Research Report: Gender in Eye Care in Bangladesh

Transcription

1 Gender in Eye Care Research Report-Banagldesh Research Report: Gender in Eye Care in Bangladesh (Breaking the Silence, Speaking the Unspoken) Supported By: ORBIS International s Asian Regional Program Conducted By: Mashuda Khatun Shefali Executive Director Nari Uddug Kendra (NUK) mashuda.shefali@gmail.com December, 2014

2 RESEARCH REPORT ON GENDER IN EYE CARE IN BANGLADESH Supported By: ORBIS International s Asian Regional Programme. Conducted By: Mashuda Khatun Shefali Executive Director Nari Uddug Kendra (NUK) mashuda.shefali@gmail.com December, 2014 Gender in Eye Care Research Report-Bangladesh Page 2

3 Table of Contents EXECUTIVE SUMMARY 9 Chapter 1: Background 25 Breaking the Silence, Speaking the Unspoken INTRODUCTION BACKGROUND OF THE STUDY Gender Construction in Bangladesh Society Gender Issues in Development WHO Gender Policy (2000) WHO Study on Gender and Blindness Gender in Blindness Study in other Countries 30 Chapter-2 33 Rationale, Objectives and Methodology Rational of the Study: Study Objectives Methodology Study Design and Sampling of Study Population Study Period: The Study Areas and Sampling of Hospital Study Population Questionnaire development and Pre-Testing The Survey Team and data Collection Instruments Data Processing and data analysis 37 Chapter 3 38 Research Findings RESULTS OF INSTITUTIONAL SURVEY: GENDER SEGREGATED DATA OF PATIENTS COVERAGE Kishorgonj District Hospital, Kishorgonj Kishorgonj Eye Hospital, Latibabad, Kishorgonj Johurul Islam Medical College & Hospital, Bajitpur, Kishorgonj Mymensingh BNSB Eye Hospital, Mymensingh National Institute of Ophthalmology and Hospital (NIO) 42 Chapter-4 43 Gender in Eye Care Services in Bangladesh Gender Differences in Access into Eye Services Male-Female Patients Ratio in Five Hospital Status of Diseases Prevalence in Four Hospital 44 Gender in Eye Care Research Report-Bangladesh Page 3

4 4.4. Gender Differences in Diseases Prevalence Status of Surgery Rates in Four Hospital 46 Chapter 5 47 Gender and Blindness in Bangladesh RESULTS OF PATIENTS SURVEY Patients Profile Types of Eye Diseases of the Respondents and Length of Suffering Reasons for Waiting to Seeking Services Women s Service Seeking Practice Factors Effects women s less/low/late rate of Women s Participation Family Consent: Requirements of Escorting Reproductive Role and Domestic Responsibility Distance of Hospital Lack of Decision Making Capacity Costs of Treatment No Source of individual Income Preference of Doctors and Reasons of Choice Institutional Barriers Identified by women in accessing eye care service Differences of Barriers between the Service Seekers and Non-Service 56 Seekers 56 Chapter: 6 58 Stakeholders Opinion and Suggestion to Improve women s Accessibility in Eye Care RESPONSES FROM MEDICAL DOCTORS AND HOSPITAL STAFF ABOUT Women Service Seeking Practice Responses from Stakeholder s Consultation Results of Observation on Gender Friendly Environment at Hospital Suggestions Made By Women Patients For Community Eye Care Program 62 Chapter 7 64 Conclusion and Recommendation CONCLUSION Recommendations Immediate Steps: Medium-Term: Long Term: 69 References 70 Annexure Error! Bookmark not defined. Gender in Eye Care Research Report-Bangladesh Page 4

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6 Acronyms WHO CSR DSF KKI NGO NIO BNSB FGD ESC DCR KEH JIMCH GOB INGO NEC NUK BCEIO : World Health Organization : Cataract Surgery rates : Demand Side Financing : Key Informant Interviews : Non-Government Organization : National Institute of Ophthalmology : Bangladesh National Services for Blind : Focus Group Discussion : Eye Screening Camp : Dacryocystitis : Kishorgonj Eye Hospital : Johurul Islam Medical College & Hospital : Government of Bangladesh : International Non-Government Organizations : National Eye Care : Nari Uddug Kendra : British Columbia Epidemiology and International Ophthalmology Gender in Eye Care Research Report-Bangladesh Page 6

7 IAPB SEVA CBM CSO CBO UZ UNO OPD BMDC UHC : International Agency for Prevention of Blindness : SEVA Foundation : Christoffel Blinden Mission : Civil Society Organization : Community Based Organization : Sub-district (Administrative division) : Upazilla Nirbahi Officer : Out Patient Department : Bangladesh Medical and Dental Council : Upazila Health Complex Definition of Notes and Concept Household: one or more members who usually live together and eat from same kitchen using same utensils from a household. Domestic Violence: any act made by any member of the family, causing physical, psychological, sexual and economical oppression to any woman member or any child of that family. Victim means a child or woman, who is or has been or is at risk of being subjected to domestic violence by any other member of the family to whom a family relationship exists. Sex: identifies bi-logical differences between men and women, such as women give birth, men provides sperms. These roles are universal. Sex-Segregated data: Any records or data counted or separated by sex in order to Follow differential affects or impacts on men and women. VISION 2020 : A global initiatives launched by WHO in 1999, to combat avoidable blindness. Gender: A development terms, identifies the socially constructed relationship between and men and women. It refers to the condition and position of men and women, boys and girls in any society defined by their existing roles, responsibility and expectation from each other. Gender in Eye Care Research Report-Bangladesh Page 7

