the information used in the
box "Gender and Health Workshops for Men,"
as well as much of the descriptive information
about the development of the men's workshops.
Moyano, Jorge Reyes, Luis H. Ochoa, Vilma
Sandoval F., Hans Raggers, and Shea
Rutstein. 1997. Encuesta Demogrnfica y
de Salud Familiar [Demographic study of
family health]. Calverton, MD: DHS/
Macro International Inc.
Ravenholt, R.T. and John Chao. 1974. "Family
planning programs: World fertility trends,
1974," Population Report, series J, no. 2,
pp. J21-J39. Washington, DC: George
Washington University Medical Center,
Population Information Program.
ReproSalud. 1998. "Algunos resultados
estadisticos de las entrevistas con
promotoras y promotores" [Some statisti-
cal results from interviews with field staff],
unpublished report.
Rogow, Deborah and Alejandro Diaz. 1999.
"ReproSalud: Evaluation of project impact
in the Chavin region: A case study," un-
published trip report to USAID/Lima and

USAID. 1995. Project paper for USAID Proj-
ect 527-0335, Reproductive Health in the
Community (ReproSalud). Lima, Peru:
United States Agency for International
Development, Mimeo.
World Health Organization. 1998. Unsafe Abor-
tion: Global and Regional Estimates of In-
cidence of and Mortality Due to Unsafe
Abortion with a Listing ofAvailable Coun-
try Data, 3rd ed. Document no. WHO/
RHT/MSM/97.16. Geneva: World Health
Further Reading
Andina, Michele, and Barbara Pillsbury. 1998.
"Trust: An approach to women's empow-
erment: Lessons learned from an evalua-
tion on empowerment and family planning
with women's organizations," report. Los
Angeles, CA: Pacific Institute for Women's

Resumen en Espa ol

En los afios 70 un grupo de siete mujeres
limefias se empez6 a reunir para cuestionar los
supuestos que definfan su vida cotidiana. Al intuir
que otras mnjeres tambi6n podrfan aprovechar la
valoraci6n y la formaci6n de conciencia que estas
conversaciones producian, el grupo organize various
talleres en los que las nujeres podian reflexionar
sobre sus propias vidas. Descubrieron que a pesar
de las diferencias, todas las mujeres compartian
inquietudes similares. Ya para 1980 el grupo habia
formado una ONG denominada Movimiento
Manuela Ramos (MMR).
A media que la crisis econ6mica y political
del Per6 se profundiz6 en los anios 80, el MMR
reconoci6 que los problems de las mujeres de los
barrios pobres de Lima se multiplicaban a la misma
vez que los servicios piblicos empeoraban. Las
Manuelas respondieron a este reto con la creaci6n
de una clinic de mujeres, un program de servicios
legales y, por l6timo, un program de generaci6n
de ingresos. En base a esta experiencia y un interns
en las dimensions political de la salud, el MMR se
estableci6 como una voz important en la
comunidad peruana de planificaci6n familiar.
Las Manuelas veian que la provision de
servicios estaba obstaculizada por la limitada
movilidad social de las mujeres, su escaso poder
de negociaci6n, y su baja autoestima. Asi, el MMR
habia empezado a perfeccionar varias estrategias
para responder a esos desaffos. Justo en ese
moment la misi6n de la USAID en Lima anunci6
una licitaci6n que efectivamente aplicaria lo que
se ha aprendido en el campo del desarrollo: que la
participaci6n comunitaria y el trabajo "desde abajo
hacia arriba" deben ser el punto de partida.
Aunque se sentian abrumadas por la magnitude del
desaffo, las Manuelas gan6 la licitaci6n. El nuevo
proyecto, ReproSalud, es una de las raras ocasiones
en que una ONG feminist hajuntado fuerzas con
una entidad donante international como USAID.
El personal de ReproSalud utiliz6 encuestas
y "talleres de diagnostico" para recolectar
informaci6n sobre los esquemas sociales de las
mujeres, sus creencias religiosas, y sus principles
necesidades e inquietudes (todo con un enfoque
en salud reproductive). En los talleres se le pedia
a las mujeres que eligieran el aspect de la salud
reproductive que fuera de mayor prioridad para
ellas. Posteriormente ReproSalud escogia una
organizaci6n de mujeres local para funcionar conmo
socio en la atenci6n al problema que se habia

