Occasional Paper 10: Volunteer health workers in Iran as social activists: Can "governmental non-governmental organisations" be agents of democratisation?

Publication Author: 
Homa Hoodfar
Date: 
December 1998
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The dilemma of the Iranian regime in dealing with one of its very successful large scale public mobilizations in the seemingly innocuous activity of low-income women delivering basic health and family planning information.

The origins of Volunteer women

The early years of the Islamic Republic of Iran were largely consumed by establishing and stabilising the new regime. The founders of the regime chose to do this not by boosting pluralism and the development of a civil society, which had been a major demand of the 1979 anti-Shah revolution.[1] Rather it was done through eliminating opposition groups and consolidating and refining the regime's ideological position on economic and social matters.[2] While the Pahlavi regime had sought to de-politicize the nation, the Islamic regime felt it needed to mobilize the public in support of its ideological and socio-political visions. This is not unlike the situation under Naser’s regime in Egypt or indeed most populist regimes. Such continuous mobilisation, however, requires the delivery of some benefits, if not political freedom. In any case with or without mobilisation the economics of control enter into the calculus of the state (Richards 1995). While the Shah's regime used oil money to pay for its development policies and elaborate state machinery, due to collapse of oil prices the Islamic regime's oil income has been much more limited, especially relative to the growing population of the country. As a result, the government has been forced to encourage public participation although it has not yet been able to reconcile this with the desire to monopolize power. In this paper, I document the existence of such a dilemma of the regime in dealing with one of its very successful large-scale public mobilization in the seemingly innocuous activity of low-income women delivering basic health and family planning information. The importance of the matter, in part, lies in its relevance to the question of whether such governmentally engineered participation, encourages the kind of politicization and public participation that would lead to further democratization in at least a social, if not a political sense.[3]

Constructing a modern Islamic society:

The emerging consensus on an approach to development differed fundamentally from that of the previous regime's trickle-down policy (Halliday 1979, Mason 1998, Amirahmadi 1990). The Islamic Republic, concerned with building its legitimacy, gave priority to meeting the population's most basic needs in an attempt to avoid alienating the Islamic regime's major constituency: the poor and less privileged. This ideological commitment was enshrined in the constitution of the new regime.

An overview of policies put in place after the revolution shows that the government identified three major channels for reaching the less privileged segments of society: the provision of basic foodstuffs, the availability of basic health care, and access to education. The budget allocations of the government clearly indicate these priorities (Table 1). The provision of basic foodstuffs was introduced as a temporary measure to counteract the hardship imposed by the Iran- Iraq war and was never intended to be permanent since it was clear that the government could not afford to sustain major food subsidization indefinitely. Since there was no history of heavy food subsidization (except for bread) in contrast to countries such as Egypt the government did not foresee major problems in withdrawing this service once the war was over.[4] Thus an elaborate rationing system was developed to ensure the affordability of minimum food and fuel requirements, despite the considerable drain this policy made on the government budget (Amirahmadi 1990).

Access to education and basic health care were the main major channels for reaching the less privileged. Education had a privileged position because the regime viewed education as a vehicle for disseminating its ideology and counteracting the Westernized worldview promoted by the previous regime. Thus, primary school manuals were quickly revised, and within a few months of the Islamic Republic's take over, a substantial amount of religious material was added to the curricula. Claims of jihad against illiteracy were the new slogans of the regime. In the heat of revolutionary fervour, hundreds of volunteers and committed personnel were trained to teach basic literacy and new schools were established in rural areas.[5] The Islamic regime has been fairly active in encouraging parents to send daughters to school (Mehran 1991; UNICEF 1995).[6] The Islamic appearance of education largely disarmed many parents who previously opposed female education on religious grounds, and there was increased social pressure to educate daughters.[7] The net result has been a higher overall rate of female literacy and a higher rate of educational enrolment among children with a reduction in the gap between enrolment rates for girls and boys (UNICEF 1995).

The statistics have enabled the Islamic regime to refute accusations that women's education would suffer, at the same time strengthening the regime's religious and ideological hold on the nation and reaffirming its commitment to improving the lot of the less privileged.

However, a consequence of the pro-nationalist policies of the regime, which included encouragement of early marriage, discouragement of family planning and re-enforcing images of women as wife and mother, was a considerable increase in the number of school aged children, the majority of whom now lived in urban areas. This raised an enormous challenge to the regime's ability to continue providing — much less improving — universal basic education. By the late 1980s, overcrowded classrooms, lack of textbooks, teacher shortages, and inappropriate buildings became topics of social debate, political jokes, and a legitimate vehicle of criticism of the Islamic regime — which remained intolerant of political criticism. All these factors made many religious leaders conscious of the problems entailed by a rapidly increasing population.

In contrast to the provisions of basic education, which is designed primarily to benefit the regime by cultivating its ideological vision of Islamic society, improving universal access to basic health services is the main avenue through which the regime has communicated its commitment to the poor and the "have not" regions of Iran. As Table 1 indicates, the government allocated a substantial segment of its budget to health. To reach the majority, it had given priority to basic health care, common diseases, and mother-and-child health centres. With the help of young and committed professionals, many of whom were familiar with the needs of the diverse geographic areas, the government designed and implemented an efficient, low-cost health system. Many of the new managers and medical personnel were themselves from smaller towns or had lived outside the major centres, and particularly in Iran's more than 40,000 rural villages (Shadpour 1994).[8]

Despite the eight-year Iran-Iraq war that placed considerable pressure on the ministry of health, its achievements are commendable. The infant mortality rate, which had remained high despite the nation's high per-capita income, dropped substantially (see Table 2). Maternal mortality decreased significantly and life expectancy increased. Overall, Iran has had a commendable improvement in its human development index. This clearly demonstrates the importance of political choices in respect to development priorities. Like the Ministry of Education, however, the Ministry of Health was facing increasing pressure on its limited resources by the young population and thus perceived the increasing rate of population growth detrimental to the well being of the nation. Following the national survey of 1986 which estimated the population at around 50 million, experts and politicians started to discuss the consequences of increased population for the country and for the regime.