8 Gender Roles: A learned behaviour in a given society, that condition activities, tasks, responsibility are perceived as male and female. Gender roles are dynamic and are changeable. Gender Equality: Means absence of discrimination on the basis of person s sex differences in opportunities, resource allocation, benefits, shares or access to services with respect and dignity. Gender Equity: Entails the provision the provisions of fairness and justices in the distribution of benefits and responsibilities between men and women. The concepts recognize that women and men have different needs and interests. Therefore these differences should be addresses in a manner that rectifies the imbalances between the sexes. Gender awareness: An understanding that is socially determined differences between men and women based on learned behaviour, which affects access and control resources and opportunities. This awareness needs to be applied through gender analysis into personal, societal, organization, projects, programs and policies. Gender Sensitivity: The ability to acknowledge and high light existing gender differences, issues and inequalities and conscious efforts to overcome those into strategies and actions. Gender analysis: Is the process of collect and analyse sex segregated data on current position of men and women or groups that the purposed project is going to benefit or affects. Without the recent data, gender issues remain invisible. Gender Needs: Based on the differential roles and responsibility of men and women, they have different needs and interest. They are strategic needs (improvement of women s position) and practical needs (improvements of women s condition). Gender Mainstreaming: Is the process of ensuring both men and women has equal access to and control over resources, decision making, and shared benefits at all stages of the development process. Gender mainstreaming emphasizes on getting the overall activities to focuses on both men and women, rather merely adding a components or unit to benefit women isolated at the margin. Women s Empowerment: Women having decision making power on their own and have access into information and resourced that they control over and continued development on their choice. Gender in Eye Care Research Report-Bangladesh Page 8

9 EXECUTIVE SUMMARY Background and Context Blindness is an increasing global health problem that afflicts approximately 50 million people and of this figure 64% are women. This figure could increase to 75 million by 2020 unless necessary efforts are made to prevent blindness among the women population. In different society, religions are common not allowed female to move alone and their social roles and living condition, working environment are more influential for getting more sight threading diseases. It is evident that, Cataract, eye duct inflammations, dacryocystitis and presbyopia are higher in female than male. More women are blind then men due to less likely to access into cataract surgery for various reasons. Blindness prevention is one of the crucial issues for WHO is covered under Vision 2020 campaign. This approach is in generally focused on avoidable blindness elimination worldwide. In 2000 WHO adopted gender policy and in 2002 conducted a study on Gender and Blindness, which identified and confirmed the gender dimension in blindness prevention. The study findings concluded with the global call for awareness of the local and national approaches to improving gender equity in eye care services use as critical steps in achieving the goals of VISION 2020.Based on the study findings and recommendations, SEVA has been taken explicit leadership in the gender and blindness global initiatives. According to the SEVA report on Gender & Blindness-Initiatives to Address Inequity updated by Alia Dharamsi in July 2012, said, Globally, two thirds of all blind people are women, primarily because they are less likely to receive services compared to men. In many settings, this disparity is even more pronounced between girls and boys. SEVA believes that to achieve VISION 2020 goals, eye care programs must develop explicit strategies to reach the most vulnerable populations, particularly women and girls. Blind life is a burden for human in general but for women in particular have much more effects that are widely ignored or bypassed by the policy makers and service providers in eye care. Thus incorporating the gender analysis and raising gender awareness among the policy makers and service providers can reshape and effective the motto of VISION 2020 by complete and right based approach. In 1999, World Health Organization (WHO), and the International Agency for Prevention of Blindness (IAPB), jointly launched VISION 2020, the global initiatives for elimination of avoidable blindness by the year Bangladesh Government first signed off the VISION 2020 in the year Being a signatory of Vision 2020, Bangladesh government formulated its first national Eye Care Plan in 2003, under the Ministry of Health and family welfare. National Eye Care Plan now operating its second phase for the period of The achievements of the previous plan shows that, the cataract surgical rates (CSR) has been increased from 900 in 2004 to 1,172 in 2011 and projected to achieve 1500 per million in 2014 and 1600 by Under the plan, Demand Side Financing (DSF) also introduced as Gender in Eye Care Research Report-Bangladesh Page 9

