Understanding the Access, Demand and Utilization of Health Services by Rural Women in Nepal and their Constraints

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1 The World Bak Yak & Yeti Hotel Complex P.O. Box 798 Kathmadu, Nepal Telephoe: Facsimile: Uderstadig the Access, Demad ad Utilizatio of Health Services by Rural Wome i Nepal ad their Costraits JUNE 25, 2001

2 List of Refereces 1. Huma Developmet Report, Nepal, Nepal South Asia Cetre, 1998, Nepal Huma Developmet Report, Kathmadu 3. Idia, Regioal Office for South-East Asia, World Health Orgaizatio, 2000, Wome of South-East Asia, A Health Profile, New Delhi 4. Nepal, Miistry of Health/UNICEF/WHO/The Microutriet Iitiative/New ERA Ltd., 1998, Nepal Micro Nutriet Status Survey, Kathmadu 5. Nepal, Natioal Plaig Commissio/UNICEF, 1998, Nepal Multiple Idicator Surveillace Fifth Cycle (March - May 1997), Kathmadu 6. Nepal, Miistry of Health, 1997, Aual Report (1998/99), Kathmadu 7. Nepal, Miistry of Health, Nepal Materal Morbidity ad Mortality Study, 1998, Kathmadu

3 Uderstadig the Access, Demad ad Utilizatio of Health Services by Rural Wome i Nepal ad their Costraits JUNE 25, 2001 Fud Provided By Geder Iovatio ad Maistreamig Fud Huma Developmet Sector Uit South Asia Regio, The World Bak

4 Acroyms ANC CBO CEDAW DFID FCHV GDI GEM GTZ HDI HIV/AIDS HMIS ICPD IEC INGO MCH MOH NGO PCRW PNC PRMGE SASES SASHD STDs TBA UNDP UNFPA UNICEF USAID VDC WDO WHO Ateatal Care Commuity Based Orgaizatio Covetio o Elimiatio of All forms of Discrimiatio agaist Wome Departmet for Iteratioal Developmet Female Commuity Health Voluteer Geder Developmet Idex Geder Empowermet Measure Deutsche Gesellschaft fur Techische Zusammearbeit (Germa) Huma Developmet Idex Huma Immue Deficiecy Virus/Acquired Immue Deficiecy Sydrome Health Maagemet Iformatio System Iteratioal Coferece o Populatio ad Developmet Iformatio, Educatio ad Commuicatio Iteratioal No Govermetal Orgaizatio Materal ad Child Health Miistry of Health No-Govermetal Orgaizatio Productio Credit for Rural Wome Postatal Care Poverty Reductio ad Ecoomic Maagemet Network, Geder & Developmet South Asia Regioal Eviromet ad Social Developmet Sector Uit South Asia Regioal Huma Developmet Sector Uit Sexually Trasmittig Diseases Traditioal Birth Attedat Uited Natios Developmet Program Uited Natios Fud for Populatio Activities Uited Natios Iteratioal Childre Educatio Fud Uited States Aid for Iteratioal Developmet Village Developmet Committees Wome Developmet Officer World Health Orgaizatio 2

5 Table of Cotet Foreword...4 Ackowledgemet Backgroud Geeral Fidigs at the Commuity Level Fidigs Related to Policy ad Programmatic Factors Recommedatios TABLES Table 1.1 Regioal compariso of Huma Developmet Idicators...7 Table 1.2 Data Collectio Sceario by District Table 1.3 Respodets by Distace from Health Facility, Health Care Seekers/No-Seekers ad Age groups FIGURES Figure 1: Place of materal deaths...9 Figure 2: Direct cause of commuity materal death (=93)...9 Aex List of refereces

