Geneva Health Forum Archive

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Poverty and the Urban Health Challenge in Nigeria.

Author(s) Geoffrey Nwaka1.
Affiliation(s) 1Humanities and Social Sciences, Abia State University, Uturu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Social Determinants and Human Rights
Summary As we consider the post-2015 development agenda, the battle for sustainability in Africa will be won or lost in the cities. The paper considers how poverty and slum conditions in Nigerian cities can best be addressed and reversed.
Background Poverty and slum conditions pose a serious public health challenge to Nigeria’s rapidly expanding urban population. Almost everywhere in these cities environmental amenities lag behind population growth. Some elite neighborhoods enjoy relatively high quality housing and residential environments, but the bulk of the urban poor live in appalling and health threatening conditions. Inadequate housing, sanitation and waste management, and the poor state of public health infrastructure have led to the spread of a wide variety of water-borne and other communicable disease. Nutritional standards are low, and food contamination is common, especially in the extensive street food industry. Indoor pollution from open fires and stoves in poorly ventilated homes is known to be responsible for many respiratory ailments among women and children who are constantly exposed to toxic fumes in the cooking areas. As environmental and health problems overlap, the poor suffer disproportionately from the adverse health effects of environmental problems. Many of the Millennium Development Goals – in health, environmental sustainability, poverty reduction and enhanced international development assistance - will not be met in Africa despite improvements in some areas.
Objectives The paper considers how best to reach the poor, decrease inequalities in access to health services, ways to forestall the growth and spread of slums, and reduce poverty which leads to slum conditions.
Methodology I have drawn from historical material and social science literature. I have also interacted over the years with the urban poor, informal sector workers, and government officials concerned with urban health and development. Many of the insights from the UN sponsored conferences of the 1990s, the Habitat Agenda, ILO's Decent Work Agenda, WHO's Healthy Cities Programme, the work of the Cities Alliance for Cities Without Slums, and some of the more recent ideas from Rio+20, and the various 'Consultations' for the Post-2015 Development Agenda will be brought to bear on the analysis.
Results .The current pattern of government spending on the health sector tends to favor the well off in society who are the main users of curative health services. The central argument is that human development ought to be at the center of the concern for sustainable urbanization in Africa. To achieve this, the paper considers how best to promote the growth of more inclusive and humane cities by reviewing discriminatory laws and codes which tend to inhibit the access of the poor to affordable land, healthcare and housing security.
Conclusion The concluding section stresses the need for appropriate and well targeted urban health and other interventions by state and local authorities, the international development community, private sector and civil society organizations, and the urban poor themselves in a collaborative effort to build safer, healthier and more equitable cities

Integrating Community Participation in Maternal and Newborn Health Services: Burkina Faso