10 pilot basis for the poorest community to improve the up taking of eye care services. Currently, Bangladesh also has drafted latest National Eye Care Plan , which quite ambitiously targeted to 70% removal of cataract surgery backlog by 2017 and 100% by But since diseases prevalence is higher among women but women s accesses into services are lower, without any affirmative actions, this target may not be achieved. Gender equity should be guiding principle in diseases control, service coverage and eliminating the demand side barriers. In this backdrop, Gender in Eye Care in Bangladesh has been initiated by Mashuda Khatun Shefali, Executive Director, NUK with the technical support and financial assistance from ORBIS International s Regional Program Support in Asia. Hope this study will generate sufficient awareness among the policy makers and service delivery agencies and undertake gender responsive approach in eye care service delivery. Gender Construction in Bangladesh Society Woman constitutes about percent 1 of the population and Bangladesh is one of the seven countries where the number of men exceeds the number of women. Though women constitute half of the population, gender inequality continues to be a core concern of human development in Bangladesh. According to the Human Development Report 2013(UNDP), Bangladesh ranks 111 out of the 148 countries on the Gender Inequality Index of 2012, which captures inequality of men and women in three dimensions viz reproductive health, empowerment and economic activity. The country also ranks as high as 86, out of 132 countries, on the Global Gender Gap Index developed by the World Economic Forum 2. The rankings on both the indices show that, Bangladesh belongs to the bottom half of countries included in each index that has exhibited high gender disparities. As such women bear disproportionately larger share of the country's poverty and hold much lower status than their male counterpart in every sphere of life. A statistical indicator of the status and progress in human development in Bangladesh is still point to unacceptable high level of deprivation and discrimination against women. Oppressive and repressive age-old traditions, unquestioned social norms, unchallenged economic dependence and financial insecurity, high illiteracy and ignorance and invisibility of women in private and public life keep women out of balance share within families, societies, and in the overall development process of the country. The socio-institutional relationship is male dominated in which the position of women in family is subordinated, dependent, exclusively relegated to the role of nurturing. Gender 1.Of the total population of million, women constitutes 49.94, source-population and Housing Census2011-Banagldesh at a Glance 2.This index benchmarks national gender gaps on economic, political, education and health criteria, and provides country rankings that allow for effective comparisons across the regions and income groups and over time.. The higher the index value, lesser is the gender gaps. Source; the Global gender gap report 2012, world economic Forum. Gender in Eye Care Research Report-Bangladesh Page 10

11 inequality is manifested through socio-economic differences and by the stratification of authority and assets between sexes through socialization process sanctioned by the stratification of society. The partilocal resident ship and matrilineal kinship culture places women as wives, daughter and mother in an inferior and dependent position that are a denial of equal opportunity in every sphere of life. Moreover, the class and gender segregated society, religious imposition in the form of restricted mobility outside home forced women's seclusion from public places often keep them enriched of access to all development process. As such women in Bangladesh remain systematically unable to safeguarding their personal needs and interests. Gender Issues in Development Gender in development term means culturally determined expectation and a set of roles and behaviour of men and women, which benefit men and women differently. The term distinguishes the culturally constructed norms and values from biologically defined aspects of being male and female 3. Gender is a culturally specific set of characteristics that identifies the social behaviour of women and men and the relationship between them. Gender is therefore, refers not simply to women or men biologically, but to the unequal power relationship between them and the way it is socially constructed. It is a relational term and must include men and women, their values and expectations from each other. Like concepts of class, race and ethnicity, gender is an analytical tool for understanding the process of inequality between men and women in any given cultural context. Since gender relations are socially constructed, it may change across of time and space. Social, economic, cultural and political forces determine gender. Gender also varies in different societies, geographical locations and cultural context and background. For example, gender roles and relationship in tribal community and plain land community is not the same. Even in different religious background, gender roles have been defined differently. It is not like one shoes fits for all. Several critics feel that dealing with both men and women together dilute the focuses on, who are the most disadvantaged group in the family and society in general all over the world. Gender equality means, equality under the law, equality of opportunity of access to human and other productive resources, equality of voice and choice and ability to influence and participate in the development process. Today, gender equality became a much more commonly used and accepted principle priority of development. Today, gender is about both and men and women. However, several critics feel that, dealing with both men and women 3 Gender: A Needed Concept,page-6,Sex and Gender, The Human Experience-James A. Doyle, Michele A. Paludi Gender in Eye Care Research Report-Bangladesh Page 11

12 dilutes the focus on women, who are more disadvantaged group all over the world. Therefore, in order to maintain the focus on women, all development programs must emphasize gender equality and women s empowerment 4. To distribute the development benefits between men and women, based on the specific needs and interests of women, gender mainstreaming approach gained popularity after it was highlighted as the main strategy or instrument for achieving gender equality and women s empowerment at the Fourth World Conference of Women held in Beijing in Since then most bilateral and multilateral agencies as well as all governments have adopted a strategy for mainstreaming gender as the key to achieving gender inclusive goals and objectives. Integrating gender approaches in policies and equate to increasing women s participation. Gender approaches are about understanding social norms for men and women who is different from each other and how they affect both problems and solution WHO s Study on Gender and Blindness Following the adoption of gender policy by WHO, in 2002, WHO, under its Department of Gender and Women s Health, conducted Gender and Blindness study a meta-analysis of population based prevalence, in Asia, Africa and industrialized countries, conducted by the British Columbia Centre for Epidemiology and International Ophthalmology. The study found that, women bear the approximately two-third of the burden of blindness in the world (Male -36%: female- 64 %.).The study also found that, Cataract is the major cause of blindness, which can be cured by simple surgery. The study for the first time has recognized that, globally, women bear a greater burden of Blindness than men (34:64%). Biology and gender inequalities combine to cause a greater blindness burden in women. The barriers that prevent women from receiving surgery are often different and vary locally. The study summarizes the following recommendations for future course of action: Awareness of the problem is needed to generate political will to address sex differentials and gender inequities in use of eye care services. At the local level it is important to identify the barriers that prevent women from receiving eye care services and to design gender-sensitive programs to reduce these. Peer motivators (women talking to other women) are likely to be more effective than health workers in promoting use of eye care services including surgery. 4.Gender and Developemnt, World Bank Institute Gender in Eye Care Research Report-Bangladesh Page 12