6 Foreword The wome i Nepal face alarmigly low health status i almost every stage of their life cycle - exposed to more social, ecoomical ad utritioal risks ad biases which are much more rampat i rural areas. Health is a state of complete physical, metal ad social well beig ad ot merely the absece of disease or ifirmity. Iequalities i health across populatio ad geder arise largely as a cosequece of differeces i social ad ecoomic status, differetial access to power ad resources ad the iheret traditioal ad cultural practices. This study o Uderstadig the Access, Demad ad Utilizatio of Health Services by Rural Wome i Nepal ad their Costraits buids o the results of past studies by examiig the perceived level of access, demad ad utilizatio of health services by rural wome themselves i five ethically ad socio-ecoomically diverse districts of Nepal. The mai purpose of this study was maily to: i) icrease our uderstadig of the social ad geder factors that are impedig improvmets i the health of rural wome ad to maistream them ito our future health assisttace strategy; ad ii) facilitate the formulatio of geder sesitive health policies by sharig the fidigs out of the study with His Majesty s Govermet of Nepal ad parter agecies. We hope that the recommedatios made out of this study have broad relevace to all itervetios related to health care i Nepal, especially those programs that are meat to beefit the rural Wome. Keichi Ohashi Coutry Director for Nepal The World Bak 4

7 Ackowledgemet This report was prepared by a team comprised of Tirtha Raa, Seior Health Specialist, Bidu Chitrakar, Team Assistat, South Asia Regioal Huma Developmet Sector Uit (SASHD), Samjhaa Thapa, Seior Social Developmet Specialist ad Krisha Thapa, Team Assistat, South Asia Regioal Eviromet ad Social Developmet Sector Uit (SASES). The field research ad draft reportig were udertake by SAMANATA, Istitute for Social ad Geder Equality ad led by Abha Darsha Shrestha ad her team. This report was reviewed ad edited by Ms. Lalarukh Faiz, a public health specialist. This study would ot have bee possible without fiacial assistace from the "Geder Iovatio ad Maistreamig Fud" of the Geder ad Developmet Thematic Group of the World Bak. We would also like to exted our sicere appreciatio to Mmes. Kari Kapadia, SASES ad Wedy E. Wakema ad Sarah Nedolast, Poverty Reductio ad Ecoomic Maagemet Network, Geder & Developmet (PRMGE) for their support. We gratefully ackowledge the professioal expertise of the cosultats from the SAMANATA, Istitute for Social ad Geder Equality for carryig out the research ad field work ad for draftig the report. We would also like to thak Mr. Ia P. Morris, SASDH for his support. The report has beefited substatively from the commets received durig a workshop held o Jue 13, 2001 where the draft report was discussed. We would like to thak Dr. B. D. Chataut, the Director Geeral of Departmet of Health Services, Miistry of Health for chairig the workshop ad Dr. Chhatra Amatya, Director of Plaig ad Foreig Aid Divisio, for orgaizig the workshop with the World Bak. Fially, we would like to express our profoud gratitude to the key iformats, commuity health workers ad the 688 wome i the study districts of Lalitpur, Sidhupalchowk, Rupadehi, Kailali ad Dadeldhura of Nepal for participatig i the study. 5

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9 1. Backgroud 1.1 Nepal was raked 144 out of 174 o the 1999 Huma Developmet Idex (HDI) (Table 1.1), idicatig a low level of huma developmet as measured by life expectacy, educatioal attaimet ad adjusted icome 1. The highly patriarchal ature of the society is reflected by the coutry's extremely low rakig (121 out of 143) o the Geder Developmet Idex (GDI) (Table 1.1), a measure of geder disparity i huma capabilities that is used to moitor progress towards achievemet of geder equality 1. This is lower tha Bhuta (119), Idia (112), ad Sri Laka (76) but higher tha Bagladesh (123) 1. Similarly, the Geder Empowermet Measure (GEM), represetig the participatio of wome i ecoomic, political, ad professioal spheres, is very low at The GEM values for Bagladesh, Idia ad Sri Laka are 0.30, 0.24 ad 0.32 respectively 1. Female life expectacy at birth is 57.1 years, lower tha that i Bagladesh, Bhuta, Idia ad Sri Laka (58.2,62,62.9 ad 75.4 respectively) 1. The female adult literacy rate is 20.7 percet, lower tha that of Bagladesh, Bhuta, Idia ad Sri Laka (27.4,30.3,39.4 ad 87.6 respectively) 1 (Table 1.1). Table 1.1 Regioal compariso of Huma Developmet Idicators HDI GDI GEM MMR IMR per Life Female global global global Per 100, live Expectacy Literacy rakig rakig rakig (I live births)+ births, 1997* Rate Coutry 1999* 1999* 1999* 1997* 1997* Year Female Male Bagladesh Bhuta Idia Nepal ** (32.9 as of 2001) ++ Sri Laka Source: * Huma Developmet Report, ** Nepal Huma Developmet Report, 1998 (value from 1996) +Wome of South-East Asia, A Health Profile, WHO, 2000, ++Basic Social Service Study: Aalysis of Social Sector Developmet, Natioal Plaig Commissio ad UNICEF,

