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Transforming relationships in Pakistani Villages.

For several decades, the government of Pakistan has invested extensively in developing its capacity to provide reproductive health services. Nevertheless, relatively few women currently use such services within the public sector. Only a minority of women undergo antenatal checkups, and fewer than one in five give birth with the assistance of a trained attendant. In addition to its maternal health services, Pakistan launched a formal family planning program in the early 60s. Nearly 35 years later, however, less than one woman in three practices contraception (UNFPA 2003). Still fewer seek medical care for reproductive tract infections.

This low rate of use does not reflect women's stated reproductive desires: For example, for every woman who practices contraception, three more express a desire to control their childbearing but are not using the services of clinics or of community-based workers. Not surprisingly, Pakistan has a high birth rate as a result, as well as a high rate of clandestine abortion. Unsafe abortion accounts for one in every eight maternal deaths in Pakistan (Fikree 2002).

Pakistani women's access to reproductive health services is limited by several factors, most notably by social barriers. Many Pakistani women lack power within their marriages to make decisions about whether to practice contraception or to seek antenatal care. This fundamental restriction is strengthened by distance from services: More than two-thirds of women who do not use contraceptives live over two miles away from a known service source (Sathar and Casterline 1998). A further impediment to care-seeking is women's perception that they will be treated poorly at the government clinics, where dismissive and rude providers are the norm. (See following section for a more detailed discussion of barriers to care.)

In the past, the government has carried out a variety of initiatives aimed at increasing contraceptive use. These include public information campaigns; demographically driven approaches to family planning, including targets and incentives; technical skills training for providers; improvements in logistics; and the introduction of new contraceptive methods. A key strategy has been the establishment of an extensive system of community health workers to provide basic health services, including family planning, at the village level.

Nonetheless--and Pakistan is not alone in this regard--such conventional interventions have made little more than a dent in contraceptive rates. Senior officials from the Ministry of Health and Population Welfare realized that they had to consider new measures to prevent pregnancy-related deaths by providing women who do not want to become pregnant with the means to control their fertility.

Zeba Sathar, the Population Council Director for Pakistan, believed that innovative strategies were needed to facilitate women's ability to overcome the sociocultural barriers that prevent them from accessing care, avoiding unwanted pregnancy, and protecting their own general health. Together with her colleague Anrudh Jain, at the Population Council, Sathar worked with government officials to design an intervention unlike any that had been conducted in Pakistan. Instead of tinkering with supply systems, new technologies, or target-based approaches, this initiative sought to change the manner in which providers interact with both their clients and coworkers. What made it even more unusual is that it addressed the central issue of social power in care-seeking, in care-giving, and, of course, in negotiating desired outcomes, such as use of reproductive health services. This story describes that intervention and its outcomes, emphasizing the transformation of service provision that resulted at the community level.

Why Services Were Failing

According to Jain and Sathar, the series of barriers that constrain women's use of reproductive health services in Pakistan stretches from home to clinic and back. The entire continuum is characterized by women's lack of social power. First, both men and women have been socialized to place a low value on women's health needs. Additionally, in most marriages, the woman typically must defer to her husband and/or mother-in-law regarding decisions about her own health care, including whether to practice contraception. (For example, among women who want to postpone or terminate childbearing in Punjab, Pakistan, 40 percent cited their husbands' fertility preferences and/or perceived opposition to family planning as the obstacle to their practicing contraception.) Moreover, social customs and limited access to cash for transportation often prohibit her physical mobility outside the household.

Power differentials also characterize the care provided by clinic and community-based workers. Typically, providers are condescending and abrupt with clients; visibly poor clients receive the worst treatment. Providers often interrupt and make treatment suggestions based on little or no real communication with the client. Moreover, the recommendations may be inappropriate to the woman's situation. In short, the clients perceive many providers as rude and incompetent, while providers may view clients as an unpleasant nuisance. (1) The only thing about which they seem to agree is that the provider holds the power to shape the interaction.

