• TABLE OF CONTENTS
HIDE
 Front Cover
 Introduction
 Background, the first seeds, and...
 Getting started
 The Coletivo's program today
 Clinical services
 Shaping the client-provider...
 Voices of Coletivo clients
 Education program
 Beyond service delivery and the...
 Advocacy
 The research program
 Coletivo members speak about the...
 Next steps and lessons learned
 Resumo em portugues
 Resumen en Espanol
 Resume en Francais
 Back Cover














Group Title: Quality/Calidad/Qualité
Title: The Coletivo
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00088800/00001
 Material Information
Title: The Coletivo a feminist sexuality and health collective in Brazil
Series Title: Quality = Calidad = Qualité
Physical Description: 24 p. : ill. ; 26 cm.
Language: English
Creator: Diaz, Margarita
Rogow, Debbie
Publisher: The Population Council
Place of Publication: New York N.Y
Publication Date: 1995
 Subjects
Subject: Women's health services -- Brazil -- São Paulo   ( lcsh )
Birth control clinics -- Brazil -- São Paulo   ( lcsh )
Prenatal care -- Brazil -- São Paulo   ( lcsh )
Mujeres -- Salud e higiene -- Brasil
Anticonceptivos -- Brasil
Genre: non-fiction   ( marcgt )
Spatial Coverage: Brazil
 Notes
Language: Summary in French and Portuguese.
Statement of Responsibility: by Margarita Diaz and Debbie Rogow ; introduction by José Barzelatto.
 Record Information
Bibliographic ID: UF00088800
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 32940490
lccn - 96230181

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
    Introduction
        Page 1
        Page 2
        Page 3
    Background, the first seeds, and setting objectives
        Page 4
    Getting started
        Page 5
    The Coletivo's program today
        Page 6
    Clinical services
        Page 7
        Page 8
    Shaping the client-provider relationship
        Page 9
    Voices of Coletivo clients
        Page 10
    Education program
        Page 11
    Beyond service delivery and the training program
        Page 12
    Advocacy
        Page 13
        Page 14
    The research program
        Page 15
        Page 16
        Page 17
    Coletivo members speak about the ups and downs
        Page 18
        Page 19
    Next steps and lessons learned
        Page 20
        Page 21
    Resumo em portugues
        Page 22
    Resumen en Espanol
        Page 23
    Resume en Francais
        Page 24
    Back Cover
        Page 25
        Page 26
Full Text












I .4-.E~!


iiii






Quality/Calidad/Qualitd, 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 and Population 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 programs.
Projects are selected for documentation in the Quality/Calidad/Qualiti series
by an Advisory Committee made up of individuals who have a broad range of expe-
rience 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 bet-
ter manage their own health care; strengthening the quality of client/provider inter-
action and encouraging continued contact between providers and clients; making
innovative efforts to increase the management capacity and broaden the skills of ser-
vice 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 pro-
grams 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 Statements made and views expressed in
Quality/Calidad/Qualite is made possible this publication are solely the responsibil-
by support provided by the Ford ity of the authors and not of any organiza-
Foundation, the John D. and Catherine tion providing support for Quality/
T. MacArthur Foundation and the Calidad/Qualitd.
Swedish International Development
Authority (SIDA).


Copyright The Population Council 1995


Number Six 1995


ISSN 0-8734-057-2









The Coletivo: A Feminist Sexuality

and Health Collective in Brazil

by Margarita Diaz and Debbie Rogow
Introduction by Jose Barzelatto






Introduction
In the past, family planning programs were designed primarily to reduce excessive popula-
tion growth, making women the objects of medicalized policies and programs designed to regu-
late fertility. The result was vertical programmatic approaches that hindered the development of
comprehensive services. This approach was driven by a "disease perspective," which was the nat-
ural outcome of the successful track record of medicine for finding "technological fixes" oriented
at solving biological problems. It is this biomedical approach to fertility, combined with cultural
myths and taboos, that has prevented population programs from adequately addressing sexual-
ity and gender issues. Amazingly, even though sexuality is at the core of reproductive life,
until AIDS, family planning programs operated quite successfully without even mentioning the
word "sex."
But, as the Plan of Action adopted at the 1994 World Population Conference in Cairo attests,
the population field has begun to shift its focus from the "population explosion" to the sexual and
reproductive health of individual citizens. There are a number of important factors behind this
shift. One factor is the recent global trend towards the strengthening of civic society. There has
been an upsurge of democracy movements and increased participation of non-governmental play-
ers in the development of national and international policies. A second factor has been the grow-
ing recognition that sexual and reproductive health is an important social good, worth pursuing
regardless of demographic circumstances.
The most important factor, however, has been the changing needs of and opportunities for
women. In the past, high mortality and women's inability to regulate their fertility contributed to
clearly defined gender roles: women reproduced and men produced. The fact that we have patri-
archal societies is no accident. But lower mortality rates and increased fertility regulation have led
to changes in the balance between reproduction and sexuality in relationships. Now more than
ever, childbearing can be initiated according to the desires and decisions of a couple, rather than
by accident, and women can become equal partners with men in all aspects of life.
This transition in sexual and gender roles and the responsibilities they entail will have a far
greater impact on humankind than will the demographic transition. By concentrating on popula-
tion growth, the population field has focused on a very important, but transitory phenomena.
Demographic transitions have taken from twenty to one hundred years, depending on the exis-
tence or not of effective family planning programs, but will probably happen anyway at varying
social costs. What is less predictable and more crucial are the changes in the balance of roles and
power between women and men. We are beginning to understand the consequences and just how
deeply society may be influenced by these changes.






The women's movement has been primarily responsible for placing all these issues in the
public arena. Today women's organizations are working to counteract the overmedicalization of
reproductive and sexuality issues; to empower communities, particularly women; to redefine gen-
der roles and responsibilities; and to promote informed public dialogue on these issues. It is
because of the crucial role they play that the Ford Foundation now supports a number of women's
health movements around the world.
While these issues are of central concern everywhere, the women's health movement in
Latin America has taken on the issues of sexuality and human relationships in a way that is prob-
ably more dynamic than in other part of the world. It is, therefore, fitting that we look to that
region for ideas on how to implement a reproductive and sexual health approach. This is partic-
ularly appropriate in terms of a number of issues the family planning field has long been con-
cerned about, such as quality of care and integrated service design as well as provider training
and motivation.
The women's movement has shown us that it is possible to translate a sexual and reproduc-
tive health approach into services, and that this can be accomplished even with modest resources,
as the Women's Sexuality and Health Collective in Sao Paulo, Brazil has done. Services like those
of the Coletivo demonstrate that it is more efficient to have satisfied clients who use family plan-
ning methods appropriately than it is to simply distribute contraceptives without caring about
what people do with them.
This brings up two crucial issues: provider motivation and the provider-client relationship.
It is not surprising that when providers feel overworked and are poorly paid, they do not treat
their clients well. Most client dissatisfaction is, in fact, due to the poor quality of their encounter
with a provider. The Coletivo shows us the importance of the provider-client relationship and
reminds us that we must offer clinic staff a meaningful work experience and a reasonable salary
to improve her/his position in life. At the Coletivo, staff feel that they are personally and profes-
sionally benefiting from their work and it shows in the quality of services they provide.
In many family planning clinics, the standard unit of evaluation-in fact the only data read-
ily available-is the number of contraceptives distributed or the number of new clients who have
been seen. But if you do a real evaluation of a client's needs, and then try to address those needs,
there is evidence that good quality services not only offer positive results from a reproductive and
sexual health perspective, but from a demographic perspective as well. In the case of the Coletivo,
while every woman who comes to the clinic may not leave with contraception (maybe because she
does not want to contracept right now or because she has an infection), she does leave with a
sense that her overall well-being is of concern to someone. Thus, she is likely to return for other
services, perhaps even contraceptive services. Additionally, those women who do leave with a con-
traceptive method are more likely than their counterparts at conventional family planning clinics
to use the method of their choice effectively, or to come back for an alternative method if they
feel they need one. This clearly illustrates the necessity to do more than just train providers to
distribute a range of contraceptive methods.
What the sexual and reproductive health approach does is place sexuality at the core of
reproductive life. It challenges what medicine and family planning have been about and calls for
a more humanistic and holistic approach to health. It is not enough for the doctor or family plan-
ning provider to merely diagnose what is wrong with a woman's body or decide what contracep-
tive would suit her best. Human beings are more than biology, and if you look carefully at their
problems, you will not be able to isolate contraception as a separate issue. What is necessary is to
listen to what people-in particular women-have to say about their own physical, mental and
social needs, and then try to address those needs.
Over the past decade, the women's health movement and the population field have begun
to engage in meaningful dialogue. Despite perceived risks of compromise for each side, these
conversations are crucial as both work towards a broader agenda of reproductive and sexual






health. Ironically, this process is not unlike some of the changes occurring in gender relation-
ships around the world. As traditional roles change and mutual respect and understanding are
cultivated, a type of marriage is formed where neither partner is necessarily diminished. This is
because such a partnership must be a two-way street and neither the assumption of bad motiva-
tion nor absolute confrontation is constructive.
These dialogues have already had a broad impact. Women's organizations, such as the
Coletivo, have worked with more established institutions, such as the Population Council and the
World Health Organization, to enhance the use of existing contraceptive technologies (like the
diaphragm), and to develop new technologies that are women-controlled and offer protection
against infection. As a result of such dialogues, biomedical contraceptive research is now begin-
ning to be directed also by users' perceived and expressed needs and not only by scientific
research opportunities.
We are just beginning to understand the complexity and depth of the changes we think are
necessary in the population field and beyond, and we are still looking for ways to achieve them.
It is not surprising that calls for such change are meeting resistance since they pose challenges
to existing social structures and religious values. This underscores the importance of coming
together to exchange ideas and explore strategies; to hear the multiple voices of civic society,
including ethical and religious perspectives. It is not enough to provide good services to a few
people. We must also be concerned with improving the lives of the majority of people-as the
Coletivo has attempted to do-through dialogue, advocacy, research and training.
The members of the Women's Sexuality and Health Collective are pioneering new ways to
provide services and involve women in their own health care. Through groups like the Coletivo,
the women's movement shows us what is possible. We must be willing to take up the challenge.