Author(s) Janet Perkins1, Cecilia Capello2, Aminata Bargo3
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Geneva, Switzerland, 3Health Department, Fondation pour le Développement Communautaire/Burkina Faso , Ouagadougou, Burkina Faso.4
Country - ies of focus Burkina Faso
Relevant to the conference tracks Social Determinants and Human Rights
Summary Improving maternal and newborn health (MNH) in regions where women and newborns suffer most requires a rights-based approach which identifies and addresses the broader social determinants of health. In Burkina Faso, we are implementing a health promotion component within the national MNH strategy. A central feature is the institutionalization of community participation in the identification of priority MNH needs as well as the design of interventions. The result is a system in which data related to social determinants of health are collected and used within the health sector. This allows the health sector to participate in addressing these determinants and promotes the rights of community members.
What challenges does your project address and why is it of importance? Despite progress over the past two decades, women and newborns in Burkina Faso continue to face elevated risks related to pregnancy and childbirth. With a maternal mortality ratio of 300/100,000, a woman in Burkina Faso faces a 1 in 55 lifetime risk of death due to maternal causes. Thirty-eight of every 1,000 newborns fail to survive the first month of life. Effectively addressing MNH demands a rights-based approach to health programming that focuses on rooting out inequities and addressing social determinants of health.
Central to a rights-based approach is the promotion of meaningful participation of individuals and communities in the development and implementation of actions designed for their benefit. Participation is both an ends in and of itself, as participation is defined as a right, as well as a means of contributing to a process of empowerment. One of the aims of our program is to integrate participatory processes into health programming. This contributes to assisting the health services in becoming aware of and designing appropriate and tailored interventions to address challenges in MNH, including social determinants, as well as to give a voice to community members and ensure that they are able to participate and are empowered in the process.
How have you addressed these challenges? Do you see a solution? Since 2006, Enfants du Monde, a Swiss NGO, in collaboration with the local NGO Fondation pour le Développement Communautaire/Burkina Faso (FDC/BF), has been supporting Ministry of Health (MoH) in implementing a programme based on the World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH. The IFC framework is designed to form a health promotion component of a broader MNH strategy, as it does in the Burkina Faso national strategy. One of the principal aims is to empower women, men, families and communities to improve MNH. A central component of the empowerment process is institutionalizing participatory processes in health planning.Notably, participatory community assessments (PCA) are conducted at the outset of district-level implementation. These assessments provide a platform for community members, with an emphasis on marginalized groups, to discuss MNH needs in the community and develop tailored interventions. During the PCAs, participants explore the broad array of factors, including social determinants that contribute to poor MNH. The ensuing results of these assessments are planned interventions which are appropriate and specific to the context as well as the initiation of the empowerment of community members as they assume influence in improving the health of their community.While participatory planning processes are not new in health programming, the IFC framework institutionalizes these processes within the broader health system to make community voices systematically represented and to allow for the systematic collection of information related to social determinants of MNH. With the endorsement of the national MoH, actors from within the sub-national MoH have been trained to conduct PCAs in collaboration with other actors working within MNH at the regional and district level. In this position, they have been able to assume the responsibility of listening to the voices of community members and of taking direct action in response to their participation. This process has created a mechanism by which community participation has been integrated within the health sector. This contributes to promoting participation, and thereby rights, of community members, and increases accountability and transparency in the health services. It allows for health inequities and socioeconomic determinants of health to be identified and addressed within the public health sector.
How do you know whether you have made a difference? To date, PCAs have been conducted in seven districts (Tenkodogo, Zabré, Kongoussi, Ouragaye, Barsalogho, and Sindou) over three regions. These assessments have effectively identified challenges related to MNH, many related to rights and socioeconomic determinants, that did not surface through more traditional, non-participatory situation analyses. These include: lack of knowledge of health behaviors during and following pregnancy; lack of awareness of danger signs during and following pregnancy; lack of planning for birth or potential complications; women’s inability to make the decision to seek health services autonomously or use family resources to pay for services due to low socioeconomic status; financial and transportation barriers to reaching health facilities; and lack of satisfaction in interactions with health care providers.