10 1.2 The ifat ad materal mortality rates i Nepal are amog the highest i the world at 75/1,000 live births 1 ad 539/100,000 live births respectively 3. About sevety percet of wome of reproductive age are aemic ad malourished 4. Wome face harsh coditios durig pregacy ad childbirth. May wome get pregat at a youg age ad do ot leave adequate space betwee childre 5. Furthermore, may are forced to do hard labor durig pregacy. Together, these factors have a egative effect o itrauterie growth ad the developmet of the fetus, resultig i uderweight ifats who are vulerable to ifectios. 1.3 Most wome lack access to basic materity care. Oly 27 percet of wome seek ateatal care oce durig pregacy 6. Of those that seek preatal care, the average umber of ANC visits per pregacy is 1.8, far short of the miimum of four visits per pregacy that are required 6. Accordig to a 1997 survey, a little over a third of surveyed wome (34 percet) said that they did ot receive ANC because they thought they did ot eed it. Thirty-oe percet said that they did ot traditioally receive ateatal care. Twety four percet of wome said they did ot kow that such services were available. Eleve percet said the health facilities were located too far away ad five percet did ot have eough moey to pay for the services. Two percet of the wome did ot have time to visit a health facility; two percet said their family members did ot allow them to seek care ad two percet said they did ot seek care because the service was poor 5i. As for childbirth, most deliveries occurred at home i usafe coditios. Oly 8 percet of births take place at health facilities ad oly 13.4 percet of births are atteded by traied health persoel 6. After childbirth, 9 percet of wome seek postatal care Figures 1 ad 2 corroborate the above fidigs. Most materal deaths occur at home (68%) due to a umber of factors that could be preveted with skilled ad timely attedace durig pregacy ad child delivery. 1.5 Despite the fact that the availability of public health services has icreased throughout the coutry, health services are still beyod the reach of most rural wome. It is reported that oly 45 percet of households have access to basic health care 5. Very little research exists i Nepal that addresses the cultural ad socioecoomic factors that limit wome's access to health care. Two recet studies have examied this issue: Focus Group Study o Reproductive Health i Nepal from Socio- Cultural Perspective (UNFPA, 1999) ad Health Seekig Behavior of Wome i Five Safe Motherhood Districts i Nepal (UNICEF, 1998). While the latter study focuses i Values are ot mutually exclusive. Wome were allowed up to three resposes. 8

11 o pregacy ad delivery related issues, the first ivestigated a broader rage of reproductive health cocers. Both studies foud geder discrimiatio, positio of wome i the family, ad lack of self-worthiess amog wome to be importat factors ifluecig their health care seekig behavior. Figure 1: Place of materal deaths 1.6 This World Bak study builds o the results of past studies by examiig the perceived level of access, demad, ad utilizatio of health services by rural wome i five ethically ad socioecoomically diverse districts of Nepal. The researchers attempt to determie why uder-utilizatio of services exists despite the high eed for health services ad the existece of a expasive etwork of over 4000 outreach level public health facilities 6. Goals ad Objectives 1.7 The goals of the study are: To icrease our uderstadig of the social ad geder factors that are impedig improvemets i the health of rural wome ad to maistream them ito our future health assistace strategy. To facilitate the formulatio of geder sesitive health policies by sharig the fidigs of this study with parter agecies ad key decisio makers i the health sector. Figure 2: Direct cause of commuity materal death(=93) Source: Figure 1 ad Figure 2 - Materal Mortality ad Morbidity Study, The objectives of the study are to: Ivestigate costraits that prevet poor, rural wome i Nepal from demadig, accessig ad utilizig health services. Examie the social ad geder issues that ifluece poor health seekig behavior i order to uderstad what factors eed to be addressed at the commuity, district ad atioal levels. Examie existig policies ad programmatic factors that prevet wome from accessig care. Methodology 1.9 Iformatio was gathered from primary ad secodary sources from February to Jue Primary iformatio was 9