13 National and local prevention of blindness programs should monitor cataract surgical coverage and trichiasis surgical coverage rates by sex as well as monitor outcome of surgery by sex. Discrepancies found should be investigated. Global awareness of and local approaches to improving gender equity in eye care service use will be critical steps in achieving the goals of Vision 2020, a global initiative launched by WHO in 1999, to combat avoidable blindness. Rationales of the Study Blindness prevention is one of the crucial issues for WHO is covered under Vision 2020 campaign. This approach is in generally focused on avoidable blindness elimination worldwide. WHO adopted gender policy in 2002 and mainstreamed the gender aspects in their entire operations, as well as adapting gender integration in blindness prevention, but Bangladesh national policies, plans and programs for eye health and prevention of blindness and visual impairment does not reflect gender responsive. In addition, WHO Action Plan for the prevention of avoidable blindness and visual impirement , also pretty general, not gender responsive. Though WHO study on Gender and Blindness, has ground breaking outcomes, Bangladesh programs does not seems beneficial from this study. WHO Gender and Blindness Prevention study findings still correspondents with Bangladesh situation. One of the ESC report (held in June, 2014) from Kishorgonj Eye Hospital, a secondary Eye care services funded by the CBM, established by Nari Uddug Kendra (NUK), shows that, 89 male patients and 112 female patients identified for cataract surgery. But 86 male has been performed the surgery, but only 46 female patients done the cataract surgery. Besides, cataract patients who performed surgery often came late and the rates of surgery patients are lower than males. From patient s home visits and patients counselling it is found that, having no individual income, women are dependent on male earners to meet the cost of services. Restricted mobility, costs of transport and unable to travel alone outside home, lack of awareness about the service providers causes an additional challenges for women for ensuring accessibility in the services. Blindness or even the refractive errors for young married women experiences divorce and difficulties in marriage and increase physical and mental violence from other family members. In case of children the lower status of girls child in the family and Son s preference in the society, girls less likely get access in to eye cares. NUK s experience in Eye Care Screenings programmes among the school girls, one girl was saying that once I was badly beaten up by my younger brother and one of my eye get injured. Since then I am suffering from eye pain and watering. I requested many time to my mother to tell my father for my treatment. They said I will be just fine automatically, not to worry. However, finally she had a chance to see doctor while she was attending the School Screening Programs implemented by Kishorgonj Eye Hospital in the occasion of celebrating World Sight Day-2014 in Kishorgonj. Gender in Eye Care Research Report-Bangladesh Page 13

14 Though Bangladesh, ratified the VISION 2020 in 2000, National Eye Care Plan has been developed and implementing, National and District Vision 2020 Committee is established and the latest (proposed) National Eye Care Plan , suggested for formation of UZ Vision 2020, but gender issues still missing in all these policy, planning and programs TORs. Besides, there are several researches study are being done or proposed future study, but mostly focuses on diseases control, and other sub-specialty areas, and there are no study yet done on examining the impact of gender on access to eye care services in Bangladesh. Gender roles and socialization is varying from country to country. This has to be home grown with its own context. In this situation, Gender in Eye Care in Bangladesh research has been initiated to meet these gaps and design the mitigation plan and policies. Objectives of the Study The main objectives of the study is to identify the socio-cultural and economic influences that prevents women s equitable access in to eye care services; secondly, to assess the institutional barriers that effects women s needs and interests in seeking eye care services; another objectives is to assess the policy gaps in the national eye care plan,programs and services delivery process effects women s accessibility, which can help developing a common strategy and advocacy plan to addresses the gender gaps in eye care policy, programs and service delivery. The study findings will provide an insight into the barriers and opportunities regarding women s full participation in eye care services. Recommendations for overcoming the barriers and taking advantage of the opportunities will conclude the report. Methodology Study Design and Sampling of Study Population The study has utilized various sampling of data collection from both primary and secondary sources. The study population includes the service seeking and non-service seeking patients, hospital doctors, administrator and other technical staff and other non-health stakeholders. The KII also conducted with the relevant personalities. The primary sources include two stages sampling with 60 service seekers and 60 non-service seekers in the study areas. Survey with non-service seeking patients has been conducted in the household levels, while service seeker survey conducted at the hospital campus. The primary data also collected from hospitals records, the hospitals staffs including medical doctors and other technical staffs with semi structured questionnaire Focus group discussions also have been conducted with the district and upazilla level stakeholders with good representation of male-and female. Other than this mentioned methodological intervention, observations also made on current eye care set up and service facilities are available in the service delivery level with particular focuses on gender friendly environment and social compliance in both government and NGO run services. The indicators of the observation survey includes the existing structural, Gender in Eye Care Research Report-Bangladesh Page 14