To address these priority concerns, community members, leaders and the health sector worked together to develop interventions. These interventions vary by district, but include health education activities (theatrical performances, culinary demonstrations, radio game shows, etc.), birth preparedness and complication readiness, mobilization of men and the broader community to increase their awareness of MNH rights and needs and enlist their participation in MNH actions, building maternity waiting homes and training health workers to build their capacities to interact with women.Preliminary results to date suggest the success of the processes and interventions. Notably, the IFC interventions have been directly integrated into the MNH action plans of each district. This mechanism has assured the institutionalization of community members’ participation in the planning of activities designed to benefit them. This has not only contributed to the promotion of their rights, but has also provided a way for the health sector to gather data and become involved in addressing the broader determinants of health, including social determinants. Where interventions have been implemented, health care providers have created links for exchanging information with communities. Male partners are accompanying women when receiving MNH services in greater numbers and health information system data has revealed an increase in utilization of MNH services. A current evaluation is assessing the degree to which the activities have contributed to change in MNH knowledge, attitudes and practices in these initial sites of implementation.
Have you or the project mobilized others and if so, who, why and how? We initiated the project based on the assumption that improving MNH cannot effectively be accomplished in a vacuum and requires the mobilization and action of a myriad of actors. As such we have mobilized a variety of agencies and sectors acting at the national, sub-national and district level. This process began with the introduction of the IFC framework at national level. Workshops were held with MoH, Ministry of Education, international organizations and others working on MNH at this level. These workshops were designed to help these actors understand the critical nature of working with and empowering individuals, families and communities and institutionalising mechanisms that allowed them to participate in reaching the goals laid out in the national MNH strategy and ultimately fulfill women’s maternal health rights. Actors from within MoH to be responsible for the IFC component at the national level were identified and their capacities built to lead these efforts.
At the same time, IFC committees, operating under MNH bodies, at sub-national and district level were formed. This structure of IFC committees has created a mechanism allowing for both horizontal and vertical communication. This has reinforced the institutionalization of community participation in MNH as actors at both the national and sub-national levels become aware of the specific needs expressed by community members as well as the social determinants of maternal and newborn health in play at the local level. They are then able to respond with centralized action when necessary and appropriate.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Notably, health care providers have created linkages for working with communities and for the exchange of information. They have contacted and begun working with community leaders, male partners, community health workers and village birth attendants. Through these links, actors in the community have become engaged in encouraging women to attend MNH services. They also transmit information from the health services to the community and gather information on an on-going basis in the community and relaying it back to the health services. This contributes to the realization of rights, including promoting community members’ rights to information and education and through ensuring accountability and transparency. It also provides a mechanism for continued community participation within the health sector.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision. To begin with, the IFC framework and its related interventions have been directly integrated into the national MNH strategy, as the health promotion component and fifth pillar of the national Plan for Reducing Maternal and Newborn Mortality: A Road Map. This has assured that it has never been implemented as a standalone, vertical program. In addition, the component is being implemented directly by MoH, with the support of outside actors, including NGOs and UNFPA. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. Moreover, while the program is still financially supported primarily by exogenous actors (i.e. UNFPA, EdM), MoH understands that this funding will ultimately expire and has identified and begun implementing strategies for resource mobilization internally.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in regional offices. Likewise, FDC/BF is a local NGO, based and operating in Burkina Faso. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country actors prevents an over-reliance on outside actors and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate in identifying their needs and designing methods to address these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is equipped with the capacity to integrate and promote community participation.

