Integrating Poverty and Gender into Health Programmes A Sourcebook for Health Professionals
Module on Malaria
World Health Organization Western Pacific Region
Integrating Poverty and Gender into Health Programmes A Sourcebook for Health Professionals
Module on Malaria
World Health Organization Western Pacific Region
www.wpro.who.int
Photograph credits: pp. 1, © 2005 Eric Thompson, Courtesy of Photoshare; pp. 3, 26, International Labour Organization/Deloche P.; pp. 38, FAO/19863/G. Bizzarri; pp. 44, © 2000 Liz Gilbert/David and Lucile Packard Foundation, Courtesy of Photoshare; cover, pp. 8, 29, WHO/WPRO. WHO Library Cataloguing in Publication Data Integrating poverty and gender into health programmes: a sourcebook for health professionals: module on malaria. 1. Poverty. 2. Gender. 3. Malaria - epidemiology. 4. Malaria - prevention and control. 5. Socioeconomic factors. 6. Health programmes. I. World Health Organization. Regional Office for the Western Pacific. ISBN 92 9061 214 2 © World Health Organization 2006 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them whether for sale or for noncommercial distribution should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int. (NLM Classification: WA 30 )
Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
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CONTENTS ACKNOWLEDGEMENTS ......................................................................................................iv ABBREVIATIONS ....................................................................................................................v PREFACE..................................................................................................................................vi INTRODUCTION.....................................................................................................................1 1. What is malaria?......................................................................................................................3 Epidemiology of malaria......................................................................................................................4 Overview of burden of disease ..........................................................................................................6 2. What are the links between poverty, gender and malaria? .....................................................8 Defining poverty ...................................................................................................................................9 The effect of poverty on malaria........................................................................................................9 Inequalities in incidence.......................................................................................................................9 Inequalities in exposure ....................................................................................................................10 Inequalities in access to prevention and treatment for malaria ............................................................14 The effect of malaria on poverty .....................................................................................................19 What is the relationship between gender and malaria? .................................................................21 Gender-related exposure to malaria...................................................................................................21 Gender-related inequalities in access to prevention and treatment........................................................22 Sex differences in the effects of malaria: a focus on pregnancy ............................................................24 3. Why should health professionals address poverty and gender in malaria control? .............26 Efficiency .............................................................................................................................................27 Equity ....................................................................................................................................................27 Human rights .......................................................................................................................................27 4. How can health professionals address poverty and gender concerns in malaria control ? ........................................................................................................................29 Integrate malaria into the poverty reduction agenda .....................................................................30 Integrate poverty and gender into malaria prevention and control ............................................31 Reduce geographic barriers ................................................................................................................32 Reduce economic barriers ...................................................................................................................33 Improve information and communication to stimulate demand ...........................................................35 Improve health system responsiveness .................................................................................................36 In monitoring and evaluation, disaggregate the collection and analysis of information .........................37 5. Facilitator's notes..................................................................................................................38 Expected learning outcomes .............................................................................................................39 Suggestions for workshop sessions on poverty, gender and malaria .........................................39
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
Session 1: Gathering and analysing information about malaria in your areaSession 2: Involving the community in information gathering .................................................................................................39 Session 2: Involving the community in information gathering..............................................................40 Session 3: Who else can health professionals work with to address the poverty and gender aspects of malaria recognition, prevention and control? .....................................................................................43 Session 4: Wrapping up ...................................................................................................................43 6. Tools, resources and references ............................................................................................44 Malaria resources ................................................................................................................................45 Malaria, poverty and gender resources ...........................................................................................45 Planning checklists ..............................................................................................................................45 General considerations ......................................................................................................................45 Exposure to mosquitos .....................................................................................................................46 Prevention of malaria .....................................................................................................................46 Treatment for malaria ......................................................................................................................47 References ............................................................................................................................................49 Endnotes ...................................................................................................................................58
