How a dialogue project helped women in Pakistan claim their reproductive health and rights
In two districts in Khyber Pakhtunkhwa province, dialogues across generational and gender hierarchies addressed cultural practices that harm women’s reproductive health and rights. Contrary to concerns that the approach might not be suitable for the conservative cultural context, the response was overwhelmingly positive and first results exceeded expectations.
Pakistan is currently at a developmental crossroads. Foreign investment is rising, enormous industrial projects are in the pipeline, yet investment in human development and gender equality is often neglected. Work done in the public health sector also has an emphasis on physical infrastructure, and attempts to improve service delivery, attitudes and the relationships between service providers and the population are limited in number and in scale. Too often the people, their way of thinking and the strong association they have with their culture is not sufficiently taken into account. Root causes such as gender inequality that foster harmful behavior are often not addressed.
The province of Khyber Pakhtunkhwa (KP) is a case in point. Cultural and tribal values, which are often discriminatory against women, discourage them from leaving their homes to seek healthcare and consequently, maternal, infant and child mortality rates are exceptionally high. The rigid nature of social and political hierarchies and gender relations create an environment which is not welcoming to outside influences that could stimulate social change. This is why conventional awareness raising campaigns against harmful traditional practices have often not been successful.
Breaking a new path to empower women to claim their sexual and reproductive rights
The Reproductive, Maternal and Newborn Health Project (RMNHP), which Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH implemented on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) between January 2015 and March 2017, understood that an innovative approach was required if customs and traditions which kept women from attending antenatal care and assisted deliveries and which uphold the preference for sons were to be changed.
A participatory approach developed by GIZ to initiate social change within traditional communities, called Generation Dialogue, had been successfully employed by German-supported projects in other parts of the world. In consultation with the Population Welfare Department Khyber Pakhtunkhwa, the RMNHP team decided to adapt this method to the local context in the form of the Community Dialogues. The GIZ project ‘Promoting Gender Equality and Women’s Rights‘ (07/2015 – 03/2018) supported this adaptation and a training of trainers in Islamabad, as a part of one of its objectives to disseminate tested and innovative measures against harmful traditional practices in partner countries worldwide.
The objective of the Community Dialogues was to raise awareness and build consensus between the generations and men and women that it was important for pregnant women to seek professional health care – and that having healthy mothers and healthy babies was beneficial for the community as a whole. A second important topic that emerged during the dialogues, and which they addressed, was the tradition of son preference and its negative effects not just on girls but the communities as a whole.
This small pilot initiative, if nothing else, was expected to help start conversations between young and old, and men and women, that had previously not been possible; and that these conversations would eventually empower women to enjoy their full sexual and reproductive health and rights. The results however, were far beyond expectations.
A highly structured process enables unprecedented exchanges
Between June and December 2016, RMNHP in partnership with the INGO Rutgers Pakistan first trained trainers who then trained facilitators to carry out dialogues in four communities in the Haripur and Nowshera districts of Khyber Pakhtunkhwa province. The facilitators first conducted focus group discussions (called Community Consultations) with a cross section of young and old and male and female community members to gauge their views on intergenerational and gender relationships and on the topics to be addressed by the dialogue process.
In each community, 48 so-called Dialogue Champions then took part in a series of five facilitated dialogue sessions between the older and younger generations, divided into women’s and men’s dialogues. The five sessions allowed the two generations to come together, bond over shared values and identify joint challenges and possible ways forward.
The structured way of proceeding gave acceptability to the process as it had the stamp of approval from the older members of the communities. Also, it allowed unprecedented female participation in both the dialogue sessions and in the public meetings at which the dialogue participants presented the results of their dialogues, including their personal commitments and their requests to various community leaders and to the community at large. According to one of the trainers “It takes exceptional courage for women from the rural areas of Khyber Pakhtunkhwa, who are barely allowed to leave the confines of their homes, to come to a public meeting in the city”.