The depressed economy and the need to reconstruct war torn regions and industries were already challenging tasks. On the other hand, the failure to deliver basic services would severely affect the credibility of the government of the mustazafin' (oppressed and powerless), which had pledged to build a just Islamic society in which all would enjoy basic health care, education, and equal opportunity. Having no other options, by 1988 the government introduced and carried out one of the most efficient family planning programmes in the economically developing world (Hoodfar 1994, 1995, 1996).[9] This represented a major ideological revision for a government whose ideologues were once among the most outspoken critics of family planning, and who had once viewed such a program as an imperialist plot.

This extraordinary success can be attributed to three overlapping factors: a comprehensive design and definition of the programme, an effective national consensus-building campaign, and efficient delivery services. These three factors won a considerable degree of support from women. To the government's credit, the family planning programme has indicated a sophisticated understanding of the complex interplay between fertility behaviour and of social, economic, religious, and political variables, including the position of women. The programme and its publicity masterfully reiterated the independence of the family, if not of women, in making choices in relation to planning its reproduction. The campaign has emphasized that the programme's central goals are to prevent unwanted pregnancies and genetic abnormalities, allow parents to space the births of their children, treat infertility, and improve women's and children's health.

Effective health care and information about different contraceptive means, including the advantages and disadvantages of each method as well as possible side effects, accompanied these campaigns. The new family planning programme as well as general health services are primarily directed at the low-income population. Since a large proportion of the adult population (particularly women) in these strata are illiterate and traditionally more receptive to oral and face-to-face forms of learning, service providers had to design non-conventional yet economically feasible means of transferring information and obtaining the trust of their clientele. Since the government had already established an extensive health network, which included a small health centre or 'health house' for each village, the problem was more easily addressed for the rural population.[10] Local people, usually a man and a woman, who were trained in basic health care, staffed these centres. Not only did their duties include providing mother and child health care and vaccinations, but they also maintained records of births, deaths and other vital health information about all members of the village. The centre also provided medical care by a doctor who visited once or twice a week; in urgent cases, the health workers referred residents to the nearest hospital. Thus the village health workers were instructed in contraceptive use and provided with information and supplies for the local population. The strategy has worked very well and contraceptive prevalence is very much higher than was initially expected especially given the rural preference for larger families.

Although development policies usually, as is the case in Iran, favour urban areas in terms of both budget and attention, health outreach in less-privileged and frequently over-populated urban neighbourhoods presented a greater challenge to the Iranian government than rural areas. Yet the success of the health and family planning programme depended on its acceptance by these urban groups. Although the government had organized factory-floor classes on basic health and family planning, these primarily benefited men who formed the majority of workers. Despite the fact that the government had introduced laws or strengthened existing ones that rendered women under the control of their male folk (husbands in particular), the government also demonstrated some awareness that women exercise considerable autonomy in decisions affecting fertility and that the collaboration of women more than men would be central to the success of the family planning programme. The cost of a neighbourhood outreach program such as existed in rural areas was beyond possibility for the Ministry of Health, yet the success of family planning, as well as health programs such as vaccinations for children, depended on such a program. In order to solve this problem, the Ministry of Health initiated the program of 'volunteer health worker women' which has proven to be very successful.

However, it has also created a dilemma for the Ministry of Health and government. This initiative focused attention on the values and possible avenues of public participation in the construction and improvement of Iranian society. It is this aspect that I will pursue in the following sections. Volunteer Women's Community Health Workers' Organization Although this extremely successful initiative is paradoxically presented as a non-governmental organization (Ministry of Health 1996), it was conceived by the Ministry of Health and Medical Education in 1991 with the major goal of reaching low-income women in major cities. If it worked it would mean a major financial saving for the Ministry of Health. In the early stages of launching the initiative the political consequences of this new program were not discussed in any serious way. "Who could imagine the image of a few barely literate women carrying contraceptive pills and appealing for the vaccination of children as political", said a medical doctor discussing the volunteer initiative. In fact the reason for launching the program was clearly a commitment to family planning more than to improving the health of the urban population. The Ministry of Health and UNICEF had already been co-operating on improving vaccination and the health of children in Iran for some years. However, the idea of involving the public had never been discussed. It was to a considerable degree the unprecedented success of rural health houses in the promotion of contraceptive that encouraged officials to think along these lines.[11] Clearly face-to-face relations were a key factor. The question was how to find economical ways of doing the same in low-income urban areas.

In 1991, an initiative was launched with a pilot project of 200 women from low-income neighbourhoods in a district, near Teheran, and by mid 1996 the program included over 20,000 volunteers throughout Teheran and all major cities in all provinces (see Table 4). Although no recent statistics have been issued, the claim of officials puts the number anywhere between 25,000 to 37,000.[12] The organization’s success has attracted funding from major international organizations, such as UNICEF and the World Bank, despite initially apprehensive assessments of the project (Bulatao and Richardson 1994; UNFPA N.D.).

Community Health Centres, which are set up in urban districts by the Ministry of Health, appoint volunteer women in each neighbourhood who act as intermediaries between local women and the Health Centre. These volunteer health workers receive basic health care training. Each volunteer covers approximately fifty to eighty households in her neighbourhood, serving as the centre's contact person and providing health information for her neighbours.

Although their single most important concern after being appointed is the promotion of modern contraception and family planning, volunteers are involved in other health matters.[13] They are expected to keep records of all families with young children, new births, and pregnancies, they invite pregnant women to visit the clinic for pre and post-natal care and for vaccinations. Volunteers also monitor the health needs of their neighbourhoods and communicate them to the centre. This well-rounded approach to neighbourhood health issues has not only been very significant in bringing legitimacy to the role of the volunteer in the neighbourhoods, but it has also made the job more appealing to the volunteers themselves. Clearly many would not have joined the organization if their role were only limited to contraception and family planning information.