___





Background
This issue of Quality/Calidad/Qualite
(Q/C/Q) tells the story of a group of Brazilian
women who came together in 1981. What
brought them together was their belief-not as
widely understood then as it is now-that con-
ventional approaches to women's health and
family planning services were overly medical-
ized, incapable of dealing with the relationship
between sexuality and contraception and dis-
empowering to clients. This small group-
whose ideas were shaped by their own experi-
ences on the exam table and in the pro-democ-
racy movement-wondered whether an alter-
native could exist for women in Brazil. They
began to imagine what kind of service would
foster a broader concern for women's health as
well as increase their level of comfort with their
bodies and their sense of entitlement and dig-
nity as women in the society. What would such
a program look like? What would it stand for?
How would it be organized? How could it be
affordable for low-income women? How would
it measure its success? And what would it take
to try to do it?
Out of these bold questions came the
birth of the Feminist Sexuality and Health
Collective (Coletivo Feminista Sexualidade e
Saude) in Sdo Paulo, Brazil. It is a story that
challenges those of us concerned with women's
health and well-being to reflect, to ask ques-
tions and to imagine.

The First Seeds
The initial group of five women who met
in 1981 began with the idea of learning more
about their own bodies, sharing that knowledge
and using it as a base for organizing women
around choices-choices about health care and
contraception, about sex and maternity, about
the rights of women. The name they chose for
their group reflects the four issues that defined
what they shared and what they cared about:
Feminism. Sexuality. Health. Collective.
Over the next few years, while the
Coletivo was engaged in this educational
process, they also contemplated the need for a
high quality, comprehensive clinical service
that truly responded to women's reproductive
health needs. By 1984, it had become clear that
no one was providing women with the kind of


service delivery they envisioned, so the
Coletivo members set themselves an ambitious
agenda: they would create their own clinic.
Planning the clinic took two years. By this
time the group had evolved to eleven women,
all from different backgrounds: about half
had a university education (including two
physicians) and half were housewives and com-
munity activists. Some were from the middle
class and others from the ranks of the poor. For
most of 1984 and 1985, Coletivo members met
weekly to clarify their objectives, design their
program and carry out training in preparation
for initiating services.
Setting Objectives
By talking with many women about their
health care, the Coletivo founders came to
understand that for most women, a visit to the
gynecologist felt degrading. Doctors spoke at
them but did not listen. For many women the
gynecological examination was an experience of
violence. But how was the Coletivo to create a
humanized and empowering experience? One
of the group's first priorities was to remedy the
tremendous power differential between repro-
ductive health care providers and their female
clients. In Brazil, almost all contraceptive and
gynecological services are provided by physi-
cians, most of whom are male. Setting aside
conventional beliefs about what could and could
not be done, the Coletivo decided to train lay
women to provide complete basic examinations,
with backup by the female clinicians.
A second step toward humanizing ser-
vices was to ensure that the interaction
between client and provider resulted in women
leaving the clinic with greater knowledge about
and confidence in themselves. This would
mean an emphasis on education that, in turn,
would allow women to make more of their own
choices. Information about one's body and
one's sexuality was understood as the starting
point for women to make effective choices
regarding their sexual and reproductive health.
A primary concern among collective
members was the usual fragmentation of
women's bodies and health needs into different
service domains. The Coletivo favored an inte-
grated service that recognized a woman's med-
ical needs are directly interrelated with her sex-
uality, her social role, her economic activities
































and her emotional well-being. This would
mean providing nutrition education, psycholog-
ical counseling and education about reproduc-
tive rights. An integrated approach also meant
that the client would see the same person for
both her initial interview and her clinical exam.
Finally, Coletivo members felt that health
care had become too oriented toward curative
medicine, and that overreliance on drugs was
often masquerading as technical competence.
Instead they chose an approach that empha-
sized prevention and the use of natural reme-
dies to reduce overdependence on technology
and drugs.
Turning these broad goals into a concrete
program design required input from many
sources. Collective members spoke to women
from all walks of life about what kind of health
care they wanted and considered the experi-
ences of the feminist health movement in other
places. Under the sponsorship of ISIS (an
international women's organization), physician
member Maria Jos6 de Araujo completed a
nine-month rotation at the Dispensaire des
Femmes, a feminist health clinic in Geneva.
Maria Jos6 explains that this visit was of funda-
mental importance for the Coletivo. "We had


imagined such a service, but we had never seen
it. Yet there I saw the very principles we had
discussed put into practice. The Dispensaire
had learned which plants and herbs it could
reliably recommend. The staff members had
created a new kind of patient-doctor relation-
ship. They believed in the power of knowledge.
We knew a clinic in Brazil would have to be dif-
ferent from one in Switzerland, but this expo-
sure was very formative for us."
Upon Maria Jose's return, convinced their
bold scheme was indeed a possibility, the
Coletivo set about refining its program plan,
developing a financial base and conducting a
training program.

Getting Started
One of the most formidable tasks was
training nonclinician members to perform
pelvic exams and basic lab tests. This process
was managed by Maria Jos6 along with two
other members, Melodie Venturi and Simone
Diniz. Melodie is originally from the United
States, where she was trained as a physician's
assistant. (A relatively new profession, the
physician's assistant is trained as a primary care





clinician who works with medical backup.)
Melodie also had previous experience working
with a feminist health center in her country.
Simone is a physician. Joining Maria Jos6,
Simone and Melodie was Rosangela Gramone,
a biologist sent by the Dispensaire in Geneva to
help them get started.
Every day for five months, Collective
members attended half-day sessions on basic
anatomy and physiology, sexuality, reproductive
diseases, contraception, preventive care and a
clinical practicum.
A small house in a working class neigh-
borhood of SRo Paulo was rented. A modest
grant from Rina Niccim of the Dispensaire in
Switzerland supported the purchase of exam
tables and basic clinical equipment. The sec-
ondhand furniture, lights and refrigerator were
all donated.
The clinic's first clients were the Coletivo
members themselves. Then came their friends
and finally, in 1986, the clinic was opened to
the public.
Today Coletivo members look back at
their original staffing plans with a smile. In an
attempt to challenge the typical hierarchical
power relationships among staff members-
particularly health providers-the group de-


cided that everyone would learn to do all the
jobs at the clinic and that they would simply
rotate their functions.
It didn't take long before Coletivo mem-
bers had to acknowledge that people have dif-
ferent skills and different interests. One mem-
ber reminisces, "A lot of our early experiences
were based on fantasy. We believed everyone
had more or less the same abilities and inter-
ests. So we thought everyone should do exams
and everyone should do cleanup. But we saw
that some of the women were never going to be
competent in the lab. And others made a mess
cleaning up! Sometimes it got funny, some-
times it was upsetting. We spent a lot of time
being worried over something being poorly
done before we gave up on our early notions."
Before long, a specific individual assumed
responsibility for financial management and
the Coletivo hired a secretary who didn't want
to perform pelvic exams.

