Dr. Uche Amazigo
Why focus on Africa?
Over one-quarter of the world's population are at risk from parasitic infections and the majority of these infections are confined to the world's poverty belt of the tropics and sub-tropics -- largely in Sub-Saharan Africa. Women constitute nearly 67per cent of the total population of Africa, and to achieve better global health condition, a focus on African women is thus necessary. Low income levels are associated with debilitating disease patterns. Thirty-eight of the world's 63 low-income countries are in Africa. Of its 500 million people, 40 per cent have less than US$1 a day to live on, 68 per cent have no proper sanitation and 52 per cent no access to safe water (Lancet, 1997). In a recent WHO report, analysis of the poverty data (UNDP 1994) illustrates the role of poverty in co-determining the health status of the populations (WHO/TF/HE/TBN/97). The report referred to above concludes that "levels of both total and rural absolute poverty" are substantially higher in the ten low performers (countries with highest negative deviation from estimated life expectancy) compared to ten high performers (countries with the highest positive deviation from estimated life expectancy). Interestingly, nine out of ten are in Africa. Of all geographic regions, Africa has the highest tropical diseases morbidity and mortality ratios (Sai and Nassim 1991).
Efficient services and special effort by health providers is needed to enhance the health status of populations in this region. Planning for health services, improving the efficiency and engendering services in any country depends primarily on information about the main causes of ill-health and death in defined areas. Data on cause-specific mortality and morbidity, in particular, data disaggregated by gender and sex crucial for effective planning are scanty for most countries in sub-Saharan Africa (Heggengougen 1996). Gaining solid and longitudinal understanding across the life span based on reliable, consistent and quality data has been re-echoed as perhaps the first action for tackling major causes of ill-health (Stephens 1996).
Given the paucity of data available to health planners in Africa, the question to ask is - can program planners achieve a reform of the health sector and or improve it? Do we have data to show where services are required? And can services and human resources be made available where they are most needed but nonexistent?
Why focus on Tropical Diseases?
Tropical diseases are to a large extent poverty-borne diseases. It has been estimated that half a billion people are suffering from tropical diseases -malaria, schistosomiasis, African trypanosomiasis, chagas disease, Leishmania (Kala Azar) and leprosy (WHO, 1993) and that a high proportion of this population live in sub-Saharan Africa. Tropical diseases produce large burdens of disability and some act synergistically with some non-parasitic diseases to produce severe disability sometimes leading to death.
Equally important is the focus on parasitic and infectious diseases. In the last decade, especially with the advent of AIDS, information on STDs, HIV, teenage pregnancies is becoming more available, but data on tropical diseases some with lifelong impact on health and economic development remains ambiguous.
In the absence of a vaccine or a 'magic bullet' for the treatment of tropical diseases like malaria and with increasing travel from non-endemic to endemic countries malaria, will become a huge problem to developed countries. Already an increasing number of imported cases including strains resistant to available drugs are being reported (Globe and Mail, 1997).
The Health of Women and Tropical Diseases
As Heggenhougen (1994) aptly notes "a Sub-Saharan female has a dramatically poorer chance of survival relative to her developed-world sister than does a Sub-Saharan male compared with his developed-world brother".
With many tropical diseases (malaria, onchocerciasis, trypanosomiasis), exposure to the bites of infective vectors is closely related to work patterns of males and females, to individual and community behaviour (Robert, 1963) and is central to transmission.
Until recently, the theory has been that because males assumed the greatest responsibility for farm labour, their exposure and infection rates would be considerably greater than those of the female members of the family.
Historical changes in economic and agricultural roles of men and women leave women with the major responsibility for subsistence farming (Okonjo, 1988) and family welfare. Adolescent and adult females in Africa now make the greatest contribution to agricultural production (FAO, 1984). These changes in roles have increased exposure of females to infective bites of flies which transmit tropical diseases and increase their role in the transmission of diseases.