Female volunteers are normally selected during the annual door-to-door fertility surveys. The surveyors are instructed to identify middle-aged women, who are mothers, who have some education, and who appear knowledgeable and sociable. At a later date, the Organization of Volunteer Women Health Workers, housed in the local health centre, contacts and invites them to join the organization. In other cases, the organizers may contact the local mosques, that normally have Koranic or other classes for women and introduce the organization and invite women to join. Some women are invited to join by their friends, who are volunteers. The officially stated criteria, though not always observed, are quite significant. The volunteer women should be married with some children (but not too many), they should be educated at least to the level of reading and writing. They should have a good standing in the community, be interested and enthusiastic in participating in the program and have the permission of their husbands.

Though presented as a means of ensuring the commitment of the husband to the new responsibility of his wife, it nevertheless, indicates that the Ministry of Health does not see any problem in a lack of autonomy for the women, as wives. In contrast, the ideologues of the regime and religious/political leaders have never mentioned the necessity of husbands' permission when they invite women to participate in street demonstrations and elections.

Attaching such a condition for joining the program reinforces the ideology of control of husbands over their wives. The absurdity of such a condition becomes clear if we imagine a similar requirement being suggested if husbands were invited to do similar public services. Clearly, few women would decide to participate if their husbands strongly objected. Yet, if they are to participate, should it not be the choice of the woman? Even if it is not observed in practice, the attachment of such a condition for a project that has claimed to be part of "Iran's reproductive rights program" is quite unsettling for those concerned with gender equity.

The volunteers, once having accepted the invitation, meet in weekly or fortnightly sessions, during which a guide familiarizes them with the concerns, principles, and organizational structures of the Ministry of Health. Volunteer duties can be assumed after a couple of months of training. They are given a card, renewable every six months, which introduces them to their neighbours.

The training includes a review of several simply written books with many useful examples on four major areas: children's health, mothers and families, public health, and common diseases. Substantial emphasis is placed on family planning and contraception information. Volunteers also learn how to fill out health information cards for the households under their jurisdiction and deliver them to the health centre. However, the most interesting part of these training sessions is the effort directed at making the training participatory, in contrast to the traditional (and current) system of formal education which relies on authority figures providing information which students are expected to accept. The manual for training the morabis (trainers and teachers of volunteer women) emphasizes that classes should be limited to fifteen women, that groups should sit in a circle, and that everybody should participate in discussion. Volunteers' experience and existing knowledge — including traditional knowledge — should be acknowledged and praised. Dr. Fatahi, the author of the primary training manual (Fatahi 1375/1996), states repeatedly that the paramount goal of these sessions is to give women confidence while improving their knowledge. In other words, these training courses are also leadership training sessions, though reference to this is carefully avoided.

In fact, the training manual is a skilful adaptation of the latest ideas on teaching for empowerment, based on the experiences of marginal groups from African Americans to Latin Americans and South Asians. The manual provides many examples of how modern 'scientific' practices can be harmful as well as helpful. There is also a discussion of the many traditional practices that are not only accessible and cheap but also more effective especially when these practices allow people to retain more control over their lives.[14] Thus trainers are to guide volunteers to be open-minded and respectful of traditional ways and knowledge, while finding tactful ways to warn mothers about harmful practices. Stories and role-playing exercises aim to teach volunteers to share knowledge without embarrassing the mothers. They are advised to establish good relations with neighbourhood mosques, and with religious and community leaders. Beyond these training sessions, the fact that volunteer women work in their own neighbourhoods and are often from similar cultural and class backgrounds as their neighbours also facilitates the programme's success.

It is important to note that while the above model is ideal and much attention has been paid to it at early stages, as the numbers of volunteers increase, the level of training varies from centre to centre. Moreover, despite a constant demand from volunteers, few books and pamphlets have been developed for their use in the field. Many volunteers who were interviewed, noted that experienced personnel are no longer involved in either their initial or refresher training. Furthermore, the commitment to creating a community in which the volunteers can share their experiences and learn from each other, is not always realised.[15]

Besides, their use for follow-up and outreach programmes, the data that women volunteers provide are sometimes used for research purposes. Officials have stated that, the Family Planning Board is in a position to collect much more in-depth and detailed information than ever before, hopefully leading to improved quality of research findings, which in-turn, facilitates the effective planning and delivery of service.

The volunteers are unpaid but are they are supplied with an information kit including four books and a bag stamped with the Ministry of Health logo, and occasional items such as a pen. They and their family members may also, receive free or priority treatment in some health care services. Several times, a budget from the Ministry of Health has allowed the organization to provide free programmes and invite successful volunteers to visit important shrines in Mashhad and other locations. There are also several new women's sports centres which volunteers can attend free of charge.

Ministry of Health officials frequently refer to the organization as an example of how the Islamic Republic has made room for indigenous initiatives and public participation. The initiative however, is not as original as they claim since the principal idea is borrowed from non-Iranian non-governmental and governmental initiatives elsewhere. For instance, the program greatly resembles China's neighbourhood grandmother system as well as non-governmental Islamic health organizations such as Pesantren in Indonesia (Sciortino et al. 1996) and Thailand and Latin American countries where housewives were mobilized for family planning and public health purposes. In fact, elsewhere (Hoodfar 1997), I have demonstrated that the government, despite its active recruitment of male mullahs in support of family planning, has deliberately ignored women’s religious preachers and gatherings which have operated independently, though individually, for centuries. Had the government really been interested in indigenous institutions, given the easy access to women of these thousands of women who operate among mostly traditional and low income neighbourhoods, they should have been the first to be recruited to promote health. However, it would have proved difficult to control such informal, autonomous institution.

To the government's credit their plan has been well adapted to the cultural setting of urban Iran. On the other hand, it is quite evident that while the government welcomes the idea of public participation, it likes to remain firmly in control of these organizations, particularly in urban settings. For instance, authorities are apprehensive about making it possible for volunteers to meet in large groups and until October 1998 despite suggestions from many volunteers, the authorities had not facilitated the production and circulation of a newsletter for them in Tehran.[16] In 1995, an interviewee in Tehran told me that it was suggested at a planning meeting that a special centre be built for the volunteers so they could come together in an independent space, share ideas and develop a sense of belonging. Apparently, the highest authorities of the Ministry of Health immediately rejected the idea, as they feared that if 25,000 strong and committed women were to gather, no one would be able to control them. Although this was presented to me (by several different individuals) as a somewhat humorous anecdote, it provides some insight into the political concerns of the government. Particularly of the governments ambivalence in wanting citizens to participate in honouring the regime's commitment to basic services, if only under its firm leadership and without autonomy. Had the government had the economic resources, it is doubtful whether it would have contemplated relying on volunteers.