BOXES Box 1: Box 2: Box 3: Box 4: Box 5: Box 6: Box 7: Box 8: Box 9: Box 10: Box 11: Box 12: Box 13: Box 14: Box 15: Box 16: Migration and the spread of P. falciparum................................................................................ 13 Access to health services among migrants................................................................................ 15 Treatment seeking for children with malaria.............................................................................23 Gender, development and malaria............................................................................................. 24 Malaria prevention and control and the right to health............................................................28 BHWs improve access to malaria diagnosis and treatment in Agusan del Sur, the Philippines..............................................................................................................................32 Extending accurate and prompt malaria diagnosis into hard-to-reach communities...........33 Reaching the poor with ITNs in Tanzania.................................................................................34 Experience with revolving funds in Lao People's Democratic Republic...............................35 Reaching ethnic minorities with appropriate and effective IEC............................................. 36 Bringing private practitioners into the National Malaria Control Programme in Cambodia................................................................................................................................. 37 Group work questions to describe the local malaria situation................................................ 40 People's knowledge, beliefs, attitudes and practices about malaria........................................ 42 Checklist of people's understanding about malaria................................................................. 46 Checklist of factors affecting community payment for bednets............................................ 47 Checklist for integrating gender analysis into malaria programmes.......................................48
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
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FIGURES Figure 1: Figure 2: Figure 3a: Figure 3b: Figure 4a: Figure 4b: Figure 5: Figure 6a: Figure 6b: Figure 7a: Figure 7b: Life-cycle of Plasmodium................................................................................................................5 Global distribution of malaria cases............................................................................................ 5 Standardized rates of reported malaria cases in malaria-endemic countries in the Region (1990-2003)....................................................................................................................... 6 Deaths from malaria in malaria-endemic countries in the Region (1990-2003)......................6 Confirmed malaria cases per 1000 in the endemic countries in East Asia................... Confirmed malaria cases per 1000 in the endemic countries in the Pacific....................... 10 10
Incidence of poverty in Kon Tum Province, Viet Nam.......................................................... 11 Proportion of ethnic minority populations by province in Viet Nam................................... 12 Proportion of ethnic minority populations by province in Lao People's Democratic Republic........................................................................................................................................12 Median net and ITN possession (as % of households) or usage (as % of children under 5 years old) in selected Asian countries by urban and rural division............................ 14 Median net and ITN possession (as % of households) or usage (as % of children under 5 years old) in selected Asian countries for the 20% poorest and 20% least poor households.......................................................................................................................... 14 Literacy rates for ethnic minorities compared to total population, selected countries.........17 Percentage of male and female malaria cases reported, selected countries in the Region, 2003.................................................................................................................................21 Who decides how married women spend their own income in Viet Nam (% of women respondents)...................................................................................................................23 Women receiving delivery assistance from a doctor or nurse/midwife in Cambodia, the Philippines and Viet Nam (%)..............................................................................................25
Figure 8: Figure 9: Figure 10: Figure 11:
TABLE Table 1: Selected species of Anopheles mosquitos in the Region...........................................................4
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
ACKNOWLEDGEMENTS This module is one of a complete set entitled Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals. It was prepared by a team comprising Sarah Coll-Black, consultant and principal writer; Anjana Bhushan, Technical Officer, Poverty, Gender and Human Rights; and Kathleen Fritsch, Regional Adviser in Nursing, World Health Organization Regional Office for the Western Pacific, based on preliminary work by Peter Kunstadter and Rita Gebert. David Bell, Eva Christophel, Pernille Jøergensen and Kevin Palmer provided thoughtful comments and helpful inputs. Marc R. Crowe edited the module. Design and layout were done by Zando Escultura.
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ABBREVIATIONS ADB AIDS BHW CMH DALY DFID GDP GFATM GNI HDI HIS HMN IEC ITN LBW MDG NGO NMCP PRSP RBM RDT RHU SMCC UN UNICEF UNDP WHO Asian Development Bank Acquired immunodeficiency syndrome Barangay health workers Commission on Macroeconomics and Health Disability-adjusted life year Department for International Development of the United Kingdom Gross domestic product Global Fund to Fight AIDS, Tuberculosis and Malaria Gross national income Human Development Index Health information systems Health Metrics Network Information, education and communication Insecticide-treated net Low birth weight Millennium Development Goal Nongovernmental organization National Malaria Control Programme Poverty Reduction Strategy Paper Roll Back Malaria Rapid diagnostic tests Rural health unit Society for Malaria Control in Cambodia United Nations United Nations Children's Fund United Nations Development Programme World Health Organization
Note: In this publication, $ means US dollar.
Abbreviations
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
PREFACE Over the past two to three decades, our understanding of poverty has broadened from a narrow focus on income and consumption to a multidimensional notion of education, health, social and political participation, personal security and freedom, and environmental quality.1 Thus, poverty encompasses not just low income, but lack of access to services, resources and skills; vulnerability; insecurity; and voicelessness and powerlessness. Multidimensional poverty is a determinant of health risks, healthseeking behaviour, health care access and health outcomes. As analyses of health outcomes become more refined, it is increasingly apparent that the impressive gains in health in recent decades are distributed unevenly. Aggregate indicators, whether at the global, regional or national level, often mask striking variations in health outcomes between men and women and rich and poor, and across and within countries. An estimated 70% of the world's poor are women.2 Similarly, in the Western Pacific Region, poverty often wears a woman's face. Indicators of human poverty, including health indicators, often reflect severe gender-based disparities. In this way, gender inequality is a significant determinant of health outcomes in the Region, with women and girls often at a severe societal disadvantage. Although poverty and gender significantly influence health and socioeconomic development, health professionals are not always adequately prepared to address such issues in their work. This publication aims to improve the awareness, knowledge and skills of health professionals in the Region on poverty and gender concerns. The modules that comprise this Sourcebook are intended for use in pre-service and in-service training of health professionals. This publication is expected to be of use to health policy-makers and programme managers as a reference document, or in conjunction with in-service training. All modules in the series are linked, though each one can be used on a stand-alone basis if required. Two foundational modules establish the conceptual framework for the analysis of poverty and gender issues in health. Each of the other modules is intended for use in conjunction with these two foundational modules. The Sourcebook also contains a module on curricular integration to support health professional educational institutions integrate poverty and gender concerns into existing curricula. All modules in the Sourcebook are designed for use through participatory learning methods that involve the learner, taking advantage of his or her experience and knowledge. Each module contains facilitators' notes and suggested exercises to assist in this process. It is hoped that the Sourcebook will prove useful in bringing greater attention to poverty and gender concerns in the design, implementation and monitoring and evaluation of health policies, programmes and interventions.