The Coletivo's Program Today
The Coletivo's activities are roughly
divided into five areas: clinical services, edu-
cational programs, training, advocacy, and
research.


do
LL






Currently 11 staff members comprise the
collective. Most work 20 hours per week
because the budget does not allow for this
number of full-time positions. Although admin-
istrative and management duties are now han-
dled by a designated coordinator, decisions are
still made democratically. And most members
still perform more than one task. Maria Otacilia
Lima Battistelli, for example, participates in
research and training activities and also con-
ducts workshops on body awareness.
The annual budget of the Coletico is
about U.S. $140,000 Previously, client fees
(which are based on a sliding scale) accounted
for 28 percent of this amount. Over the past
few years, the worsening economic situation in
Brazil has meant that fees have not kept pace
with costs, and client fees now contribute only
17 percent of revenue. None of the Coletivo's
programs (including its training program) cur-
rently pays for itself.
But the Coletivo's goal has always been to
create a model of quality care rather than a
model of self-sufficiency; the organization
expects to remain dependent on outside
donors. The Coletivo started with a small grant
from the Dispensaire and currently receives
support from private foundations in the U.S.
and Europe.
Nor have numbers been a priority. Only
about 2500 women pass through the Coletivo's
doors every year (most for clinical services
alone, but several hundred for educational pro-
grams and several hundred for both), and there
are no plans to expand. The Coletivo measures
its success as a provider on its ability not only to
offer care that is respectful of women but in
some instances, even transforms their lives.
Clinical Services
The clinical services begin with a woman
filling out her own health history. Along with
medical information, the form asks whether or
not the woman has a regular partner. Other
questions ask whether the woman has any con-
cerns about sexuality and/or experiences with
violence that she would like to discuss. These
questions help staff to gear the counseling ses-
sion to the individual situation of each client.
The counseling session reviews the
woman's charts and her concerns. The staff
member may spend a half hour explaining early


diagnosis, self-treatment and prevention of
yeast infections; allowing a woman to talk about
experiences of violence; or discussing job
stress, fatigue and nutrition.
The clinical exam is then performed by
the same person who does the counseling, to
break down the barrier between the social and
clinical aspects of care and to build more mean-
ingful rapport with the client. The annual gyne-
cological exam includes a bimanual and abdom-
inal exam, a Pap smear, breast exam and review
of the breast self-examination technique. The
physicians are always available for consultation
in difficult cases.
There are aspects to the exam that may
shock traditional family planning providers.
First, the woman puts in her own speculum.
Second, she is offered a chance to see her own
cervix with a mirror. Coletivo members find that
women tend to be mystified by their own bod-
ies and have no mental picture of their cervix.
They have learned that the simple act of show-
ing them a part of their bodies that has been
known to their gynecologists and male part-
ners-but not to them-helps women claim
their bodies as their own. Another nontradition-
al aspect of the exam is that the client is wel-
come to bring her partner into the exam room;






indeed, a good number of
partners do attend. The exam
also includes a blood pressure
check and screening for repro-
ductive and urinary tract infec-
tions. Wet smears and preg-
nancy tests are performed on
site, but gonorrhea and Pap
tests are sent to a local lab.
Referrals are made for syphilis
and HIV testing.
Contraception, preg-
nancy testing and prenatal
care are all available. Contra-
ceptives provided include
condoms, spernicides, the
diaphragm, natural family
planning, pills and the IUD.
This range of contraceptive
options is remarkable for any
clinic in Brazil, where pills
and sterilization account for
close to 85 percent of all con-
traceptive use and other
methods are almost unavailable. Few providers
in Brazil know how to insert IUDs, and far
fewer still know how to measure for a
diaphragm. Coletivo staff members are fully
trained in the clinical and counseling aspects of
these methods (the IUD is the only method
provided exclusively by the physicians) and are
committed to allowing the necessary time to
ensure that a client can use her method effec-
tively. For example, in screening for contraindi-
cations, the Coletivo staff asks every prospec-
tive IUD client not only whether she has more
than one sexual partner, but also whether her
partner may sometimes have other partners.
Providing this broad but unusual range of
choices has not been easy from a management
standpoint. Contraceptive provision is not
taught in Brazilian medical schools, and there
are almost no contraceptive technology training
programs available locally. To learn how to
insert IUDs, Coletivo physicians had to leave
Sao Paulo (a city of 17 million) for training at
CEMICAMP in nearby Campinas, a special-
ized family planning clinic associated with an
international research center. They learned
about natural methods from the Swiss
Dispensaire.


Providing diaphragms presented even
more hurdles. Maria Jos6 and Rosangela were
able to teach other staff members how to fit
diaphragms and teach women how to use them,
but procuring supplies of diaphragms and sper-
micidal jelly and cream proved far more diffi-
cult. United States Agency for International
Development (USAID)-funded suppliers were
not shipping any diaphragms to Brazil, and
there was no local manufacturer. Over the
years, the Coletivo kept up with the demand by
relying on the generosity of institutions such as
The Pathfinder Fund and CPAIMC, a large
family planning clinic in Rio de Janeiro. Today
the Coletivo purchases its diaphragms from
Semina, a woman owned and operated manu-
facturer in Brazil that is itself an outgrowth of
the women's health movement.
The Coletivo was strongly motivated to
make the diaphragm available. First, members
were concerned about the serious lack of con-
traceptive choice in Brazil, where oral contra-
ceptives remain the only widely accessible tem-
porary method (outside of illegal abortion).
They harbored serious concerns about the
huge numbers of women for whom the pill was
not an appropriate method, either for health or






personal reasons. Second, because of their con-
cern for women's autonomy, they were inter-
ested in a method that women could stop or
start (use or not use) independently and that
also provides some protection (when used
with a spermicide) against infections. And
finally, although many programs are unwilling
to provide the kind of education and counseling
required for effective diaphragm use, for the
Coletivo meaningful client-provider inter-
actions are a sine qua non.
At the Coletico, diaphragm education
begins with an introduction to the method. The
staff can also teach women fertility awareness
techniques so that they do not have to use the
diaphragm all month long or can use double
protection at the time of ovulation. Concerns
about how the diaphragm may interfere with
sex are discussed openly, and staff members
sometimes suggest that their male partner can
actually insert the diaphragm as part of love-
making.
During the exam, women who decide to
try the diaphragm are shown their cervix with a
mirror and encouraged to touch it with their
finger. Maria Jose explains, "You might think
women would be too shy to touch their cervix.
But when they see it in the mirror they are
amazed. They are curious to know their own
bodies when it is made safe for them."
The clinician then establishes the correct
diaphragm size for the woman and she is given
a chance to try inserting it herself. Finally, she
is given appointments for follow-up visits in
one week and three months, however, she
is encouraged to return at any time if she
has a problem.
The Coletivo staff feels strongly that
with thorough counseling, methods like the
diaphragm can have much wider acceptance.
Indeed, as other clinics in the Sao Paulo area
have learned about the availability of the
diaphragm services at the Coletivo, they have
begun referring increasing numbers of women
interested in this method to them. As a result,
although the Coletivo': clinical program
remains small, the demand for the diaphragm
has risen steadily: 40 percent of all contracep-
tive users coming to the clinic now request this
method.


The Coletivo also offers prenatal care,
which includes not only regular check-ups but
also extensive nutrition counseling along with
the Coletivos natural childbirth/prenatal edu-
cation and support groups. Male partners
usually participate in these groups. They appre-
ciate the considerable attention given to topics
such as fathering and the male-female relation-
ship. Arrangements for birthing care are gener-
ally made with a nearby hospital or midwife.
In addition to the counseling, which is
seen as part of basic medical services, the
Coletivo provides more in-depth psychological
counseling as needed. Psychologist Otacilia
Battistelli sees some clients for up to a year
with fees based on a sliding scale.

Shaping the Client-Provider
Relationship
As part of the attempt at demedicalizing
health care, there is no formal sign on the front
of the Coletivo building. Nor do clients
encounter anyone dressed in a white coat.
Although the building is clean, there is no
strong odor of disinfectant typical of most hos-
pital-based clinics in Brazil. When the client
enters, she is greeted by Ceci, the receptionist.
If she is new, she is asked to fill out her own
medical history form. (Those who cannot read
or write are, of course, given assistance.)
Having clients complete their own medical
records is not just a time-saving device. The
staff explains that "a woman's active participa-
tion in her own health care begins at this
point." Critical information is also entered into
a computer database.
An important element of what makes the
Coletico's services unique is time. First visits
last about 60 minutes and subsequent visits last
about half an hour. According to Maria Jos6,
"We have not tried to resolve all health prob-
lems women face or to deal with the whole
population. We have been trying to show that a
high quality of care is possible, but that it
requires us to give women more time." While
many in the family planning field may find this
time allotment unrealistic, the Coletivo staff
firmly believe that without providing this
amount of time, clients would not be able to






















q:

q .


adequately explore their own concerns, learn
about their bodies as well as all the services
available at the clinic and establish a trusting
relationship with their provider.

Voices of Coletivo Clients
The women who attend the Coletivo are
generally from the western part of Sao Paulo
surrounding the clinic. Most (68 percent) clinic
clients are poor or working class women.
Another 17.8 percent have a middle class
income (5 to 10 times the minimum salary), and
14.3 percent have an upper-middle-class
income (over 10 times the minimum salary).
Considering that public sector services are free
and that Brazil has been suffering from a severe
economic crisis for some time, the large pro-
portion of poor and working class clients who
are willing to pay even a small fee for care at
the Coletivo is impressive.
Today most Coletivo clients learn about
the clinic the same way women did when the
Coletivo first opened its doors: through friends.
Creuza and Fernando heard about the Coletivo
from Fernando's buddy, Jorge. Creuza says,
"Jorge told me this place was different, that the
doctor spent a lot of time with you, they give


you enough attention, and that Fernando could
come in with me during the appointment."
While waiting for her exam, Creuza reports
that she feels happy about being there because
she was warmly received and because she liked
filling out her own medical history form.
Illustrating how much quality care is worth to
people, Creuza explains that she traveled for
two hours to get to the Coletivo, because good
care is worth it.
Twenty-one year-old Roberta is also a new
client. A male friend told her that the Coletivo
"is a friendly place, where the people make you
feel comfortable, and there are no doctors in
white coats." Roberta says previously she had
been to another provider, where the male doc-
tor made her feel "as if I had been assaulted,
humiliated." Here at the Coletivo, she says her
visit was "what I hoped for. I found comfort
and understanding."
Cristina is a single 30-year-old and has
been coming to the Coletivo since it first
opened. She explains, "When I was a teenager
I went to the gynecologist for help, because I
was taking the pill and I didn't feel good. The
doctor told me the best method was to get mar-
ried." Cristina then heard about the Coletivo.