Sathar and Jain argued that women were not likely to use health services without addressing the two central obstacles in their way--social constraints and poor treatment by providers. They met with senior officials from the Ministry of Health and Population Welfare--Dr. Naushaba Chaudhury, then Director General at the Ministry of Population Welfare, and Dr. Reza Zaidi, Deputy Coordinator of the National Program for Family Planning and Primary Health Care--about tackling these obstacles directly. Fortunately, the concurrent reorganization of the Ministries of Health and Population Welfare created an openness to trying new approaches, and the government agreed to collaborate with the Council on an ambitious training program. As Sathar explained, "We wanted to address psychological, social, and physical access. We had to concern ourselves with enhancing women's power in the family, for example, seeking the support of family members, so they could seek care in the first place. We also had to transform the client-provider relationship, which included challenging providers' power over clients."

Jain and Sathar understood that power dynamics also characterized the relationships between providers at different levels within the hierarchy. Senior staff typically speak in a rude and authoritarian manner to their supervisees. Anecdotal reports indicated a problem with sexual harassment in some sites. Moreover, lower-paid staff are generally excluded from any role in decisionmaking. As Sathar explains, "Our premise was that workers who feel powerless treat their clients poorly in turn; hence, there was a need to foster critical thinking among the staff about the entrenched social dynamics in their hierarchal relationships with each other."

Sathar stresses that it was necessary even to consider how power dynamics affected the personal lives of staff members outside of work. After all, female staff members go home every day to domestic situations in which their actions are typically circumscribed by their relationships to their husbands and/or extended families. Sathar recalls, "We were focusing on social power in a range of contexts."

In this way, the government embarked on a behavioral change training program for providers that went beyond typical counseling skills to include a focus on recognizing power dynamics in a range of human relationships. The objective was for trained providers to develop greater awareness about their interactions with other human beings; the desired outcome was for them to offer their clients greater respect and more useful support for meeting their reproductive health needs. Although providers at all levels were trained, the community-based workers who make home visits constituted the majority of trainees.

Establishing Consensus on the Team

The government asked the Population Council to design and test the intervention with public-sector workers in Punjab province. Jain helped shape a hypothesis, plan of action, and evaluation elements to ensure that the intervention was practical and could produce useful research findings. (2) Sathar put together a team comprised of five Council staff, four of whom were physicians originally from either the public sector or from nongovernmental organizations (NGOs).

Initially, the medically oriented intervention team expressed hesitations about focusing on the client-provider relationship; instead, they leaned toward a technical course aimed at upgrading providers' technical skills. In the hopes of resolving this conflict and building consensus, Sathar organized role-play exercises in which she, Jain, and the team members enacted a series of typical public-sector encounters. They based their vignettes on their own experiences of observing workers or as patients.

For one such exercise, the two junior members of the team enacted a recent actual encounter one of them had experienced with a doctor. The "patient" expressed concern about a skin blemish. The "doctor" glanced at her blemish and wrote a prescription for a face cream without looking back at the client or offering instructions about how to use the cream. The patient, an educated professional in the health field, left without understanding what the rash was or how to treat it--and felt frustrated. This simple example from their colleague's own experience enabled the physicians to see that such interactions are neither uncommon nor acceptable and may bear no relationship to the provider's technical competence.

The team developed a list of the behaviors exhibited during the visit of an ordinary female client. They observed that staff spend very little time with the woman; make no effort to learn what her problem is; speak to her in a judgmental tone; blame her for her situation; do not inquire about her home situation to assess what will work best for her; do not listen; do not provide her with choices; do not check to make sure that she understands instructions; and say nothing supportive to her.

In reflecting upon the interaction, the team had to acknowledge that doctors are far more likely to display negative behaviors than are lower-paid providers such as village workers, who are closer in social class to their clients and who reside in the same communities where their clients live. The doctors on the team also recognized that they had never been taught how to interact appropriately with patients.

The intervention team learned that the client-provider interaction is, in essence, an unacknowledged power relationship and reached a consensus that training should focus on improving these interactions by teaching interpersonal awareness communication skills, paying special attention to power in relationships. The training would reach all levels of staff, from supervisors and physicians to lady home visitors.