Module on Malaria
Introduction
Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals Module on Malaria
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
Introduction alaria remains a global public health problem. Approximately 40% of the world's population lives in more than 140 countries at risk for malaria. In the Western Pacific Region, malaria is endemic in 10 countries. The incidence rate in the Region ranges from 161.7 per 1000 people in Solomon Islands to 0.04 in the Republic of Korea. The strategies employed to prevent and control malaria have been effective in reducing the burden of disease in countries in the Region. Yet, as analyses of health outcomes become more refined, it is increasingly apparent that poor and marginalized populations in the Region might not be benefiting from investments in malaria prevention and control. The challenge for health care professionals is to ensure that effective malaria prevention and control initiatives reach poor and marginalized populations in the Region. This module is designed to improve the awareness, knowledge and skills of health providers regarding
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poverty and gender concerns in malaria prevention and control. It is divided into six sections: ! Section 1 defines malaria, its transmission and symptoms, the malaria vector, and its distribution. ! Section 2 examines WHAT the links are between poverty, gender and malaria. ! Section 3 discusses WHY it is important for health professionals to address poverty and gender concerns in malaria control programmes from efficiency, equity and human rights perspectives. ! Section 4 discusses HOW health professionals and malaria prevention and control programmes can address poverty and gender concerns in malaria prevention and control. Examples of good practice are presented to illustrate potential interventions. ! Section 5 provides notes for facilitators. ! Section 6 is a collection of tools, resources and references to support health professionals in their work in this field.
Module on Malaria
1. What is malaria?
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
1. What is malaria? Epidemiology of malaria alaria is caused by an infection with a onecell parasite of the genus Plasmodium.3 Malaria in humans results from an infection with one of four Plasmodium (hereafter referred to as P.): P. vivax, P. ovale, P. malariae and the potentially fatal P. falciparum.4 P. falciparum is the predominant form of malaria infection in the Western Pacific Region , except for areas in China north of 23 degrees N, the Republic of Korea and the highland areas of Papua New Guinea.5 Only P. vivax has been reported in the Republic of Korea.6 In several areas throughout the Region, the malaria parasite—especially P. falciparum —has become resistant to chloroquine and other commonly available antimalarial drugs. The malaria parasite is transmitted to humans through the bite of an infected female Anopheles mosquito, of which there are many different species. The female Anopheles mosquito picks up the parasite when she bites an infected human for the blood she needs to nurture her fertilized eggs (see
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Table 1: Selected species of Anopheles mosquitos in the Region Vector An. dirus Location Forested and hilly areas Forest Breeding Biting Exophagic Resting Exophilic Countries China, Lao People's, Democratic Republic, Malaysia, Viet Nam Endophilic Cambodia, Malaysia, Philippines, Viet Nam
An. minimus
An. sundaicus
Coastal areas
An. sinensis An. maculatus
Hilly areas
An. balabacensis An. farauti complex
Forest Coastal areas
An. punctulatus complex An. koliensis An. flavirostris
An. litoralis
Highland streams and inland areas Coastal and inland areas Forested foothills and mountains Coastal areas
An. leucosphyrus
Freshwater
Endophilic Cambodia, Malaysia Viet Nam, southern coastal areas Republic of Korea Exophilic Malaysia, Philippines, Shallow, relatively Exo- and Southern China, still water exposed endophagic Viet Nam to sun light Malaysia, Philippines Early biting hours Exophilic Shallow pools Exophagic Papua New Guinea, Fresh water and Partially exophilic Exo- and brackish water and Early biting hours endophilic Solomon Islands, Vanuatu tolerates salinity Highly anthropophilic 17-25 parts per thousand Papua New Guinea, Fresh water Solomon Islands, Vanuatu Papua New Guinea, Solomon Islands Philippines Partially endophilic, Exophilic Shaded clear fresh water, slow- prefers buffaloes to flowing streams humans Brackish water Endophilic Malaysia, Philippines (southern islands only) with salinity of 17-20 parts per thousand Malaysia
Endophagic Along grassy streams in clear, unpolluted water Brackish water, Exo- and lagoons, marshes endophagic
Note: Complex refers to sibling species Sources: Bruce-Chwatt LJ. 1980; and personal communication with Dr. Raman Velayudhan.
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Figure 1: Life-cycle of Plasmodium Parasites multiply in human liver and bloodstream causing fever and chills
Infected mosquito bites human
Human
Malaria symptoms usually appear 9-14 days after an infection, although this can vary with different species of Plasmodium. Fever, headaches, chills and vomiting are the most common symptoms. Without treatment, falciparum malaria can kill by infecting and destroying red blood cells, and by clogging the capillaries that carry blood to the brain and other vital organs.7 In areas of high malaria transmission (stable transmission areas), such as Papua New Guinea, Solomon Islands and Vanuatu, repeated malaria infections provide inhabitants with partial immunity. In contrast, unstable malaria areas are characterized by outbreaks and irregular epidemics among people with low immunity.8 In stable and unstable areas, pregnant women and children under 5 years old are at greatest risk of the most severe clinical symptoms of malaria. This is because a woman's immunity is temporarily depressed during pregnancy, while the immune system of small children is not developed fully. Antibodies from their mothers might protect infants during the first 6 months of life.
Mosquito bites infected human
Mosquito
Parasites multiply in mosquito gut and migrate to salivary glands Source: Adapted from Roll Back Malaria's What is Malaria?
Figure 1 for an overview of the life-cycle of the Plasmodium). Malaria can also be transmitted through a blood transfusion. Inside the human host, the parasite transforms through its complex life-cycle in the liver and red blood cells, and uses various mechanisms to avoid the host's immune system.
Figure 2: Global distribution of malaria cases
Areas where malaria transmission occurs
Areas with limited risk
No malaria
This map is a visual aid only, it is not a definitive source of information about malaria endemicity. Source: World Health Organization 2005c.