Volunteer Women's view of their work:

A close review of available documents on the initiatives and statements of many officials in charge of the volunteer women, suggested that the voices of volunteers were never presented. The absence of any study dealing with their perceptions and aspirations[17] prompted a small qualitative survey of volunteer women on their self-perceived roles and their impact on the lives and on the neighbourhoods.

The 28 interviewees were chosen from three different districts of greater Tehran. One district was a model centre that had received much attention from officials and from interested national and international visitors who are usually directed there. The other two districts are poorer and newer neighbourhoods. Six of the 28 interviewees were between the ages of 20 and 30; and fifteen were between the ages of 31 and 40; and seven were between the ages of 41 and 47. Sixteen had a high-school level of education and eleven had secondary school; only one woman had more than high school. All but two of the interviewees were married, with children.

Responses to the question, why had they joined the program, varied from, "for the first time, I had a chance of doing something for my community", to "I thought that if nothing else I will learn about many health issues for myself, and maybe others would benefit, too". Others said that they had always wanted to have a chance to get out of the house and have a public role, e.g. to be a teacher, but that family or husbands would not agree. While many husbands had resisted the idea of them looking for a job, they had not objected to volunteer work since it was unpaid labour and it did not involve leaving the neighbourhood. Some women said that their husbands initially were not too happy and that had it not been a government organization, they would not have allowed them to join.[18] All interviewees said that their husbands now were very happy and satisfied with their work as a volunteer. There are even indications that in some cases, the quality of the marital relationship had changed for the better. When we asked the interviewees to explain what had made their husband begin to or continue to support their activities, the replies were insightful, both culturally and ideologically.

Examples:

My husband had always objected to my working, even though I had a high school diploma and could get a job as a teacher, or something like that. You know men do not want their wives to work because they feel that if they bring money home then they will not obey or respect them. They feel they can no longer play the king of the home. They assume their wives would not try to comfort them when they come home from a day of work. Other men may feel embarrassed in the community because many traditional people may think that the husband cannot, or is too lazy to, support his wife and children. This bothers men a lot. However, now that I can work as a volunteer that receives no pay, he does not feel bad. Moreover, he can see that I have learned a lot from my training and that I also teach our neighbours and relatives. Because they respect me, he also feels proud of me.

Another 39-year-old woman, who had been working for 3 years said: My husband didn't want me to work, and having children and living a long way from the town would make it impossible to have a job. But I must tell you that being home all the time and not having many relatives in Tehran, where I had come to live since my marriage, made me short tempered and I was often hard on my children and my husband. But, now that I go to the clinic and meet with other women and learn something, I have changed. I am a different person. I love my neighbourhood. I continuously think about what we can do to improve it. I also have become a better housewife. My home is clean. I pay much more attention to hygiene. I cook better and more nutritious food and tell my husband and children why I cook this food and not the other. Neighbours, family, everyone respects me more. My husband calls me "khanom (madam) Doctor", and when his friends have questions on health or family planning he comes and asks me. You see we have now become more like friends, because now that I am more involved in society, I can talk to him about health matters, bus services, trying to encourage the municipality to create a sports area for our children and so on. Never before did I get into these kinds of talks with him or any one else. Now my life has changed.

Another woman interviewee said. “It is interesting that I always thought that men did not want women to learn anything because they liked to believe that women are less intelligent. But now that I am a volunteer and I have learnt so much, it appears that he enjoys it almost as much as I do. We argue less, we discuss things more, whether it is about children and neighbours or relatives or the country as a whole. I do think the government should encourage this public role for women; it does not cost them anything, we do a lot for nothing, and it adds to the value of family [and she jokingly added] it can help to bring the divorce rate down."

Among the 30 women interviewed, not one mentioned that their husbands disapproved of their work. Some husbands help them with their reports or work they had to prepare for meetings. Given that these interviewees are from low-income neighbourhoods and are representative of more conventional segments of the Iranian urban population, their testimonies bring into question the assumption that Muslim societies are not yet ready to accept a public role for women. The issue may instead be more about the form that such participation takes.

All interviewees were asked to list all their activities: first, those that they do as part of their responsibilities and then those extra activities that they may do as a result of becoming a volunteer. Beside door-to-door visits and keeping a record of the basic health information of their households, volunteers referred women to the clinic, informed them about pre-natal and postnatal care and vaccinations, encouraged women to go for Pap smear tests, something which only recently became more widely available. Since most women are reluctant to have an internal examination, they resist taking this test. However, women are finding ways to convince women to go for the test. Many volunteers spend considerable time informing their neighbours about nutrition. The information dispensed was not always picked up during in their training, but rather was gleaned from newspapers and women's magazines such as Zan-e-ruz. The other kind of activity they engage in is improving the neighbourhoods by organizing and then demanding that the municipality provide them with services not automatically available in many outlying newly developed low-income neighbourhoods of Tehran. For instance, regular garbage collection, paving major roads, or creating green spaces or neighbourhood playgrounds for children out of undeveloped land formerly used as garbage dumps. In this respect, however, there were marked differences between the activities of volunteer women that worked with a more organized centre as compared to women who merely had a minimum health education at their urban health clinics. For instance, women from Hakimieh were more inclined to encourage the neighbours to petition for asphalt, clean water, better bus services, sport facilities for the youth, and so on. Many had initiated these activities and had brought other women and men including their own husbands, to work as a collective, had organized meetings in their homes, and had formed pressure groups to encourage the municipality to deliver the services.