15 administrative, managerial and operational facilities that meet women s needs and encouraged women s access into the services. Study Period: The study has been carried out from September to November, The Study Areas and Sampling of Hospital Considering the limited time and resources, a guided number of hospitals has been selected covering both rural and urban set up, government, private and NGO run Eye Care services in Kishorgonj, Mymensingh and Dhaka districts. A total of five hospitals have been selected from this districts range from secondary to tertiary level hospitals. The selected hospital includes the following: 1) Kishorgonj District Hospital, Kishorgonj (Govt) 2) Johurul Islam Medical Colleges and Hospital, Bajitpur, Kishorgonj (Private) 3) K. Zaman Eye hospital (BNSB) Mymensingh, (NGO Run) 4) Kishorgonj Eye Hospital, Kishorgonj (NGO run) and 5) National Institute of Ophthalmology and Hospital (Fully government), Dhaka. Among the five hospitals Kishorgonj District Hospital and the Johurul Islam Medical College and Hospital are the general hospitals with separate eye care units. NIO and Kishorgonj Distrcit Hospital is fully government run hospital, NIO is a speciality tertiary eye hospital and post graduate eye institute. Johurul Islam Medical Colleges and Hospital, a general hospital with an eye department along with a medical college. Kishorgonj Eye Hospital is a NGO run specialized secondary eye care hospital and K. Zaman Eye hospital (BNSB, Mymensingh) is a specialized district level tertiary eye hospital. Despite the diverse ranges and categories of the selected hospital, women s access and trends and service seeking practices of women has been sought from this hospital, which gave a comparative status of service seeking practice and achievements. Study Population Only adult women married, unmarried or single status has been randomly selected for the study both in service seeking and non-service seeking categories. Medical staff of the selected hospitals and relevant stakeholders for FGD, like schools teachers, elected representatives, journalists and KII informant interviews has been identified for data, information collection and expert opinion from the selected hospital areas. Questionnaire development and Pre-Testing The survey tools comprised with three sets of questionnaire, one for the service seeking patients, one set for non-service seeking patients, and other sets for hospital doctors and technical staffs. A customized questionnaire has been developed for each selected study population. Field test has been conducted with each group of study population prior to execute the study. The findings of the fields test have been incorporated and finalized the questionnaire. Gender in Eye Care Research Report-Bangladesh Page 15

16 The Survey Team and data Collection Instruments Considering the technicality of the eye care services, under the supervision of principal investigator a three member s survey team has been formed from Kishorgonj eye hospital, includes one ophthalmic paramedics and refractions, Counsellor, Unit manager, micro credit headed by the Outreach Manager. The outreach manager supervised the entire data collection and quality control. He supervised the data collection work, checked and corrected every questionnaire if any. Data Processing and data analysis Questionnaire was validated after the data collectors submitted the questionnaire to the supervisors. Every questionnaire were checked and corrected if any incomplete answers found. A relational data sheet was prepared using Microsoft Excel and tabulation prepared using the data sheet. The layout of frequency tables and analytical tables were prepared and used to prepare the report. RESULTS OF HOSPITAL SURVEY Gender Differences in Access into Eye Services The hospital patient s records review from five hospitals during the last 12 months shows that, a total of 353,697 outpatients received the services. The male female ratio is 52.39%: 47.61%. But in the outreach clinics women patients accounts for 51.48%. Outreach programmes in rural areas may reduce almost all barriers that women patients are currently encountering. However, among the five hospitals except Kishorgonj Eye Hospital, rests four hospital does not have provisions of organizing ESC. Except KEH, other hospitals patients consultation time till 2:00 p.m. So lack of day long services, and ESC, the cataract Surgery rates (CSR) is low. Besides, all tertiary hospitals in the public sector provide services only to walk-in patients. Gender Based Diseases Prevalence Cataract, refractive error, presbyopia, conjunctivitis, corneal diseases, Dacryocystitis and Glaucoma are found most common diseases are treating the studied hospital. The total patients of these diseases are 131,962, out of this 69,956 (53%) are women and 62,006(47%) are men. It is noticed that, there are sharp gender difference in diseases prevalence and diseases patterns between men and women. More men are suffering from corneal diseases and higher number of women is suffering from DCR and Refractive error in particular than men. Except corneal diseases, other diseases prevalence is higher among women. Gender Differences in Surgery Performance Data on cataract surgery patients from four hospitals for the last one year is 13,293, and only 5,580 (41.97%) surgeries have been done. Similarly, 7,741 patients identified with DCR, and only 2799 (36.15) surgery has been done. In case of RE, records from (KEH and Gender in Eye Care Research Report-Bangladesh Page 16