What is malaria?
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
Knowledge of the behaviour of mosquitos has long been recognized as a key factor in ensuring the success of malaria control programmes. Different species of Anopheles mosquito exhibit varying feeding, breeding and resting patterns. Different species breed in a great variety of water sites, from temporary puddles in human footprints to permanent streams and marshes. Female Anopheles mosquitos bite almost exclusively between dusk and dawn, although some species might feed during the day in densely covered forests.9 Some species feed mainly outdoors (exophagic), while others feed inside houses (endophagic). Similarly, some species tend to rest outdoors (exophilic) and other rest indoors (endophilic). Table 1 describes some of the different vectors found in the Region.
estimated 350-500 million acute malaria cases occur annually, killing 1.5-2 million people—with 90% of the deaths in sub-Saharan Africa. Worldwide, the combined morbidity and mortality from malaria was estimated to be 45 million disability-adjusted life years (DALYs)11 in 2000. This accounts for roughly 11% of DALYs lost to all communicable diseases.12 Malaria is endemic in 10 countries in the Western Pacific Region. These are: China, Cambodia, the Lao People's Democratic Republic, the Republic of Korea, Malaysia, Papua New Guinea, the Philippines, Solomon Islands, Vanuatu and Viet Nam. The Region has reduced malaria-related mortality and morbidity significantly. In 2003, approximately 400,000 malaria cases were confirmed in the Region, which translates into an incidence rate of reported and confirmed malaria cases of 0.25 per 1000 people. Yet, among countries in the Region, the incidence rate ranges from a high of 161.7 in the Solomon Islands to a low of 0.04 in the Republic of Korea. Figures 3a and 3b present the standardized rates of reported malaria cases and deaths in malaria-endemic countries in the Western Pacific from 1990 to 2003. The epidemiology of malaria in the Region ranges from high endemic transmission in the Figure 3b: Deaths from malaria in malaria-endemic countries in the Region (1990-2003) Cases per 1000 persons per year 100 10 1 0.1 0.01 1990 1992 1994 1996 1998 2000 2002 2004 Solomon Islands Vanuatu (No trend line due to small population)
Overview of burden of disease Malaria remains a global public health problem. Approximately 3.2 billion people (about 40% of the global population) in more than 140 countries are at risk of contracting malaria (Figure 2).10 An Figure 3a: Standardized rates of reported malaria cases in malaria-endemic countries in the Region (1990-2003) 1000 Cases per 1000 persons per year 100 10 1 0.1 0.01 0.001 0.001 1990
1992
1994 1996
1998
2000
2002 2003
Solomon Islands Vanuatu Papua New Guinea Lao PDR Cambodia Malaysia
Philippines Viet Nam China Republic of Korea Regional Average
Papua New Guinea Lao PDR
Cambodia Malaysia Philippines Viet Nam Regional Average
Source: World Health Organization and United Nations Children's Fund 2005.
Source: World Health Organization and United Nations Children's Fund 2005.
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Pacific to "pockets" of epidemic transmission at high latitudes. In East Asia, these pockets generally are found in remote hilly and forested areas, and are thus termed "forest malaria." Further, no cases of malaria have been reported in urban areas of the endemic countries in the Asian
areas of the Region. This pattern has been attributed to the high levels of pollution in urban areas. In contrast, malaria is found in urban areas of Papua New Guinea, Solomon Islands and Vanuatu, where the vector lives in a wider range of habitats.
What is malaria?
2. What are the links between poverty, gender and malaria?
Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals Module on Malaria
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2. What are the links between poverty, gender and malaria? hile malaria is not exclusively a disease of the poor, the deprivation associated with poverty can increase the risk of malaria. The relationship between malaria and poverty plays out along a number of distinct, yet interrelated, pathways. Poor and marginalized communities might be more likely to suffer from malaria than non-poor communities, because their geography and environment are more hospitable to mosquitos than areas inhabited by non-poor communities. Poverty also might reduce the likelihood that households will adopt appropriate preventive measures (such as sleeping under an insecticidetreated net [ITN]) and curative measures (seeking timely health care for fevers). This can result in greater malarial morbidity and mortality among the poor than the non-poor. Conversely, malaria might impoverish poor households further through the costs of preventive and curative measures, as well as the inability to work while ill. Importantly, because gender and poverty interact to produce unique disadvantages among poor women, gender is considered separately in the discussion that follows. In the sections below, the interrelationship between poverty and malaria is discussed first. After reviewing how some aspects of poverty might increase the exposure of poor households to malaria, poverty-related barriers to prevention and treatment for malaria are discussed. This is followed by a review of how gender might influence exposure to malaria and access to prevention and treatment for malaria. This section begins with an overview of available data on reported malaria cases disaggregated by sex. Although more malaria cases are reported among men than women in general, some evidence suggests that this might be because of the barriers women may face when seeking to access prevention and treatment for malaria.