The active role of volunteer women in this process, conveying the needs and priorities of the neighbourhoods, brought much prestige and status to the volunteer women. Moreover, it encouraged others either to join the organization or become active in mobilizing their community to demand services. They proudly counted what they had achieved, how they had learned from the other volunteers' mistakes, and how they guided each other in these activities. They had often skillfully employed the support of the officials in the Ministry of Health for their demands from the municipality. These kinds of public activities were not completely new, in fact, pre-oil boom (pre-1973) urban Iran had experienced them particularly through neighbourhood associations. However, the role of women, particularly among the more conventional segments of the population, was very new.[19]

Many volunteers from the organized centres developed strong friendships while working together and consequently, met regularly. One volunteer had moved to a distant neighbourhood but continued to come back for volunteer work in her old neighbourhood and to participate in the same weekly training. She loved her old neighbours and friends. "We have become closer than sisters", she said. Many arranged to arrive early at the centre to teach each other skills such as sewing and knitting.

The situation, however, was very different in the other two neighbourhoods where the involvement of the centre was less, and the primary concern was with health matters. The trainers were not as interested in creating a group atmosphere where volunteers would get to know each other. A couple of interviewees said that they did not know any other volunteers at all. They had received their training alone from the morabie, and on occasions when they met others there was no attempt to help them become acquainted with each other. Despite this, they were still glad to be a volunteer, they thought that the neighbourhood and their relatives valued their services, and they felt more confident as persons. These were their opportunities for meeting others and forming a group to identify with, even when they worked separately in their own neighbourhoods. But there was considerable variation among the different centres. One variable was whether the officials in a given community health centre were interested in and supportive of the volunteer initiatives. Also resources may not always be equally distributed nor earmarked for the volunteers' use.

There were other sorts of activities that the volunteers engaged in. Given that they worked in low-income neighbourhoods, they often came to know of households that could not buy necessary medicines; or of a daughter who did not have a minimum trousseau to get married; or a husband who had lost his job, and so on. The volunteers often tried to mobilize their network to collect money or find jobs for the needy in their neighbourhood. They provided personal services, such as taking a sick child to the clinic, cooking for a family whose mother was sick or hospitalized, or helping with the lessons of a child who had missed school. These activities stimulated respect and trust of the neighbourhood towards the volunteers. In the context of Iran, becoming acquainted with families would inevitably mean getting involved in family problems, both among in-laws and within couples.

Many volunteers had learned to deal with such issues by trying to curtail disagreements. In response to the question of what makes a person a good volunteer, most women said respecting the confidentiality of what they knew of their clients lives, ironically something many said they had never thought about in training. Some felt that the first commitment a volunteer should make before becoming active is to never disclose a family's personal information to outsiders. "This would avoid a lot of trouble", said one. Another factor was to be good tempered and keep a good sense of humour, all the time remembering that all you expect from your work is the blessing of God. The third frequently mentioned factor was good training. Those with more years of experience, tended to mention that in the past, experienced doctors and teachers would come to teach them; but that now it was mostly students — who are good but do not have the necessary life experience for training volunteers, since one needs more than technical information in one's dealing with neighbours. In response to the question what would they do if given the responsibility of organizing the volunteers, some 50% per cent of the interviewees said that they would provide more training, especially in first aid. They would pair the more experienced volunteers with newcomers. They would encourage more collective activities for volunteers, particularly trips to other districts or cities so as to learn from each other's experiences. Some people explained how much they had learned from their trip to Mashhad where they had met volunteers who worked there and in other districts in Tehran. Some specified that these collective meetings could be in the context of visiting shrines, a comment that was repeated independently by a few, and is interesting for several reasons. First, it might be motivated by the idea that it might sound like a more legitimate activity in the eyes of the Islamic government. Secondly, historically and culturally, women have always enjoyed much more freedom of movement if their reasons were religious; thus they could anticipate that neither their families, husbands, or neighbourhoods would be concerned should they go for these "zayara" religious visits, even over as much as a few days.

Another major suggestion was the provision of better, more diverse and simply written books that they could lend to women in the neighbourhoods, many of whom are attending literacy classes and would like to have material at the level of their current reading skill. All interviewees from the more organized centres would like to have facilities and training workshops for women, both volunteer and non-volunteer, but also for the youth who have little to keep them busy, out of trouble, and eligible for jobs. This, they pointed out, has several advantages. One is that women can earn some income for themselves and improve their material conditions. Some women had attended income generating activities that had been organised for them.

Secondly, some of the income could be invested in improving the neighbourhood, for example, pay for greenery or setting up better sport facilities. Some, but not all, interviewees were asked if they anticipated at some stage wanting to stop being a volunteer. Many said only if they were very sick and felt that they could no longer work. Others said not if they did not have to. Two women, as though the thought had not crossed their minds, became worried and asked if anyone would be asked to stop being a volunteer. Clearly, they are doing a great service for the country and are saving much money for the government by delivering good, efficient service at a very minimal cost, the women themselves feel rewarded. More importantly they have become agents of change by sowing the seeds of public participation in their neighbourhoods and family.

Cost-benefit analysis:

Like all other organizations, the Ministry of Health is concerned with efficiency and the return on its investment; the volunteer women's organization is no exception. A study for the Ministry of Health designed and carried out a cost-benefit analysis, under the supervision of Dr. Malak-Afzali.[20] The cost-benefit analysis focused on three major variables: changes in the level of knowledge regarding family planning, the cost of family planning, and the level of fertility. Other variables, such as children's vaccinations; pre-and-post natal visits of mothers to clinics; and numbers of Pap smear tests, all of which could easily have been subject to mathematical analysis, were completely ignored. This, in itself, indicates that the Ministry of Health has not seriously regarded women as family health workers or reproductive health workers despite its occasional claims. Rather, the volunteers are primarily seen as family planning agents. Given that improvement in primary health has been stated as a major goal of the Ministry of Health, such an omission is very telling of the real priorities of the Ministry.

Nonetheless, the results of the study conducted by the Ministry indicated that while volunteers made no difference in the level of knowledge and contraceptive practices for women of reproductive years, their presence correlated with the safe use of contraceptives which rose 20% more than in a control area.[21] There was also a 50% reduction in the number of unwanted pregnancies in the neighbourhoods under the volunteers' cover. The study concluded that the presence of volunteer women, though not having an impact on the quantitative expansion of family planning, did help with the safe use of contraceptive methods and how to make use of the government health system.[22] There has thus been a reduction in crude birth rate and total fertility rate.

