Section 4: Prototype Workshop

The GPIH Workshop

A typical three day GPIH workshop attempts the following objectives:

1. To give participants conceptual clarity on

(a) Why gender analysis of health program is needed

(b) Basic precepts of GPIH and its four tools

2. To give participants essentials skills in using GPIH tools

3. To help participants self evaluate their health program through GPIH

 

GPIH workshop takes the participants through these mile stones:

 

Figure 1

 

Following is a workshop schedule which was used often in Swayamsiddha, with minor changes to suit local factors like participant’s level of comfort with new concepts, ability to absorb and finish group tasks and other pressures (like last bus for commuters!)

Workshop Schedule

Day	Session	Activity	Purpose
Day 1	1	·              Participants’ introduction ·              Introduction of workshop objectives (Roadmap) ·              Recapitulation of basic Gender concepts[1] & GPIH definition ·              Problem Response analysis: Analysis of the local problems and programmatic responses of the agency. ·              Tool 1: Patterns of Ill-health, is introduced, explained, discussed and adapted to local context	Problem Response analysis is conducted to help participants get into “eco-health” frame of mind[2]; so that they are geared to look at their local issues & programs analytically.
	2	·              Service provider Free listing ·              Constraints on accessibility and availability ·              Tool 2: Health service provider analysis, is introduced, explained and discussed	To bring out the gaps between need and supply & dimension of quality of health services
	3	·              Tool 3: Factors affecting who gets ill - is introduced through a case study about a woman’s health issue	Important to make participants understand that tool3 (and 4) are not meant to capture only women’s vulnerability to certain health issues; Hence use of 2 case studies.
	4	·              Tool 3 is used again to analyze another case study, this time involving men’s health issue
Day 2	1	·              Tool 4: Factors affecting response to illness – introduced using a woman’s case study	Two case studies are used to emphasize that tools have no inherent bias for any sex and that in true spirit of gender, men’s problems should also be analyzed in depth from gender perspective.
	2	·              Tool 4: Factors affecting response to illness – repeated using a man’s case study this time
	3	·              Tool 3 practiced for a new local health problem	This practice session emphasizes: maintaining inter/ intra tool linkages and coherence and The significant differences between tool 3 & 4
	4	·              Tool 4 practiced for a new local health problem
Day 3	1	·              Recap of 4 tools
	2, 3	·              Group work: Take a local health issue and do a complete analysis from tool 1 to 4. ·              Group work: Plan an intervention (specific activities) based on this analysis ·              Compare present program against the ideal comprehensive intervention planned by you ·              Brain storm- How these tools can be used in future program planning exercises?	Important to see if the analysis is making a logical use of various bits of information generated by the different tools; Is there coherence in the entire process? Is the intervention planning making use of the preceding analysis?
	4	·              Open session for questions / suggestions ·              Workshop feedback

A Typical GPIH workshop

Here we briefly describe a typical 3 day GPIH workshop and its methodology.

 

Pre-requisites

Physical: a hall for 15-20 people to sit and also to subdivide in to 2-3 groups;

Charts, markers, board etc.

Participants: Mixed (women, men) groups, from diverse backgrounds (ANMs, Rural animators, field workers, supervisors and program managers) work fine; Analysis benefits immensely by the variety of information coming from such a group.

Number of participants, ideally about 12-15, but could range from 10 to 20.

Level: Some prior knowledge of gender issues is helpful. General awareness of health issues is also useful. Participation of people who supervise, review and plan health programs like Field supervisors and program coordinators, can be very useful.

 

Methodology has to be highly participatory since it deals with deep seated values, beliefs and project work. Intense discussions have to be interspersed with energizers, games or other type of activity which helps to change the rhythm of the workshop.

 

Day one

First Session

1. Introduction of participants: some creative method which doubles as an ice-breaker too, if the group is not very familiar or comfortable with one-another.

2. Facilitator next introduces GPIH by asking a question:

What is Gender? What is its relevance to your work?

A simple definition of GPIH is then introduced, built on their responses.