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education and health outcomes, access to services, and resources and skills. This definition also covers additional aspects, such as voicelessness, vulnerability and powerlessness to influence decisions that affect their lives. In the Pacific, for example, income or consumption poverty tends to be low or nonexistent. Yet, households in the Pacific can be vulnerable to natural disasters; be isolated or remote; lack economic choices (or opportunities to earn a cash income); have limited access to educational, health and financial services; and suffer from social exclusion.13 For more information on how poverty is conceptualized and measured, please refer to the foundational module on health and poverty in this series. Members of the same household tend to experience poverty differently, depending on factors such as gender, age and marital status. Women tend to be particularly disadvantaged. The United Nations Development Programme (UNDP) estimates that 70% of the world's poor are women.14 In addition, women lag behind men in almost every social and economic indicator of well-being.15
The effect of poverty on malaria Inequalities in incidence
Defining poverty Poverty is increasingly considered multidimensional. This definition of poverty moves beyond the narrow association of poverty with low income and consumption. Instead, poverty is understood to encompass other forms of deprivation, including economic opportunities,
Malaria is increasingly understood to be a disease of the poor. An estimated 58% of malaria deaths occur among the poorest 20% of the world's population.16 The inequality of this distribution is higher than that for any other disease of public health importance.17 Within the Region, except for the Republic of Korea, the burden of malaria rests squarely on developing countries (Figures 4a and 4b). Except for the Republic of Korea and Malaysia, these countries are classified as lowincome and lower-middle-income economies.18 Four of the 10 malaria-endemic countries in the Region are classified as least developed countries: Cambodia, Lao People's Democratic Republic, Solomon Islands and Vanuatu.19 Papua New Guinea has a similarly low human development index of 0.542.20 These five countries suffer the highest burden of malaria in the Region. Important inequalities in the distribution of malaria are also found within countries. However,
What are the links between poverty, gender and malaria?
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
Figure 4a: Confirmed malaria cases per 1000 in the endemic countries in East Asiaa 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 3.87 3.4
Figure 4b: Confirmed malaria cases per 1000 in the endemic countries in the Pacifica 180 160 140 120 100 80 60 40 20 0 161.7
69.27
0.58 0.02
0.47
0.46 0.04
14.29 540 Papua New Guinea 540 Solomon Islands 1,080 Vanuatu
290 320 430 970 1,030 3,550 11,280 Cambodia Viet Nam Philippines Republic of Korea Lao PDR China Malaysia Countries are ranked by gross national income per capita in 2002, Atlas method (current $) Sources: World Health Organization Regional Office for the Western Pacific 2002; and World Bank, Country Classification. a
Countries are ranked by gross national income per capita in 2002, Atlas method (current $) Sources: World Health Organization Regional Office for the Western Pacific 2002; and World Bank, Country Classification.
a
the number of underreported malaria cases is considerable in some countries in the Region. In the Greater Mekong subregion (comprising Cambodia, Lao People's Democratic Republic, Myanmar, Thailand, Viet Nam, and Yunnan Province of China), an estimated 36% of the population live in malaria-endemic areas with inadequate vector control.21 As in the Philippines and Malaysia, malaria is concentrated in remote forested and hilly areas, particularly affecting indigenous peoples and migrants into these areas.22 The provinces of China where malaria cases are reported are all classified as having low and medium human development.23 During the 1990s, malaria transmission in peninsular Malaysia was concentrated most heavily in Pahang and Kelanta, which are among the least developed and least urbanized states. By 2000, malaria was virtually eliminated in the states of Perlis, Federated Territory of Kuala Lumpur, Selangor, Melaka and Kedah. However, it remained high in the less developed and more rural states of Sabah and Sarawak.24 In 2000, 27% of children under 3 years old in Viet Nam reportedly had a fever in the 2 weeks preceding the survey. Such fevers were reportedly more common in the Central Highlands (49.3%) and in the Northern
Uplands (29.9%), where the majority of ethnic minorities dwell, than among the other regions of the country. Fevers were also found to be more prevalent among rural children than among urban children.25 In 2001, the incidence of clinical malaria cases was 10.9 per 1000 among the 10 provinces with the highest share of ethnic minorities, compared with 1.2 cases in the 10 provinces with the lowest share of ethnic minorities.26 Inequalities in exposure
Low household income Low income and consumption are important aspects of poverty. Poor households and individuals are prevented from consuming goods and services that otherwise would protect them against the risks of malaria. A literature review was undertaken in 2003 to critically assess evidence on malaria incidence or vulnerability to the effects of malaria.27 Citing studies from countries worldwide, the review concludes that the poorest countries suffer the greatest burden of malaria. However, evidence from household- and community-level case studies that stratified data along socioeconomic lines present conflicting pictures of the distribution of malaria incidence among poor and less poor households. Case studies that use material assets as a proxy for poverty do not reveal
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a consistent positive association between asset poverty and a greater incidence of febrile episodes (as a proxy for malaria) at the household level. In sub-Saharan Africa, a link between low income and the incidence of fever has been observed at the district level.28 Few studies from the Region disaggregate and analyze data by income or consumption level. For those that do, a clear picture of the relationship between low household income and malaria does not emerge. Among pregnant women seeking care at a remote district hospital in Lao People's Democratic Republic, those with self-reported low income (less than 50,00 kip) were more likely to test positive for malarial parasites in their blood (87.5%) than women with high income (more than 90,000 kip). However, because only 1.5% of respondents reported high incomes, and only 16 women tested positive for malaria, the results are not significant.29 In contrast, malaria was positively associated with household income in Trad Province, Thailand.30 Peak transmission of malaria was found to coincide with the hardest period economically for families living in the Philippines.31 Social exclusion An important aspect of poverty is that it often overlaps with, and reinforces, other types of social exclusion—such as those based on race, ethnicity, geographic location (urban/rural) and gender—that perpetuate inequalities. The social exclusion of ethnic groups is often reflected in the relatively lower levels of development and higher rates of poverty in the areas where they live. For example, the Human Development Index (HDI)32 of provinces in the Philippines ranges from 0.925 in Metro Manila to 0.372-0.560 in provinces with higher concentrations of indigenous groups, including the Muslims of Mindanao.33 In Viet Nam, roughly 70% of ethnic minorities were considered poor in 2002, compared with only 23% of the Kinh/Chinese majority. The gap is widening between the proportion of ethnic minorities and Kinh majority living in poverty.34 This has been attributed largely to the geographic, social, linguistic and cultural isolation of minority populations.35 Figure 5 presents the proportion of ethnic minority households among poor house-
holds in Kon Tum Province, Viet Nam. Likewise, UNDP reports that the vast majority of the 2 million individuals living in poverty in Lao People's Democratic Republic are members of ethnic minorities.36 Figure 5: Incidence of poverty in Kon Tum Province, Viet Nam Poor households (%) Kon Plong 49 Dak Ha 29 Dak To 48 Ngoc Hoi 36 Sa Thay 33 Dak Glei 42 Kon Tum Town 18 Average 32 Poor Kinh households (%) 10 13 21 13 29 1 9 12 Poor ethnic minority households (%) 60 52 61 42 37 44 47 50
Source: Asian Development Bank 2002b.