As she recalls her first visit: "It really moved
me, seeing my genital organs in the mirror. The
[cervical] self-exam was the thing that affected
me the most." Commenting on what else makes
the Coletivo different from other providers,
Cristina comments, "The visit is a shared
responsibility-the doctor-patient relationship
is really different from other places." She also
mentions the availability of alternative treat-
ments, such as yogurt for certain vaginal infec-
tions, as an important advantage.
Crislaine, though only 19 years old,
echoes similar sentiments. She describes the
birth of her 15-month old as a trauma. She was
not allowed to have her husband with her, and
her requests for a hand to hold were answered
with the doctor's order to "grab the bedpost."
Afterward, Crislaine came to the Coletivo for
contraception. First and foremost, she values
the Coletivo because of its "respect for women's
condition."

Education Program
Because at the Coletivo clinic visits tend
to involve a significant amount of client educa-
tion, the boundary between clinical services
and educational components is less distinct
than at other institutions. Group workshops are
the primary activity of the education compo-
nent. Simone Diniz, Regina Rodriguez,
Melodic and Maria Jos6 all lead workshops on
such topics as sexuality, self-esteem, adoles-
cence, premenstrual syndrome, nutrition, con-
traception, menopause and pregnancy/natural
childbirth. Most of the workshops meet once a
week for eight weeks, but the prenatal group
generally continues for five or six months.
All of the workshops rely heavily on inter-
active techniques that respect the experiences
of each participant, underscoring the Coletivos
belief in the power of knowledge. The giving of
information and exchange of experiences serve
as points of departure for further reflection
about one's identity as a woman. The comment
of 24-year-old Heliani, as she left her first work-
shop, is typical: "All this made me think about
my body and my role as a woman."






Beyond Service Delivery
Community development specialist David
Korten has argued that the evolution of non-
governmental organizations (NGOs) generally
can be defined by the way in which they con-
front the problem around which they are orga-
nized. For example, most NGOs begin by pro-
viding immediate relief and welfare services.
Then as it becomes evident that the need out-
strips the NGO's ability to provide these ser-
vices, many organizations engage in community
organizing and development. Eventually, they
move toward addressing the more fundamental
causes of the problem through policy change.
The most advanced NGOs serve as a national
actors and policy voices.
According to this scenario, the Coletivo
started out at a fairly sophisticated stage: not
only did it intend to meet individual needs
through small-scale service provision, but it was
also committed to educating women about
what is wrong with the current health system
and to demonstrating to policymakers what is
possible. However, before long it had moved to
the third stage as members realized that a
model of humanized care, no matter how "suc-
cessful," would not spontaneously result in
other providers following suit. Within three
years of its opening, the Coletivo had set up a
training institute, developed a research compo-
nent and begun playing a high-level advocacy
role, not only in Sio Paulo but on a national
level as well.

The Training Program
First came interested visitors from Peru,
Colombia, Argentina and other regions of
Brazil. Then the Coletivo began sponsoring
informal apprenticeships and making presenta-
tions at professional conferences. By 1991, the
Coletivo had begun a formal training program.
Currently, the Coletivo offers three dif-
ferent courses for health care professionals.
The first is a 20-hour seminar on women's
health care. Open to both health professionals
and interested lay people, this course reviews
women's reproductive health care needs from
both a technical and a social perspective.
Participants learn about topics such as women's
limited ability to protect themselves against
sexually transmitted disease, reproductive


rights as human rights, basic concepts of sexu-
ality and sex education, and skills for fostering
an effective group process. The second course
is a more in-depth version of the 20-hour
course. Although the Coletivo distributes occa-
sional flyers to health professionals, it recruits
most attendees by word of mouth. In the past
few years, close to 350 participants, mostly
female, have enrolled in these courses.
Increasingly, these participants come
from all across Brazil. The staff is learning that
the course is most useful to participants who
have had little or no exposure to these themes
from a gender perspective; for them, the course
helps shape the way they see clients and
enables them to understand how their clients'
priorities may differ from those of the health
establishment.
Tereza is a nurse who took this course
after hearing a friend at work talk about it. She
wrote, "After one week of so much information,
I wanted to know much more about women's
health. I really didn't know there was so much
to know. This week changed my life."































The third training option is a more indi-
vidualized clinical rotation at the Coletivo. This
is aimed primarily at clinicians who are also in a
teaching or policy position in the public sector.
Lasting three months, this course often focuses
on how to provide diaphragms, as such training
is not available elsewhere in Brazil. Close to 50
providers from across Latin America have
attended the clinical practicum at the Coletivo.
While it has not been able to systematically
evaluate the impact of these training programs
on the participants' professional lives, the
Coletivo is encouraged by the number of "grad-
uates" who refer their colleagues and friends to
the course.

Advocacy
Brazil began its return to democracy in
the late 1980s, after decades of military dicta-
torship. Many of the same activists who earlier
fought to re-establish democracy in Brazil are
today working to make that democracy mean-
ingful, largely through the work of nongovern-
mental organizations. The feminist movement
has been instrumental in this process of demo-
cratic construction, and its commitment to
developing a civil society with popular partici-
pation and an emphasis on the values and


responsibility of citizenship remain central to
its work.
Indeed, while achieving reproductive
freedom has become a primary concern of
women's organizations around the world,
Brazilian feminists were probably the first to
define reproductive rights explicitly as an ele-
ment of citizenship. Indeed, one of the leading
voices promoting reproductive rights on the
agenda of the international women's move-
ment, as well as in Brazil, has been a successful
little clinic and training program in Sio Paulo:
el Coletivo Feminista Sexualidade e Saide.
Among the first public advocacy projects
the Coletivo helped launch was a series of dia-
logues (encontros) between feminists, biomed-
ical researchers, church representatives and pub-
lic health leaders on issues affecting women's
reproductive health in Brazil. These biannual
dialogues have focused on issues such as mater-
nal mortality, abortion, ethics in research, and the
implementation of the federal government's pro-
posed women's health program.
Anibal Faundes, a leading family planning
physician who also conducted NORPLANT trials
in Brazil, participated in these dialogues. He
recalls, "the dialogue between women's health
advocates and physicians is not an easy one.






There is incomplete and often incorrect infor-
mation on both sides and verbal passion
within either group does not always stimulate
understanding. Each dialogue experience,
however, is better than the earlier one, as we all
learn to listen and to accept new ideas, new
perspectives, and to understand that in spite of
errors committed in the past-on both sides-
many women and physicians have a common
commitment to improving women's health and
well-being."
Adrienne Germain, vice president of the
International Women's Health Coalition (which
has funded the dialogues) explains that "the
dialogues gave representatives from different
sectors of the society a unique opportunity to
get to know each other and to seek common
ground. The experience in Brazil was also
important for women in countries such as
Nigeria, where similar dialogues are now
beginning." The Coletivo also belongs to a con-
sortium of feminist health organizations in Sdo
Paulo that jointly produce and disseminate
a magazine, Enfoqlue Feminista (Feminist
Focus), to advocates and providers across the
country.
The Coletivo:s message about rethinking
how we provide family planning and women's


health care is also being heard by a broad range
of policymakers. Maria Jos6 recently completed
four years as the director of the Women's
Health Program for the municipality of Silo
Paulo. Coletivo member Simone Diniz was
similarly named to a senior governmental po-
sition concerned with women's affairs. A
cofounder of the Coletivo, Magaly Marques,
was invited to work for International Planned
Parenthood Federation/Western Hemisphere
Region (IPPF) in New York, where she coordi-
nates projects concerned with quality of care
and the status of women. Coletivo members
have also served as advisors to the World
Health Organization's Special Programme in
Human Reproduction, the Population Council
and other USAID-funded agencies.
Although the Coletivos unique way of
doing business has won it admirers within the
population field, many skeptics have ques-
tioned its arguments. For example, when the
Coletivo staff argued at conferences that low-
income women could successfully use the
diaphragm, many family planning and popula-
tion professionals wanted to know: What are
the pregnancy rates among these users? What
are their continuation rates?
As Maria Jos6 explains, "These were