3. Workshop roadmap is put up on a wall and discussed. This helps participants understand the major milestones to be achieved over next three days.

4. Problem Response Analysis

 A volunteer is requested to come forward and free-list the problems (inclusive of health ones) in the area. When a comprehensive list is ready on the chart / board, she is asked to list her organization’s response to these issues. Problems and responses are thus listed in two columns on the board by the volunteer, often prompted and helped by colleagues. Facilitator asks her to draw arrows between those problems & responses, which have a linkage and explain them. This exercise gives the facilitator a glimpse of the local context, helps the participants to get going (and more vocal) and will get the group tuned to the eco-system approach to health- central to the unfolding GPIH. The resulting list could be something like this:

Problem Response Analysis
Problems	Program response
White Discharge	RCH Education
Malaria control	Mosquito net
Malnutrition	Kitchen garden Nutrition day celebration Water Interventions
Water borne diseases	Awareness, Chlorination
Water fetching over long distances	Hand pump, span pump
Unavailability of primary treatment	Nature cure, Health check up program, Herbal cure inputs to SHGs
Infant and maternal mortality	Training of field functionaries, TBAs, Growth monitoring, Immunization
Drudgery of SHG women	Washing platform, Cattle tank, Ball bearing, portable stove, tree plantation

 

Sometimes, participants are also able to bring out undesirable effects of an intervention from health perspective: Ball bearing may increase the efficiency of grinding stones at home but in some instances it may attract larger amounts of grain to be ground and may aggravate low back pain of the housewife. This exercise helps participants to move away from immediate causes of ill health and sets the stage for a broader socio-economic analysis. 

The participants are asked to free list health problems in their area. Tool 1 is now introduced. Handouts in regional language must be provided to facilitate comprehension and discussion. Various labels of tool 1 are explained. The group is asked how many of these labels are appropriate for their area. They are encouraged to make suitable changes in the handout given to them.

Small group activity: Once the tool 1 grid is finalized to reflect local specificities, two or three small groups are made and are given 1-2 health problems to analyze, from the list of local health problems. They have to discuss and fill up tool 1, using whichever method they feel comfortable with. Some groups would use just a plus mark to indicate that the problem is common among young children of Kokna tribe during winters for example. Another group may represent it on a scale of 0 to 5, where 0 means ‘no incidence’ and 5 means ‘very common’. Ensuring uniformity here serves no purpose and could inhibit the group.

In the plenary, they present their findings where feedback is moderated and enriched by the facilitator. Another way to accomplish this in less time: Display all the outputs (Tool 1 charts) at once on a wall, where the groups offer comments and question each other’s outputs, moderated by the facilitator. This exercise emphasizes the importance of knowing in depth the profile of the segment of the population being most affected by the problem. The question to help this is:
How do you know that the said problem is rare among other groups? Why do we want to know this? How will it affect the program planning?

Second Session: The group is asked to free list various service providers catering to their community - private and public, formal and informal, traditional/indigenous and allopathic/bio medical. It is emphasized that to plan well, one needs to know, who is affected by the problem (tool 1) and also what services are available to them currently. The latter is the subject of tool 2– service provider analysis; this tool is introduced now. Why some people / groups may not be able to utilize certain services is discussed: constraints on accessibility and availability of health services.

Questions to stimulate discussion are:

·        What segments, communities or groups go to these various health care services? For which illness do they go? for which they will never go?

·        Reasons for those persons going and for others not going to the health care service? Does it have anything to do with the timing and location of services, money needed to avail it, confidentiality offered or practiced, effectiveness of the service, prevalent norm, appropriateness regarding it?