Because the village-based workers were both greatest in number and the most open to the ideas presented in the training, this effort became a community-level activity. Hence, this article focuses primarily on those workers and how they were transformed by this intervention.

Laying a Foundation for the Training

After reviewing a range of training resources, the team tailored a workshop specific to its goals and to the cultural setting. The Population Council turned to Rozan, a local NGO that had conducted training for health professionals and police officers on how to interact with the public. Public health employees, like police offers, are considered to be more powerful than the public they serve and are often perceived in a negative light.

Ambreen Ahmed, a psychologist at Rozan, and her colleagues taught their behavior-change model to the Council's intervention team (see box below). Going into the Rozan workshop, most of the Council team was highly skeptical about the usefulness of "consciousness raising about interpersonal power" as a stimulus for the kind of the changes they hoped to promote among public servants. At the end of the five-day workshop, however, they were convinced that the Rozan behavior-change training was effective. They set about adapting the exercises for reproductive health providers.

The team's next step was to identify specific, teachable behaviors to help providers to: (1) "humanize" their relationships; (2) assess the social context--including dynamics of power and gender--in which a client lives that governs her ability to seek care; (3) help a client define her own sexual and reproductive choices; and (4) in some measure empower her to implement her decision.

The team wanted a model that would guide staff in executing these behaviors and that went beyond existing communication models for improving client--provider interactions. The model they developed--practical for use in any kind of health service--is called SAHR. SAHR means "dawn" in Urdu, suggesting a new beginning for providers. More importantly, SAHR is an acronym for a list of sequential behaviors:

* Salutation refers to overall rapport building: greeting the client, inquiring about her well-being, about her family members, how she traveled to the clinic, and other culturally appropriate questions to generate warmth and build the confidence necessary for any authentic interaction. The word "salutation" also implies respect, for example, by sitting at the same level with the client, whether on a chair or (in the community) on the ground.

* Assess implies going beyond simply asking about the client's immediate medical needs to seeking understanding of the issue in a wider dimension. For example, community workers should observe the nature of relationships between various family members, so that they can identify potential gatekeepers or allies whose support will be important in allowing the client to adopt the plan she wants. This approach acknowledges existing power relationships within the family, but at the same time, empowers women to capitalize on these relationships in ways that allow them to meet their health needs in the short run.

* Help the client by providing relevant information, choices, and support for making and implementing her own decision. Most providers need to learn how to assist the client to sort through information and enable her decisionmaking. Information that the providers supply can help to empower clients when they try to convince uncooperative family members about the choices they would like to make.

* Reassure by informing the client that a decision or solution can be renegotiated if the current option does not work; the provider can give referrals, suggest a return visit, and offer supportive messages (for example, she or he will talk to family members who may present obstacles).

Simply put, SAHR is a model that emphasizes dynamics of social power and assists providers in helping clients sequentially to meet their needs. The commanding principle is respect for the equality of human beings and an awareness of the ways in which equality is constantly being undermined.

Implementing Staff Training

Drawing from the Rozan workshop, the Population Council team developed a five-day participatory curriculum to help participants (1) become more aware of social power in general; (2) improve the quality of their interactions with clients; and (3) improve their relationships with each other. They tested the entire course and materials (and rehearsed their own delivery) in a pilot workshop for staff in two districts, then refined the curriculum. Subsequently, the team conducted nine additional workshops for a maximum of 25 trainees per group, reaching a total of 180 staff. The majority were community-based workers, although their supervisors, together with doctors and other providers, accounted for a third of the group. Some highlights from the curriculum are described here:

Helping Participants Become More Aware of Social Power in General

The trainers presented an overview of how power operates in Pakistani society and how this power is reproduced in human relationships. Participants enumerated various sources of power, including knowledge or skills, experience, physical strength, wealth, social class, and official status; in some of the workshops, participants included gender in the list. One exercise paired participants in a game illustrating the different ways that people exercise power. One participant was to hold his or her fist closed tight while the other attempted to open it by any means possible. Some attempted to open the fist by brute force, others offered monetary inducements, and still others tried to reason gently. A few tried mechanisms to "get what they wanted" in ways that reflected their own sense of relative powerlessness, for example, tricking the person with an offer to shake hands or softening them with flattery. This exercise demonstrated the various ways that people seek to alter the balance of power in a situation.