-I
a ~'






important questions, and we didn't have the
answers. We began to realize that by docu-
menting the experience of diaphragm users, we
could not only demonstrate the acceptability
and effectiveness of the diaphragm to policy-
makers, but we could also generate information
about how to improve our own services. So our
concerns about both policy issues and quality
care eventually led us into research."
The Research Program
Although the Coletivo had carried out an
informal ethnographic research study docu-
menting clandestine abortion practice, the
diaphragm study was its first formal investiga-
tion. In this effort they collaborated with two
other diaphragm providers-a large univer-
sity-based clinic and a private physician-to
analyze outcomes of diaphragm use. The
Population Council provided technical assis-
tance.
The results surprised everyone, including
the Coletivo. The first finding was that use fail-
ure rates were quite low in all three centers: a
stunning 6 percent. The oral contraceptive-
the most popular method in Brazil-is thought
to have considerably higher use failure rates.
The second finding was that 72 percent of new
users were still using the method after one year.
Another lesson was that low-income women
proved to be just as capable as any other group
in using this method. But the most startling
finding had to do with a variation in protocols
and outcomes among the centers. At one of the
centers (not the Coletivo), the provider gave
women unusual instructions for using the
diaphragm: he told them to use the diaphragm
without spermicidal jelly, but to leave it in the
vagina at all times, removing it only to wash it
and reinsert it once a day. The effectiveness
and continuation rates at this center were the
highest of the three sites.
The Coletivo staff is pondering these
results in its unique way. Maria Jos6 comments,
"We see the results as tentative, but we are
intrigued. After we discussed the findings
among ourselves, we shared them at special
meetings with other providers and feminist
advocates. Then we called meetings with our
clients, both because we believe in sharing


the results of research with the human subjects
and also to learn what they think about
these results.
"The women were very enthusiastic about
the possibility that they could use the
diaphragm differently. One big problem with
the diaphragm is the difficulty of planning sex
an hour in advance or stopping in the middle of
sex to put in the diaphragm. The other problem
women face is that the jelly is expensive, smells
bad and is messy. If it turns out that women can
really wear the diaphragm all the time and skip
the jelly, this method will become an important
option not only in Brazil but also across Latin
America. What does it mean when we are
investing millions of dollars to develop a con-
traceptive vaccine while we still don't know if
the diaphragm needs jelly?"
Others agree that is an important question.
USAID, the Population Council and the Coletivo
are currently involved in discussions regarding a
more carefully controlled clinical trial to examine
the relative use-effectiveness and continuation
rates for the diaphragm with and without jelly. In
the meantime, the encouraging results even with
jelly have reminded population agencies that the
diaphragm is an important option not currently
available in Brazil and other countries as well.
Early this year, the World Health Organization's
Special Programme in Human Reproduction
convened an interagency working group on bar-
rier methods involving various international pop-
ulation agencies. This group has made the intro-
duction of the diaphragm into selected countries
its first priority.
The idea for another research project
came out of the process of preparing this article.
The advisory co-mmittee of Q/C/Q began to
question whether the Coletivo's long-term costs
per client were really as high as we had all
assumed. We wanted to know how much up-
front investments in quality (education, counsel-
ing, and providing real choice) can reduce the
long-term costs of revisits, discontinuation, and
unwanted pregnancy among dissatisfied and
confused clients. The low-income status of most
Coletivo clients made this question even more
relevant. In collaboration with staff of the
Coletivo, Q/C/Q sponsored a research study to
examine this question from various perspectives.






The study had three components and the
findings from all three are compelling.

Cost Per Client Analysis
At the Coletivo, the average annual
cost of providing a client with comprehen-
sive reproductive health care, including
contraception is about $40 (from $33.49 for
pill users to $42.30 for diaphragm users). Half
of this cost is for basic family planning services
and supplies. The cost for extended counseling
(on topics such as sexuality and nutrition) and
for reproductive tract infection screening and
treatment accounts for another $10. And the
final $10 is the cost of a Pap Smear.
Although to most programs in Brazil ten
dollars seems too exorbitant to invest in basic
screening, instituting universal Pap Smears was
precisely the priority recommendation made by
the World Bank review of women's reproduc-
tive health in Brazil. The Bank found that an
investment in reducing cervical cancer was
probably the most effective way to save both
money and lives.
Indeed, an unapologetic up-front invest-
ment is characteristic of the Coletivo. Because
the initial counseling and exam are so thorough,
most new clients only get contraception at their
second visit, generally one week after the first.
Use of the diaphragm requires an additional
follow-up check one week after the fitting
(although not all women return for this third
visit). So 88 percent of the total annual cost per
client ($37.22 per diaphragm user) is invested
in these early visits.
Although a few women return for contra-
ceptive checks, changes of method or preg-
nancy tests, the majority of revisits after this
point appear unrelated to contraceptive use. Of
the remaining five dollars spent over the rest of
the year, about three dollars goes toward treat-
ment of other gynecological complaints, the
most common being reproductive tract infec-
tions/STDs. Contraceptive follow-up actually
costs the Coletivo only about two dollars for the
remainder of the year. Thus, their intensive
investment in cultivating autonomous, edu-
cated contraceptive users seems to pay off:
women are coming back to the Coletivo (with
infections, breast lumps, and other health prob-


lems), but they generally do not have problems
with their contraceptive.

Cost of Effective Diaphragm Use
With our second set of questions we
sought to analyze more specifically the costs to
achieve particular outcomes, specifically the
realization of a diaphragm user's reproductive
intentions.' One goal of a contraceptive user is
to avoid pregnancy. We adjusted the $42.30
annual care cost to reflect diaphragm failure
rate, i.e., to calculate the average annual cost
per non-pregnant client.2 This figure is $45.07.
Another goal of a contraceptive user is to
find a method with which she is satisfied. When
we also included method continuation in the
calculation, the annual cost to serve a non-preg-
nant woman continuing with her method after
one year rose to $60.99. It is important to
recall that these calculations also assume that
improved reproductive health is part of a
client's reproductive intent.
If we were to base our calculations on the
$20 it costs for contraceptive services alone
(i.e., exclude the cost of the added reproductive
health care), the cost per non-pregnant client
would be only $21.31 and the cost per non-
pregnant, continuing user would be $28.84.
Certainly this figure is lower than the one-year
cost of providing NORPLANT', which costs
$23 for the implants alone plus considerable
physician time (and which also rises further
when one adjusts for discontinuation rates).
While the last set of figures may provide
better comparisons to standard family planning
services, they also assume that diaphragm
effectiveness and continuation rates would be
the same without the Coletivo's comprehensive
reproductive health care package. Coletivo
members doubt this would be the case and they
have no interest in finding out: they believe the

See Brnce and Jain's Implications of Reproductive Health for
Objectives and Efficacy of Faily Planning Programu (New York:
The Population Council, 1993), a useful discussion of reproduc-
tive intent as a valuable contraceptive outcome measure.
2 This is calculated using the total cost of serving 100 women
for a year divided by the number of those women who are not
pregnant at the end of the year.
This is a similar calculation with the denominator comprised of
those women who are both non-pregnant and continuing users.


































reproductive health package is vital in its own
right and should not be viewed solely as a
means to enhance contraceptive use.
At the Coletivo another element of
clients' "reproductive intent" is for women to
feel more knowledgeable about and comfort-
able with their reproductive organs. Unfor-
tunately, prospective contraceptive trials have
never included self-awareness and comfort lev-
els as an outcome variable. While there is
strong anecdotal data indicating the impor-
tance of such awareness and comfort to clients,
we have no quantitative data which would allow
us to measure the rate with which this outcome
is achieved.
The Costs of Achieving a Desired
Outcome: Oral Contraceptive Use
In Brazil the oral contraceptive is freely
available over the counter. The retail cost for 12
pill-packs of the brand used by the Coletivo is
about $24. Obviously, this is considerably less
than the $33.49 it costs for a year of compre-
hensive reproductive health care and pills at
the Coletivo. But what kind of results are actu-
ally being achieved through over-the-counter
provision of the pill?
We wanted to know what it cost the
Coletivo for each pill user who was both clini-


cally appropriate and satisfied with the infor-
mation she had received along with the pill.4 An
audit of client charts found that 100 percent of
pill users at the Coletico had been screened for
basic contraindications, and a survey of their
pill users found that 72.5 percent of clients felt
satisfactorily informed about the pill. Adjusting
for these figures, the Coletivo's cost of serving a
satisfactorily informed, clinically appropriate
pill user increases to $46.19.3
We then carried out a parallel analysis for
women who have always gotten the pill from a
pharmacy. Earlier research by Hardy et al
demonstrated that one-fourth of women get-
ting oral contraceptives from pharmacies had
absolute contraindications to pill use." Our sur-


SVell-informed use is part of basic informed consent; client
satisfaction with the information process was selected as the
most practical indicator for this study. Other indicators of
well-informed use also appear in the literature.
s Again, we arrive at the adjusted figure by calculating the
total cost of providing 100 pill users with comprehen-
sive reproductive health care plus contraception for a
year, divided by the number of those women who were satis-
factorily informed and clinically appropriate users, i.e.,
$33.49x100 $/72.5.
SHardy E.E., et al, "Contraceptive pill: adequacy of use
among women in unions. [Adequacao do uso de pilula anti-
concepcional entire mulheres unidas]," Revista de Saude
Public. v. 25 n. 2 pp. 96-102, 1991.






vey of 141 women who regularly get their pills
from the pharmacy also found that only 16 per-
cent felt they had been satisfactorily informed
about the method. Adjusting for these out-
comes, the cost of achieving a satisfactorily
informed, minimally clinically indicated pill
user from the over-the-counter system rises
astronomically from $24 to $200.' From any
policy perspective that respects clinical screen-
ing and informed consent, the Coletivo's thor-
ough approach now begins to look prudent.
The Coletivo developed its program
based on the belief that there are social payoffs
to a society which help women become more
autonomous in their sexual lives. This fairly
extensive cost-analysis, in combination with the
World Bank review, suggests there are com-
pelling financial payoffs as well.' Many donors
are now rethinking the narrow outcome indica-
tors used in the past (such as couple years of
protection-CYP-and numbers of new ac-
ceptors) in favor of more meaningful indicators
of reproductive health and satisfactory fertility
regulation.