 

Again, 2-3 subgroups take up 1-2 service providers and do an analysis; A typical output may resemble following in part:

Tool2 Name	Distance	Pvt/Pub/	System	fee	Clientele.	Go for what ailments?	Will never go for what ailments	Reasons for not going	Rem
1.	2.	3.	4.	5.	6.	7.	8.	9.	10.
BAIF PTC	0 km	Voluntary	Ayur+Allop	2 Rs	All, women more than men	Fever, Diarrhea, Dressing of wounds, Body pain, Skin disease,  Burns	TB, Snake bite, Delivery, Accidents	Only basic skills available
Limdha Pvt Doctor	5 km	Pvt	Allop	20-50 Rs	All	Fever, Vomiting, Diarrhea, Dressing	TB, Delivery, Accidents, Snake bite	Needed facility/ drugs not available
Bhagat	0 km	Informal	Ayur + Tantrik	5-10 Rs	Kotwaliya, Vasava	Mental health problems, snake bite, fracture, Joint pain, Jaundice	Accidents, Delivery, TB	Limited role (faith healing)

 

 

Third Session: First case study (part 1) translated in the regional language is distributed, and discussed in small groups. Facilitator makes sure that everyone has understood the story and finds it believable. Next, the group analyses the reasons operating behind Phalguni’s backache. Facilitator introduces tool 3 and explains various labels (row & column heads) and how to fill the format. In this plenary session conducted by facilitator, small groups (as made previously) brain storm and list the reasons. They are asked next, which reasons should go into which box – and why. This generates interesting debate among groups, where facilitator has to moderate and help people with suitable examples for various boxes. For example: what could be a suitable example for box 12 (tool 3)?

In the unorganized agriculture sector, for the same work women tend to get less daily wages. Why? Is there a gender norm that man’s work must be treated as of more inherent value? Who benefits and who perpetuates it? The market? How does it contribute to her vulnerability to sickness?

Participants may struggle to understand this interplay of row and column heads and would need suitable examples to illustrate the point. A typical output of this session may look like this:

Tool 3: Reasons behind Phalguni’s backache (case study 1, part 1)
Why do different groups of men and women suffer from ill-health	At Household level	At Community level	Influence of States/markets international relations
How does the ENVIRONMENT influence who becomes ill?		·                       Forest has shrunk (community responsible for it) ·                      Communal Water source far from village	·                      Natural resources (forest, water) under state control which has not cared.
How do the ACTIVITIES of men and women influence their health?	·                      Phalguni has too much domestic work, to be done in bent posture
How do the BARGAINING POSITIONS of men and women influence their health?	·                      More children (Phalguni cant decide family size) ·                      Early Child bearing ·                      Husband refused to buy solar cooker	·                      More children (society norm) ·                      Poor path to forest and water ·                      Forest path not being priority of panchayat	·                      state unable to prevent early marriages
How does access to and control over RESOURCES influence the health of men and women?	·                      To carry excessive weight over long distances (no access to draught animal?)	·                      No access to panchayat funds to repair path ·                      Women in panchayat not able to sway decisions	·                       Contraception not provided / promoted by state ·                      Unsuitable Policy of world bank, bypassing Phalguni’s village
How do GENDER NORMS influence health?	·                      More children being born ·                      Excessive workload on women ·                      Boys not helping in domestic chores	·                      Early Child bearing ·                      Boys not helping in domestic chores ·                      Women having “sankoch” & not using the new contraption (harness) to carry load

 

Fourth Session: The facilitator asks – what is Gender?
The response mostly brings up the correct theme: inter-relationship between roles ascribed to women and men by the society. Building on this reply, facilitator states that men too must be vulnerable to certain health problems just because they are men! So, let us analyze another case study to understand this phenomenon in some depth. Part 1 of the second case study Better sex ratio in a mountain village is shared in small groups. Tool 3 is used to analyze various reasons responsible for higher mortality among men in Kuthalsain as above. Following is a sample output:

Tool 3: Higher mortality among men in Kuthalsain (Case study 2, Part 1)
Why do different groups of men and women suffer from ill-health	At Household level	At Community level	Influence of States/markets international relations
How does the ENVIRONMENT influence who becomes ill?		·                        Poor Land, poor water resources forces them to dangerous jobs	·                       Media promotes “manly” professions like Army
How do the ACTIVITIES of men and women influence their health?		·                       Taking ‘jhula’ down from high trees ·                      men having to work in remote forests ·                      Driving on mountain roads	·                      State offers no other job, career
How do the BARGAINING POSITIONS of men and women influence their health?
How does access to and control over RESOURCES influence the health of men and women?		·                      Poor facilities for higher education in the region	·                      Poor facilities for higher education by state in the hills
How do GENDER NORMS influence health?	·                      Appeal of “manly” professions ·                      Pressure on men to earn at any cost and provide for children’s higher education	·                      Appeal of “manly” professions ·                      Men running grocery are looked down upon ·                      Driving after drink due to peer pressure	·                      Armed forces recruit men, not women