It is regrettable that such an elaborate study of such a well-rounded and successful project chose such a narrow focus for its cost-benefit analysis. This is significant, given that, from the outset, the family planning program had that an improvement in the status of women as a means of encouraging smaller families was one of its goals. However, a review of the activities and programs of the Ministry of Health does not give any indication that an attempt was made to address the relationship between women's position and their fertility behaviour or general health nor were there any steps made to improve women's status.[23] An exception in this trend to overlooking the status of women could have been this volunteer women project, if only the authorities had ideologically perceived it as such. However, the reality is that appending all activities surrounding family health and public health matters to the work of volunteers has been a means of winning legitimacy for the women to work as family planning agents.

Attracting attention:

The success of the Volunteer Women has attracted the attention of international funders who are concerned with health, population, and, in some cases, with the promotion of public participation and a "civil society". This attention, particularly given the ministry's need for funds, on the one hand, and the prestige that such a successful mobilization of the public has brought the government and the Ministry of Health, on the other, has acted to promote this organization. Municipalities, particularly Tehran under the leadership of Karbaschi, a man of considerable commitment and vision for the future, have been close allies of and collaborators with the Ministry of Health in the volunteers program. It is also important to mention the role that International Habitat, Istanbul, 1996, played in diversifying the activities of the Volunteers' and broadening the interest of municipalities in their agency. Members of municipalities participated in many national and regional meetings and were expected to report on their progress in areas covered by the International Habitat conference. In this process, officials themselves learned much about the issues and were stimulated by the programs that other developing countries have adopted. On the other hand, each nation was also to be represented by its NGOs working in that field, and Iran had essentially none. To save face, the authorities tried to create a facade of having active NGOs,[24] they identified the Volunteer Women Health Worker as another possibility and began to intensify their work with them. The Ministry of Health welcomed this collaboration.

The Tehran Municipality early on introduced the Volunteer Women program to the importance of public health and a clean environment for the general well being of everyone, and also provided some training and pamphlets related to public health. Wherever available, sport facilities for were open, free of charge for Women Volunteers. Visits to shrines and other areas of public interest were sponsored. Volunteer women were to take an active role in promoting public health, for example by advising people not to dump their garbage in the streets, not to raise animals at home, and so on. In return and so to promote the social prestige of the Volunteer Women, the municipality delivered requested services as discussed above. What is not quite clear is the stage at which the Volunteers became involved in petition writing and the mobilization of neighbourhoods for demanding services (such as electricity, water and green space).

In more recent years, interestingly, several other bodies, attached or semi-attached to the state, notably women's organizations have developed an interest in co-opting the Volunteer Women Health Workers.[25] These "associations" had been concerned with women’s issues but had never before been open to other women. Neither had they envisaged a serious social role for themselves. However, following their recent exposure to the UN international conferences such as the ICPD and the Beijing women's conference, they began to conceive of having a grassroots base for themselves. It is not quite clear to what extent such a desire is based on empowering women or only promoting their own social and political prestige.

Nonetheless, the co-option of the Volunteer Women, an already existing and functioning body, was an attractive prospect for them, especially since some senior female health workers are members of the Women's National Committee. This situation has created both a dilemma and a nightmare for the Ministry of Health that initiated and funded the training of the Volunteers. Since the Ministry had not planned to fund such a large organization indefinitely, it wanted to pass it on to a different governing body. But they have several significant concerns. First, the authorities in the Ministry are determined to insure that its’ primary function, community health work, is not diverted to other volunteer activities. Second, the expenses of the organization need to be paid without inciting the Volunteer Health Workers to begin demanding monetary rewards.

These concerns are quite strong on the part of the Ministry of Health's officials. Dr. Malake Afzali, recently delivered a speech in appreciation of the services the Volunteer Women, noting that their reward was the blessing of God. He insisted that those who work for monetary reward do not enjoy the same fulfilment and social respect.[26] A third concern, particularly of the founding fathers, is to prevent the organization, especially in Tehran, from falling into the hands of those with larger political motivations; at the very least it would politically reflect negatively on them and the Ministry of Health. Indeed, it is the political concerns that have most preoccupied the Ministry of Health. Dr. Naser Ghrarib, the vice Chancellor of Beheshti Medical University, in a recent interview appearing in the Volunteers' Newsletter, pointed out that volunteers are a vast organised force that should consider their work as ethical and social, and should register as a legal entity. But at all cost, they should keep away from politics.[27] Volunteers in other provinces have had a sort of newsletter since 1995.[28] But the fear that a central voice might create a sense of belonging to a larger organization prevented the establishment of a newsletter for volunteers in Tehran until this year.

Since 1996 there have been two suggestions for solving the Volunteers’ dilemma. Both of these suggestions were made without consulting the Volunteers who are typically viewed as resources for development. The first was to register the organization as an official GO-NGO under the guidance of the Ministry of Health; the members of the board of directors would be appointed from influential personnel in the Ministry. The organization, under the facade of integrated development, would add an income generating wing, in which the volunteers would also work to generate the income to partly pay for the running and training of volunteer health workers.

Under this plan, a variety of government organizations would be involved in the project: the Ministry of Welfare, would provide vocational training; Jahad, a national foundation would provide carpet looms and other technical/material support; the municipality would provide space; and the general Bureau of Co-operation, would provide loans for various initiatives. There has been some debate whether the employees of the Ministry of Health and the other ministries are equipped to engineer an economically viable project.

However, most officials seem to be more concerned with a politically safe, rather than an economically viable, option. The other idea is to turn the organization in each province into a non-profit and self-sustainable NGO thereby allowing each to develop its own income generating activities through production and through the raising of funds from national and international agencies and interested individuals. This suggestion seems to win little favour since most officials believe that neither society nor women, themselves, have the capability to run such NGOs.[29] While the debate on the future of the Volunteer Women's Organization continues, a variety of projects have been tested. While some provinces have more decisively chosen their route, the situation in Tehran, with by far the largest number of volunteers, is less clear. Regardless of larger plans for the formal institutionalisation of Volunteer Women, they have been encouraged to register some 17 independent co-operatives, some of which have started to experiment with income generating activities. The advantage of registering the volunteers as smaller organization is, of course, to avoid developing a sense of belonging to a large independent organization. On the other hand, it encourages other ministries to foot the bill for promoting their income generating activities. It remains to be seen whether these experiences will encourage more women to join the organizations and learn to develop a sense of collective identity and solidarity concerning their common demands.