Coletivo Members Speak about the
Ups and Downs
Have there been difficulties and doubts
along the way? Of course.
Ten years ago Rosa Dalva Faustinone
Bonciani was among the Coletivo's founders.
Today, at 42, she reflects back on her individual
concerns and those of the group. "At that time,
I didn't know this would be a life project. I
come from a very poor family in the country
and was studying to become a pharmacist. I had
stopped my studies to care for my two children.
Then I met Maria Jos6 and decided to help
start the Coletivo. I did finally finish my studies
but I never really worked as a pharmacist. So I
don't have a profession in the formal sense to
fall back on.
"The work has its difficulties. This is a
laboratory. We learn, we invent a new way of
working. This is not easy, trying to overcome
old, crystallized ways of being-personally and
professionally."

7In this case, the calculation is $24x1009/16x.75.
"The i.. I .....' are currently preparing a more detailed
discussion of this cost-effectiveness study for separate
publication.


Despite the emphasis on equality, "status"
still comes into play. Often it is the physicians,
Maria Jos6 and Simone, who are invited to par-
ticipate in international meetings. This places
a particular strain on the Coletivo, because it
is difficult to recruit other physicians to join
an unhierarchical, as well as low-paying orga-
nization.
Over the years, several members have
taken leaves of absence to pursue other inter-
ests and then returned. Several have restored
their original enthusiasm and commitment
through opportunities to travel and meet with
feminist health advocates and policymakers in
the international arena. And while new mem-
bers have joined, a few old friends have parted
not to return.
But the greatest ongoing problem the
Coletivo has faced is the same issue most pro-
grams face: finances. Rosa explains, "The hard-
est part has been the lack of professional secu-
rity. We constantly depend on outside finances.
As a result of our limited finances, there is only
[enough] funding for me to work part-time, and
I have to work in another job to support
my family."
Because it is outside the circle of pro-
grams supported by mainstream population
donors such as USAID, the United Nations
Population Fund or IPPF, the Coletivo has
relied on support from the International
Women's Health Coalition, the MacArthur
Foundation, European foundations, and other






private donors. Client fees continue to provide
a significant contribution toward covering
costs, but meeting the remainder of expenses
on a steady basis has always been-and may
always be-an ongoing worry for the Coletivo.
Despite the problems, Coletico members
insist that their work is a tremendous source of
personal pride. Rosa explains, "Sure, it's a con-
stant challenge. But every time we take a step
forward, we feel 'This is worth it.' And people
admire me for working here, even when they
don't really understand what the Coletivo is.
They feel moved. My oldest brother finds it
very interesting that I came from a rural village,
have six sisters, and ended up here! The
answer? I don't know, something I found in
myself gave me the impulse to rebel against the
submission and domination-including eco-
nomic domination-that is machismo, which is
so strong in the countryside."
Thirty-one-year-old Celia Cipriano joined
the Coletivo six years ago by answering a classi-
fied advertisement for a bookkeeper. She
smiles and recalls, "I had never heard of femi-
nist collectives. It scared me. I was a bit lost the
first six months, as I learned about health and
women's issues. But I think I make an impor-
tant contribution here. And I've grown so much


personally. I get to attend conferences. I partic-
ularly try to go to conferences about abortion
and ones about using humor at work. And I
refer my friends here. People love the work-
shops, like the one called 'Our Dreams.
"My mother, Sofia Elias Cipriano, worked
here for a while too-still does sometimes,
cooking and maintaining the building. My mom
had a sixth grade education. Here she came to
know another way of life for herself, among
people who were very open and friendly."
We asked Celia about the disadvantages
of working at the Coletivo. She told us she "still
hasn't found them."
Simone Grilo Diniz is a physician and a
long-time feminist. In addition to providing
clinical support at the Coletivo, Simone is
engaged in research and training. She
explains, "Before the Coletivo, I had my work
as a feminist activist on one side and my work
as a physician on the other. The Coletivo
allowed me to synthesize these sides of myself.
And it has allowed me to see that the problems
we experience as women are not just our own,
isolated problems. This has had a good impact
on my self-esteem. In this sense, having an
active political commitment becomes very
calming!"


19






Maria Jucinete De Souza enrolled in a
health and sexuality group that the Coletivo
organized in her low-income neighborhood in
the mid-1980s. Today she performs pelvic
exams as a Coletivo staff member. In reflecting
on the path her life has taken, she muses, "I got
married, came here from Bahia (a poor state in
the northeast of Brazil), and then I had my chil-
dren. I was a housewife and also a domestic
worker. After attending the sexuality workshop,
I could see that the life I was leading was not
the one I wanted.
"I began to participate in the meetings of
the women's movement, relaxation groups and
in neighborhood organizing. In this way I came
to know Maria Jos6, who was organizing a train-
ing course for women's health care. I was inter-
ested and decided to participate. I realized that
my childhood hope of becoming a teacher was
still there, but with a different angle: to be an
educator in the area of women's health. Even
though I hadn't gone to high school, the train-
ing and help I got from the other women at the
Coletivo enabled me to become a clinician,
which I still am today.
"The personal changes have been so big
compared to the tasks I was doing as a house-
wife. Now I have the opportunity to improve
myself financially and also to grow as an indi-
vidual capable of achievements. Every time
clients come back to the clinic or tell their
friends about us, I feel these achievements are
acknowledged."

Next Steps
By the early 1990s, rent of the Coletivo's
clinic had risen to 20 percent of its total budget.
So in 1993, with funds raised both in the U.S.
and Brazil, Coletivo members realized one of
their long-term dreams: they bought their own
building. Located across the street from the
former location, the new Coletivo is situated in
a large, airy and beautiful former residence.
Since moving in, the Coletivo's operating costs
have declined significantly, offering the group
some marginal fiscal security. But beyond this,
the staff members sense a new pride and confi-
dence in the organization's stability. The
Coletivo staff is currently looking forward to
carrying out the next stage of diaphragm
research, collaborating on the cost-benefit
analysis, adding a few new members (particu-


larly another physician) and exploring the issue
of male involvement.
In the meantime, the phone rings and
there is another woman with an unwanted preg-
nancy whom they wish they could help. A letter
arrives requesting the Coletivo to host three vis-
itors from the Philippines. A fax announces a
meeting about a proposed sterilization law. And
the door opens and a woman enters. The
Coletivo is reminded once again why it carries
on. Such are the blessings and the burdens of
what Rosa calls "a work of passion."

Lessons Learned
The Coletivo runs a clinic, a training insti-
tute and a public education program. It pro-
vides leadership to the Brazilian government
and women's health movement and is active in
research and international policy affairs. Such
accomplishments would be impressive for any
program. Remember, reader, that this is a
group of just 11 women.
Based on their personal experiences, the
Coletivo members never strayed from their
belief that by learning about their bodies and
actively participating in the design of their own
health care they, as women, could not only
improve their health but also strengthen their
identities as women, as sexual beings and as cit-
izens. They set out to enable individual clients
to know their own bodies, make their own
choices, recognize their own rights. They have
"given voice" to thousands of women. Twelve
years later, the Coletivo has found its own voice,
taking what it has learned by providing services
and speaking to the world.
What can we learn from the story of the
Coletivo Feminista?
1. By knowing what it stands for, even
a small program can have an enormous
impact in shaping ideas and options for
women's health care. The Coletivo has never
deviated from its original objectives and its
membership has remained fairly stable. Yet it
has managed to continually evolve, remaining
open and flexible to new ideas and different
perspectives. Rather than resting on its laurels,
the Coletivo has constantly sought new allies
and new avenues in an effort to reach closer to
its ambitious goals.
2. Women place great value on ser-
vices that meet their health needs as they






























perceive them. Although finances make it
impossible for most services to provide clients
with the time and attention they receive at the
Coletivo, it is important for us to know how
much women value such care. If we understand
women's priorities, we are better equipped to
think creatively about how to respond to them
and to argue more effectively that their needs
be considered by policymakers. Because if we
lose sight of what women really want, we can


easily get lost despite our efforts to improve the
quality of care.
3. Those of us involved with family
planning research, policymaking and pro-
gram implementation can gain new ideas
and establish useful working relationships
from communication and collaboration
with feminist health advocates.
4. Never underestimate the power of
the human spirit-or your own imagination!


To Our Readers
Initially, we at Quality/Calidad/Qualite thought this essay might have to be
written either for those women around the world thinking about starting alternative
programs, or for established family planning professionals wanting to understand
more about the international feminist health movement. Ultimately, we have tried
to keep both audiences in mind. We would love to hear from you about this issue.
Tell us about your yourself and your responses to reading about the Coletivo.