Addressing Power Dynamics in Client--Provider Relationships

The training included a generic communication-skills module that strengthened providers' listening and verbal and nonverbal communication skills and their ability to deal with difficult clients. Video vignettes (made by the training team) showing negative interactions enabled providers to see how harsh their behavior looked and felt from the outside; positive vignettes specifically modeled constructive behaviors.

To underscore the importance of assessing a client's situation thoughtfully, the trainers conducted an exercise in which they asked the participants if they knew what their wristwatches look like. The trainer asked them each to draw the dial without looking at it. Comparing the drawings to the watches, which they see every day and which are far less complex than a human being, reminded the participants how easy it is jump to faulty conclusions about the situation of another person. This exercise led to a discussion about the need to bring humility rather than a sense of omniscience to their observations of and interactions with clients.

Challenging Existing Hierarchies Among Staff

Although the training emphasized the ways in which power relations generally govern the lives of clients, it also illustrated the point that the same rules govern most providers' lives as well. The training team promoted this awareness in several ways. For example, they decided to break with tradition by inviting staff at all levels to participate jointly--from male doctors to lady home visitors. They included community workers from both the population welfare department and the health department in the same workshop, to help erase the sense of inequality that members of these groups feel. (3)

When the participants arrived on the first day of the training, they found not only an unexpected diversity among their fellow trainees, but learned that everyone (including the trainers) was sitting on the floor. The trainers reinforced their messages about equality with role-play exercises involving paramedics acting as doctors and doctors as clients. The providers clearly noted and worked with these disruptions in their everyday patterns of status and gender that characterized their institutional relationships.

In an explicit attempt to enable participants to enhance their own self-awareness, the trainers conducted an exercise focused on identifying their strengths and weaknesses. One by one, each participant told about some personal experience and the feelings it had engendered. This sharing fostered a sense of trust among participants. Finally, the trainers adapted Rozan exercises that enabled participants to reflect on their role as public servants in Pakistani society. The workshop ended with a discussion acknowledging that each individual--regardless of her or his official role--contributes to the environment and that nobody acts in isolation.

At the conclusion of the training, participants were asked for anonymous feedback. They indicated that they appreciated having an opportunity to discuss abstract concepts such as gender and power in a concrete way. They also enjoyed the interactive format and the feeling of community generated during the workshop, both of which were a departure from their usual training experiences.

One physician, who was also a district manager, responded to the training with the following comment: "After participating in the role-plays where I had to take my sick child to a provider, for the first time I felt how humiliated, helpless, and frustrated you can feel if the provider is hostile and arrogant toward you. It was indeed a very bitter experience. The importance of how you behave with your client dawned on me for the first time. I can now empathize with the poor clients. I [will] make it part of my supervisory visits to see to it that clients are dealt with in a humane manner by the providers as envisaged in the SAHR approach."

The workshop had its difficult aspects, most of which had to do with making abstract concepts understandable. For example, the trainers realized that they had underestimated how strange the concept of "client-centered services" would appear to public-sector providers in Pakistan. Although the trainers attempted to explain in detail both the concept and the specific objectives of the workshop, participants had no point of reference for these ideas. Hence, they had no clear sense of what benefits the training might produce for them; this confusion generated a skepticism that took several days to lessen. The trainers realized that future workshops should begin from within the participants' own frame of reference.

Similarly, three days elapsed before participants began to sense the link between self-awareness and their role in society. Because the trainers had had the same experience during the Rozan training, they were prepared for this delayed response. Nonetheless, they felt some tension while waiting for the participants to absorb this message. This training may require a more intuitive model.