 

In summing up, we ask- what use is this tool 3, to overall planning process?
To prevent people falling sick, what our program needs to do – that is what it tells us ie. Information of a preventive nature.

 

Day Two

First Session: A rapid participatory recap is conducted with the help of participants. Tool 4 as handout is distributed and a question is asked: In what way is it different from tool 3 and why? The similarity is obvious. Differences come up as the participants go over it a few times: third column has changed from Influence of States/markets/ international relations to Available health services. First row for Environment is missing.

Both these changes are understood if one looks at the name and the purpose of the tool. Tool 3 deals with the scenario before falling sick while tool 4 deals with circumstances coming into play after falling sick. Environment (eg. ill ventilated kitchen) has a role in contributing to sickness but is no obstruction to its treatment. After falling sick, available health services influence outcomes; while state policy and market forces may contribute to people’s vulnerability to falling sick in the first place.

The participants are now given part two of the first case study- Backache in women. In small group task, it is discussed and constraints on Phalguni’s return to health are sorted out. Next, groups brainstorm as to which constraint belongs to which box of tool 4 and why. Questioning why is important since at times, one factor may have more than one interpretation and assigned to two boxes.

Once this exercise is over, we sum up by asking, why this information is important for program planning: This tool generates information useful for ‘curative’ content of the health intervention. Here is a sample output:

Tool 4: Factors making Phalguni’s recovery difficult (case study 1, part 2)
How are men’s and women’s responses to ill health influenced by gender?	Household	Communities	Available health services
How do the ACTIVITIES of men and women influence responses to illness	·                      Too much work load- no time for self care		·                      PHC timing clashes with her schedule
How do the relative BARGAINING POSITIONS of men and women influence responses to illness?	·                      Phalguni cant go to PHC on her own; depends on husband to take her
How does access to and control over RESOURCES influence how men and women respond to ill health?	·                      White discharge and Backache was taken as an insignificant problem by Phalguni ·                      To link backache with white discharge (lack of correct info) ·                      Superstition about cure	·                      White discharge was taken as an insignificant problem by Phalguni ·                      To link backache with white discharge erroneously ·                      Superstition about cure (lack of correct info) – community promotes it among women	·                      PHC is 10 Km away ·                      Only one bus service was there. ·                      Timings of Bus and PHC being inconvenient ·                      Health Team of the NGO visits the village only once a week. ·                      Location of the PHC unsuitable
How do GENDER NORMS affect responses to illness	·                      Cow has to be milked by woman ·                      Young child will eat only from her hands ·                      Phalguni had to stay back for DIL’s delivery	·                      Phalguni had to stay back for daughter in law’s delivery ·                      Phalguni cant show her back to a man (doctor)	·                      The only doctor available was a male

 

Second Session: Tool 4 is used to analyze second part of the second case study, dealing with Ramesh’s accident and subsequent events. Methodology is same as above. But the group often needs help in grasping the insidious nature of male socialization (psychological part), leading to certain lifestyles (smoking, drinking, gambling, go getter attitude etc) and preference for certain occupations; Subtle but proven connection between heart diseases and bottled up emotions in case of men is often used as an example. Specifically, while concluding, facilitator asks:

Which events would have taken a different turn in this case study, if Ramesh was to be replaced by a woman, say his wife, everything else being equal?