In a recent review, Amazigo (1994) observed that certain health conditions and problems associated with the highly prevalent tropical infectious diseases (e.g malaria, schistosomiasis) are shared by males and females at almost equal prevalence rates but they have each particularly serious consequences for females because of their reproductive functions. These problems exacerbate risk during pregnancy and childbirth.
A few tropical infectious diseases cause gross disfigurement. Leprosy, lymphatic filariasis, schistosomiasis, leishmaniasis and onchocerciasis are all diseases that disfigure the body - (SLIDES), hence, men and women are affected but differently socially, economically and psychologically. Studies demonstrate that these diseases are particularly cruel for adolescent females and women because of their effects on marriage prospects (Amazigo and Obikeze, 1990), education and self esteem ( Ovuga et al, 1996). The results of multi-country study on the social and economic effects of onchocerciasis demonstrated that school-age girls whose parents have severe onchocercal skin disease (OSD) are 2.6 times more likely to drop out of school than their counterparts from non-OSD families (TDR/WHO,1997).
Some if not all tropical diseases have direct health effects that go beyond the immediate female victim. Malaria in women leads to low birth weight either by premature delivery or impaired growth in utero (TABLE) and in pregnant women provides an opportunity especially in Plasmodium falciparum infection for parasites to invade the fetus itself (McGregor, 1983). In women with onchocercal itching the duration of breastfeeding was reduced by more than 9 months for 25 per cent of the infected women who breastfed infants after the onset of disease condition (Amazigo, 1994).
Women have thus been subject to government attention in the provision of health services not for their own sake, but largely for their roles as mothers and for being responsible for family members health (Rathgeber and Vlassoff, 1993).
In this discussion paper, infectious and parasitic diseases (malaria, tuberculosis, onchocerciasis ) selected were chosen because they have deleterious impact on women and the size of their burden as measured in Disability-Adjusted Life Years (DALYs) (Murray and Lopez, 1994). Even when infections from them do not proceed to mortality they generate considerable morbidity in men and women.
The threat from malaria is a global and not an African issue. One billion people are at risk from malaria and between 1-2 million deaths per year are due to malaria and 90 per cent of the deaths are in Africa. Given the global warming and increased international travel, urban malaria is now a major public health problem in Africa and persons from developed countries who have no immunity are at great risk.
On March 13, 1998 a new global initiative was announced by the new Director General of WHO, Dr Bruntland to Roll Back Malaria. The program aims at reducing malaria deaths (2.7 million deaths per year) by 50 per cent by year 2010 primarily through control activities including rebuilding health care services. The Roll Back Malaria is initiative a new opportunity to the African region to control malaria but several issues need to be carefully considered in implementation of this new attack to avoid past mistakes which resulted to both insecticide and drug resistance.
In the search for new insecticides it will be useful to explore the potentials of traditional herbs in use in the communities by local people as mosquitoes repellents (e.g local herb, Nchawu - which the Igbos of Nigeria burn to ward off mosquitoes). Also, such local coping mechanisms, and or capacities should be explored.
In the last two decades, it is estimated that 40 per cent of fevers are due to malaria (Brinkman and Brinkman, 1991), therefore, strategies for the control of malaria have shifted with a major focus on reducing mortality and morbidity with prompt and presumptive treatment of fever.
There has also been increasing recognition that the success of any control strategy would depend on a number of factors including the behaviour of patients especially mothers and caretakers of young children, the need to understand treatment seeking behaviours (Oaks et al, 1991) the choice of treatment. Research studies have shown that women's choice and time of treatment are dependent on such factors as:
b) access to health facilities ;attitudes of providers, cultural beliefs about the cause and treatment of malaria.
Self-medication is a common approach by people when they experience signs and symptoms of malaria. Given the high incidence of malaria in Africa, the lack of or near absence of laboratory facilities at peripheral levels for clinical (biomedical) diagnosis, malaria has remained a problematic issue. Studies for a better understanding of the criteria used by women and village health workers in predicting malaria are highly desirable. Such studies, will afford experts insights into malaria transmission modes and have already been identified in Nigeria (Okonofua et al, 1992), Liberia (Jackson, 1985) and in Zimbabwe.