Physical Activity Program for People with Severe and Persistent Mental Illness in the Community.

Author(s) Kamden Hoffmann1, Adrienne Walnoha2, Jennifer Sloan3, Praewpannarai Buddadhumaruk 4, Hsin-Hui Huang 5, Jeffrey Borrebach6, Patricia Cluss7, Jessica Burke8
Affiliation(s) 1Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, United States, n/a, Community Human Services , Pittsburgh, United States, 3Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, United States, n/a, UPMC, Pittsburgh, United States, 5Department of Family Medicine, University of Pittsburgh, Pittsburgh, United States, Department of Biostatistics, University of Pittsburgh, Pittsburgh, United States, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, United States, 8Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, United States
Country - ies of focus United States
Relevant to the conference tracks Social Determinants and Human Rights
Summary People with Severe and Persistent Mental Illness (SPMI) are at greater risk of medical issues compared to the general population due to lifestyle issues including cigarette smoking, poor physical fitness and poor nutrition. The purpose of this paper is to describe Community Based Participatory Research (CBPR) methods used to tailor a physical activity program among people with SPMI, demonstrate its impact on participants, the agency and the community, and suggest future research based on lessons learned.
Background Approximately one-fourth of U.S. adults experience a diagnosable mental disorder each year, contributing to 25 years of life lost to disability and premature mortality. SPMI affects 1 in 17 people. Lifestyle issues including cigarette smoking, poor physical fitness, and poor nutrition lead to a greater risk of medical issues among people with SPMI compared to the general population. People with SPMI may experience low satisfaction with life based on poor living conditions, lack of and discontent with social relationships, lack of health services, and unemployment. Physical activity has been shown to have an effect on physical and mental health outcomes among people with SPMI in community settings. More work is required to design and tailor physical activity programs to address these barriers and identify other perceived barriers and benefits to participation. Community Based Participatory Research (CBPR) may be a useful approach in gathering more information to achieve this goal.
Objectives The aims of this paper are to: (1) Describe CBPR methods used to develop a project to address physical activity promotion among people with SPMI; (2) Explore the impact of the physical activity program on participants, the agency and the community and (3) Present implications for future research based on lessons learned.
Methodology Development of the research/community collaboration was through a partnership between the University of Pittsburgh Graduate School of Public Health and Community Human Services (CHS), a local service organization located in a neighborhood in Pittsburgh. CHS serves the greater Pittsburgh area through programs including homeless assistance, mental health, health and wellness and family assistance for those with low levels of socio-economic resources. The two phase CPBR project included 1) formative research used to design the tailored intervention and 2) a pilot of the tailored intervention. Using a pre-post descriptive design, a pilot project was conducted to explore the feasibility in implementing a physical activity program in the CHS setting among clients with SPMI and to gather data about the impact on the physical and mental health of participants. Project participants included men and women who met the following inclusion criteria: satisfying conditions for SPMI as defined in the DSM-IV, age 18 or older, physician’s clearance, and current enrollment in a CHS program. The “On the Move” intervention was designed using feedback from focus groups. It consisted of two 40-minute exercise sessions per week held on site at CHS. To explore the impact of the physical activity program on participants, agency and the community, the team systematically collected daily notes to document the process during implementation and PALS recorded notes and attendance after each exercise session. The university researcher met weekly with staff and bi-monthly with the community and academic team members. The team used an investigator-designed survey combining instruments available in the research literature to measure demographic characteristics, mental and physical health, mood, perceived social support and motivation. Changes in mobility were measured weekly using the Timed Get up and Go Test (TUG). In order to develop lessons learned and areas for improvement of research, an open ended questionnaire adapted from other studies was administered at the end of the intervention. Statistical analyses consisted of descriptive statistics, including means, standard deviations, paired t-tests, and logistic regression modeling. Stata software version 12.0 was used to perform TUG test regression analysis and SPSS version 20.0 was used for pre-post analysis. Descriptive case studies were developed through the analysis of quantitative and qualitative data.
Results Sixteen of forty potentially eligible participants signed consent forms to enter the program. The majority of participants were female (56%) and Non-Hispanic white (46.7%) or Non-Hispanic black (40%). Of the sixteen enrolled participants, five (31%) participated regularly (i.e. approximately half or more of the exercise sessions) and eleven (69%) did not (mean: 5.6; median: 3; range: 17). Reasons for infrequent participation included increased mental health symptom severity, conflict in participation due to official disability status, complex service schedules and exacerbation of medical issues related to obesity. More men than women terminated participation after enrolling (85% vs. 56%, respectively). Although quantitative results from the pre- and post-surveys did not show significance based on the intervention, the survey did show improved trends in mood, social support, and physical and mental health outcomes. Although not statistically significant, the TUG test results showed improved mobility among those that participated regularly. These participants’ TUG scores decreased approximately two seconds when compared pre- and post-intervention. The post-intervention questionnaire provided details about participants’ perceived experience with 'On the Move'. While some participants experienced barriers to participation, feedback shows that the intervention was well received and lead to perceived health improvements. Many of the participants expressed a fitness improvement or a perceived increase in social support regardless of the number of sessions attended. At the agency level, CHS staff involved in the research gained a deeper understanding of the intervention. Consistent team meetings strengthened the effectiveness of the partnership. Regarding program development CHS staff members were enthusiastic about the program, but were also overburdened with the extra work needed to implement it. Some CHS staff were eager to participate in the exercise sessions while others felt disconnected to the program. The community showed interest in participating in the sessions and contacted the university researcher about participation, availability of take-home guides and community resources. When the possibility of a follow on program to On the Move was announced, community members contacted CHS staff to sign up.The tailored exercise sessions were based on the expressed needs of the participants.
Conclusion On the Move was a gender specific, group based exercise intervention developed via intensive collaboration with staff and clients of a community agency serving people with SPMI. It was tailored to fit the perceived exercise benefits, barriers and preferences of people served by the agency. Although similar recruitment methods from other studies were used including word of mouth and staff referral, it was difficult to obtain the desired number of participants. Despite the concerted efforts of CHS and On the Move staff, development of consistent engagement was challenging. Women adhered more regularly to the exercise sessions than men. Even with reminders and announcements, after the fifth week a majority of the men had dropped out. As noted in other studies the high attrition rates could be partly linked to the severity of participants’ diagnoses, adherence to pharmacological treatment, employment, and conflicting schedules. In addition, there are gender differences in recovery patterns and severity of disorders. Anecdotal reports from participants and the small TUG time changes provide some descriptive outcomes which suggest that the On the Move project had a beneficial impact regarding participants’ physical and mental well-being. The design and development of the intervention involved all partners at each stage. CHS staff brought invaluable experience in their knowledge and understanding of the participant population, community setting, and complex social dynamics. The university researchers brought experience in research, implementation, data collection and analysis, and physical activity. This partnership led to participation from some CHS staff during initial recruitment, but motivation to encourage participation from clients remained difficult among other CHS staff. This could be related to the staffs’ own perceived wellness concerns. Individuals who do not value physical activity or have limited physical capacity may not be able to advocate effectively for these types of activities. Developing a worksite wellness program alongside the exercise program for people with SPMI could create a normative atmosphere for wellness. Without the development of a strong partnership, expressed community need and each partners’ expertise, this research might not have been undertaken. Although programs may not adopt the model applied in this research there are important elements that should be considered when adapting a program akin to this.

