Title: Addressing Gender Issues with Men and Couples in a Reproductive Health Service in Ecuador: A Case St
1Addressing Gender Issues with Men and Couples in
a Reproductive Health Service in Ecuador A Case
Study in Organizational Change
- Bonnie Shepard, Senior Program Manager
- International Health and Human Rights Program
- François-Xavier Bagnoud Center for Health and
Human Rights
2Ecuador
- Small, but geographically and culturally diverse
- 13 million population, 37 rural
- 35 indigenous minorities
- Low-income country
- 52 earn less than US2 a day
- Reproductive health
- Maternal mortality 210 infant mortality 33.4
- Fertility rate 2.87
3Institutional context
- APROFE IPPF affiliate in Ecuador
- 20 clinics in 15 cities and towns
- Mainly serves urban and peri-urban population
- Now serves low-middle income strata
- Withdrawal of external funders
- Main support historically came from USAID, and
from IPPF
4APROFES GOALS
- Increase sustainability by increasing numbers of
paying users - Implement IPPF Vision 2000 and ICPD/Beijing
principles - Comprehensive approach to health
- Respect for reproductive rights
- Commitment to womens empowerment and male
involvement
5APROFEs strategies 1990s
- Increase numbers of paying users
- Diversification of services (including sexual
health) - Increased marketing
- Quality of care with a gender framework
- Male involvement
- Serving couples, and increasing numbers of male
users - Implement IPPF Vision 2000 and ICPD/Beijing
principles - Train providers in gender issues
- Quality of care training emphasizes respect and
warmth - Treat the whole person through diverse services
6Gender-related health risks
- Male norm of multiple partners
- Male work entails travel away from home
- Low priority to women and girls in allocating
food - Violence among men, risk-taking behavior
- Violence against women, coerced sex
- Mens reluctance to seek health care
- Lack of male involvement in FP
- Women have sole burden of housework and child
care, less leisure than men
7Gender-related Obstacles to Increasing of Male
Users
- Stereotyped attitudes towards Men
- Male Attitudes to Health Care
- Child Care
- Men demand higher quality of care
8Male Involvement in APROFE
- Male clinic 1991-1993 a failed strategy
- under-used
- Image of APROFE as women-only
- resistance to vasectomies
- Donors mainly interested in CYPs
- sex segregation
- Impractical surgical facilities in female
clinic, and women invaded male clinic - Unnecessary Men expressed no need for it
- Not conducive to sexual health, which mandates
treatment of couples
9Broader Focus for Male Involvement mid-1990s
- From FP and CYPs to reproductive and sexual
health, gender equity - Focus group study 1997
- Men didnt want male clinic. They wanted quality
care and friendly treatment - Low opinion of APROFE services felt excluded.
- Need was established multiple partner norm, high
risk before marriage, low acceptance of FP methods
10Strategies for Male Involvement
- Jan. 1998 protocol to encourage involvement of
female users partner - Media campaigns stressing services for both men
and women (1996) urology services (2000) - Changes in hours, appointments
11Success in Increasing Numbers of Male Users
12Indicator of couples served
- 1999 to 2000 of couples served doubled in the
4 clinics in the study - 2001-2002 In Guayaquil clinics, of users
increased by 11, while of couples seen
increased by 74.
13Indicators in Incorporating Gender Frameworks
- Indicators for providers
- 1st stage Accept social construction of gender
roles - 2nd stage Understand risk factors and gender
- 3rd stage Actively promote gender equity
14Treating the Couple and Gender Issues
- Balancing male involvement and users rights to
privacy - Need to ask users consent in private
- Diplomacy and subterfuge needed sometimes in
order to speak to women privately - Need to ask consent at each stage teamwork
essential - Dealing with patterns of male domination
- Providers encouraged women to speak
- Some providers advocated on behalf of women to
get men to accept treatment needs
15Practical vs. strategic gender interests in
sexual health
- Practical interests are short-term, solvable
- e.g. curing an STI, providing information to help
prevent a future STI - Strategic interests are root causes
discrimination, power imbalances, and sexual
gendered norms - e.g. addressing inequities in gender roles that
put women and men at risk of STIs
16APROFEs Achievements in Addressing Practical
Interests
- With most couples, practical interests addressed
- Standard approach
- focus on treatment, not blame future, not past
- referrals for counseling
- Barriers
- Highly emotional situation
- Patterns of male domination made treatment
impossible in some cases
17Lessons Learned on Male Involvement with Gender
Equity
- Personal invitation by female partner most
effective in increasing mens clinic usage - Educational outreach necessary to fully address
strategic gender interests - Continuous quality of care supervision and
training needed