Not everyone responded equally well to the workshop. Because the workshop modeled equality, the lower-level staff--for whom it became an exercise in empowerment--responded more favorably than the doctors, who initially were skeptical. Moreover, because the community workers were younger and newer at their jobs, they may have been more receptive than the doctors to new ideas. Despite the physicians' skepticism, the team felt their presence was essential, because the mixing of staff in an equalizing environment was what allowed all participants to experience and reflect on the issue of social power.

The Initial Assessment

One premise of the workshop was that trained providers would feel empowered to address inequalities in their work and home environments. Indeed, the workshop illuminated some of the discomfort people had been tolerating. One community-based worker chose to disclose instances of sexual harassment she had endured from her supervisor. Another woman felt emboldened enough to leave an abusive marriage and set up an independent household, a courageous step within the social and cultural context of Pakistan.

To learn whether the training experience led to changed interactions with clients, the trainers observed a subgroup of the community-based providers two months after the workshop and recorded their specific behaviors. (4) The results were mixed.

The community workers had clearly changed the way they conducted their house visits. Instead of honing in directly on the "eligible woman" as they had done previously, they focused more broadly on the family and on community health. They exchanged greetings with various family members such as mothers-in-law, inquiring after their health and offering suggestions. As a result, many mothers-in-law--who are not the targeted beneficiaries of any government program but who wield enormous influence over young wives--also received attention and warmed to the visitor. As a result, the community worker's visit no longer caused family friction hurtful to the client.

The community workers were not fully applying the SAHR model, however. They were not building upon the rapport they established to assess the specific needs of clients. For example, in discussing family planning, providers rarely asked a woman whether she wanted to prevent pregnancy for a few years or permanently, or whether she had any previous experience with contraception. They were still more likely to choose a method for the client and advise her about using it.

Rather than give up on these workers or decide that the SAHR model was too ambitious, the team decided to invest in further training. Four months after the initial training, all the participants were given an additional two-day workshop emphasizing topics that needed reinforcement.

The Assessment of Impact

After the second training, the team again observed interactions between providers and clients both in the pilot area and in a control area where providers did not undergo training. (5) They also conducted focus-group discussions with both groups. The findings from these sources corroborated each other.

Client Feedback

Among the clients, some stated that the community health workers had always treated them satisfactorily. Hence, because no pretraining focus-group discussions were conducted, assessing how much positive behavior is a direct result of the training is difficult. Those women who reported a change in the worker's behavior made comments like the following:
 Now she questions more and sits for
 a longer time and discusses.

 She talks with my mother-in-law and
 convinces her to give me permission
 so that I can practice family planning.

Some women expressed a desire that community workers be able to treat more problems:
 They (the workers) should have medicines
 for white discharge.
 Sometimes the problem is so serious
 that we have to go far away to a town
 or the woman may die.

CHWs Talk About Their Change in Behavior

The community workers reported greater job satisfaction and self-confidence. They were particularly proud of their skills in approaching a family, listening to clients, speaking in simple conversational language, observing household dynamics, and helping a client make a decision that she could successfully implement. Interestingly, a number of workers reported that they had learned to control their tempers and to be more patient. They were gratified that they were able to respond to the needs of clients' family members, but also noted that by building these ancillary relationships, they were strengthening the ability of the primary client to have her own needs met. Finally, they shared that having greater self-confidence enabled them to approach their clients in a more egalitarian, open manner. A number of them reflected on their changed practices:
 Previously we spoke Urdu to people.
 Now we have started to speak their
 way [Punjabi].

 We used to feel hesitant to talk, but
 now we ask open-ended questions,
 using simple language. Now the hesitation
 has finished, and women also
 talk to us as if we are one of them.

 Previously, if two or three women
 came, I would deal with them simultaneously,
 but now I talk with them

 We used to ask questions of clients,
 but we did not confirm whether they
 understood or not. Now we ask them

 Our inferiority complex is gone, and our
 sense of responsibility has increased.

 People used to offer us a chair out of
 respect, and they sat on the floor. But
 now ... if she is sitting on a cot, then
 we also go and sit with her, and if she
 is sitting on a chair, then we also sit
 on a chair.