Evidence from countries in the Mekong subregion shows that the hilly and remote areas that are endemic for malaria tend to have a high concentration of ethnic minorities. Unlike in the rice fields or cities in the lowlands of Viet Nam, the ecology of the mountainous areas where the majority (about 75%) of ethnic minorities live is well suited to malaria transmission.37 In 1994, communes in Binh Thuan, Viet Nam were classified along a continuum of four stages, from low to highly endemic areas. Communes classified as highly endemic zones (stages 3 and 4) were in forested mountain regions of the province and were populated by poor ethnic groups.38 Non-Khmer ethnic groups comprise the majority in the two most mountainous and isolated provinces in Cambodia.39 In Malaysia, the Orang Asli (indigenous peoples), who live in the rural interior of the country, appear to be especially vulnerable to malaria. The Orang Asli tend to be poor, live in inadequate housing, and have limited access to health care.40 Location and environment In many countries, urban areas are often favoured over rural areas in public resource allocation. This often leads to skewed development, with poverty
What are the links between poverty, gender and malaria?
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
Figure 6a: Proportion of ethnic minority populations by province in Viet Nam
Figure 6b: Proportion of ethnic minority populations by province in Lao People's Democratic Republic
Percentage of population 0 (Nonminority Province) 1 - 25 26 - 50 51 - 75 76 - 100
Percentage of population 0 (Nonminority Province) 1 - 25 26 - 50 51 - 75 76 - 100 Special Zone Boundaries are not necessarily authoritative. Source: (1) National Statistics Center [Lao PDR], 1995, Lao Census 1995: Preliminary Report. (2) Classification of ethnic groups employed in the 1995 census, interpreted based on 1999 input from the Lao Front for National Construction, Department of Ethnic and Social Classes. Boundaries are not necessarily authoritative. Cited in Asian Development Bank 2001.
Boundaries are not necessarily authoritative. Note: Province names have been left off nonminority provinces for clarity. Source: Sophie Witter, 1993. Working with Ethnic Minorities in Viet Nam: an Introduction to the Issues. Data from the 1989 Census. Cited in Asian Development Bank 2001.
falling more slowly in rural areas. In 1999, for example, the three richest metropolises in China—Shanghai, Beijing and Tianjin—topped the country's HDI rankings, while the bottom comprised rural provinces from the western part of the country.41 Throughout the Region, poor households are concentrated largely in rural areas. In Cambodia, 90% of the poor reside in rural areas, while 94% and 74% of the poor in the Philippines and Viet Nam live in rural areas, respectively.42 An estimated 80% of the population in Vanuatu subsists in rural areas.43 Likewise, an estimated 27% of the population in urban areas of Lao People's Democratic Republic live in poverty, compared with 41% in rural areas.44 Malaria generally occurs in rural areas within countries in East Asia. For example, malaria occurs seasonally in poor rural communities near rice fields and hill areas in southern China.45 In Lao People's Democratic Republic, the malaria parasite rate was found to be higher in a village in a forested region of Attapeu Province (which was difficult to
access during rainy season when malaria cases tend to peak) than in the other villages covered by the study.46 Ethnic minority groups in countries around the Region have relocated from upland villages to those in lower areas. This can occur for a number of reasons, including the loss of livelihood or availability of productive land in other areas of the country.47 A study in 2002 showed that illness, including malaria-related morbidity, increased in households in some resettled communities in Lao People's Democratic Republic. This was attributed largely to a lack of immunity against malaria among ethnic minorities, who had been living in upland/highland areas more than 1000 meters above sea level where vectors do not exist.48 Housing For the poor, living conditions are often characterized by inadequate housing and overcrowding,
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which can increase the risk of malaria. Dwellings that are hastily constructed, or made of readily available materials, might allow mosquitos to enter more easily than well-constructed housing with screened windows, thus increasing vector contact.49 In Sri Lanka, the density of indoor-resting mosquitos was significantly higher in poorly constructed houses than in those that were well constructed.50 The resurgence of malaria in Binh Thuan Province, Viet Nam in 1999 is attributed largely to settlers migrating into the forest zones. These migrants tended to live in semi-permanent huts in conditions that are not always suitable for bednets.51 Some evidence suggests that overcrowding might increase the risk of malaria, because mosquitos are attracted to the higher concentration of carbon dioxide and other chemicals in crowded houses.52 Family living space also might not be separated from domestic animals, and the animals' body temperature might attract mosquitos. Occupation and migration Poor households often earn their livelihoods from multiple sources. For example, farmers in Lao People's Democratic Republic and the Philippines tend to augment their income with non-timber products collected in nearby forests.53 Studies have demonstrated a significant link between regular work in the forest and increased risk of malaria.54 Roughly half of the active population regularly worked in the forest in Suoi Keit commune in Binh Thuan Province, Viet Nam. Regular forest work was found to be a strong and significant risk factor for malaria. Among households in the village with bednets, sleeping in the forest regularly (without a bednet) was associated with an eightfold higher risk of malaria. Notably, the risk of malaria among households in the village that did not use bednets was similar whether or not an individual slept in the forest or not.55 In countries with forest malaria, migrants into forested areas are particularly at risk, because they lack immunity to malaria. Migrants might be drawn to the forests for a variety of reasons, and might or