El proyecto habia sido concebido
exclusivamente para mujeres, pero este enfoque
fue cuestionado casi de inmediato. Las mujeres
en las comunidades dijeron que querian involucrar
a sus maridos. Inicialmente el personal del
proyecto se preocup6 por la posibilidad de que se
le quitaran recursos a las actividades para mujeres,
pero al poco tiempo decidieron modificar el disefio
seguin las demands de las mujeres.
Uno de los desafios importantes en un
proyecto como ReproSalud es c6mo evaluar sus
actividades. Aunque el disefo del proyecto re-
sponde al sentido comin, estudiar su impact
result ser una tarea compleja. Al final de cuentas,
al proyecto se lo juzgara segin el 6xito que tenga
en fomentar un comportamiento que promueve
salud y la utilizaci6n de servicios (incluso los de
planificaci6n familiar). Pero teniendo en cuenta
que se requieren various pasos para que una mujer
tome control de su propia salud reproductive, se
decidi6 evaluar el 6xito del proyecto en base a
ciertos hitos interinos. Estos pueden ser el
potenciamiento de la mujer como individuo
(mejoras en la autoestima, control sobre el dinero,
conciencia de sus derechos, conocimiento de/
comodidad con su cuerpo); el potenciamiento de
la mujer dentro de su familiar (reducci6n en la
violencia familiar, satisfacci6n en la vida sexual y
en la vida familiar en general); y la capacidad de la
mujer de propiciar su propia salud reproductive.
Hasta la fecha se han registrado cambios positives
en cada uno de estos tres indicadores.
La experiencia de este proyecto conjunto del
MMR y USAID demuestra que este tipo de
cooperaci6n puede tener 6xito, y ademis ofrece
varias lecciones. (1) Aunque el MMR era pequefio,
habia acumulado experiencia en casi todas las
actividades requeridas por el proyecto; (2) Las
Manuelas poblaron el equipo directive de
ReproSalud con mujeres que ya estaban en el
Movimiento, lo cual asegur6 unidad y el apoyo del
rest de la organizaci6n; (3) USAID proporcion6
apoyo tdenico y professional a las Manuelas; (4) El
aspect mis important del proyecto fue la
claridad de sus prop6sitos; (5) S61o un proyecto
flexible es capaz de escuchar a las mujeres; (6)
Varios elements programAticos fueron
fundamentals para el 6xito: la inclusion de
hombres, el fortalecimiento de la autoestima y la
acci6n colectiva parecen haber sido especialmente

R4sum6 en Francais

A la fin des ann6es 70, un group de sept
femmes a Lima a commence a se rencontrer pour
voir sous une nouvelle lumiere leur vie de tons les
jours: quelles 6taient leurs r6alit6s et que
souhaitaient-elles? Anim6 par le sentiment que
chaque femme appr6cierait cette validation et
prise de conscience, le group a organism un ate-
lier permettant aux femmes de r6fl6chir a leur
existence. Le group a constat6 que les femmes
partagent les memes problkmes et preoccupations.
En 1980, le group fondait une ONG, choisissant
le nom de Movimiento Manuela Ramos (MMR).
Alors que la crise 6conomique et politique
au P6rou prenait des proportions de plus en plus
graves pendant les ann6es 80, le MMR a reconnu
que les femmes des taudis de Lima se heurtaient
a des problemes de plus en plus pr6occupants en
m6me temps que s'amenuisaient les services pub-
lics qui leur 6taient fournis. Face a cette situation,
les Manuelas tel qu'elles avaient commence a
s'appeler ont cr66 un dispensaire pour les femmes,
un programme de services juridiques aidant ces
dernieres et elles ont mis sur pied un petit project
aux femmes de gagner de l'argent. S'inspirant de
son experience concernant la r6alisation de
programmes et de l'intr&ft qu'il portait aux ques-
tions de politiques prises dans un sens plus large,
le MMR s'est d6clar6 parties prenante au sein de
la communaut6 de planification familiale du P6rou.
Les d6fenseurs et les professionnels de la
sant6 de la femme savaient depuis longtemps que
la prestation de services 6tait entrav6e par la
mobility social limited des femmes, leur pouvoir
de n6gociation restreint et la faible estime qu'elles
avaient d'elles-memes. Mais de fait les Manuelas
avaient commence a s'attaquer a ces problemes et
leurs m6thodes reussissaient. Aid6 par l'arriv6e
d'un personnel sensible a la question a la mission
USAID a Lima, un appel d'offres d'un caractere
unique a 6t6 lance cherchant a atteindre des
femmes dans les regions les plus pauvres du P6rou.
Les Manuelas ont pr6sent6 une soumission pour
un project appel6 ReproSalud et leur contract a 6t6
adjug6. ReproSalud est l'une des rares fois oh une
ONG f6ministe s'alliait a un important bailleur de
fonds international pour mettre en oeuvre un
programme de grande envergure.
Le personnel de ReproSalud a utilis6 des
enqu&tes individuelles et des ,ateliers de diagnos-
tic> d'un caractere participatif pour r6unir des in-
formations sur les modes sociaux, les systemes de
croyances et les principles preoccupations des
femmes (surtout en ce qui concern la sant6 re-
productive). On a demand aux femmes locales
participant aux ateliers d'indiquer quel 6tait le
problkme prioritaire sur le plan de la sant6 repro-