-91


- 'A
; ^J^^






Resumo em portugurs


No passado, programs de planejamento
familiar eram desenhados primonrdialmente com o
objetivo de reduzir o excess do crescimento popu-
lacional, fazendo das mulheres objetos de political
medicalizadas e de programs desenhados com o
objetivo de regular sua fertilidade. Ap6s a recent
Confer&ncia Internacional de Populagco e
Desenvolvimento (Cairo 1994), a necessidade de
urma visao mais ampla em relacito a saide reproduti-
va tem sido fortemente apoiada; por6m, existed
ainda vArias questAes relacionadas a implementagao
destes objetivos. Esta edicgo do Q/O/Q document a
experiincia de um grupo de mulheres brasileiras
que se juntaram em busca de alternatives ao trata-
mento medicalizado da safide feminine e acabaran
abrindo sua pr6pria clinic.
As membras do Coletivo passaram anos fazen-
do pesquisa, conversando comn mulheres a respeito
de sua sauide e buscando o treinamento necesstrio
para oferece-las um tratamento amplo de saide
reprodutiva. Para a grande maioria das mulheres
brasileiras, uma visit a um ginecologista (que na
maioria dos casos 6 umn home) 6 uma experiencia
desagraddvel; baseado nisto, o Coletivo decidiu
treinar mulheres leigas para fornecer exames
ginecol6gicos basicos, com a presence de uma mddi-
ca na clinic. Este conceito de tratamento reconhece
que as necessidades de saide das mulheres estao
intrinsecamente relacionadas com sua sexualidade,
seu papel na sociedade, suas atividades economicas
e seu bem-estar emotional. Como resultado, as
clients saem da clinic corn um maior reconheci-
mento do sen corpo e de sua sexualidade. Almn do
mais, o Coletivo enfatiza a prevengao e o uso de
rem6dios naturais para diminuir a dependencia da
tecnologia m6dica e dos rem6dios alopaticos.
Atualmente o Coletivo tern seu pr6prio pr6dio
e possui 11 membras que atendem urma media de
250 mulheres anualmente. As atividades do Coletivo
constam das seguintes: services clinics, programs
educacionais, treinamento, advocacia e pesquisa. Os
preyos dos servios sao baseados no poder aquisitivo
das clients e, considerando-se os problems
econ8micos do Brasil, os lucros corn estes servigos
representam apenas 17 por cento do ornamento total
da organizaglo. Entretanto, comno o objetivo princi-
pal do Coletivo 6 o de criar um modelo de assisten-
cia de saiide e ndo a auto-suficiencia, a organizagao
continue a defender da ajuda de doadores.
No Brasil, 85 por cento das mulheres usam a
pilula anticoncepcional e a esterelizagl.o como m6to-
dos contraceptives; outros m6todos contraceptives
sao praticamente inacessiveis. Este fato foi ina-
ceitivel para uma organizagao que se preocupa em
poder oferecer opc6es is mulheres. Por6m, oferecer
outros m6todos contraceptives no Brasil tamb6m


nao 6 fAcil. Sendo assim, o Coletivo teve que procu-
rar um dos poucos lugares no pafs onde se oferecia
treinamento para inseriAo do DIU.
O Coletivo tambem se sentiu muito motivado
em oferecer o diafragma as suas clients. Isto
porque a organizagao nao estava somente preocupa-
da com o grande n6mero de mulheres tomando pilu-
las com contra-indicaqao, mas tanmb6m porque que-
ria oferecer as mulheres uma opcao que Ihes permi-
tisse comegar ou parar de usar um metodo quando
quizessem, e que este metodo pudesse ao mesmo
tempo oferecer alguma protecgo (quando usado em
conjunto com o espermicida) contra infecyoes. O
argument mais comum existente contra o diafrag-
ma 6 o de que toma muito tempo para ensinar o sen
uso correto para as mulheres. Por6m, tempo nao
represent uma questao para o Coletivo: a primeira
consult de uma client dura aproximadamente uma
hora e visits posteriores duram aproximadamente
30 minutes. Enquanto alguns programs de planeja-
mento familiar podem considerar isto impraticivel,
o pessoal do Coletivo cr@ que este tempo dedicado
As consultas e necessario para que as mulheres pos-
sam discutir suas preocupag6es, aprender sobre seus
corpos, se tornarem cientes dos servigos oferecidos
pela clinic e estabelecer um relacionamento de
confianqa com a professional de sa6de.
E investor no tempo compensa, pois atual-
mente quase 40 por cento das clients de contra-
ceptivos que visitam o Coletivo vio a procura do dia-
fragma, e o Coletivo recebe tamb6m refer&ncias
vindas de outras clinics. Respondendo ao interesse
crescente no m6todo, assim como em sua filosofia
centrada no client, o Coletivo atualmente oferece
cursos para profissionais de sadde provindos de out-
ros estados do Brasil e de outros pauses latino-
americanos.
O Coletivo tambem desenvolve pesquisas
que documentam o sucesso de sua filosofia.
Recentemente, a organizaqao foi escolhida dentre a
outros tres lugares para participar de um estudo
sobre o uso do diafragma, que resultou num indice
de falencia de somente 6 por cento, isto 6, um indice
ben menor que o atribuido A pilula no Brasil. Como
parte do process de produgao desta publicayio, a
organizacao tamb6m participou de um estudo de
pesquisa simples que demonstrou que o investimen-
to initial do Coletivo no tempo 6 lucrative, quando a
media deste resultado 6 o sucesso de um m6todo e
a satisfacyqo da client.
O Coletivo Feminista Sexualidade e Safide
continue a explorer novas formas de oferecer seus
serviqos de maneira que as mulheres participem de
sua pr6pria saide reprodutiva. Atrav6s de seu tra-
balho, elas nos mostram que isto 6 possivel, contan-
to que estejamos prontas para enfrentar desafios.






Resumen en Espahiol


En el pasado, los programs de planificaci6n
familiar eran diseinados con el prop6sito exclusive de
reducir el crecimiento excesivo de la poblaci6n. Con
este fin, michos de estos programs convertian a la
mijer en un objeto de political mndicas que lbsca-
ban controlar so fertilidad. Desde que concluv6 la
Conferencia Internacional Sobre Poblaci6n v
Desarrollo (El Cairo, 1994), muchos sectors han
reconocido que la salud reproductive require una
perspective mns amplia, annque muchos todavia
preguntan c6mo dicha apertura se pnede Ilevar a
cabo. Esta edici6n de Q/C/Q relata la experiencia de
un grupo de mujeres en Brasil que se form como
alternative a la tradici6n medicalizada en la salud
femenina y termin6 por former su propia clinic.
Las miembras del Coletivo dedicaron various
anios a la investigaci6n, entrevistando a mujeres
sobre temas de salud y consiguiendo la capacitaci6n
necesaria para ofrecer un servicio complete de salud
reproductive. Para la mayoria de las mujeres en
Brasil, las visitas al ginec6logo [que casi siempre es
var6n] suelen ser experiencias desagradables. Por lo
tanto las mujeres del Coletivo decidieron entrenar a
vollntarias para que pudieran realizar eximenes
ginecol6gicos baisicos, bajo la supervision de
ginec6logas profesionales. El enfoque del Coletivo
reconoce que las necesidades midicas de la mujer
estan intimamente ligadas a su sexualidad, su papel
en la sociedad, su actividad econ6mica y su bienes-
tar sicol6gico. Las mujeres que pasan por la clinic
del Coletivo salen con una mejor comprensi6n de
sus cuerpos y de su sexualidad; la clinic hace
incapi6 en la prevenci6n y el nso de remedies natu-
rales para reducir la dependencia en teenologia y
drogas.
En la actualidad el Coletivo cuenta con un
edificio propio y un equipo permanent de 11
miembras que sirven a unas 2,500 mujeres por afio.
Las actividades se dividen en cinco nimbitos: servi-
cios clinics, programs educativos, capacitaci6n,
asesoramiento legal e investigaci6n. Los servicios se
cobran en base a los ingresos del client; dados los
problems econ6micos de Brasil, estos ingresos s6lo
represented el 17% del presupuesto total del
Coletivo. El prop6sito del coletivo siempre ha sido
crear un modelo de la calidad en la atenci6n, no uno
de autosuficiencia econ6mica, por lo cual la clinic
sigue dependiendo del apoyo de agencies donantes.
Los anticonceptivos orales y la esterilizaci6n
representan el 85% del uso total de anticoncepci6n
en Brasil; los otros m6todos easi no existen. Para una
clinic que buscaba proveer verdaderas opeiones
anticonceptivas, esta era una situaci6n inadmisible.