Here is a typical output:

Tool 4: Constraints on Ramesh’s recovery (Case study 2, part 2)
How are men’s and women’s responses to ill health influenced by gender?	Household	Communities	Available health services
How do the ACTIVITIES of men and women influence responses to illness	·                      Place of accident being too far away form the village
How do the relative BARGAINING POSITIONS of men and women influence responses to illness?	·                      Ten thousand Rs were needed for treatment		·                      Forest produce – being illegal for Ramesh ·                      No transport being available in the night
How does access to and control over RESOURCES influence how men and women respond to ill health?	·                      Ten thousand Rs were needed for treatment ·                      Village did not have a transport means	·                      Ten thousand Rs were needed for treatment ·                      Village did not have a transport means ·                      No qualified doctor being in the village	·                      Hospital being 40 km away ·                      Dealing in Forest produce (Ramesh’s occupation) – being illegal, Hospital will have to report to police ·                      No transport being available in the night ·                      No qualified doctor being in the village
How do GENDER NORMS affect responses to illness		·                      Men running grocery store are looked down on

 

An interesting debate occurs around the question: Can woman give consent for amputation of her leg, if necessary? Who is freer to do so- woman or man? Unmarried woman or married woman? What if it is uterus (hysterectomy) and not her leg? This brings out subtle norms governing these choices in different strata / communities of society.

A rapid recap of tool 3 and 4 is done. Participants are asked: which boxes in tool 3 & 4 will be the most difficult and most easy to address through a program. This further results in a discussion about how we use information generated by these tools for program planning and about strategic Vs practical gender needs: Factors listed in the row for gender norms, may be most difficult to change, but will have to be addressed in the long term interest of women and men, affected by them. Often different answers will come up depending on the background, beliefs and attitudes of the participants. It would be useful to emphasize that there are no standard “correct” answers.

Another way to recap tool 3 and 4 is to give the group a number of zopp cards with caselets written on them and ask them to arrange them on a big chart with tool 3 or 4 outline. This is a more interactive and spontaneous way of finding out how much participants have grasped and what their difficulties still are.

Third Session: Two or three health problems are given for analysis with tool 3 for practice, as small group task. Often the problem may already have been used for tool 1 analysis (who, where, when). The group is reminded that the problem should not be analyzed from the point of view of general public. Rather, if on day 1, tool 1 analysis has shown the problem to be commoner among young Warli[3] girls in off road villages during monsoons, then tool 3 analysis must keep these specifics in mind. It will be their (Warli young girls) activity and environment which should come up in tool 3 grid, if it makes them vulnerable to the given health problem. It is important to remind the group that all the tools are inter-related and should not be seen & used in isolation.

In the plenary session, groups review each others’ grid and offer a critique, moderated by the facilitator. Again, asking why a certain factor has been put in a particular box, would bring out a mass of information, which the group may have discussed but may not have put down on the chart.

Fourth Session: Same health problems as above are given for analysis with tool 4 now, as small group task. Besides the above precaution that this exercise must take cognizance of preceding analyses, facilitator also emphasizes the fact that while tool 3 highlights the factors which make one vulnerable to a particular health problem, tool 4 deals with constraints which come into operation after falling sick and makes it difficult for her or him to seek help. One deals with factors before falling sick, the other after- to put it simply. Forgetting this, some participants tend to produce similar lists of factors both in tool 3 and 4. In the end we summarize the purpose of both the tools: help plan preventive (tool 3) and curative (tool 4) contents of a Health intervention.

 

Day 3

First Session: A rapid recap of the four tools is conducted. Next, the participants are divided in to small groups, depending on their numbers. On previous days, participants had learned & practiced one tool at a time, often overlooking the inter-connections. Now in small groups, a common health problem is given for complete analysis from tool 1 to 4, leading to intervention planning, as a holistic exercise. If there are two groups, consider giving one a woman’s issue like Leucorrhoea and the other, a man’s issue like Urethral discharge (‘Dhaat’) or Alcoholism.

After each step, findings are shared or presented and peer reviewed. If some of the analysis was already done in the previous sessions like service provider analysis (tool 2), it is not repeated and used as it is. Finally, all four analyses are displayed together and the group tries to see

·      Is the center of the analyses all through, the same affected segment of the population? Same women? Men? Children? Tribe?