Despite Purdah, women and men attend joint meetings and ‘talk straight’
Pakistan’s Khyber Pakhtunkhwa province is a strictly gender-segregated society where women observe ‘purdah’, meaning they do not interact publically with men even on family occasions such as funerals or weddings. When the project team planned the intervention, they were unsure whether it would be possible to get the male and female Dialogue Champions to meet, an important part of the fourth of five Dialogue sessions, at which the male and female participants are meant to jointly develop a coherent plan against harmful practices which they will then jointly present, at the public meeting, to the community at large. Against all expectations, the community members were so enthused with the Dialogue process and its potential that they themselves found flexibility in their hitherto rigid norms. With a curtain separating men and women, involving the local elders and getting children to showcase songs and skits, an environment was created that kept cultural sensibilities intact and allowed women to participate alongside the men in the public meeting. The facilitators went another step forward by holding the joint sessions in the village community centres (Hujras) which are traditionally reserved for male gatherings and to which women have never been allowed entrance. The fact that male and female Dialogue Champions had joint meetings in the Hujras was in itself a significant and highly symbolic achievement. One community elder stated: “The greatest change has occurred in me; my attitude and behaviour towards my mother, wife and daughters have changed a lot”
Independent project reporting teams monitor changes
To ensure careful monitoring, trainers, facilitators and dialogue champions acted as the eyes and ears of the process by recording every significant step and outcome of the Dialogues. In addition, independent project reporting teams were sent to field activities to interview individuals involved in the process. Community Consultations were held at the beginning and end of the process to be able to track developments in the difference in views, ways of thinking and subsequently practices. Community members were trained to document their journey using the ‘Most significant change stories’ technique, a form of participatory monitoring where they reported the changes they saw in their lives due to the Community Dialogues.
Community members report improved attitudes towards professional health care
Amongst the most encouraging findings that the above monitoring and evaluation process elicited, was the increase in the number of pregnant women seeking healthcare, and the fact that the Dialogues had helped break down barriers between health workers and women. Babu Gulla, a middle-aged woman, told the independent reporting team that she had lost her 20-year-old daughter because of handling by an unqualified birth attendant. “I have come here along with other members of my family because I don’t want them to fall victim to what I faced out of ignorance”.
Due to the cultural taboos surrounding women seeking healthcare, the village based healthcare workers had hitherto often felt unwelcome inside homes and there was a level of mistrust between them and the community. The Dialogue sessions removed these biases and built trust between the two groups. According to Rameez, a 26 year old man, “it may take several years to change the mindset of the people, but the community dialogue already managed to induce people to start visiting doctors more often than they used to”.
Government officials take a personal interest in the process
Another positive result was the attention which government officials and elected representatives paid to the process, most notably the highest executive officer i.e. the Chief Minister of the province, who took a personal interest in the intervention and its ability to empower women. Local officials, who saw the Dialogues as an opportunity to engage with the public and garner political support, not only attended public meetings, but ensured administrative support to help eradicate son preferences and unsafe child bearing practices from the communities. The new local government ordinance in KP had created a new tier of government at the village council level and the Dialogues coopted those newly elected village representatives by keeping them constantly informed of the progress, and by even inducting some of them into their cadres of facilitators and Dialogue Champions. This proved to be a safeguard against conservative opposition and ensured constant public participation.
What made these changes possible? A retrospective analysis
There is no doubt that the Community Dialogue approach is unique in the sense that it encourages change of harmful traditions and practices to come from within the community itself thus nurturing the local ownership so necessary for sustainable impact.
Throughout the intervention GIZ maintained a low profile allowing the trainers and facilitators to be the face of the process, to avoid the notion of foreign interference that had undermined previous social and behavior change campaigns.
Another important element was the incorporation of key influencers like the religious leaders. Their guidance was sought on the issues of women’s reproductive health and rights, and son preference and its effects, through an Islamic lens. Working in tandem with them ensured their active support to the extent that they started to give weekly sermons in the mosques on the topics discussed. Local government officials were other key influencers with whom synergy building proved to be crucially important in giving the community a stake in the dialogue.
Perhaps the most important factor was the dialogues’ tapping of the strong need within these strictly segregated communities to express their thoughts, opinions and concerns about matters that affected everyone’s daily lives, yet which could hitherto not be discussed because of their sensitive nature. A local government official from Haripur summed up why the Community Dialogues were seen as unique: “No serious effort has ever been made in Pakistan to come up with a health policy that engages the family in a dialogue, particularly in rural areas. This is the first time that someone has actually asked us what we think and what we need.”
In the light of the positive developments which the dialogues evoked in the communities it targeted, the Local Governance programme in Khyber Pakhtunkhwa, which GIZ implements on behalf of BMZ, is currently considering how to adapt and implement the Dialogue approach to promote participation and social change in other areas of community development.
Shahmir Hamid, M&E Consultant for RMNHP