Section 5: More On GPIH Tools

Important considerations while using them

General Comments

·     Should the message be aimed at Field functionary level or program manager level? In a mixed group, it is often difficult to decide where to pitch the message. No easy answers. But ensuring that small groups made for different exercises or activities are truly balanced helps. Participant to participant learning takes place in the small groups.

·     Emphasize implications for planning after each and every tool. Participants tend to forget and the tool becomes stand alone concepts. Asking questions like: If you planned on the basis of this tool, what particular aspects will be emphasized or get changed in your plan & implementation?

·     For planning, it is important to view all four tools together. If tool 1 shows up that the problem affects Kotwalia young males, then subsequent tools and intervention must not lose this focus. When viewed in isolation, the planned intervention may not take advantage of all the useful bits & pieces of information generated by all four tools.

·     In true spirit of Gender, it needs to be emphasized that tools can and must be used both for women and men’s problems. Thus using two case studies, one ‘female’ other ‘male’ is helpful.

·     Self assessment of their programs at the end should be least directive.

 

Specific Comments

Tool1

Emphasize the need to make column and row heads exhaustive, comprehensive. Group may not realize the need for doing so in the beginning. For example, a group may see no need to include Parsis (Zoroastrians) as one of the column heads in tool 1 on following grounds:

·      They are a very small minority in their project area.

·      They are often well educated.

·      They are rarely poor in their project area.

After some discussion the group may realize that their knowledge of the community in question may be limited: that some Parsis may have started marrying into local tribal communities and these new ‘Parsi’ families may suffer handicaps similar to tribals. Again in certain contexts, like metros, Parsis may attract more violence, since old couples often live alone in apartments. So keeping these facts in mind, tool 1 should be adapted to local situation.

 

Tool 2

Following terms, as constraints on using a particular service should be explained with examples:

·      Timing (eg. inconvenient timings of a Government Hospital)

·      Location (distance, locality, lack of transport)

·      Money (eg. high fee structure of a private hospital)

·      Confidentiality (HIV + client in a Government service: how long her/his identity remains confidential?)

·      Effectiveness (Government medicines at PHC are often considered useless.)

·      Norm (are women free to go to a male gynecologist?)

·      Appropriateness (For delivery, who is more appropriate as a service provider – Dai or a Nurse? in what setting?).

 

 

Tool 3 & 4

·     Explain labels especially for tool 3 and 4 well. State and market, and their influence on individuals are somewhat abstract concepts. Some examples from their own context which can help are: Why migrant labor in your region comes from a certain part of the country? Why is Gujrat a dry state? What happens if this policy changes? How will it affect people’s health?
Similarly ‘activities’ represent economic/ subsistence activities; child eating mud or men playing cards is not an activity in that sense etc

·     Keep examples ready for various boxes (T3, T4) while introducing the tools. Examples illustrate the point and help comprehension greatly.

·     Sometimes participants tend to use broad labels (ignorance, poverty etc) while analyzing factors for T3 and T4, instead of isolating specific factors in depth and detail; This creates confusion later when the factors have to be put into the grid. “Poverty” per se could go in to various boxes, depending on the way, it is understood or explained: Poverty can lead to lack of toilet in the home (box 1, tool 3). It could refer to extra workload on woman in a poor household, which cant afford buying fuel wood, fodder etc and hence the woman has no time to practice personal hygiene (Box 4 and 10, Tool 3). So broad labels like Poverty could be assigned to all the boxes, which would prevent further analysis and pin-pointing of the real factors.

·     In Tool 3 and 4, people tend to forget the difference (before sickness, after sickness). This has to be stressed a few times.

·     Some participants stretch logic too far to put a factor in a particular box. This could have merit in some cases. One discovers quite unusual ways of looking at an issue. A PHC having just a male doctor – is that the outcome of insidious gender norm operating among service providers? Initially, we thought that it reflects gender norm of the community not the service provider / policy maker - since community tends to send more boys than girls for medical career, leading to scarcity of lady doctors. It is the community which frowns on women being attended by a male doctor, even though the woman in question may have accepted it as a matter of course. After a lengthy debate, we agreed that a subtle gender norm does operate among service providers too: Many District Health officers would prefer male doctors for ‘tough postings’ as they are considered more ‘efficient’ where fulfilling national targets are concerned.

·     The participants who have some experience in health sector (like ANMs) may want to discuss “biological factors” more than the other factors; this can veer the discussion in to an area which offers little scope for intervention. It is important to de-emphasize biological determinants of illness and move on to social factors.