The workers described using their new skills to assess a client's overall needs in a manner that was sensitive to her background.
 I assess the situation of the home,
 whether the client is worried or
 happy. If she is worried, then I ask the
 reason for her worries.

 We have come to know about immunization
 and reproductive health ...
 about where to refer the client if a
 child or elder becomes sick. I also
 have come to know who has power
 in the house and talk with her first so
 that she does not get angry.

 For those women who cannot talk
 with their husbands and are afraid,
 we try to help them and try to create
 a feeling of self-awareness.

Perhaps more importantly, providers are behaving in a less authoritarian manner and beginning to include the client as an equal partner. This shift is seen clearly in the way family planning services are being delivered.
 Previously we used to say, have yourself
 operated on, but now we tell
 them to make their own decisions.

 We have to ensure that there is a level of
 equality,, keep eye-to eye contact while
 talking, listen to her attentively, use
 reflective listening, behave properly.

 I used to assume that people should
 come to me instead of my having to
 visit them. After the training, I visited
 three or four households that earlier I
 would not visit.

The providers sense the effect of their efforts:
 Now clients also discuss their personal
 matters with us.

 Now they think us as their well-wishers.
 Previously, our behavior was
 aggressive. They did not tell us their
 family problems, but now our behavior
 has changed.

Now people have confidence in me, and I also have confidence in them.

The workers also report some persistent challenges:
 If the power of decision is with the
 husband or father-in-law, then the
 daughter-in-law says that she cannot
 go with us without his permission.
 Such a situation is difficult.

 Our family members say that there
 are some people whose position or
 reputation is not good; they do not
 allow us to go there.

 Women are afraid to deliver in hospital.
 It is also a problem that there is
 no lady doctor in the hospital. We
 explain that there can be a problem
 during delivery. We tell them that the
 treatment is free, but it is difficult to
 convince them.

 They don't tell us the date of their
 menses. If they are pregnant, they
 don't even tell us that. Our register
 gets spoiled because the clients do
 not tell us. Sometimes they tell us
 false dates of delivery. They say, "The
 government does not feed our children.
 Why do you come and note
 their names?"

Workers' Relationships with Supervisors

Some workers report that some supervisors are now more supportive and are offering more guidance:
 She used to tell us how to work, but
 now she explains in depth, [for
 example], how to fill the community
 chart.... If we did anything wrong,
 she used to get angry, but now even
 if we ask repeatedly, she does not get

 She used to be very strict and snubbed
 us, but now the supervisor explains
 things with patience, and if there is
 any problem, she tries to solve it.

 Previously, we were afraid that our
 supervisor was coming; she used to
 go and complain in the office and
 have our salary stopped.

This improvement in worker--supervisor relations is not, however, universal:
 Supervisors" training should be conducted
 again so that [our supervisor]
 does not snub us in front of others.

 She is same as before. What she did
 before, she is still doing. There is no
 change in her behavior and method
 of supervision.

Improved Institutional Operations

Another outcome of the workshop was that the staff of the health and the population welfare departments drew closer to each other. The workshop was their first shared experience, and they are beginning to provide referrals to each other's services. In this way, the workshop contributed to consolidating the national merger between the Ministry of Population Welfare and the Ministry of Health.

Expansion and Replication

In 2001, the Pakistani government expressed interest in replicating the SAHR model on a larger scale. Dr. Zaidi, from the National Programme for Family Planning and Primary Health Care, together with a representative from the United Nations Population Fund (UNFPA), conducted an independent monitoring of sites where staff had undergone the training. Zeba Sathar admits that she was initially concerned about this visit:
 I didn't know whether they would
 appreciate the intervention being
 tested, especially since both gentlemen
 were physicians, and our training
 did not focus on improving
 providers' technical competence.

Sathar need not have worried. Dr. Zaidi returned from his visit convinced that the SAHR training had had a positive impact on his cadre of lady health workers. He had spoken with a number of the workers, who impressed him with their confidence and engagement.