17 BNSB-Mymensingh) shows that the number of patients identified with RE is 55,070 and only 15,389 (27.94%) has been received the treatment. Doctor s Responses: Doctors from all five participating hospitals shared a common view that, a women patient are slow and seeks services much later than they required. Women patients take more time for consultation and persuasion to complete the treatment. Women patients are often irregular to complete the medication course and resist using eye glasses. In case of surgery advice, a women patient seeks medication. Many of them are afraid of surgery. Women are less aware of their diseases and neglect and delay treatment even in case of Cataract, DCR surgery. Due to women s reproductive role during pregnancy and lactating conditions needs careful treatment, safe medications needs to be provided. FGD Responses: The participants of FGD were found quite knowledgeable about the eye diseases patterns and prevalence, service delivery agencies and types of services are available around the district and socio-cultural and other barriers that are preventing women accessing into services. Women suffer just being a woman and financially suffer just being a member of a poor family. GOB s Community based free of costs services and committed services may overcome the situation. A poorest woman needs to have free treatment and surgery. More institutional and community based awareness rising is suggested. Women patients also need to motivated about the eye diseases and its implication in their lives. Family based counselling also recommended. Awareness rising among the Teachers and Students at the education institutes may be a good media to channel the information to the family as peer learning. Case Studies: Three case studies gathered by the present study are summarized in Annex-4. All the case studies reported lack of family support and financial inability that prevented them to seek care. As a result the waiting time for services is in an average 6 month to 4 years. Results of Observation on Gender Friendly Environment: Observations on current eye care set up and whether gender friendly services facilities are available, shows that, separate ticket counter, wards and toilets for male-female are available all hospitals except NIO. Individual ticket counter, separate waiting space, priority consultation, female doctors for female patients, breast feeding room/corner, are not available to any of the study hospital. Low cost or subsidized treatments for women patients, privacy maintenance are practicing by all hospitals except JIMCH. Special treatment and counselling for victims of violence and special arrangements to attract female patient, except, KEH no other hospital has these facilities. Suitable location and easy transportation facilities are available to all studied hospital. Gender in Eye Care Research Report-Bangladesh Page 17

18 RESULTS FROM PATIENTS SURVEY Socio-Economic Status of Patients The socio-economic status of both service seeking and non-service seeking women patients reveals that 40% are illiterate, 16% can sign only and 23.33% have primary education. Annual income of both groups is at the range of 10-20, 000(20%) 50-60,000 (20%) and reaming have different range of income. Among the service seeking groups 70% and 50% non-service seeking are married and housewife. Among the non-service seeking 40% are widow. The heath of families is usually husband, son and father. The service seeking patients are comparatively younger and the non-service seeking patients are older. The length of waiting for the service seekers is shorter than the non-service seeking women. Diseases prevalence among the surveyed population Highest number of service seeking patients came to see doctors with the Blurring Eye (26,67%), Refractive error(26.67%), Eye Pain(10%,) and 3.33% for cataract. But among the non-service seekers, 53.33% are suffering from cataract, 26.67% Blurring Visions and 6.67% have DRC. The aging is a big factor that matters for seeking and not seeking services. Comparatively the service seeking patients are younger and their husband paid the cost of the services, but non service seekers are found older, widow (40%) and depended on their son for social protection and financial support. Younger age women are found prompt seeking services, who mostly were suffering from infectious or other diseases. Among the service seeking groups cataract is very low (3.33%) Barriers women are facing in accessing Eye services To identify the barriers that women are encountering in accessing into eye care services, patients are categorized in two categories: service seekers and non-service seekers. Two different sets of questionnaire survey have been conducted among the service seeking patients and those identified with diseases but not seeking services. There are common barriers from both the categories of patients are suffering from. These are: Socio-cultural influences: Due to women s low status in the family, their health does not get priority for treatment. Women had to seek permission from their male counterparts, includes husband, (50%), son (38.89%), and father (11.11%). Therefore, women had to wait to visit hospital until somebody takes her to see doctors and provide necessary financial support. The average length of waiting for the service seeking groups is 1-10 days (16.67%), days (10%), days (16.67%), 3-6 months (20%) 1-2 yrs. (13.33%) 2-3 yrs. (10%). Non-service seeking patients waiting time is much longer. Their length of waiting is longer than service seeking groups. The non-service seekers lowest waiting time generally 6-12 month (26.67%), 1-2 yrs. (33.33%), and 2-3 yrs. (36.67%). Gender in Eye Care Research Report-Bangladesh Page 18

