A Gender Analysis of Access, Use and Management of Bed Nets in Tanzania.

Author(s) Flora Kessy1, Jacqueline Matoro2, Elizeus Kahigwa3, Jacques Mader.
Affiliation(s) 1Dar es Salaam Campus College, Mzumbe University, Dar es Salaam, Tanzania, Swiss Development Cooperation, Swiss Development Cooperation, Dar es Salaam, Tanzania, 3Swiss Development Cooperation, Swiss Development Cooperation, Dar es Salaam, Tanzania, Federal Department of Foreign Affairs, Swiss Development Cooperation, Dar es Salaam, Tanzania.
Country - ies of focus Tanzania
Relevant to the conference tracks Social Determinants and Human Rights
Summary The paper explores the gendered perceptions of the access, use and management of bed nets. It looks at the extent to which the bed net distribution campaigns in Tanzania has taken account of gender issues at both the design and implementation stages. The Tanzania National Voucher Scheme was by design gender unequal because it targeted women over men and was also gender-blind as it ignored gender norms, roles and relations and differences in opportunities and resource allocation between women and men. A more gender transformative approach in social marketing programs is imperative to enable wider coverage and use of bed nets.
Background Malaria control has received major attention and increased resources in recent years due to the significant public health and economic impact of the disease. This has translated into both in national level policies and in local/sub-national government practices. There has also been significant growth of political commitment towards malaria control which has affected national policies. Major efforts have gone into implementing the National Malaria Control Strategic Plan starting with the pilot provision and social marketing of Insecticide Treated Mosquito Nets (ITNs) in 1998 through a subsidized voucher scheme to help expectant mothers access ITNs. This was followed by launching of the Tanzania National Voucher Scheme (TNVS) in 2004, the introduction of the under–five catch up campaign (2008) and most recently (2010) the universal coverage campaign.The TNVS program focused originally on pregnant women and infants—with these categories being the only groups eligible to receive a subsidy on purchase of a mosquito net. Increased availability of resources has facilitated a free bed nets distribution campaign for those under the age of five. Subsequent universal coverage campaigns provided free bed nets to households with the aim of covering every sleeping space.
Objectives The paper sets out to explore the gendered aspects of access and use of ITNs through the different mechanisms for mosquito nets distribution in Tanzania. The objectives of the study were to;
(i) Document the perceptions of men and women towards the TNVS approach.
(ii) Explore the gendered aspects of TNVS that improved/hindered access and use of ITNs.
(iii) Explore whether the change in approach to universal coverage (free distribution of LLINs through the under-five catch-up campaign, and the universal coverage campaign) enhanced the gendered aspects in access and use of mosquito nets.
Methodology The study was conducted in Dodoma Region, central Tanzania. A Multi-stage sampling method was used. First, census Enumeration Areas of Dodoma Municipal, Kondoa, and Mpwapwa districts were selected followed by sampling of wards and then households to be visited. A total of 24 Enumeration Areas were identified (8 from Dodoma Municipal, 11 from Kondoa and 5 from Mpwapwa districts). From these Enumeration Areas a total of 21 wards were sampled. The households were then sampled randomly in order to avoid bias in the results.One of the issues in the line of inquiry was the proportion of households with children below five years of age. The assumption was that if a household had children below five years of age, the women within that household had been exposed to ITN messages and would have obtained ITN (other factors remaining equal). Therefore, in addition to the projected population of the district, the proportion of under-five children (estimated by the National Census Projections at 18.4% in 2010) was used as a basis in the sample size calculation. Based on these criteria, a total of 487 households were sampled and interviewed as follows; 158 from Dodoma Municipal, 110 from Mpwapwa and 219 from Kondoa districts. In order to obtained balanced views both men and women were interviewed. A total of 243 males and 244 females were interviewed.Data from the households were collected using a semi-structured questionnaire that contained both open and closed ended questions. The questions focused on the following main thematic areas; respondents’ demographic information, household awareness, access and ownership of ITNS and the resultant gender aspects therein, the gendered perceptions of the TNVS, the under-five catch up and universal coverage approaches, the gender relations in the use and management of ITNs at the household level, and the economic status of the households.Selected men and women also participated in Focus Group Discussions (FGDs). A total of 11 FGDs (6 for women only and 5 men only) were held with participants ranging from 7-10 members. Thus, a total of 93 individuals participated in the FGDs (52 and 41 males and females respectively). Other respondents in the study were Key Informants (KI) such as Malaria and Integrated Management of Childhood Illnesses Focal Persons, Village and Ward Executive Officers, TNVS agents, and ITN retail shopkeepers.
Results Due to limited resources, TNVS had a risk group/targeted approach and hence the gender inequality was by design. However the existence of gender-blindness was due to a certain degree of oversight of the gendered aspects in planning and implementing TNVS. The approach was gender-blind in several major ways;
1. The approach ignored gender norms, roles and relations. The communication campaigns on awareness of the importance for pregnant women to sleep under ITNs only targeted women without considering the important role men play in decision making about who actually utilizes the nets within the household. Notwithstanding, it also ignored the household sleeping patterns by portraying a woman sleeping with a child in a mosquito net while in many instances the father also shares the bed with the mother and therefore sleepe under the same ITN. However, at the household level, some gender balance in the use of the mosquito nets has been maintained although more women were sleeping under mosquito nets compared to men. Where mosquito nets were in short supply, boys and girls (above 12 years but below 18 years) were the least likely to sleep under a net.
2. The approach ignored differences in opportunities and resource allocation for women and men. Women had to use their savings because men did not pay for their ITNs.
3. The approach considered pregnant women as homogenous group which is not the case. There were destitute group of women who couldn’t redeem their vouchers.Although not by design, the universal coverage campaign could be termed as gender sensitive. This is in the sense that it tried to promote equality of access (regardless of gender) by providing mosquito nets to all members of households based on sleeping spaces not yet covered. Under the program other groups, who were not eligible under the TNVS were to receive nets. Men on the other hand interpreted the universal coverage program as their opportunity to receive nets and more men collected mosquito nets distributed under this program compared to those who went to collect nets from the other two programs on behalf of their spouses.Management of mosquito nets was considered to be in women’s sphere from washing, hanging, re-treating, hanging down and tucking and to make sure that all children slept under bed nets. However, as far as collection and funding is concerned, there is a clear untapped space for men to participate in mosquito net management.
Conclusion The possibility and timing of another round of universal mosquito nets distribution is unclear, yet families keep growing by the day. In order to sustain coverage and use of LLINs, mechanism building on the TNVS should be continued in order to take care of the pregnant women and newborn children. But a more gender transformative approach is needed in social marketing programs for mosquito nets, as well as in the distribution approaches adopted. In the case of social marketing, publicity could focus on messages that illustrate spouses taking part in accessing and managing bed nets as equal partners. Messages that show either spouse taking part in redeeming/purchasing nets, washing, treating, and even hanging down and tucking the net for children to sleep under or messages portraying male involvement in decision-making on the purchase of nets, and tackling stigmas attached to men redeeming bed nets with the voucher on behalf of their wives could be particularly useful and may help address the underlying causes of gender imbalances in the access, use and management of mosquito nets. Specific messages on the benefits of investing in mosquito nets should also be prepared in order to sensitize males who often control financial resources. It is clear that men need space to contribute to the access, use and management of mosquito nets and they can play very important roles if properly sensitized and allowed the space to get involved.In order to enhance acceptance and increased exposure of these messages, the communications should be piloted (e.g. test new messages with women only or men only or mixed group of men and women) in order to ensure a gender sensitive/specific/transformative approach and thus ensure that messages are interpreted as intended.

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