The inequity in social relations between men and women in rural Peru denies women the power to take responsibility for their own reproductive health. Nor are they able to articulate their health problems and express how they would like to be treated. Women in such dependent relationships find it impossible to question the social order. Health workers need to take into account the inhibitions of these women and encourage more democratic relationships between men and women. To improve the reproductive health of women in rural and peri-urban regions, the Manuela Ramos Movement runs a project called ReproSalud ("Reproductive Health in the Community"), which seeks to help women develop skills that will allow them to exercise their rights over their sexual and reproductive health.

Good communication between the women and the Ministry of Health (MOH) is essential, and health officials should recognise women as "subjects with rights." To foster this relationship, ReproSalud focuses on strengthening the women's capacity to organise themselves, so that their dialogue with the MOH can take place in an equitable environment, where both parties accept each other as partners to improve health status. Specifically, ReproSalud seeks to:

• strengthen women's capacity to identify problems, and consequently develop and implement projects that improve their lives;
• develop community skills regarding reproductive health education;
• promote the dissemination and full enjoyment of sexual and reproductive rights for women;
• strengthen women's community organisations and improve women's health and quality of life.

Since 1995, ReproSalud has worked in rural and peri-urban settings, involving nearly 165,000 women and men from the poorest areas of the country. It has trained more than 7,700 community reproductive health promoters and established about 2200 community-based organisations (CBOs), whose activities have reached some 2500 rural and peri-urban communities.

Examples of leadership experiences

In 1999, health workers at a rural community in the Amazon forest province of Ucayali instructed members of a Mothers' Club to come to the local health centre for a PAP smear for cervical cancer. However, the Mothers' Club had already planned a different activity. The Club president's suggestion that they come on a different date caused some annoyance among the health workers.

What changes had taken place in the lives of these women that empowered them to make their own decisions, overriding those made by the health staff? An earlier self-assessment on reproductive health by 244 women supported by ReproSalud, revealed the surprising outcome that nearly half of them ranked vaginal infections as the most important sexual health problem, although most health professionals had expected maternal mortality would come out as the most important problem. However, the women had an integrated conception of how vaginal infections are linked to pregnancy and delivery complications, as well as with difficulties using contraceptives, the possibility of getting cancer, and ultimately, death. In the past, these women's daily reality of subordination and lack of recognition made it difficult for them to control their own lives. Now, the Mothers' Club members had educated themselves about their sexuality, their bodies and how to take care of them. They had strengthened their skills and capacity to learn and educate others. When they requested a later date for the test, they were thus able to mobilise other women in the community as well.

Better knowledge about their sexual and reproductive health encouraged the women to advocate in their communities for healthy practices, generating a sense of self-confidence to become community leaders in defence of their sexual and reproductive rights. They act as role models and references for communities' women's health problems. They have also begun to act as mediators with local government representatives, to solve problems they consider priorities. The women value their relations with MOH professionals and technicians, whom they now consider allies. The Mothers' Club now has regular contacts with the health centre staff, which has helped health-care providers understand the women's perspectives and establish a mutual trust.

Education on violence – other examples

In an Andean district of Ayacucho Province, a group of women leaders took the initiative to invite the local authorities to celebrate the International Day of Non-Violence Against Women (25 November) and. They prepared various dramatisations of the violence they suffer daily to show the health authorities, the police and local government what violence really meant to them. They hoped the authorities would develop a more open attitude toward finding solutions. As a result, the various parties formed a Community Vigilance Committee on Violence Against Women. The committee comprised the head of the health centre, the mayor, the governor, police representatives and the women leaders who had taken this initiative.

A third example shows how women leaders of Huancané organised a march through the centre of town to present their grievances concerning problems of violence and reproductive health. During this march, they presented petitions to every single authority in the province, demanding coordinated action and more sensitivity from the institutions in addressing violence and reproductive health. The women used a traditional activity, marches, to present their demands to the authorities and at the same time sensitise the public.

Getting better organised

The community workers and CBO leaders with whom ReproSalud has worked decided to strengthen their movement by forming two new organisations. The Network of Community Promoters in Reproductive Health groups together all district health promoters. ReproSalud trains them in reproductive health issues identified by the women. They are enabled to promote and teach reproductive health practices, linking the women in the community with the local health centre staff.

The second organisation, the Committee of Defenders of Sexual and Reproductive Rights, includes the chairs of women's CBOs and associations. Each Committee of Defenders consists of representatives of district organisations that are clients of a state health centre. The Committees work with the Network of Community Promoters, developing activities to promote and defend women's sexual and reproductive rights and maintain civil awareness. They have before them an enormous challenge: to promote and lead a movement for women's health.