·      Have the tools been used properly?

·      Is the analysis deep enough? What is it about their activity, environment etc which makes them vulnerable?

 

Second Session: The same small groups are now asked to develop a comprehensive, even ideal intervention plan in the light of the preceding analyses. They are given the following heads to be kept in mind:

·      What activity actually will be done? (its contents)

·      Who will be responsible for it? Who will participate in it?

·      When will it be conducted? For how long? Frequency?

·      Who will be its focus? (Target group? beneficiary? participant)

·      Will any special methodology be used? 

This often takes the form of a grid as below:

Intervention Plan for TB : Objective- To reduce the prevalence of TB in 3 years by half

	Activity	Who will be responsible	Where, for whom	When, frequency	Other / method	What help needed
1.	Base line survey to register all families with cough > 6 wks	Local team (F,M)	Project villages All family survey	One month complete	A survey form will be used, Door to door	Help from Village key person, Trg, PHC
2.	Primary data collection (PHC, Dist Hospital, Pvt practitioners)	From PHC Baif staff	PHC, CHC, Dist hosp, Will inform them also	15 days	Meeting with MO, CMO, Interview	Project leader AC, PC
3.	Health check up camps	PHC-MO, CHC-MO, staff; BAIF doctor & Staff	In a central village	1 mo after survey; Jan-Feb	Health camp; Lab investigation	CHC, PHC, Village school, Key person, Panchayat, NGO, local institutions,
4.	Complicated cases referral	PHC-MO	To CHC, Dist Hosp	15 days After camp	Transport arrangements (PHC)	GO, NGO
5.	Treatment; Arrangement of medication	PHC ANM, NGO	Village, Door to door	If + in screening camp	Door to door, ANM, Balwaadi worker, SHG	PHC

 

Now all the tools and intervention plan are put together for peer review; the facilitator and the group look for convergence and consistency in the two: the analyses and the proposed intervention. Do they justify each other? Any deviation is discussed. This is one of the most important steps in the entire workshop:

For example: if tool 1 shows that the problem affects warli young girls in the off road villages, does the intervention plan try to focus on them? If tool 2 shows that most affected people go to Bhagat in their area, does the health education campaign try to work with Bhagat or bypass them? If tool 3 & 4 mentions that one of the problems are- women do not have enough privacy to practice personal hygiene or recommended treatment (eg. Sitz bath) – is this being addressed somehow in the intervention?

Next, the group is asked to self evaluate their current efforts against the problem just analyzed. They compare their current program against the proposed intervention plan and rank various activities / components on a scale of 0 to 10 and add it up to work out an overall percentage. This process too ends in a peer review. The group is encouraged to think in terms of how programs can be planned better next time rather than rejoice or worry about the score their program has received.

A group produced following table in a GPIH workshop:

S.N	Self evaluation of Program Activities	Out of 10
	Base line survey for skin problems	7
	Basic curative treatment for skin problems	5
	Preventive health education – hand washing, nail cutting, bathing, fungal infections, causation through dirty water	4
	promotion of Low cost bathroom construction	8
	Nail cutter distribution- schools, SHGs	3
	Ensuring clean water availability	9
	Hand pump repair, Spring development	8
	Total	62.8%

 

Third Session: The group brainstorms on how to actually go about using these tools during program planning; Questions to ask are:

·      Can these tools be actually used in your organization?

·      How? To what purposes?

·      What will they have to do in order to use them?

·      What changes will the tools have to undergo, to be ready for use?

The facilitator moderates this session and jots down the ideas on a chart; Later she critically evaluates these ideas and shares them with the group in a sum up exercise. The group often comes up with deep insights at this point. It would be worthwhile to find out what the normal planning cycle / process being used is.

The facilitator tries to emphasize- that there is nothing mysterious about the tools: the matrix format helps us to think critically (and generously) and that the matrix can be adapted.

Fourth Session: An open session for any and all questions. A brief recap is conducted. Workshop feedback is taken. Participants are thanked and workshop concludes.