12 gathered from questioaires, focus group discussios ad iterviews with key iformats at the household, commuity ad cetral levels. Secodary iformatio was geerated from published documets Districts were selected accordig to several factors icludig geographical regio, ethic compositio, socio-ecoomic characteristics ad available health istitutios ad services. The districts chose were Lalitpur, Sidhupalchowk, Rupadehi, Kailali ad Dadeldhura (see Map). The costituecy of the districts represet a variety of ethic groups: Newar; Magar, Gurug, Rai ad Tamag; Yadav ad Ahir; Damai, Sarki ad Kami; Brahma ad Chhetri The selectio of village developmet committees (VDCs) was based o: i) existece of the Productio Credit for Rural Wome (PCRW) program, ad ii) distace from the health facility. It was assumed that members of the PCRW program would be more kowledgeable ad iformed about diseases ad more likely to seek health care tha o-members. They are termed as the seekers while other wome are termed as o-seekers. Oe VDC where the PCRW program was beig implemeted was withi two hours travel time of the earest health service facility while the other was more tha two hours travel time from the earest health facility. The hypothesis was that whe people have to travel for more tha two hours to a health facility, they would be less likely to visit the health facility due to time restraits, trasportatio costs, etc. The staff of the Wome Developmet Sectio i the district assisted i idetificatio of the VDCs. Te VDCs were selected for the study, two i each of the five districts. Focus group discussios were held i the each of these VDCs The Wome Developmet Officers (WDOs) ad local commuity workers assisted i the selectio of focus group participats. The selectio of participats for Table 1.2: Data Collectio Sceario by District VDC-1 withi two hours travel to the earest health facility ad VDC-2 more tha two hours travel to the earest health facility I each VDC selectio of PCRW members (seekers) ad o-members VDC - 1 VDC - 2 Seekers i Years No-Seekers i Years Seekers i Years No-Seekers i Years < >35 < >35 < >35 < >35 3 focus group 3 focus group 3 focus group 3 focus group discussios discussios discussios discussios Total focus group discussios = 12 10

13 focus group discussios was guided by the three age groupigs used i the UNICEF ad UNFPA studies metioed above. Group 1 cosisted of wome 18 years of age ad uder; Group 2, wome years of age ad Group 3; wome above 35 years of age (Table 1.2) Twelve participats, 6 married ad 6 umarried wome, were chose to participate i the focus group discussios at each of the 10 selected sites. I all 720 wome were expected to participate i 60 focus group discussios but oly 688 wome participated because the umber of respodets uder 19 years of age i Rupadehi was lower tha expected. Table 1.3 shows the actual umber of participats i the focus group discussios categorized by distace from health facility, membership i the PCRW program ad age group Qualitative iformatio was gathered from focus groups discussios ad iterviews usig checklists ad guidelies developed by the researchers. At the cetral level iformatio was gathered by iterviewig key persoel i the Miistry of Health, Departmet of Health Services ad Natioal Plaig Commissio (key iformats). At the rural commuity level, iformatio was gathered through focus group discussios comprised of local wome, commuity health care service providers, female commuity health voluteers, traditioal birth attedats ad iformal iterviews with service providers at health facilities (key iformats). 11