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.

Enhancing Access and Quality of Care in Developing Countries through Integrated Provider Empowerment and Environmental Safety

Author(s): E. I. Okechukwu*1, A. C. Onyenwenyi2, G. F. Upham3, B. M. Kady4
Affiliation(s): 1Action Family Foundation, 2Institute of Child Health & Primary Care, Lagos, Nigeria, 3Safe Observer Int’l, France, 4Society for Women and AIDS in Africa, Kinshasa, Democratic Republic of the Congo
Keywords: Healthcare, safety, stigma, waste management, provider confidence

The weak healthcare in developing countries engenders chaotic management of medical wastes, thereby exposing care providers and patients to risk of injuries and infections by deadly blood-borne pathogens aside environmental degradation. Millions of women as healthcare personnel, domestic care providers or pregnant mothers and babies on immunization or children at play are primary casualties of unsafe healthcare practices especially improper handling of medicare wastes. In the absence of safety nets among health providers, the fear of contracting infections at the workplace compromises the quality of services rendered to patients especially those infected or affected by HIV/AIDS. WHO estimates that in developing countries, over 60% of injections are unsafe, and 10% of the global workforce are at risk of needle stick injuries capable of transmitting blood-borne pathogens. A survey of five West African countries (including Nigeria) revealed that public containers meant for household refuse receive more than 50% of medical wastes. There are anarchical practices at the collection, sorting and stocking, transport and elimination phases.


In 2005, Action Family Foundation, civil society groups, Safe Observer International and academics from the Institute of Child Health and Primary Care of the Lagos University Teaching Hospital initiated interventions to mainstream proper healthcare waste management in Nigeria through capacity building, community mobilization and practical medical waste handling services. We developed survey instruments and obtained baseline data on the knowledge, attitude and practices of stakeholders; co-hosted with the state agency two annual medical waste management summits and raised community awareness to the hazards of unsafe medicare waste practices as well as organized sensitization sessions for different professional groups. We are engaging in the project as an intervention research work to build the local capacity, conduct research and generate data to inform scaling up and replication to other regions.


Presently, about 15% of the over 3000 healthcare facilities are being covered. Generators are sorting waste at source, and are expected to budget for waste disposal while the government Waste Management Authority supplies consumables and carts waste regularly. The public is more aware and empowered, including holding their care providers accountable for medicare waste.

Lessons learned:

The advocacy and community mobilization expertise of civil society groups when matched with political will of public service organs can reconstruct people’s attitudes and enforce desired practices with modest investments. Our initiative brought together patients, practitioners, consumer groups along with persons living with, or affected by nasocomial pathogens. The presentation will draw on work in process in Nigeria, Uganda, India and globally. We shall share the locally applied strategies, challenges and success stories of Action Family Foundation’s pioneering work in mainstreaming integrated medical waste management.

