Implementing the ICPD Paradigm Shift in the Pakistani Context: Challenges of Gender, Power and the Health System

Ali M. Mir, Population Council

IMPLEMENTING THE ICPD PARADIGM SHIFT IN THE PAKISTANI CONTEXT: CHALLENGES OF GENDER, POWER AND THE HEALTH SYSTEM The very essence of the Cairo agenda is its call for a client-centered approach. The aim is to move away from macro concerns and those with contraceptive use and fertility reduction targets to meeting needs of individuals. The other important component of the paradigm shift is to incorporate reproductive health concerns and to move away from the provision of family planning services or maternal health each by themselves. An overarching concern throughout the ICPD agenda is the importance of empowering women as a goal in itself but also to ensure that they are able to meet their reproductive health needs. Pakistan has among the worst reproductive health indicators in the developing world. Access to health and family planning facilities especially in the rural areas has remained outstandingly weak. Maternal and infant mortality rates are unacceptably high at above 300 per 100,000 and 80 per 1000 births, respectively. Furthermore, the gap between contraceptive use and the desire to space or limit births at well above 33 percent is amongst the world’s highest. Women in Pakistan face greater obstacles than men in being able to address their general as well as specific reproductive health needs. Research within Pakistan as elsewhere has demonstrated that there is a link between women’s autonomy decision-making, mobility and reproductive health outcomes (Casterline et al 2001, Mahmood and Ringheim 1997, Jaffarey and Korejo 1995). A “new” approach to traditional family planning programs Pakistan, a typical developing country has family planning services, which are of poor quality, traditionally provided by the Ministry of Population welfare outlets and not integrated within the general health care system. The system pursues targets to monitor performance of the family planning program, and women’s autonomy is weak and mobility limited, both associated with unmet reproductive needs and poor reproductive outcomes. It is in such a setting that implementing the ICPD paradigm shift and operationalizing its main features within the public service delivery system is a formidable challenge. This paper will describe an intervention introduced in 1999 –2000 within the public health system in Sargodha, a typical district in Pakistan. The intervention comprised of a special training , which attempts to bring about a behavioural change in providers in clinics and in the community to do the following: 1. Assess household gender and power relations to empower women to meet their own reproductive needs 2. To be more client centered in addressing their clients’ family planning intentions and limitations (financial, familial etc.) 3. To address a broader range and larger number of reproductive health needs rather than family planning alone For the first objective, the innovation here was to broaden the approach from the concept of quality of care which traditionally assesses services availed by clients once they access a provider (Bruce 1990) to incorporate elements of perceived quality of services on the part of the clients, which prevents them from utilizing the services at all. Therefore, improving quality of services also requires addressing some surrounding elements such as gender relations and power structure in the household. Thus perceived needs and perceptions about availability and quality of services among clients are as important as among their families. The training was designed to address the issue of making providers recognize the power structure existing within clients’ households and to learn to confront it in order to address women’s reproductive health needs. The second objective addressed a major challenge within the current public service delivery system, which is to dismantle existing power relationships between providers and clients mainly through changing the nature of their interaction. Most often the power relationship between the providers and their clients acts as a barrier that prevents clients to be able to fully discuss and describe their needs. This social distance between clients and providers is rooted in the training received by doctors and paramedics in most countries, especially Pakistan. Even providers who have been taught in the art of counseling for provision of family planning services subscribe to the school of thought that holds clients to be ignorant, who have to be informed. Therefore the emphasis is on telling the clients what to do, rather on asking and assessing their situations. Providers in clinics were taught communications skills of listening and of allowing two way discussion and negotiation. In community based settings providers visit the homes of the clients the interaction is governed and influenced by almost similar constraints that are observed at the static facility level. At the community level due to the similarity in the social status of the clients and the providers the social distance between them is less to contend with. However as doctors who are based in the static facilities train the community-based providers, they too assess and address client needs by following the traditional medical model. In addition, within the client’s home the interaction is also influenced by the presence of friends and family, the general lack of privacy and in general how family members perceive the provider. Once again providers were taught to incorporate the opinions, and conversations with other family members. To achieve the third objective, the intervention took advantage of some of the emerging opportunities in 1999-2000 offered by the integration of services of the traditionally separate Ministries of Health and Population Welfare. The Population Council intervention was one of the first instances where providers from both ministries were trained jointly in providing a client centered approach to reproductive health services. Providers from the two ministries were taught the advantages of combining family planning with safe motherhood and infant health, and to move away from their traditional areas of concentration. New approach to evaluating quality of care in family planning programs The intervention is an operations research project with a substantial component of research in the intervention and control sites. The paper proceeds in its second section to discuss some of the research findings based on data collected through a) situation analyses b) community surveys and c) qualitative interviews and observations in both intervention and control areas. The emphasis here is to discuss the validity of traditional methods of evaluation and the possibility of using other means to evaluate behavioural changes associated with this particular intervention. Situation analyses have been used extensively in family planning research to observe and evaluate provider –client interactions and to conduct provider interviews. We did a baseline and a follow up situation analysis in the intervention and control areas to see if there were any signals of change in attitudes and behaviour after the training While the results are plausible there is strong reason to believe that new instruments and approaches may be required to assess changes in behaviour such as areas of power in the household, key decision makers in the household, application of negotiation skills, and respect for client’s rights and dignity, which are outside the scope of traditional surveys and questions of quality of care. In other words, innovative approaches to family planning service delivery may call for a revisit of traditional instruments of enquiry such as surveys and situation analyses. References Bruce, J. (1990) “Fundamental elements of the quality of care: A simple framework”. Studies in family planning 21,2:61-91 Casterline J.B., Sathar, Z.A., Haque, M.U. (2001) “Obstacles to Contraceptive Use in Pakistan- A study in Punjab” Studies in Family Planning” 32,2:95-111 Mahmood, N. and Ringheim, K. (1997) Knowledge approval and communication about family planning as correlates of desired fertility among spouses in Pakistan International family Planning Perspectives 23(3): 122-129 Jaffarey, S.N. and Korejo, R., (1995) Social and Cultural factors leading to mothers being brought dead to hospital International Journal of Gynecology and Obstetrics Suppl (2): 97-99