Based on the government's enthusiasm, UNFPA/Pakistan signed an agreement with the Population Council in 2002 to train 3,000 additional community and clinic workers in five districts, along with a parallel training for Dr. Zaidi and a number of federal and provincial program managers. To carry out the expansion, the Population Council team is reproducing the training materials and conducting a training-of-trainers. Efforts are also under way to apply the SAHR model to obstetric-care providers, community-based transportation workers (responsible for transporting women to healthcare facilities during emergencies), and medical students.

Remaining Challenges

The project faces a series of ongoing challenges. For example, UNFPA's support for expansion raises questions of maintaining the quality of the intervention. The expansion-phase workshops will be led by Ministry of Health employees, who may not be as keenly motivated as was the original Population Council team. Moreover, the government does not currently have a plan for assessing and responding to the need for periodic follow-up training. Council staff are hoping that adequate monitoring of the expansion will enable the government to identify areas that require modification or attention.

Building demand from clients is another challenge. Zeba Sathar believes that the team should have conducted parallel, modified workshops for women at the village level. Such workshops could raise women's expectations regarding their rights within the family and what they receive from health-care providers, and provide them with support and tools to begin exercising those rights. The Council hopes to organize such community-based workshops in the future. As Sathar says, "We have unraveled one of the difficulties toward empowering poor, uneducated women to meet their reproductive health needs, but there is still a long way to go in this process of transforming long-entrenched attitudes and behaviors."

Chronic systemic problems--similar to those in most developing country settings--ultimately undermine quality of care and demoralize workers. These problems include delayed salary payments, disruption in supplies of medicines, and lack of vehicles for transporting clients or supervisors. Clients' continuing negative experiences at clinics eat away at the goodwill created by the community worker who gave them the clinic referrals.
 In training they had given us a list.
 We have not received oral rehydration
 supplements for the last year. We
 are not getting alcohol, bandages,
 cotton, or chloroquine.

 This month I took three clients for
 tubal ligation. On our return, the vehicle
 did not even leave us at the bus
 stop because the driver said that he
 didn't have time. Patients at that stage
 are only semiconscious, and they
 keep staggering.

Persistent culturally entrenched condescension toward lady home visitors remains:
 The doctors don't give any importance
 to us. Yesterday, the watchman
 and the attendant did not allow us to
 go inside to meet the doctor, and the
 doctor went away.

 The attendants don't give importance
 to ladies at all, and it is worse with
 lady health workers. Even though we
 have brought the patient and even if
 she is in serious condition, no priority
 is given. They see us according to
 our turn. Clients who go with us they
 say, "You are attached with hospital
 but still they don't listen to you." We
 feel insulted in front of them.

Perhaps more important, the Pakistani government continues to evaluate workers on the basis of targets achieved. Such an emphasis ultimately constrains the workers' ability to put the needs of the client foremost. As Jain explains, "Method-specific targets and quality of care are incompatible. Targets force providers to motivate or persuade women to accept a specific method in order to fulfill their targets. On the other hand, quality is about helping a woman choose a method appropriate to her needs."


We wish to thank Debbie Rogow for her substantive contributions and editorial guidance as we prepared this article.


Fikree, Fariyal. 2002. "Reproductive health in Pakistan: Evidence and future directions." Journal of Pakistan Medical Association 52(1): 34-41.

Sathar, Zeba and John Casterline. 1998. "The onset of fertility transition in Pakistan." Population and Development Review 24(4): 773-796.

Sathar, Zeba, Minhaj ul-Haque, and John B. Casterline. 1998. "Unmet need in Pakistan: Findings from a study in Punjab." Paper presented at international workshop on "Unmet Need for Family Planning in Comparative Perspective." Nairobi, Kenya, 23-24 June. Workshop organized by the Population Council.

United Nations Population Fund (UNFPA). Country programme document for Pakistan. 31 October 2003. < exbrd/2004/firstsession/dpfpa-cpd-pak7.doc.p.2>. Accessed 20 March 2004.