References:

Alderman, Harold and Joachim Von Braun. 1984. "The effect of Egyptian Food Ration and Subsidy System on Income Distribution and Consumption" Research Report No. 45. International Food Policy Research Institute, Washington, D. C. 24.

Amirahmadi, Hushang. 1990. Revolution and Economic Transition, the Iranian Experience. New York: State University of New York Press.

Bulatao, Rodolfo and Richardson, Gail (1994) Fertility and Family Planning in Iran, World Bank, New York.

Fatahi, Mansor (1375/1996) A Workshop Manual for Training Trainers of Community Health Workers. Ministry of Health and UNICEF, Tehran. [Farsi]

Gellner, Ernest 1991. Civil society in the Historical Context" in International Social Science Journal 43:495-496.

— 1988. Culture, Identity and Politics. Cambridge: Cambridge University Press.

Halliday, Fred. 1979. Iran: Dictatorship and Development, London: Pelican Books.

Hoodfar, Homa. 1997. "Muslim Women Mullahs as Volunteer Reproductive Health Counsellors." Presented at IUSSP conference, Cultural Perspectives on Reproductive Health. Rustenburg, South Africa, 16-19 June.

Hoodfar, Homa. 1996. "Bargaining With Fundamentalism: Women and the Politics of Population Control in Iran." Reproductive Health Matters 8:30-41.

Hoodfar, Homa. 1995. "Population Policy and Gender Equity in Post-Revolutionary Iran." In Family, Gender, and Population in the Middle East: Policy in Context, ed. Carla Makhlouf Obermeyer. Cairo: The American University in Cairo Press.

Hoodfar Homa, (forthcoming). Gender Equality and Population Policy in the Islamic Republic of Iran., Columbia University

Huntington, Samuel. 1993. "The Clash of Civilizations." Foreign Affairs.

Ibrahim, Saad Eddin 1995. "Civil Society and Prospects for Democratization in Arab World", in Civil society in the Middle East. edited by Augustus Richard Norton, New York, Leiden: E. J. Brill

Khouri-Dagher Nadia, 1996, The state, Urban Households, and Management of Daily Life" in D. Singerman and H. Hoodfar (eds) Development Gender and Social Change in Cairo. Blomington: Indiana University Press

Lewis, Bernard. 1993 "Islam and Liberal Democracy" The Atlantic Monthly 271 no.2:89-94.

Malek Afzali, Hossein. 1370/1992. Vaziet-e salamat-e madaran va kudakan dar jumhuriyyeh islamiyyeh iran (The Health Status of Mothers and Children in the Islamic Republic of Iran). Tehran: Ministry of Public Health, Health Education Division.

— and Mandana Askari-Nasab 1997. cost-Effectiveness of women Health volunteer project in a selected PHC Activities (family planning). Teheran University of Medical Sciences and Health Services.

Mehran, Golnar. 1991. "The Creation of the New Muslim Woman: Female Education in the Islamic Republic of Iran." Convergence 23 (November 4), 42-52.

— 1992. "Social Implication of Literacy in Iran." Comparative Education Review 35(2): 194-210.

Mason, Mike. 1998. Development and Disorder: A History of the Third World since 1945. Toronto: Between the Lines

Richard Alan 1995. Economics pressures for Accountable Governance in the Middle East and North Africa" in Civil society in the Middle East. edited by Augustus Richard Norton, New York, Leiden: E. J. Brill

Sciortino, Rosalia; Natsir, Lies Marcoes; and Mas'udi, Masdar F. (1996) 'Learning From Islam: Advocacy of Reproductive Rights in Indonesian Pesantren'. Reproductive Health Matters 8, 86-97.

Shadpour, Kamel. 1994. The PHC Experience in Iran. Teheran: United Nations Children's Fund.

UNICEF. 1995. "The profile of Girl child in Islamic Republic of Iran". Teheran.

UNICEF. 1995. Community health volunteers: Achievements and future prospects for empowerment, report of a workshop (May 28-29, 1995).

UNICEF. 1996. The community Health Volunteer, Iran's innovation in urban health care. paper presented at a UNICEF regional meeting, Cairo, Egypt.

A first draft of this paper was presented at a panel organized by the Population Council, at the annual Anthropological Association Meeting, (Philadelphia, Dec. 1-6). The data presented in this paper are part of the Women and Law program which was carried out under the auspices of the Women Living Under Muslim Laws Network and was funded by the Mellon Foundation. I would like to thank Dr. Parvin Maroofi and Dr. Saamieh Asskary for their support and advice on the research project. My thanks also to Ms. B. Roshdieh for her participation and management of the research project and to Nelofer Pazira and Anthony Hilton for their comments and editing efforts.

 




FOOTNOTES

[1] Iran, given its history of authoritarian state, lacked a vibrant formal civil society. During the years of the Pahalvi regime (1924-1979) only when the regime started facing crisis did a variety of associations surface and citizens openly discuss social and political issues. It was, as many believe, the lack of democracy and public participation that led to a rejection of the regime by all classes and to the mass Iranian revolution (Halliday 1979)

[2] This process was especially difficult as the political leadership was composed primarily of independent religious leaders with little political experience let alone skill in running a populous country that was fully integrated into the world economy. This period also witnessed some of the worst abuses of human rights in modern Iranian history.