ductive. Ensuite, ReproSalud a choisi un
groupement feminin local qui allait devenir le
partenaire des efforts faits pour lutter contre le
problem identified. Les problkmes prioritaires
6taient les suivants: infections du tractus genital,
grossesse non souhait6e et complications li6s a
l'accouchement. Le project avait 6t6 congu en
ciblant uniquement les femmes mais cette notion
a 6et rejet6e de suite. En effet, les femmes de la
communaut6 souhaitaient que leur mari participe
et le personnel du project a modifi6 la conception
en r6ponse aux demands des femmes.
Pour un project comme ReproSalud, il se pose
une question important: comment 6valuer ses
activities et efforts. Malgr6 une conception des plus
logiques, les complexit6s liees a l'6tude de son im-
pact ne sont pas des moindres. En dernibre
analyse, le project sera jug6 a l'aune de sa r6ussite
en ce qui concern la promotion du comportement
favorisant la sant6 et l'utilisation des services. Mais
au regard des tapes que doivent emprunter les
femmes pour prendre en main leur propre sant6
reproductive, le project cherche a 6valuer la r6ussite
rencontr6e a des jalons int6rimaires, par example,
l'autonomie et l'habilitation des femmes en tant
qu'individus (meilleure estime d'elle-meme,
davantage de contr6le sur l'argent, connaissance de
leurs droits, connaissance de leur propre corps); leur
position au sein de la famille (notamment les
changements au niveau de la violence conjugale et
une vie sexuelle et familiale satisfaisante); la capacity
des femmes a promouvoir leur propre sant6 repro-
ductive (6valuee par le biais des comportements de
promotion de la sant6 adopts a la maison,
l'utilisation des services et I'interaction efficace avec
les prestataires de la sant6). Des changements
positifs ont 6t6 not6s pour tous les trois types
d'indicateurs. L'histoire finale de ReproSalud est
loin d'etre ecrite. L'exp6rience du travail conjoint
entire le MMR et I'USAID montre non seulement
qu'une telle collaboration est possible mais d6gage
6galement des lemons vitales. (1) Le MMR 6tait petit
mais comptait pourtant une experience portant sur
pratiquement tous les aspects du project; (2) Les
Manuelas avaient mis a la t&te du project leur propre
personnel, assurant ainsi une bonne cohesion et une
bonne solidarity avec le reste de l'organisation; (3)
L'USAID a fourni un soutien technique et
professionnel aux Manuelas; (4) Un but bien clair
repr6sentait la parties la plus important de ce project;
(5) Le project doit faire preuve de souplesse pour
pr&ter l'oreille aux demands des femmes; (6) Un
certain nombre d'616ments programmatiques sont
essentiels pour garantir la r6ussite: fire participer
les hommes, renforcer l'estime de soi-mreme et
prendre une action collective.

About the Authors

Judith Bruce is a Senior Associate in the International Programs Division of the Population
Council in New York.
Debbie Rogow has worked as a Senior Advisor and Researcher in international reproductive
health for more than fifteen years. Her collaboration with and assistance to the Manuela Ramos
Movement has been on behalf of the International Women's Health Coalition, USAID/Pop Tech,
Futures, and the Population Council.

QualitylCalidadlQualite Advisory Group

Ian Askew Nicole Haberland Elizabeth McGrory Jill Sheffield
Karen Beattie Joan Haffey Kirsten Moore Cynthia Steele
Martha Brady Judith Helzner Nancy Newton Nahid Toubia
George Brown Kathleen Kurz John Paxman Gilberte Vanintejan
Judith Bruce Ann Leonard Julie Reich Beverly Winikoff
Adrienne Germain Magaly Marques Debbie Rogow

Photography: Debbie Rogow and ReproSalud
Printing: Graphic Impressions
Editorial and Production
Coordination: diane rubino

QualitylCalidad/Qualite Booklets Currently Available
Celebrating Mother and Child on the Fortieth Day: The Sfax Tunisia Postpartum Program
by Francine Coeytaux, Introduction and Afterword by Beverly Winikoff, 1989. (Available in
English; text in Spanish and French available in typewritten format)
Man/Hombre/Homme: Meeting Male Reproductive Health Care Needs in Latin America by
Debbie Rogow, Introduction and Afterword by Judith Bruce and Ann Leonard, 1990. (Avail-
able in English and Spanish)
Gente Joven/Young People: A Dialogue on Sexuality with Adolescents in Mexico by Magaly
Marques, Introduction by John M. Paxman and Afterword by Judith Bruce, 1993. (Available
in English and Spanish)
The Coletivo: A Feminist Sexuality and Health Collective in Brazil by Margarita Diaz and
Debbie Rogow, Introduction by Jose Barzelatto, 1995. (Available in English and Portuguese)
Doing More with Less: The Marie Stopes Clinics of Sierra Leone by Nahid Toubia, Introduc-
tion by Grace Eban Delano, 1995. (Available in English)
Introducing Sexuality within Family Planning: The Experience of Three HIV/STD Preven-
tion Projects from Latin America and the Caribbean by Julie Becker and Elizabeth Leitman,
Introduction by Mahmoud F. Fathalla, 1997. (Available in English and Spanish)
Using COPE to Improve Quality of Care: The Experience of the Family Planning Association
of Kenya by Janet Bradley, Introduction by Judith Bruce, Soledad Diaz, and Carlos Huezo,
Afterword by Kalimi Mworia, 1998. (Available in English and Spanish)
(Each English edition contains a one-page summary in both French and Spanish.)
We invite your comments and ideas for projects that might be included in future editions of
Quality/Calidad/Qualite. If you would like to be included on our mailing list, please write to
Quality/Calidad/Qualite, Population Council, One Dag Hammarskjold Plaza, New York, NY
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