19 Distance of hospital also another prime barrier prevents women from seeking services. 20% women said the distance of nearest hospital is 10-20km, km,(10%), 31-40km (26.67%), 41-50km (20%),51-60km(20%),61-70 km(10%). Since women have experience using private transport traveling to and from hospital also affects them. Due to insecurity of commuting alone, they need attendant to seek services % women needed attendant while visiting hospital, and only 23.33% women were able to visit hospital without any companion. Lack of Decision Making: Women irrespective of married, unmarried, widowed women found unable to make decisions for their own treatment. Women seeking services, decisions are made by husband (50%), Son (38.89%) and father (11.11%). Costs of Treatment 77.78% service seeking patients and 56.67% non-service seekers reported financial constraints make them unable to seek services, because 76.67% women have no personal source of income. They are fully dependent on their male counterparts for meeting the costs of treatment including transportation. As such, 33.34% service seekers costs of services are born their husband, 30% contributed by Son, 3.33% by daughters and 10% women received financial support from relatives and others. Only 23.33% women paid their cost on their own sources, as they are able to earn cash income on their own. Women have own source of income able to make decisions for their treatment. These barriers can be categorized in different levels: Familial and personal Level: The survey reveals that, both service seeking and non-service categories of respondents said number one barriers that they are encountering are financial constraint, 56.67% : 77.78%. Distance of hospital (6.67%), involved transportation, unable to travel alone,(6.6%), Lack of family support(13.33%), old age (6.67%), Lack of own source of income, not aware of own health(6.67%). Other barriers include the household responsibility, social barriers, ignorance, Pregnancy, breast feeding and child rearing also prevents women from seeking services comfortably and timely. Service providing Agency Level: The survey findings shows that, lack of separate toilets for women patients (3.33%), lack of separate waiting space (13.33%), lack of female doctors for consultation (3.33%), Lack of separate ticket counter for women (3.33%), No Canteen facility for women (6.67%). Cent percent women recommended for organizing more community based screening camps. So that most of the socio-cultural barriers for women to seek services will be mitigated. This will reduce length of waiting time for service seeking, waiting hours for old age women, pregnant mother/ with young children (56.67%), more specifically, the required services are mentioned bellow: Gender in Eye Care Research Report-Bangladesh Page 19

20 Separate waiting space-20% Priority Consultation services to pregnant/lactating mother/mother with children-17% Separate waiting space for women-17% Arrange transportation for women-17% Reduce waiting time-17% Increase the number ticket counter-10% Differences of Barriers of women service seekers and non-service seekers: But comparative study between services seekers and non-service seekers shows that, women over age ranges between seeks services earlier as they are younger housewives having young children along with household responsibility. Besides, pregnancy, breast feeding, child rearing also prevents young married women to attend eye care services in time. But their treatment costs are born by their husband or father. These groups of women are often irregular of completion of medicine course and deny using glasses. Comparatively, women over age of are more likely not seeing eye doctor, because 40% of them are widow lives under the guardianship of son. At this age, women themselves and their families does not see worthwhile to spend money to correct women s eyesight. Another common trend of women s service seeking practice is coming to see doctor late. Both service seeking and non-service seeking patients has to wait for certain length of time before they come to consult doctor. But there are some degrees of difference in length of waiting between young housewives and elderly women. Among the service seekers, 23.34% lengths of waiting time is 1-3 years, but 36.67% non-service seekers length of waiting time before seeking services is 2-4 years and plus % non-service seekers main cause of waiting was financial constraints and 83.33% reported to their family members about the complaint and had to wait until they responded. Conclusion and Recommendation The recommendations are mainly drawn based on the output of the compilation of the suggestions given by the respondents, hospital doctors, staffs, Community Stakeholders, policy makers and also the expert judgment of the researchers of the study. Considering the sustained and widely acceptable socio-cultural barriers, and other factors that prevents women from equal access to services, reduce the diseases burden, long waiting time and its consequences on women, gender blindness in policies, programmes and service delivery patters as against the VISION 2020 goals time line, by 2015, the recommendations have been made through three pronged areas- policy level, service delivery level and Community level in short term, medium term and long term. Gender in Eye Care Research Report-Bangladesh Page 20

21 Immediate Steps: Gender Sensitization - At National Policy and Programmes level Though Bangladesh singed the VISION 2020 in 2000, and undergoing with national eye care plan and operating wide range of programs, the Cataract Surgical Rates is still far behind the expected level. The rate of increase CSR from 900 in 2004 to 1,172 in 2011, which is a very poor progress. A current Cataract Surgical rate is estimated about The WHO gender and blindness survey findings- called for global awareness of and local approaches to improving gender equity in eye care service use will be critical steps in achieving the goals of VISION From this perspective more specifically the following actions needed to be taken with an immediate effect: Gender consultation with National Eye Care representatives: A national consultation needs to initiate to share the concepts of gender in blindness issues with the BNCB, NEC representatives under the MOHFW, Bangladesh Ophthalmological Society, and development partners supports blindness prevention in Bangladesh. So that, eye care design, plan, implementation strategy, human resources and budgetary implication that seriously defecated the cataract surgical rates, surgical coverage and prevents women s eye care seeking practice can be improved. Gender Review of the present National Eye Care Plan: The current NEC must evaluate the outcomes and impact of the plan from gender perspective, these means separately assessing the impact of gender on access to eye care services. The findings can be used to mainstream gender equity approach in the proposed NEC for the period of Gender Sensitization to the VISION 2020 Committee members: Vision 2020 committee members both in national, district and UZ Committees needs to be sensitized on Gender and Blindness and VISION 2020 goals with an immediate effects. More women and civil society representatives in this committee also need to be increased. So that, the scope and the functions of the Vision 2020 Committee is achieved. Needs for wide-scale Survey based/action Research on Gender gaps in Blindness prevention Program: A wider scale research study covering all types of service providers at all levels needs to be initiated immediately for policy makers, service providers, practitioners and development activists for developing collective strategy towards eliminating feminization of blindness in particular and combating avoidable blindness in general. Needs to Introduce Gender Segregated Monitoring System: Sex segregated monitoring system by all blindness prevention activities/program covering from national to local, tertiary to secondary to primary must installed. All public, private and NGO run hospitals should routinely collect data by sex on cataract surgical rates, surgical coverage and outcomes. Any differences found, necessary corrective actions should be made accordingly. Gender in Eye Care Research Report-Bangladesh Page 21