might not be predominantly from poor households. Malaria remains endemic in the forested mountainous areas of the central and southern Tay Nguyen highlands of Viet Nam. In these areas, highly profitable woodcutting and agricultural activities attract workers from other non-endemic provinces and bordering areas in Cambodia and Lao People's Democratic Republic. People migrating into endemic areas in the Philippines have been found to be especially vulnerable to malaria.56 Large population movements across the Chinese border are seen to be a factor contributing to malaria in Yunnan Province.57 Civil unrest also might force people who lack immunity to malaria into malaria-endemic areas. Box 1: Migration and the spread of P. falciparum58
While migrants into forested areas tend to be particularly vulnerable to malaria due to their lack of immunity, they also might transport malaria back into malaria-free zones when they return to their homes or search for work in other areas. During the 1990s, for example, many male workers travelled from communities in Thailand to the gem-mining areas of Borai Province in Cambodia. When they returned to their homes in Thailand, malaria tests revealed that some workers had been infected with resistant strains of P. falciparum. Malaria tests performed at a clinic in Mae Sot district of Tak Province in western Thailand found that 80% of these infections had been acquired in Borai.
Malnutrition and concurrent infections Individuals dwelling in poor households are often malnourished. Malnutrition encompasses not just protein-energy malnutrition, but also deficiencies in micronutrients such as iron, vitamin A, iodine and zinc, in particular. Underweight has been identified as a contributing factor in 60% of all child deaths in developing countries. 5 9 Underweight is believed to increase the susceptibility of children contracting malaria for various reasons, including reduced immunity. Evidence strongly suggests that micronutrient deficiencies and general undernutrition increase the burden of malaria morbidity and mortality.60 In Espiritu Santo, one of the northern islands of
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Vanuatu, a study (1992-1993) found a significant association between P. vivax malaria and underweight children less than 5 years old.61 In North Woresa District of East Sepik Province, Papua New Guinea, a randomized study observed that children given vitamin A supplements experienced 30% fewer episodes of P. falciparum malaria than children in the control group.62 The results of a later study in this area showed a 38% reduction in clinic visits for slide-confirmed malaria among children in the group receiving zinc supplements.63 Individuals in poor households are more likely than those in better-off households to suffer from concurrent infectious and parasitic diseases in addition to malaria. Research in southern Lao People's Democratic Republic showed that concurrent health complaints are common in poor Mon Khmer villages.64 This might contribute to the severity of malaria, and complicate its diagnosis and treatment. Inequalities in access to prevention and treatment for malaria
tant method of preventing deaths from malaria.66 Yet, in the Lao People's Democratic Republic, for example, only 24% of the population was sleeping under a bednet in 2000, while an estimated 51% of the population of Solomon Islands was sleeping under bednets in 1999.67 As discussed below, some evidence suggests that bednet use is higher among non-poor than poor households (Figures 7a and 7b). Preventive measures, thus, might be missing poor individuals and households that face greater exposure to malaria than those that are better off. Studies from the Region likewise have shown that individuals might delay seeking treatment for malaria in public health centres. Only 20-40% of individuals with malaria receive treatment in formal health facilities, according to the studies.68 A community-based survey in four provinces of rural Cambodia shows that from 2000 to 2001 only one third of malaria cases had contacted a health facility, and that 80% of deaths from malaria occurred in the home.69 In China, estimates sug gest that cases might be underreported by up to 40% among county and township hospitals. Underreporting might be even greater among village health workers and private health providers.70 Figure 7b: Median net and ITN possession (as % of households) or usage (as % of children under 5 years old) in selected Asian countries for the 20% poorest and 20% least poor households 100 80 Proportion (%) 60 40 20 0
Prevention is a key aspect of malaria control, and prompt treatment is considered the most imporFigure 7a: Median net and ITN possession (as % of households) or usage (as % of children under 5 years old) in selected Asian countries by urban and rural division 100 80 Proportion (%) 60 40 20 0 Net usage Urban
ITN usage
Net possession Rural
Net usage Least poor
ITN usage Poorest
Note: Data derived from national surveys between 1999 and 2004 Source: World Health Organization and United Nations Children's Fund 2005. 65
Note: Data derived from national surveys between 1999 and 2004 Source: World Health Organization and United Nations Children's Fund 2005. 65
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Inequalities in access to malaria prevention and control might arise from financial and nonfinancial barriers. Separately and together, these barriers can delay or prevent the poor from accessing health care services. For example, based on the findings of a recent literature review, poor households are more vulnerable to the effects of malaria than less poor households, possibly because poor households have less access to treatment for malaria than non-poor households. Furthermore, household expenditure on prevention for malaria is correlated more strongly with income and socioeconomic status than with household expenditure on treatment. However, the cost of seeking treatment for malaria infection is likely to be heavier for poor than nonpoor households.71 These barriers—physical access, economic costs, sociocultural barriers, and lack of knowledge and awareness, which leads to low demand for services—are considered below. Geographic access As discussed above, poor households tend to be concentrated in