14 1.15 Each focus group participat also filled out a questioaire, which i effect quatified some of the qualitative resposes give i the discussios Preparatio for the field visits icluded orietatio ad traiig for the etire survey team orgaized by the cosultats assiged to the study. The questioaire, tools ad techiques pre-tested i Chapagao of the Lalitpur District. I the field, five teams of two research officers gathered data ad iformatio, oe i each district. Ivetory appraisals of the health service facilities were also coducted. Table 1.3: Respodets by Distace from Health Facility, Health Care Seekers/No-Seekers ad Age Groups Distace from Districts Health Facility Health Care By Age Groups Near Far Seeker No-Seeker 19 Yrs Yrs >35 Yrs Lalitpur Dadeldhura Sidhupalchwok Kailali Rupedehi Total Geeral Fidigs at the Commuity Level 2.1 It was assumed that there would be some differece i the level of demad, access ad utilizatio of health services amog care-seekers ad o-seekers. However, this was ot the case. This was probably due to methodological problems related to the selectio of VDCs. VDCs were selected oly o the basis of presece of the PCRW program ad distace from the health facility. Factors such as availability of local trasportatio, average icome level of the commuity, ad status of the PCRW program were ot take ito accout, so the costituecy of the VDCs were perhaps more homogeous tha expected. 2.2 Lack of kowledge about illesses Wome could describe oly obvious symptoms of their illess such as headaches, fevers, joit aches ad body aches. They were more kowledgeable about pregacy ad delivery related problems tha illesses such as tuberculosis, malaria ad typhoid. This lack of kowledge cotributed to their delay i seekig care. 12

15 2.3 Lack of decisio makig power ad iability to pay The majority of wome would cosult family members, usually the head of the household ad /or whoever cotrolled the cash/family fiaces before seekig care. Approximately half (51.2 percet) of wome cosulted their husbads percet cosulted family members such as their mother i law or sister i law ad 3 percet cosulted eighbors ad frieds. Wome who eared moey through self-employmet or PCRW credit sometimes used the small amout of moey they eared to pay for health care, but most wome would oly seek care o their ow accord if services were free. 2.4 Disregard for illesses I all districts wome were recogized to be ill by family members oly whe they were bedridde or uable to perform their daily tasks. The wome felt that most illesses would get cured by themselves. Those who sought care for geeral illesses first tried home medicie. If this was ot successful, they visited traditioal healers. If they were still sick, those who were able to access care would the visit the earest health facility, usually the health post, followed by the hospital, sub-health post, private medical shops ad cliics ad NGO facilities. Whe girls uder 18 were sick, they iformed their mothers about their illess but hesitated to visit health facilities if they eeded gyecological or family plaig services. They oly visited the hospital if they were seriously ill. 2.5 Uwilligess to disclose illesses Wome did ot disclose symptoms such as vagial discharge due to shyess or illesses such as tuberculosis ad leprosy due to fear of beig ostracized by family members ad the commuity. 2.6 Low value give to wome's lives Family members ad wome themselves place a very low value o wome's lives, thus wome's health is ofte igored. 2.7 Distace from health facility Some wome were uable to access care due to distace to health facility ad lack of a meas of trasportatio. 2.8 Lack of time Respodets i all of the five study districts reported that lack of time due to their heavy work burde restricted them from seekig health care. 13