The transmission of malaria is not, and should not be seen as a matter for only health professionals. Because women are the primary care takers control initiatives as the Roll Back Malaria should focus on and harness the benefits of participatory planning by involving women from the outset in the determination of the needs and priorities of malaria control, planning and implementing measures that are feasible and acceptable to improve health. The role women can play in malaria control partnership programme will be discussed later in this paper.
In order to establish sustainable control programmes, strong partnerships between local women's groups and health services is necessary. It must be recognized that as stake holders, the lead role must be shared by both in the control of malaria at least until Africa can boast of adequate number of trained health staff and availability of functional facilities at the peripheral levels. Presently, the acute lack of both staff and facility at the peripheral level underscores the need for the role of women in the home treatment of malaria and in control to be encouraged. In order to circumvent this anomaly, active involvement of communities, in particular, women's groups to the fullest extent possible, should be an integral part of policy in malaria control for every country in the subregion.
Tuberculosis is the single biggest infectious killer in women. It kills nearly 2 - 3 million people yearly. It is primarily a lung infection caused by inhalation of droplets containing tubercle bacilli of cough spray from tuberculosis patients. Mycobactarium tuberculosis and M. Africanum are two predominant causative strains in Africa.
In many Sub-Saharan African countries especially Central and East Africa, the incidence of TB has increased with the advent and increasing occurrence of human immunodeficiency virus (HIV) seropositivity. In a number of these countries one in three people with HIV die from TB due to neglect, they also infect hundreds of HIV-negative persons with TB bacteria.
Surprisingly, policy makers in most Sub-Saharan African countries are still unaware that TB is a great threat, that 95 per cent of the eight million new TB cases every year occur in developing countries, Africa with an incidence of 272 per 100,000 population which is approximately a ten-fold incidence rate compared with an incidence rate of 27 per 100,000 for European countries.
Equally sad is the observation that many policy makers have continued to neglect TB despite current knowledge that untreated TB follows a rapidly fatal course in HIV infected persons - hence Chreiten (1990) reference to both diseases as "the cursed duet". The presence of Mycobacterium tuberculosis leads to accelerated replication of HIV; evidence that AIDS and
TB accelerate each other has been documented (Pope et al, 1993). Worst still, in HIV sero-positive TB patients, because of poor health status, there is increase incidence of adverse reactions to available drugs and poor response to therapy compliance to TB therapy is as low as 30 - 45 per cent in Sub-Saharan Africa.
According to WHO Global Tuberculosis Programme (GTP) recent reports over 900 million women are infected with TB world-wide and they are also at greater risk from HIV infection.
Directly observed treatment short-course (DOTS) is the WHO/GTP recommended strategy for the detection and treatment of TB, a strategy described in the 1993 World Development Report, as one of the most cost-effective strategies. In a collaborative TB control programme of the Ministry of Health in Guinea and the WHO, Guinea's TB cure rates using DOTs are today recorded as over 80 per cent.
Because patient compliance is the most important determinant for success in the treatment of tuberculosis health sector initiatives must be designed to promote compliance by women. Given that stigma attached to Tuberculosis often leads to isolation and divorce of women health policies should emphasize on community directed programmes with inputs from different community groups, in a fashion acceptable within the specific cultural setting of the population.
Partnership with women for health reform
There is no gainsaying the fact that women play crucial roles both in family and society's health care. It is imperative that such roles remain focal points for health care reforms to ensure their full participation.
Experience has shown however, that sustaining women's participation in health-related projects is difficult. This is largely because their primary concern is the welfare and nourishment of children and their husbands. Women frequently give higher priority to income generating activities, water supply projects than to activities to reduce the incidence of particular diseases.