Rozan: Enhancing Awareness of Self and Others

Rozan's behavior-change training seeks to strengthen specific interpersonal skills:

* Becoming more aware of how others respond to our behavior. As we pay more attention to the responses elicited by our behavior, we become more sensitive to our own strengths and weaknesses, and tend more to behave in ways that elicit a positive response.

* Becoming more aware of how inequality, including gender inequality, operates in relationships. By reflecting on concrete situations, trainees learn about gender and power dynamics, about how these translate into poor health outcomes for women, and they learn ways to break hierarchies and promote egalitarianism.

* Reflecting on one's role in society. Public behavior that elicits a positive response reinforces a sense of one's role and responsibilities in society. In one exercise, participants imagine an ideal society. Typically, participants identify a society that provides universal justice, food, shelter, security, health care, and livelihood. The next part of the exercise asks participants to identify their role in that society and how they can help to create such a world.

* Improving interpersonal communication skills. Trainees learn how we transmit messages about how we see ourselves vis-a-vis others. As an example, Rozan trainers tell a story of three men breaking stones on the side of a road. On being asked what they were doing, the first man said that he was breaking stones; the second that he was breaking stones to build a road; the third, that he was breaking stones so that a road could be built for the children going to school. Thus, each man's message incorporated a different perspective about his relationship to others.

What Does It Add Up To?

The intervention team knows that a training program alone cannot fundamentally transform deeply entrenched cultural and institutional conditions with one or two workshops. Nonetheless, this intervention has effected a small but meaningful shift in the way health workers interact with clients, in their own self-awareness, and in their job satisfaction. By focusing on relatively simple behavioral changes anchored to a fairly sophisticated analysis of power dynamics, the SAHR training can make a large difference for a few people, and a moderate but real difference for millions. As Anrudh Jain, the original force behind this project, says, "This is do-able. And it's getting done."

Lessons Learned

Even a large, bureaucratic, and authoritarian public-sector program can improve community-based services by focusing not on technology, targets, or infrastructure but, rather, on power and gender issues.

When providers learn to treat a client as an equal and active partner who is an "expert" in her own right, the provider--and not just the client--ends up better satisfied.

Those who are lower in the hierarchy--such as community workers-- are more willing to change and modify their behavior. Providers who are higher in the hierarchy, including physicians and supervisors, may need regular reinforcement to internalize new ideas about power and gender so that they become more sensitive and sympathetic toward their clients.

(1) In clinic settings, anecdotal evidence abounds about the particularly harsh treatment of poor or "scruffy" clients; for example, many clinicians conduct a superficial examination of a woman whose clothes are not clean. When the doctor is not present, paramedical staff often emulate this behavior, treating clients with the same disdain that characterizes typical doctor-client interactions.

(2) The project in Pakistan is one of four country studies that the Population Council is undertaking to document the feasibility of improving quality of care and the effect of improved quality on women's reproductive behavior. This effort is directed by Anrudh Jain.

(3) Even though staff from both the health and the population welfare departments serve the same clients and provide similar services, they regard themselves as separate. The recent merger of the two ministries had revealed an underlying rivalry between them; community workers of the health department tend to look down upon the community workers in the population welfare department because their training programs have been weaker.

(4) Although clinic staff are not the focus of this report, their behavior was also followed; they were found to be applying the lessons of the training less effectively than the community workers were.

(5) Again, results were most satisfactory among community workers. The observers assessed whether these workers inquired about the family's well-being (50 percent of trained workers did so compared with 34 percent of workers observed in the control areas); about who makes major decisions in the household (69 percent versus 55 percent, respectively); about whether the client can persuade that person (27 percent versus 14 percent, respectively); and about whether the client must seek permission to go for an examination (76 percent versus 16 percent, respectively). Providers who underwent training were also more likely to explain more than one contraceptive option, to encourage clients to speak, and to verify whether they had understood instructions pertaining to their choice of method.
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Author:Ramarao, Saumya; Mir, Ali M.
Geographic Code:9PAKI
Date:Jan 1, 2004
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