16 2.9 Alcoholism ad Violece Alcoholism amog husbads was reported to be a problem i all districts except Dadeldhura. This limited the fuds available to wome to seek health care. Violece agaist wome was reported i Lalitpur, Rupadehi ad Kailali. Fear of such violece cotributed to wome's reluctace to voice their eed for healthcare services Caste discrimiatio Caste (for low caste wome) discrimiatio by commuity members ad providers restricts certai wome from accessig health care services Presece of female health services providers I all of the five study districts, the absece of female health service providers ihibited wome from visitig the health service facilities. Wome were reluctat to cosult male health workers especially whe a gyecological examiatio was required. Most of the time, assiged health service providers were abset from the health posts ad oly peos ad clerks were available to provide services. This was particularly true i the hill districts of Sidhupalchok ad Dadeldhura where the health facilities were less accessible Age Wome over 35 years of age were i a better positio to access health care because they were more empowered to voice their eeds ad had more cotrol over family resources Educatio Icreased educatio of wome ad their husbads was positively correlated with icreased utilizatio of all health services ANC ad PNC services The proportio of those reportig to have utilized ateatal care was higher tha those who used delivery ad postatal services. Wome who discussed their health problems with their husbads were foud more likely to use ANC, delivery ad PNC services. Wome from uclear families were more likely to use ANC, delivery ad PNC services tha wome who beloged to a joit family. Those wome who egaged i self-employed agricultural work were more also likely to use such services Level of satisfactio with health services Of the wome visitig the health facilities just over oe third (35.6 percet) of them reported full satisfactio with the services they received. The causes of 14

17 dissatisfactio with the health care received were perceived iaccurate diagosis of the disease, iadequate supply of medicies, ad absece of skilled service providers Flow of iformatio There is iadequate iteractio ad flow of iformatio betwee service providers, cliets ad local commuity based orgaizatios (CBO's). This has sigificatly costraied service demad, access ad utilizatio. 3. Fidigs Related to Policy ad Programmatic Factors 3.1 Lack of uderstadig of geder cocepts at the policy ad plaig levels Although the Govermet ratified its full commitmet to wome's developmet ad advacemet i the CEDAW, ICPD ad Beijig Platform of Actio, their actios have ot adequately backed their commitmet. I the Miistry of Health, we oted that a geeral impressio exists that all the eeds of woma are beig addressed through various safe motherhood ad reproductive health programs. I reality, this is ot the case. Aside from such programs, the same services are provided for males ad females without specific provisios to suit wome's differet biological eeds ad without addressig the critical social ad ecoomic factors that limit wome's access of healthcare. 3.2 Iadequate political commitmet There is ot adequate political commitmet to uderstad ad lift geder related impedimets that limit wome's access to healthcare. At the service delivery level, isufficiet mechaisms are i place to ehace the role of female commuity health voluteers, traditioal birth attedats, local mothers' groups, users' groups of other sectors, health facility support committees ad local commuity members, so they ca better support wome's health. 3.3 Missig data i HMIS There is a lack of geder dissaggregated data i the health maagemet iformatio system of the MOH to guide the developmet ad assessmet of health policies, plas ad programs. 15

18 3.4 While reviewig the records of the health facilities, it was foud that data was collected about patiets' sex, age ad illess, but ot by ethic group. The recorded geder disaggregated data was foud ot icorporated i the regular HMIS reportig. 3.5 No-health factors costraiig wome's access, demad ad utilizatio of health care, such as their socio-ecoomic status ad cultural factors are ot icluded as idicators i the existig iformatio system. Adhoc small-scale studies coducted by doors o safe motherhood ad reproductive health have icluded such data, but it has ot bee fully cosidered by policy makers while desigig health programs. For example, iadequate actio has bee take cocerig the three critical delays that occur durig child delivery ad sigificatly cotribute to higher levels of materal mortality: i) delay i decisio-makig at the household level to take the wome i labour to health facilities, ii) delay i trasportatio to the health facility, ad iii) delay i receivig care at the health facility level Lack of commuity represetatio At the district level, o mechaism is i place to guaratee commuity represetatio i the plaig process accordig to caste, class ad geder, or to receive feedback from service users regardig quality, quatity ad appropriateess of services provided. 3.7 Lack of kowledge/cotrol over resources More tha 50 percet of the developmet budget i the health sector comes from exteral sources ad most of aid moey is maaged by door agecies. Due to this, the MOH does ot have a accurate picture of expeditures of door assisted programs. At the atioal level, there seems to be a cosesus to icrease fudig for social sectors but whe it comes to the actual allocatio of public fuds, the amout allocated for o-salaried recurret expeditures i the health sector is ot sufficiet to cover the essetial health care eeds of the populatio. 3.8 Cetralized budget allocatio system All major policy decisios i the health sector are based o a cetralized budget allocatio system ad cetrally decided health priorities. Programmig is idirectly determied by budget allocatio decisios made by the Miistry of Fiace for the health sector. Thus, it appears that the MOH's capacity to egotiate with Natioal Plaig Commissio, the Miistry of Fiace ad door agecies is limited with respect to fiacig prioritized health programs ad support services such as health facilities maiteace, drug supplies ad itegrated traiig of health workers. It 16