Thus, to maximize the chances of sustainable TB control project, and in particular patient treatment compliance, the use of non-conventional methods in training non-health personnel deserve serious consideration. For instance, women trained as peer group educators would accomplish more in reaching traumatized and stigmatized females and males in their environments as would health workers. Local women's groups could counsel and provide
support to affected persons, help to identify potential TB patients and assist the health services with improving compliance rates especially among HIV infected individuals.
Also, since early treatment of malaria is the major target of control and self-medication has been a concern to health providers mothers and care takers of young people need to be able to administer early, appropriate treatment. Because 80 per cent of malaria cases are treated at home, rural women trained as peer group educators would reach and inform their peers about self-medication, overusing of antimalarial drugs.
In each community, therefore, women should be encouraged by the health service to select from among themselves persons to be trained; these will train their peers to recognize signs and symptoms of severe malaria, on the dangers of long delays before hospital admission. Local women groups should be encouraged to form with district or peripheral health teams, malaria-surveillance teams to help with identification and treatment of cases. In Kenya, training of rural shopkeepers has been shown to improve the administration of correct dosage of antimalarial drugs (Kayondo, personnal communication, 1998).
A word of caution, achieving and sustaining community participation in health related control projects is difficult and policy makers should be aware of this from the outset when restructuring the health sector.
Restructuring the health system
The World Development Report (1993) concludes that problems associated with inefficient health systems will continue to hamper progress in reducing the burden of illness and disability and impede efforts of health providers to cope with new and emerging diseases (e.g. AIDS) and parasitic diseases -malaria and tuberculosis. The concern therefore is the inefficiency of health systems and services in Africa. Thus the notion to restructure the health sector with gender as an integral component.
At least eighty percent of tropical diseases problems of women and their families are preventable or can be addressed at the primary level of care but the cases in females are under-reported at health centre and hospital levels. The reason is women do not appear at these facilities for treatment in numbers commensurate with presumed morbidity rates. Many theories have been advanced that poor representation of women are due to cultural requirement that women seek medical help only with the permission of the husband, when clinical symptoms are severe and obvious, lack access to health services, delays at health centres. Also, there are reports that women who seek medical attention receive inferior treatment at health services (Vlassoff & Bonilla, 1993, Manderson et al, 1997).
The question to ask is - by focussing on gender in tropical disease control can we reduce mortality, morbidity rates or prevent the upsurge of malaria and TB epidemics? In many African States, a three-tier structure (primary, secondary and tertiary health care) of the health system has been in place for two to three decades. With the declaration at Alma Ata primary health care was adopted by most countries as the cornerstone of the national health system and community participation in the planning, management and evaluation of the local health system.
Whilst it has been argued that " the strength of the national health system would depend on the quality of the health services at the community level -the origin of all the health problems in the nation" (Ransome-Kuti, 1998), a more fundamental change is necessary in today's health policies and programmes to effectively address the health needs of women. These changes are necessary at all three (primary, secondary, tertiary) levels of the health system. And the challenge for the health providers in the sub-region is both political and technical.
Tropical diseases, their impact on women and women's health needs have remained neglected issues principally because under privileged women are not heard, are under represented in political, technical and economic decisions. More broadly, women who are the 'supposed' beneficiary of the health policies do not see their sentiments and health needs adequately reflected in policies and programmes. To them on-going health initiatives are 'white man's' programmes and not 'our programme'.
The challenge is political because restructuring the health services and instituting reforms would need changing the power relationships between national and international providers of health and the recipient communities. In other words, adopting the bottom-up approach; accepting community as a lead stakeholder in health reform.
Also, in restructuring the health sector, policies should emphasis the critical issue of the interaction between health care givers, the community and potential partners in the private sector. The potential partners in the private sector are neglected aces in health delivery. But in the last decade, the public 's expectation of the role of the private sector in health matters has changed. Increasingly the private sector, in particular, pharmaceutical companies are being requested by WHO to join as partners in the control of tropical diseases.