Why Taking into Account Social Determinants is Essential to Reach a Successful Global Health Policy? An Example from the HIV-Care Sector in Burundi


J. Cailhol*1, T. Nahimana2, L. Munyana2, H. Ntakarutimana2, F. Musanabana3, D. Diack4, M. Dubreuil4, C. Arvieux5, O. Bouchaud1, T. Niyongabo2

Affiliation(s): 1Infectious and Tropical Diseases, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France, 2HIV-care centre, University Hospital of Bujumbura, 3HIV-care centre, Prince Régent Hospital, Bujumbura, Burundi, 4Project Department, ESTHER, Paris, 5Infectious and Tropical Diseases, University Hospital of Rennes, Rennes, France
Keywords: Social determinants; HIV-care; global health policy; international funding

Health policy usually targets epidemiologically defined population in a specific intervention programme. However, the sectorisation of health problems and the development of health policies, missing ‘surrounding’ socio-economic determinants, may result in inequitable long term results.


In Burundi, the HIV sector is mainly financed by international funding (IF), including the Global Fund (GF). By this way, HIV-infected people can have access to care, antiretrovirals and opportunistic infections medications free of charge. IF can also contribute to major the HIV-healthcare professionals (HCP) salary. Indeed, because of extremely low incomes, public sector HCP move frequently through the country or migrate towards foreign countries, attracted by higher salaries and better working environment. In Burundi, there are now less than 250 physicians left. Through three examples, we will attempt to demonstrate that health policies should consider social determinants.


Example 1: Burundi is one of the poorest countries in the world (more than 70% of the inhabitants earn less than 1 dollar per day): as a result, few people can afford a medical insurance. Apart from HIV-infection, in case of any disease, patients either pay by themselves, almost always helped by their community or remain without any medication. In governmental hospitals, physicians are aware that some common medications such as amoxicillin or cotrimoxazole are available through the GF and use these GF-drugs without regard to HIV status. This behaviour cannot be condemned as physicians cannot leave a patient without medication only because he is not HIV-infected. However, these medications are becoming out-of-stock quickly, and it is impossible to produce accurate estimations of the need in opportunistic infections medications. After all, who will be blamed by the GF for this misuse of a specifically HIV-dedicated funding?
Example 2: HIV-patients must be highly adherent to their medication to be successfully treated. Many patients, who are fully aware of the importance of the treatment for their own health, are forced to interrupt their treatment because they cannot afford daily food. A quick overview of temporary lost of follow-up patients revealed that most of them did not have any money for the monthly transportation costs to their care-centre. On the same way, sustained adherence to HIV prevention cannot be expected if poverty does not allow inhabitants a prospective sight. Indeed, why would they care for their tomorrow’s health if today they don’t have enough food for themselves or their family?
Example 3: Due to better funding in the HIV-sector, deleterious consequences can be expected for the general population and for HIV-patients as well. First, many physicians, even though scarce, are concentrated in the HIV sector, dropping other priority sectors (paediatrics, diabetes mellitus…). Among HIV-sector, well-trained physicians leave the public care sector to join up with international agencies (particularly the WHO and UNAIDS) and also NGOs. Sometimes, pair-educators earn better salaries than nurses or even physicians, leading to a demotivation and conflicts between HCP.

Lessons learned:

Lessons learned in the expanding access to HIV-care in Burundi, i.e. IF repartition and organisation of prevention and HIV-care may be applied to other sectors, leading to a global health policy. Health determinants are linked together and merged into social determinants. Ideally health policies should consider the whole population and its social determinants, instead of focusing on one particular group of diseased people. In concrete terms, for instance, using part of IF dedicated for example to TB, HIV and malaria (GF) to provide HCP viable salaries and medications for other sectors would probably result in a significant improvement of global health.

