When Seeing Is Believing – Building a Gender Equitable Eye Health System in Bangladesh

In January 2016, The Fred Hollows Foundation began work in Barishal Division, Bangladesh, under the Seeing Is Believing programme with the goal of building a Gender Equitable Eye Health System. Through gender sensitive programming, the Foundation aimed to increase access to sustainable, quality eye health services among marginalized and underprivileged community members.

The programme’s goal was 25,000 cataract surgeries and 375,000 free eye health screenings. In Q2 of 2016 of the 1,786 surgeries conducted, 931 patients were male (52%) and 855 were female (48%).
At the end of the four year project in December 2019, we conducted 25,000 surgeries, with 10,949 male (44%) and 14,051 female (56%) patients; 375,088 patients were screened at eye camps, 156,713 were male (42%) and 218,375 female (58%). According to MIS data, 56% of women (up from 42%) now had access to eye health services.

The journey was not without roadblocks. Gender inequality was deeply ingrained in the social behaviour and culture. Attitudes and access to healthcare improved, as data showed; but women still struggled, socially and economically, in that they had little independence and freedom.

A Baseline Knowledge Attitudes & Practices (KAP) study was conducted in 2016 to understand the existing scenario and help design and implement a response. Although male and female respondents felt they had similar rights to access healthcare, education, services and jobs, women said they had little say in the family decision making process (45%), local government activity (42%), ownership of property (17%) and free movement outside the family (15%).

The main barriers identified were:

• Socio-cultural: less access to information, women were not allowed to travel alone and did not prioritize themselves in accessing healthcare
• Infrastructural: lack of outreach services, skilled service providers and proper equipment at public hospitals
• Socio-economic: financial constraints, dependency on male members for treatment costs, lack of privacy at health facilities
• Lack of Social and Behaviour Change Communication: inadequate knowledge of cataract, negligent community leaders unaware of the consequences of eye health problems and dormant empowerment of women

To address these issues, the team brainstormed with local NGOs, public administration, community leaders and a social marketing platform to identify a four pronged approach to reduce the gender gap and destabilize existing social norms that were contrary to equitable treatment.

1. Eye Camps were established in remote areas to reach disenfranchised communities which lacked access to basic information. The camps were promoted far and wide targeting women through billboards, distribution of leaflets and discussions at community gatherings. 375,000 community members were screened through these camps, 58% of whom were women.
2. Cascade Training covering gender sensitive eye care messages along with health counselling was conducted with community members.
3. Referral System was an ingenious and beneficial approach. Social structural mechanisms prevented women from seeking formal medical attention – but encouraged them to seek medical advice from local pharmacists. As a trusted source of information for women, The Foundation facilitated training for 500 pharmacists.
4. Training Sessions on basic eye care and gender sensitization were conducted with Ophthalmologists, Medical Officers, Sub Assistant Community Medical Officers and service providers from NGO partners. This promoted equitable service delivery and less gender discrimination and higher quality services.

The programme sought to establish sustainable improvements to reduce the gender gap and promote higher use of eye health services. Renovations at partner hospitals included; a separate nursing corner, separate seating for women, separate waiting rooms for elderly patients as well as a new section for post-operative female patients. An electronic token system was introduced at hospitals to stop men from pushing women out of the queue.At an end line survey on satisfaction, more than 80% of female patients were satisfied with service provision at health centers.

Mitigating socio-cultural barriers and increasing engagement within communities while reducing the gap for gender norms required innovation. Eye care for women, especially adopting early cataract surgeries were core messages relayed through health workers, volunteers from clinics and community members, using interactive materials such as billboards, miking, folklore, uttan boidok (courtyard orientation).

Some communication activities targeted men as men control household financial resources and make decisions for all family members. Advocacy and counselling were administered directly to them, targeting husbands of married women, fathers of adolescents and the eldest sons of widows.

The School Screening programmes were also a hit, as school going children played a significant role as advocates in their families. They became educated and knowledgeable on the importance of eye care, especially to their mothers and elderly community members. They helped to inspire their parents to go for regular eye check-ups and attend eye camps and outreach centres.

Author: Zareen Khair Ph.D, Cluster Lead- Bangladesh & Nepal. Global Programs, Country Manager, The Fred Hollows Foundation, Bangladesh