[3] The existence of such a limited space for public participation has frustrated many Iranians who are wondering why the creation of a civil society has taken so long, given that the infrastructure of a modern society has been in place for some decades. The explanations for this state of affairs by the socio-politically observant, Iranians as well as non-Iranians, vary greatly. On the one hand, the new Orientalist position, similar to that of Huntington (1993) - Lewis (1993) and Gellner (1991,1988), who claim that the culture and religion of the region is hostile to the nurturing of democracy and the creation of civil society. Ironically, many elements in the Iranian state and government hold a similar view, and therefore, they argue that it is pointless to try to "import" pluralism and western democracy to the culture. Others argue that it is not the culture or religion but the history of dictatorial state(s) that prevents the creation of a civil society. Their recommended recipe is to challenge the state and force it to become accountable. Yet there are others, including many senior bureaucrats of the regime, who claim that it is neither the regime nor the religion but rather it is the people who have not yet achieved a sufficient political maturity to make a civil society workable. Accordingly until such a day, the government should dictate what is best for the nation.

[4] For debates on subsidization of basic foodstuff and its political consequences in Egypt see Alderman and Von Braun 1984, Nadia Khouri-Dagher 1996.

[5] During the early years of the revolution, many young men and women worked in the poorer districts as teachers or nurses for little or no pay. They did so under the auspices of Basiaj (mobilisation) which is an organization under the leadership of the Supreme leader, and not the government, and it is committed to the regime's ideological Goals.

[6] However, the content of educational material besides including much Islamic studies, continues to depict clearly segregated and specific gender roles for men and women.

[7] Moreover, as Mehran (1991, 1992) has documented, a successful adult literacy campaign was launched; a noteworthy aspect is that the classes have attracted more women than men. My own field research (1993-1996) in Iran indicates that flexible class hours, particularly in rural areas, as well as the possibility for woman without childcare to bring their children with them to the class, have particularly encouraged many women to participate (Hoodfar forthcoming).[8] In addition to hospitals and community health centres in the towns and cities, the Ministry of Health has established "health houses" in the larger villages, which provide basic health care for the population of the surrounding area. These small health care outposts are staffed by two health workers (one man and one woman) who are usually recruited and trained from the local village. The health houses keep records of all residents, with particular attention to pre- and post-natal care. Nurses oversee most routine cases and a doctor providing specialised care visits each health house twice a week.

[9] The Iranian family planning program was ratified before the Ayatollah Khomeini's death in 1989. As Iran's supreme religious/political leader he was a one-time opponent of the shah's family planning program.

[10] For a comprehensive description and discussion of the Iranian rural health network, see Shadpour, 1994. This efficient, low-cost system was designed by doctors and health officials (such as Dr. Malak Afzali) who had completed their compulsory military service under the shah as Health Corps members in rural areas and as such, they had first-hand experience of the problems and conditions.

[11] Ironically, it is now the volunteer model that is used as corrective of what is seen as a shortcoming of the rural health houses model.

[12] The discrepancies stem from the fact that dropouts are normally not counted. Moreover, some officials use the target numbers as actual numbers and usually are not very careful about the figures they use. At a meeting organized to celebrate the success of volunteers, the two major official speakers for the Minster used two different figures of 37,000 and 30,000.

[13] Despite the important volunteer important contribution to general health matters, particularly family health matter and vaccination of the children, the Ministry of Health continues to view their effectiveness only in terms of family planning matters. For instance, see the cost-benefit evaluation of women volunteers project by Malake-Afazali (himself a major engineer of the WHV and Askri-Nassab).

[14] For example, the manual compares feeding babies manufactured baby food of dubious quality with the traditional practice of breastfeeding.

[15] These were supposed to happen in their weekly meetings at the urban health centres.

[16] Given the existence of some regional autonomy within the system and the lack of a hyper-political atmosphere, the volunteer women's organization in several other cities were able to produce and circulate their own local newsletter long before their counter parts in Tehran were given the same opportunity in September 1998.

[17] 17. I was offered on many occasions a visit to one of the centres to talk to officials and volunteers at their meetings. However, my suggestion/request of a more in-depth study on the perception of volunteer women was politely pushed aside. numbering from one to five. The manner in which they had come to be involved in volunteering varied. Ten women had come to know about the volunteer health workers through friends or relatives who were volunteers themselves who subsequently had introduced them to the health centre for training which is where they began their activities. Six were enlisted through surveyors (the local fertility survey). Six were invited to join the service when they had been referred to the local health centre as patients. Four people had heard about and joined the program through their Koranic classes after the health centre had contacted the mosque; and one person had read an announcement and invitation on the notice board of her local health clinic. Five of the interviewees had worked as volunteers for one year; five women had worked for a year and a half; four for two years; and four for three years; and ten interviewees had worked from four to five years.

[18] A similar view is held with regards to the question as to whether or not women should be employed by the government. Although government pay is lower then the private sector, many families would only allow their daughter/wife to work in the government sector. The real reason behind this is the fear that in the private sector, individual male owners in charge may use their position to sexually molest women. Even when the actual threat is not there, the assumption of such a threat prevents families from allowing their daughters to work.

[19] The only other cases that I know of are women in shantytowns in Tehran who, during the Shah's time organized to resist the bulldozing of their homes.

[20] He is one of the most committed and innovative directors of the Ministry of Health and has been for the most part behind the conceptualization of the family planning policy and played a vital role in designing the volunteer women's program.

[21] This includes a percentage of women who would have gone to the private sector or used other traditional methods, but have now chosen to utilize the community health centre.

[22] The above statement appears to be contradictory since reduction of unwanted pregnancies and safe use of contraception indicates improvement of knowledge and practices of couples.

[23] A major exception is the near closing gap between female and male infant mortality rate.

[24] During this period the Interior Ministry made it possible for at least one real environmental NGO (as oppose to governmental NGOs) to register.

[25] For instance there are several women's offices (attached or semi-attached to government) such as the National Women's Committee which came to exist in the early years of the revolution, though they have remained small in number and influence.

[26] The speech is published in Rabet-e-Salamat, (the volunteers newsletter, 1998, September No.1 page 3.

[27] The interview was published in Rabet-e-Salamat (Volunteer health workers' newsletter) 1998:2 (2-3)

[28] Kurdistan had it s first newsletter in 1995.

[29] For a summary of some of these concerns raised by officials see the UNICEF report on a two-day workshop (May 28-29, 1995) on Community Health Volunteers: achievement and future perspectives for empowerment.