Two recent examples has led to the free donation of ivermectin by MERCK & Co Inc ( APOC document, 1996) and of Albendazole by SmithKline & Beechem (TDR News, 1998) for the control of onchocerciasis and lymphatic Filariasis respectively. The first led to the launching of a regional Programme in Africa, the African Programme for Onchocerciasis Control (APOC); a unique health development partnership programme by affected communities, Ministries of Health, non-governmental development organizations (NGDOs), four UN agencies and donor countries. APOC's ivermectin distribution strategy is unique because the community is allowed to exercise authority over decisions. Because the drug, ivermectin is safe, the treatment approach is determined by the community, and the community assumes full responsibility for its organization and execution with minimum medical supervision. This approach requires building true partnership with affected populations and holds promise for sustainability.
Reforms in the health sector should also consider what reforms need to be introduced in education sector to achieve the desired changes in the health sector and improve the quality of care. Patterns of sexual inequality are entrenched in our educational system and tied closely to cultural views about gender roles whereby some tasks are not perceived suitable for boys (Heggenhougen, 1996).
As in the case of health, a holistic and life-span approach to women's education needs to be adopted. Policies framework on women's education and health need be co-structured to compliment each other. To extend this reasoning further, a new framework on female education need to address more specific health issues relevant to group of communities.
The development of appropriate, affordable and gender sensitive programmes on tropical disease care means a shift from the age-long traditional biomedical paradigm. The paradigm shift must be first to broaden the focus of our understanding and to entertain views from women in planning control initiatives. Often, one wonders why research hypothesis should begin with the assumption of the biomedical positions rather than the traditional beliefs since it is the beliefs that determine behaviour.
The cornerstone of national policies on control of malaria and TB, therefore, must be community participation. Community participation in tropical disease health initiatives largely falls on women in their roles as first-line-household health providers and consumers. Successful women development and health projects have all involved women from the outset "in the planning, organization, implementation and expense (time, money and material) of all health activities". (Rugendyke 1991).
The initiation process of health reforms is another important factor deserving careful consideration. Because culture, social and traditional beliefs influence people's ways of life, ideas from the outside (biomedical) must not be imposed on the community or on women. Rather, programmes should be introduced by dialogue. Health policies should be guided by priorityhealth needs determined with input by communities.
Planning approach and policies should be regularly reviewed and modified from setting to setting. Thus, generalization about effectiveness of one approach relative to another are of limited use.
New health policies need to show evidence of the synergy between education and health and should encourage partnership of health and education programmes.
To implement sustainable policies with integrated gender aspects, government expenditures in the sub-region as well as the contribution of the multi- and bilateral agencies need to be allocated to a direct attack on poverty.
New approaches and strategies and establishing partnerships with women as primary providers of health and, the private sector will be important to respond to today's and future challenges from malaria, TB and other emerging tropical infectious diseases.
In the effort to reform the health sector and put in place sustainable systems one must accept given available data that the health sector alone, overburdened with other health problems competing for limited resources, cannot improve the health of populations. Therefore, working together in partnership with communities, ministries of education and finance, women's affairs, agriculture, industries, private sector and with broader strategies will lead to sustainable programmes.
Addressing disparities and inequalities in access to health care by women should be the primary responsibilities of governments in restructuring health services.
For health systems in Africa to benefit from the on-going debate on reform and gender there is the need to understand the relationship among parasitic diseases, parasitic and non-parasitic diseases and disease determinants at different ages and for males and females. At present, health service statistics in many countries do not yield such information and will not do so over time given the uncertainty of available denominator data for comparisons. Policies should emphasize the collection of reliable and consistent data.
In conclusion, globalization poses new challenges from malaria, but also presents opportunities for building partnerships. However, as cautioned by Manderson at al (1996), the challenge for health providers in the sub-region is both political and technical. And alongside any efforts to identify sustainable approaches, re-echoes the proposition by many (Brems and Griffiths, 1993) that the process of identifying women's needs is 'listening to women'.