Crossroads of Inequality: Health of Elderly Populations and Access to Healthcare

Author(s): N. Chikhladze*1, N. Pitskhelauri2
Affiliation(s): 1Faculty of Medicine, Department of Public Health, 2Faculty of Medicine, Tbilisi State University, Georgia
Keywords: Inequality, access to healthcare, ageing

Increase of the elderly people number brings a sharp question of the main recourse. The mentioned situation creates serious problems for the society, because expenses, allocated for healthcare and social protection of the contingent is a hard burden to the country’s economy. The consequences of the economical crisis in Georgia have the most serious impact on persons over 60.


We have studies basic tendency of Georgian Population’s general structure, peculiarity of structure by sex and age, what determine demands of healthcare, trends of core health indicators, accessibility to healthcare.


In 1989 the Georgian population was at the medium level of demographic ageing (14.4%), during a very small period (5 years), in particular, in 1994 the index has reached level of ageing in developed countries (16.2%). From 2000 the very high level of ageing (18.4%) was evident and continuous to increase up till now. An absolute number of long livers goes up, their share in the population’s general structure is still high, and these tendencies are still the most prominent in indigenous Georgian population. In 1970-2006 population under 15 years was decreased by 1/3, from 31% to 21.5%, and share of the elderly population (65 and over) increased from 8% to 13%. Geriatric practice in older population increase risk of morbidity and polypathology. For the life of older population healthcare issues are very important. Interesting tendency is in the process of study of sex structure of 60-year and over age group. In 2006 this age group was constituted of women for 60%, 40% - men. With increase of the age interval, women’s share also increases. If in 60-64 year age group men were 43,21%, women 56,9%, in 100-year and over age group men were only 11,2%, women – 88,8%.
While the expenses on the social needs sharply shortened, the change of the ‘Soviet’ model of healthcare, which provided the population with free medical service for tens of years, took place. The new model of the healthcare payment was at first unacceptable both psychologically and economically. Persons over 60 have no means to buy neither expensive, nor cheap medicines, as well as different aid apparatus (hearing aid, glasses and other), it is absolutely inaccessible to purchase for them. Also it is inaccessible to get high quality out-patient and in-patient medical services.

Lessons learned:

Concerning the Caucasus long livers phenomena, Georgia even in the beginning of XXI century is the hearth of traditionally long liver population and reserves one of the leading places in the world twenty of long livers populations. This fact in spite of the difficult economic and social situation of transition period needs in-depth study-complex research of the Georgian long livers contingent, taking into account medical (especially Mental Health-Mild/Vascular Cognitive Impairment), social, economic, and psychological factor of their life.
It is necessary to carry out special measures to overcome poverty and eradicate extreme indigence through- out the country in the following directions: improvement of health policy and the system of access to healthcare for population under 60, reform of social security and the system of social assistance.

The Unrecognized Groups: Lesbian, Bisexual, Gay, and Transgender in Nepal

Author(s): S. L. a. l. Acharya1
Affiliation(s): 1National Association of People Living with HIV and AIDS in Nepal, Kathmandu, Nepal
Keywords: Sexual minorities, high privilege of HIV/AIDS, stigma and discrimination from society

All human beings are born free and equal in dignity and rights. This first sentence of Universal Declaration of Human Rights, adopted almost sixty years ago by the General Assembly of the United Nations, is an important for the lesbians, gays, bisexuals, transgender, PLWHA, and minorities. The world has gradually accepted that human beings have different sexes, racial or ethnic origins that differences must be respected and not be used as reasons for discrimination. But my country still does not accept two other aspects of human diversity.


To find the real situation of sexual minorities in Nepal, white feather Nepal - a community-based organization of sexual minorities - has conducted a study at Kathmandu in June 2007 among 257 MSM/MSW members regarding their situations in terms of their fundamental human rights. It focused on how mainstream society is treating them, while accessing to health service, education, and legal rights and persuading jobs after knowing their sexuality. The survey was purely qualitative, the method was group discussion.


