| Gender issues in health projects and programmes |
|4. Gender issues in primary health care|
The use of health services may be seen as consisting of three main components:
Decision: recognising the need to seek health care, and deciding to seek care;
Contact: making contact with a source of health services delivery;
Care: obtaining adequate and appropriate care.
Women's use of appropriate health services is constrained by barriers acting at each of these levels: first, in deciding that it is necessary to seek help for the health problem. Decisionmaking is affected by a woman's power and selfesteem, as well as her level of knowledge. The woman may deny even to herself that a problem exists. Or she may not recognise the condition as abnormal. Even when a woman recognises that a problem exists, in the event of its being a gynaecological problem she may be too shy or embarrassed to seek outside help, and may prefer to tackle it at home, through home remedies. Even if a woman wants to seek medical help, she may be unable to do so since the decision to do so does not rest with her, but with her husband or elders in the family. She may be expected to cope by herself with any health problems she has, unless they are very serious. Because of this, women may hesitate to complain of ill health.
The second point at which women ability to obtain health care is constrained is in reaching a place of service delivery. Having decided to seek health care, a woman has now to overcome a series of other obstacles, such as distance from the health centre, and lack of time and money. There may be no-one to look after her children; the timings of the health centre, and the long queues, may mean losing a day's work and wages. In many cultures, a woman may only travel if accompanied by a male family member, and therefore his convenience and interest become a determining factor.
Third, when she reaches a health facility after overcoming these barriers, a woman may still not receive appropriate or adequate health care. First of all, the health centre may not be in operation, because the doctor and nursing staff do not come regularly. If there are no female health staff in attendance, women may not express all their concerns to the male health staff. The services of the health facility may be limited to a narrow spectrum, with only MCH care aimed specifically at women. Reproductive health problems are many and varied, and women may not find either the facilities for screening, or personnel with appropriate skills. More often than not, women patients may be sent back after superficial treatment of their symptoms. Lastly, even if a woman begins treatment, the opportunity cost of follow-up may be too high for her to continue with, and complete? the treatment.
Women's access to health care is thus a complex issue, going far beyond merely putting a health facility in place. The barriers to women receiving health care are caused by women's status at individual- and community-level, as well as by national policies. These individual and community-level barriers are composed of two elements: problems women face as a result of being poor, illiterate and powerless, due to factors including class, race or ethnicity; and problems arising from the fact that they are women in a patriarchal society which has inherent gender-based discrimination.