No obstante, result inuv dificil ofrecer otros mIto-
dos en Brasil: las mienmbras tulieron lque buscar los
pocos sitios en el pais done se ofrece capacitaci6n
en la inserei6n de DIUs.
Las miembras del Coletivo taibi6n querian
powder ofrecer el diafiagma. No sl6o les preocpalba
el elevado nimero de muneres que dependent de
anticonceptivos orales a pesar de presenter con-
traindicaciones para el uso de la pildora, sino que
querian powder ofrecer una opci6n anticonceptiva
que fuiera facil del iniciar y dejar a corto plazo, a la
vez que ofreciera un nivel de protecci6n contra
infecciones (siempre \ cuando se lo utiliza con
espermicidas). El arglmento tipico en contra del
diafragma es que para asegurar el uso correct se
require demasiado tiempo para la orientaci6n ini-
cial de la usuaria. Pero al Coletivo le sobra el tiem-
po. Las visits iniciales duran en promedio una hora,
y las siguientes tipicamente alacanzan los 30 minu-
tos. Aunque muchos programs de planificaci6n
familiar no podrfan aceptar este tipo de horario, el
personal del Coletivo cree esta es la unica manera de
powder explorer todas las inquietudes te las ususarias,
educarlas sore sus propios cuerpos, fauniliarizarlas
con los servicios disponibles en la clinic y establecer
una relaci6n de confianza.
Esta inversion en tiempo ha dado buenos
resultados. Hoy en dia casi el 40% de las mujeres
que buscan un metodo anticonceptivo en el Coletivo
piden el diafragma, y muchas de estas vienen referi-
das de otras clinics. Como respnesta al creciente
interns en este metodo v en el enfoque particular de
la clinic, el Coletivo lha empezado a ofrecer cursos
de capacitaci6n para profesionales de salud que
\ienen de otras parties del Brasil y Am6rica Latina.
El Coletivo tambien realize investigaciones
con el prop6sito de documentar el exito de sus prac-
ticas. Recientemente la clinic tom6 parte en un
studio sobre la utilizaci6n del diafragma (con dos
otras clinics) que encontr6 una taza de embarazo
de s6lo 6%-un nivel much menor al de la pildora
en Brasil. Como parte de la preparaci6n de este fol-
leto el Coletivo tambien particip6 en various estudios
que demostraron que la inversi6n de tiempo hecha
por la clinic result costoeficaz cuando se la mide
en t6rminos de la utilizaci6n exitosa de anticoncep-
tivos y la satisfacci6n de las usuarias.
El Coletivo sigue creando nuevas maneras de
proveer servicios e involucrar a las mujeres en el
cuidado de su propia salud. A trav6s de su trabajo,
las integrantes del Coletivo nos demuestran lo que
se puede lograr si estamos dispuestas a aceptar el
desaffo.






Resume en FranCais


Autrefois, les programmes de planification
familiale avaient pour but principal de reduire la
croissance excessive des populations, faisant des
femmes l'objet de politiques medicalisees et de pro-
granmmes destin6s a r6glementer leur fertility. Suite
a la r6cente Conference Internationale sur la
Population et le D6veloppement (Le Caire 1994), la
necessity d'une approche plus global concernant la
sant6 g6n6sique (reproductive) a 6t6 largement
endorse. Cependant, nombreux sont ceux qui se
demandent comment s'v prendre. Cette edition de
Q/C/Q document experience d'un group de
femmes br6siliennes qui, unies dans la recherche
alternatives aux soins medicaux destines aux
femmes, ont fini par ouvrir leur propre clinique.
Les membres de Colectivo ont pass des
ann6es a faire des recherches, parlant aux femmes
de leur sant6 et relevant la formation n6cessaire
pour offrir a celles-ci des soins comprehensifs de
sante reproductive. Pour la plupart des femmes du
Br6sil, une visite chez le gyntcologue (presque tou-
jours de sexe masculin), est line experience telle-
ment desagreable que Colectivo a decide de former
des personnel qui ne sent pas du metier, a donner,
avec l'appui de femme-m6decins, de simples exam-
ens medicaux. Leur approche reconnait que les
besoins des femmes dans ce domaine, sont directe-
ment relies a leur sexuality, leurs roles sociaux, leurs
activists 6conomiques et leur bien-&tre 6motionnel.
Ainsi, les clients de Colectico quittent la clinique
avec une meilleure comprehension de leur corps et
de leur sexuality. En outre, Colectico met l'accent
sur la prevention et I'utilisation des remedes
naturels afin de r6duire l'extr&me d6pendance sur la
technologies et les drogues.
Aujourd'hui Colectivo possede ses propres
batiments et emploie 11 membres qui servent pres
de 2500 femmes chaque ann6e. En g6n6ral, les
activities sont divisees en cinq sections: les services
cliniques, les programmes 6ducationnels, la forma-
tion, les plaidoiries et la recherche. Les problimes
6conomiques du Br6sil 6tant pris en consideration,
les honoraires des clients sont calculus selon leur
pouvoir d'achat, et, repr6sentent seulement 17
pourcent des revenues. Cependant, le but de
Colectivo a toujours et6 de cr6er un module de qual-
it6 des soins et non un module d'auto-suffisance. Par
consequent, I'organisation continue a dependre de
l'assistance des bailleurs de fonds.
Au Br6sil, les autres m6thodes n'6tant pra-
tiquement pas disponibles, les contraceptifs oraux et
la st6r6lisation repr6sentent pres de 85 pourcent de
l'ensemble des diff6rents contraceptifs utilis6s. Ceci
n'otait pas acceptable pour une organisation qui a
come but de donner des options aux femmes. Mais
offrir d'autres m6thodes au Br6sil n'6tant pas facile,


les membres ont du rechercher in ou deux endroits
dans le pays oil une formation en insertion des DIV
6tait disponible.
Colectivo 6tait egalement decide a rendre le
diaphragme disponible a ses clients. Elle 6tait non
seulement concernee par le grand nombre de cas de
contre-indications pour les femmes utilisant la
pilule, mais elle voulait aussi offrir aux femmes une
option leur permettant de commencer oi d'arr@ter
volontairement une m6thode; m6thode qui dans ce
cas, pourrait offrir une protection centre les infec-
tions lorsqu'elle est utilis6e avec un spermicide.
Argument g6n6ralement utilis6 centre le
diaphragme est que le temps pris pour former les
femmes a sa bonne utilisation est trop long. Mais le
temps n'est pas un probl me pour Colectivo. Les
premieres visits prennent en moyenne une heure
et les visits suivantes a peu pres 30 minutes. Alors
que de nombreux programmes de planification
familiale considbrent ce lapse de temps pen efficace,
le staff de Colectico le croit indispensable pour que
les clients puissent explorer, de manibre satis-
faisante, toutes leurs preoccupations, apprendre a
connaitre leur corps, d6couvrir les services qui leur
sont disponibles et 6tablir une relation de confiance
avec les membres de la clinique.
Cet investissement en temps vaut la peine.
Aujourd'hui pres de 40 pourcent des clients pour la
contraception demand le diaphragme et Colectico
recoit maintenant de nombreuses recommendations
des autres cliniques. En r6ponse a l'int6ret accru
pour cette methode, ainsi que leur approche centre
sur la client, Colectico offre maintenant plusieurs
course de formation pour les professionnels en soins
de sant6 qui viennent d'autres regions du Br6sil et
de l'Amnrique Latine.
Colectico entreprend 6galement des
recherches pour documenter le succes de leur
approche. Rkcemment, elle 6tait un des trois sites
choisi au Br6sil pour participer a une 6tude sur I'u-
tilisation du diaphragme, une mithode qui a un taux
d'echec de seulement 6 pourcent taux beaucoup
plus bas que celui de la pilule. Comme parties inte-
grante au processes de d6veloppement de cette
publication, Colectivo a 6galement particip6 a de
simples 6tudes de recherche qui ont demontr6 que
son investissement initial en temps 6tait en fait effi-
cace au niveau coit, particulierement quand on le
measure en terme de l'utilisation r6ussie d'une m6th-
ode et de la satisfaction du client.
L'Entreprise Collective sur la Sexualit6 et la
Sant6 des Femmes continue a &tre une pionniere
dans les nouvelles manieres d'offrir des services et
d'amener les femmes La tre plus responsible de leur
sant6. A travers son travail, elle nous montre ce qui
est possible si nous sommes pretes a reliever le d6fi.







About the Authors


Debbie Rogow is a senior consultant to international reproductive health
organizations. Margarita Diaz is a practicing registered midwife who has worked
in research and training in the areas of family planning and sexual health in Chile
and Brazil; she currently heads the Education, Training and Communication Unit
at CEMICAMP in Brazil. Jos6 Barzelatto is Director of the Reproductive Health
and Population Program of the Ford Foundation which focuses on social, cultural
and economic factors affecting improved reproductive health and sexuality.




QualitylCalidadlQualit6 Advisory Committee


Ian Askew
Karen Beattie
George Brown
Judith Bruce
Ethel Churchill
Adrienne Germain
Joan Haffey
Margaret Hempel
Ann Leonard
Magaly Marques
Margaret McEvoy
Kirsten Moore












Design:
Cover Photo:
Typography:
Printing:


Nancy Newton
John Paxman
Geeta Rao Gupta
Debbie Rogow
Jill Sheffield
Cynthia Steele Verme
Lindsay Stewart
Kerstin Trone
Nahid Toubia
Gilberte Vansintejan
Beverly Winikoff
Margot Zimmerman












Ann Leonard
Pamela Duffy
Line & Tone Group, Inc.
Graphic Impressions


We invite your comments and your ideas for projects which might be included in
future editions of Quality/Calidad/Qualiti. If you would like to be included on our
mailing list, please write to Ann Leonard, Quality/Calidad/Qualite, The Population
Council, One Dag Hammarskjold Plaza, New York, N.Y. 10017, U.S.A.


























































































































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