In the study, 178 were transgender MSW, 79 were MSM. Where 117 were PLHA, 136 had at least one STI. 96 were restricted from school due to their sexuality. All the respondents were stay out of the family. 90% of MSW and transgender reveal that they refused to give basic treatments at health centres. Doctors believes every MSM and MSW possess HIV with out investigating. 68.2 transgender MSW reported they refused to give citizenship due to their feminine get up and forced them to come with masculine get up and name. 67.9 reported they were shack out from the school, 92.8 reported they are facing trouble to rent apartment, 99% reported even their skills and qualification, they are refused to offer job at public and private section.

Lessons learned:

The study reveals that though we talk about equality and fundamental rights of individuals, there are big groups who are struggling for their identities. It is vain to talk about fundamental rights until we recognized them. Thousands of minorities are thrown at street and compel to sell their body and practicing unsafe sex, using drugs, are rapidly infecting day by day from STI and HIV .

Vulnerable Populations and Inequalities in Health: The Case of Marginalized Women with Substance Abuse Problems

Author(s): M. P. Romero1
Affiliation(s): 1Researcher on medical sciences E. Direction of epidemiological and psychosocial research, National Institute of Psychiatry, Mexico city, Mexico

Vulnerable population, women, substance abuse, equity

Background: Interest in health inequalities has grown in recent years. The World Health Organization (WHO) defines them as health variations that are unnecessary, avoidable and unfair (Whitehead M, Dahall G, 2007). These inequalities are also gendered. Gender is a concept that incorporates the social factors associated with men and women’s different patterns of socialization, which in turn has to do with family roles, work expectations, types of occupation and social culture which also affect the process of health and illness. In this work we use the concept of gender quoting Ettore (2002): ‘gender is a process and an institution…As a process, gender is a part of all human interactions. Gender shapes the meaning of “female” and “male” and “masculinity” and “femininity” on cultural, political and economical levels. As an institution, gender is a part of culture just like other components of culture such as symbols, language, mores, norms, values and so on. Gender is a “stable” form of structured inequality and it is embedded in culture’ (p. 329). When women experience the damaging effects of gender whether as a social process or an institution, women are at a greater disadvantage because ‘masculinist’ (male privileging) more than gender-sensitive structures and paternalistic epistemologies predominate. In addition to gender inequalities, there are also social and economic inequalities that give rise to marginalized groups. Therefore, for vulnerable populations, ensuring healthcare coverage an access to good-quality, appropriate public and private sector services is an ongoing a challenging proposition (Ferguson 2007). Type of study: A non-experimental, descriptive, ex-post facto cross sectional study was undertaken in two women’s prison in Mexico city. A non probabilistic sample of 213 women was selected, with the following inclusion criteria: current or sometime consumers of alcohol, tobacco and drugs, aged between 18 and 65 who can read and write.

The aim of this paper is to discuss from the theoretical framework of gender perspective and vulnerable population’s literature, the burden of disease of substance abuse in vulnerable women, specifically data from a research with minor delinquents and women in prison.


Among the interviewed women 14.6% have lived in a shelter or NGO before the prison and 39.5% have lived in the street. The third part (30.5%) ran away from home at least once while being children and 21.6% live with persons different from their parents. On the day they committed the offence 41.8% were under the effects of drugs and 18.8% on alcohol. Among the drugs they used while or before committing the crime, 26.85 % had used cocaine. The most commonly reported crime among the interviewees was theft (51.6%) in different forms (non-specific/simple, qualified, aggravated, non-specified, burglary) followed by drug related offences (possession, traffic) 23.5 % and the third crime was homicide (8.5%). According to their response 43.7% reported having been in a correctional facility before.

Lessons learned:

Prison is an environment with special difficulty in the promotion of health. At the individual level, prison takes away autonomy and may inhibit or damage self-esteem. Common problems include bullying, mobbing and boredom, and social exclusion on discharge may be worsened as family ties are stressed by separation. However, imprisonment is also a unique opportunity for all aspects of health promotion, health education and disease prevention. Vulnerable groups as the women in prison and minor offenders are disadvantaged groups who would normally be hard to reach. It is the prison, therefore a prime opportunity to address inequality in health by means of specific health interventions as well as measures that influence the wider determinants of health (Haton P., 2007).