19 leaves limited provisio to take ito full cosideratio of wome's overall health cocers besides safer motherhood program. 3.9 Lack of wome i decisio makig positios I the health sector, there are a sigificat umber of wome i the labor force. However most of them are occupyig peripheral ad assistat level techical positios. Very few are i maagerial, programmig ad policy level decisio makig positios Iadequate traiig of health persoel Adequate traiig opportuities to peripheral level health workers with regard to wome's health eeds ad o-health factors that limit their health seekig behavior are ot provided. Protocols, mauals ad guidelies regardig data maagemet, diagostic capability ad proper couselig icludig supportive supervisio ad moitorig to ehace the quality of care are ot adequate Iadequate staff ad medical supplies affect services provided Retetio of core health staff at the level of health facilities due to lack of motivatio - especially wome - is a major cocer. Most of the time, midwives ad MCH workers are abset i the health posts ad sub-health posts limitig the availability of critical safe motherhood ad reproductive health related services. 4. Recommedatios 4.1 This study idetified several factors that limit wome's demad, access ad utilizatio of health services. Socio-ecoomic ad cultural factors delay decisios to seek health care ad limit wome's ability to demad ad access care. At the health facility level, systemic problems limit wome's access ad utilizatio of health care. At the atioal level, health policies ad programs are ieffective ad do ot accout for differeces based o geder. 4.2 However, there are reasos for optimism due to the presece of: i) a expasive etwork of health facilities; ii) some level of awareess of health issues amogst the cosumers; iii) icreasig orgaizatio ad mobilizatio of user groups at the commuity level to permit a structured dialogue with users, provided that service providers icrease their efforts; iv) a mechaism to pool resources icludig cotributio from service users through expasive itroductio of commuity drug 17

20 programs ad various health isurace schemes, thereby icreasig wome's capacity to demad services; ad v) a slightly better uderstadig of importace of geder maistreamig i health amog policy makers ad program maagers. Takig all these facts ito cosideratio, a set of detailed recommedatios are give below. At commuity level 4.3 Icrease kowledge regardig wome's health Icreased kowledge ad awareess of wome's health eeds must be provided to wome icludig their spouses ad family members. Awareess ad sesitizatio about commuicable diseases such as HIV/AIDS, STDs, tuberculosis ad leprosy must also be icreased i order to ed the stigma attached to such diseases. Adolescets should have access to sexual ad reproductive health educatio startig at a early age. This ca be doe usig IEC materials, iterpersoal cosultatios such as literacy classes ad mother's group meetigs, school ad adult health programs ad local campaigs. 4.4 Work with traditioal faith healers ad commuity based health workers We must help build the capacity of traditioal healers ad FCHVs to idetify the risk factors of the major diseases affectig wome ad childre, relay iformatio about the importace of prevetive actios, immuizatio, ANC, safe delivery ad PNC care, stress the importace of adoptig safe sex practices to avoid HIV/AIDS ad STDs, motivate wome to visit health facilities ad esure timely referral to appropriate health facilities. 4.5 Participatio of wome i health maagemet Active participatio of local wome i commuity based health service maagemet, particularly TBAs ad FCHVs is ecessary. Existig wome's groups such as microcredit groups, mother's groups, commuity forestry user groups, water/saitatio user groups, ad religious groups must be mobilized to advocate for the icorporatio of local health eeds ito health policies ad programs. I places where wome's groups are o-existet, wome should be facilitated ad ecouraged to express their health cocers through periodical cosultatios with the existig local orgaized groups. 18

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