22 On side Optic dispensing should be provided to poor patients: More poor/referral patients are seeking services to tertiary level hospital. Currently NIO is not dispensing eye glasses. NIO and other tertiary hospitals should operate optic dispensing. Community Level: Initiate Community Based Eye care services (Eye Screening Camps): The communities ophthalmological approach is already are being used by different services providers, especially by the NGO run clinics/hospitals. These include organizing Eye Screening Camps in the villages level, which enabled women to seek services on their own with easy access, low costs and less time. Government Collaboration to these groups of NGOs may enhance their programme performance. Few NGOs also organize Child sight screening camps at eth primary schools, which contributes to prevention of childhood blindness prevention. With Government of INGOs financial and technical support these programme also may be expanded for higher coverage. Court Yard meeting : Service providers in local may organized community level mobilization lie organizing Court yard meeting with households with both male and female groups to raise the awareness on the implications and importance of eye health; since often male members of the family in the form of father, husband, Son and son-in-law make the major financial and personal decision for women, needs motivational activities directed to them as well. Demand Side Financing should be gender responsive: The purpose of the Demand Side Financing is very timely intervention to eliminate the demand side barriers. But conscious efforts should be made that poorest women are treating as the eligible patients for voucher scheme. Currently the criteria of selection of eligible patients are only based on poverty level. Since diseases prevalence including cataract is higher among women, gender concerns should be incorporated in the eligibility criteria of patient s selection. Besides, Govt. primary health workers and NGO workers awareness raising training should include a gender awareness component. Medium-Term: National Policy and Programmers level Gender Mainstreaming in Blindness prevention programs: Gender policy/ protocol/ guidelines should be developed by government which should be obliged and applicable for all respective service providers; Mainstreaming issues in the national Eye Care Plan, NEC, Vision 2020 Goals in Bangladesh perspective, Women s participation in Planning, research, decision making, management, and service delivery levels needs to be improved. Gender Focal Person: Gender focal person should be designated by all respective service providers to ensure and enforce the integration of gender aspects in eye care services Gender in Eye Care Research Report-Bangladesh Page 22

23 delivery, design, implementation, human resources and budgetary allocation, monitoring and reporting. Gender Sensitization Training to Eye Care Service Providers: Since changing gender roles and responsibilities are beyond the scope of the service providers, all eye hospitals staff must be provided with gender awareness training. So that they can improve their knowledge and skill to address the issues. Orientation to the Journalists: The print and electronic media journalists (specially the heath correspondents) may be trained on gender in blindness preventions issues. Member journalists from Press clubs of all over Bangladesh may be mobilized to through this training to promote the services for women and the poor. Awarding the best served and Brest Practice Hospital on Gander Balanced services: Government/NEC can launch a yearly awards system to the hospital who took necessary steps to increase the number of women patients, performed highest number of cataract and other surgeries successfully with maintaining standards hospital protocols towards eliminating blindness in Bangladesh. Initiation of awareness campaign through Media: All mainstream electronic and print media including radio s should be brought under a strong regulation, where they should publish/broadcast the messages of the importance, implications of blindness and the necessity of eye services as a critical issues of health, social problems and women s empowerment. Annual Coordination Meeting of Eye Service Providers: Annual National coordination meeting may be held between GOB, NGOs, Media and the tertiary, secondary and primary level service providers (if possible with clients representations), to monitor the progress, achievements, barriers needs to be overcome and the find the joint way forwards. Needs Periodical NGO Coordination: According to the proposed National Eye Care Plan ( ) 86% cataract surgery are done NGOs run clinic/hospital, 10% by the Government hospital and only 4% are done by the private practitioners. If GOB provides necessary guidelines along with technical and financial resources, these NGOs run clinics/hospital may performed higher number of surgeries with high turnover of female patient s coverage. GOB s collaboration with National NGOs should be strengthened. INGOs financial, technical collaboration with National NGOs should be increased. Community level Village Awareness Program: Aravind Eye Care model of Villages Volunteer s training program may be replicated as they trained to identify the cataract and other common eye diseases in the villages. They are then brought to the base hospital by the village volunteer. Gender in Eye Care Research Report-Bangladesh Page 23