Building Women’s Citizenship
On a hot, dusty day in the middle of a long drought, I attended a day-long assembly convened by the Ministry of Health’s Reproductive Health and Family Planning Program in Chulucanas, the provincial seat of Piura, Perú. The bare auditorium with wooden seats had no ventilation, and held about 200 people mostly women wiping sweat from their brows and fanning their faces with whatever pieces of paper were at hand. Present were more than 100 representatives of the Rural Women’s Networks from throughout the rural region of Alto Piura, all of the midwives and some health authorities of the zone, municipal authorities, and NGOs. The 1995 meeting was called to present the findings of a participatory evaluation on the quality of the women’s health services in the public sector, part of a national experiment in women’s participation in the health sector. The evaluation, conducted by a local NGO, included surveys of health providers and clients, as well as observations in health centers. It is a testimony to these women’s commitment to dialogue that in spite of the oppressive heat, most of the participants were still in the auditorium, talking with each other, at the end of the day.
Notable among the women’s findings were the presence of some new issues related to reproductive health, not traditionally addressed by the health services problems within the couple, and domestic violence. After both providers and women’s organizations had noted the need to provide a more holistic service, the midwives presented their work plan for the year: two Pap smear/cervical cancer prevention campaigns and two sterilization campaigns, at appropriate 3-month intervals. (In Peru, a “campaign” is usually modeled on the traditional vaccination campaigns, aiming for maximum coverage over a limited space of time, and waiving the usual fees for the services.) An NGO representative got up after this presentation and said, “Wait a minute. What does this have to do with everything we just heard?” After all, what was the point of having this evaluation, if the work plans were already set in stone before the meeting? In the ensuing discussion, it soon became clear that little could be done; the mandates for the campaigns came from the central authorities in Lima.
Further dialogue revealed serious ethical problems with the cervical cancer campaigns, in particular because of user fees. The drought meant many campesino families were desperately short of cash. The women in the assembly complained that while the Pap smear itself was provided free during the campaigns, they had to pay for the return visit to learn the results, and some testified that they had returned home without their reading. While this meeting did not discuss the ethical problems in the sterilization campaigns, chilling accounts of coercion emerged shortly thereafter. While the outcome of the meeting was inconclusive and frustrating, it was just the beginning of a longer process of change.
The meeting in Chulucanas took place at the end of the first phase of a five-year program in Perú organized by Consorcio Mujer. Similar evaluations and dialogue meetings took place in 1994-1995 in Cusco, Tarapoto, and in three low-income neighborhoods in Lima. From 1996-1999, the program trained both women’s organizations and providers in concepts of users’ rights, and helped them to design joint work plans to improve the quality of a key health center, usually one that was to serve as a “hub” under the ever-evolving decentralization plans of the Ministry of Health. At the time, I was closely connected with the Consorcio Mujer program as its funder. I was the Program Officer for the Ford Foundation in Santiago, Chile, where I was in charge of the sexual and reproductive health program for the Andean and Southern Cone Region.
I had many conversations with the Peruvian women’s organizations about the theoretical and political framework for the Consorcio Mujer program. We saw this effort as an experiment in ways to encourage a transition to democracy in the health sector, just as similar transitions were occurring in the political realm in many countries in Latin America. We recognized that many efforts in the public health and population fields have been devoted to working with health providers and family planning services to improve quality of care and respect for individual rights. On the other hand, only feminist and some community health NGOs have worked consistently on transforming the “demand side” of the system the users. In the traditionally vertical context of a biomedical setting, both providers and users are prisoners of unspoken assumptions and corresponding roles in a paternalistic system.
The shift to a more democratic system entails greater consciousness of and respect for users rights on the part of providers, and both consciouness of rights and the ability to demand respect for these rights on the part of users. To achieve this shift, a profound process of questioning of assumptions and attitudes on both sides is necessary. Programs may implement more conventional measures such as changes in indicators of quality, mechanisms for user feedback and community involvement, and greater quality-related incentives, but changes in attitude are fundamental. Furthermore, few examine how health sector reforms and the financing of services create incentives and disincentives that affect quality and respect for users rights. How can programs help users construct their identities as citizens with rights, so that they demand their rights and recognize violations of rights? How can programs help health providers respect these rights within the framework of improving quality, and help them be more receptive to horizontal relationships with users? The Consorcio Mujer program was designed to respond to these questions.
When adequate health care is framed as a basic human right, the whole dynamic surrounding attempts to improve quality of care changes. Under the paternalistic model, health services benefit users, and health providers are doing low-income people a favor by serving them. It is viewed as extremely bad manners to complain about the quality of favors received. In a citizenship model, the service is a right, not a favor, and users have the right to decent quality as well. In the paternalistic relationship of provider and patient, the provider knows what is best. In a democratic relationship of equals, the user has a right to information, and participates actively in health promotion with the providers. Several quotes from the training courses throughout Perú illustrate this shift.
“Before the providers were the authority, and the patients asked us to help them as a favor. Now we say, “We are employed thanks to the patients.” Clinic Director, Lima
“Now we can complain and denounce mistreatment.. We communicate with the superiors.” Leader, women’s group, Tarapoto
Pilar Puente, the former project coordinator in Piura, described the process in the users’ training workshops: “What is new about the module is the concept of citizenship and rights. While the women [community health promoters] already had some idea of these concepts, now they were able to internalize them. The women reflected deeply. At the beginning of the training, they said that the quality of the services was just fine. Then, as we probed more into the different aspects of users rights, the incidents of violations emerged- having to do with lack of privacy, inadequate information, mistreatment. At the beginning, I didn’t think that the women were going to open up, but I was wrong. Little by little, they began to talk about everything they had left unsaid, and to express it with all their emotions. One woman wept as she described how she had been humiliated.”
This process Puente describes is a vivid reminder of the limitations of user surveys in health care; when women have low expectations, little consciousness of their rights, and low self-esteem, they are not apt to express dissatisfaction with services. She also illustrates the psychological/social aspect of the processes of change leading to more democratic cultures; feminists and human rights activists in Latin America describe this aspect as “constructing oneself as a bearer of rights (sujeto de derechos).” Some more prosaically refer to constructing “self-esteem,” but the psychological community-based goal is more than that, since the change process is not just individual, but involves recognizing oneself as part of a group (citizens, women, low-income neighborhoods, youth, etc.) with rights. Constructing democratic cultures involves transforming both governments and the populations they govern, both health systems, and those they serve, on many levels. The social and cultural levels leading to recognition and defense of citizen rights are a necessary part of the change process.
Bonnie Shepard was a Visiting Fellow at DRCLAS from 1998-2000 and conducted research with support from the Ford Foundation for a more comprehensive case study based on the Consorcio Mujer programs and other programs in the Andean and Southern Cone Region. She is now a consultant, a member of the Board of Directors of the Boston Women’s Health Book Collective, and a Visiting Fellow at the François-Xavier Bagnoud Center for Health and Human Rights in the International Health and Human Rights Program at Harvard School of Public Health. She can be contacted by e-mail at «BonnieShepard@alumni.ksg.harvard. edu>.
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