rural and remote areas throughout the Region. Experience shows that these areas generally benefit less from government spending on health than do non-poor areas.72 In Vanuatu, for example, almost 75% of the health budget in 1996 was allocated to urban, rather than rural, services. As a result, only 20% of the population benefited from public spending on health.73 Primary health care is similarly underfunded in many countries. This results in poor coverage of primary health interventions and other health interventions targeting the poor. In rural areas of Lao People's Democratic Republic, for example, 75% of the population lives more than 3 kilometres (km) from the nearest hospital, dispensary or pharmacy. By comparison, 100% of the urban population have access to health services.74 Rural household members, therefore, must travel farther to reach health care services than those from better-off households. A study in Papua New Guinea revealed that poor households have less access to health care facilities than nonpoor households.75 Remote islands in the Pacific, such as Torba and Tafea in Vanuatu, can suffer particular transportation constraints.76
Ethnic minorities residing in hilly and mountainous areas might have particular difficulty accessing health services. A study in the provinces of Xieng Khouang and Oudomxay, Lao People's Democratic Republic, found that respondents had to travel an average of 4 hours to the nearest hospital, 3 hours to the nearest health centre and 2 hours to the nearest midwife. Ethnic minority villages figured predominantly among the most distant villages.77 A case study in Binh Thuan, Viet Nam noted that health services were largely lacking until the early 1990s in the remote communes populated by ethnic minorities.78 Similarly, in Woresa district of East Sepik Province in Papua New Guinea, distance was found to be an important barrier for individuals seeking care for malaria. At 3.5 km, mean attendance decreased by 50% of the potential attendance rate.79 In 2000, only 10% of children living in rural areas of Lao People's Democratic Republic received appropriate treatment for malaria.80 A study in the Solomon Islands found that patients living more than an hour from a Box 2: Access to health services among migrants Migrants into malaria-endemic areas are often particularly vulnerable, yet their access to local health care, including malaria control, frequently is limited. In 1999, workers migrated into the forest areas of Binh Thueng Province, Viet Nam to work on infrastructure projects, such as roads and hydroelectric plants. The majority came from other provinces and tended to live in temporary camps, where appropriate preventive measures for malaria were not adopted. Importantly, these camps were not covered by local health services until a special programme was established to incorporate them into malaria prevention and control measures.81 Migrants into an endemic area of the Philippines explained that health services were inaccessible, because of their unfamiliarity with the local dialect, their shyness about their status as newcomers to the area, and their experience with local staff discouraging them from accessing services.82 Illegal migrants face unique constraints in accessing services, as they might not be eligible for care in public health facilities. For example, illegal migrants in some countries might be unable to receive impregnated bednets free from the government.
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health clinic had a higher mean 12-month malaria incidence than patients who travelled less than an hour to reach the clinic.83 Economic barriers When health services are available, the costs associated with preventive and curative treatment for malaria might deter or prevent the poor from seeking care. Further, the cost of malaria-related preventive methods has been found to be higher in rural than in urban areas.84 Spending on malaria prevention, such as bednets, appears to be associated with household income or socioeconomic status, with better-off households allocating a larger share of their income to malaria prevention than poor households.85 Data from a survey in Cambodia suggest that households in the poorest quintile were the least likely to say that they would buy a bednet from the local market.86 The main reasons respondents in Honiara, Solomon Islands gave for not using a bednet was lack of financial resources and a hot climate.87 The costs of seeking care can be divided into direct costs (such as fees for services), indirect costs (such as the cost of transportation) and opportunity costs (such as lost wages from time away from work). Although the absolute cost of seeking care as a share of non-food expenditure might be lower for the poor than that for the non-poor, the relative cost of seeking health care is higher. A 1999 health survey found that, among ethnic minorities in Lao People's Democratic Republic, nearly 50% of respondents whose households had suffered a serious illness in the previous 12 months did not have adequate financial resources to pay for the health care of a sick family member. Among the Lao majority, the proportion of respondents who reported similar financial constraints was 40%. Importantly, ethnic minority respondents were unable to supplement their financial resources from other sources, such as by borrowing money or selling assets.88 Financial costs were found to deter individuals from seeking treatment for malaria in the Philippines as well.89 Studies from countries in Africa also found that costs were associated with delays in seeking treatment.90 Children living in
better-off households are more likely to receive appropriate treatment for malaria than children in poor households in sub-Saharan Africa.91 Although antimalarial drugs might be available for free in public health care facilities in some countries in the Region, studies have found that purchasing drugs from private pharmacies for self-treatment is common, such as in Morong, Philippines.92 Here, the antimalarial drug Fansidar costs 15 pesos per tablet (three tablets are required for treatment), while chloroquine costs 5 pesos and 10 tablets are required. The cost of drugs for one course of treatment was estimated to be equal to half a day's wage in the locality.93 Because of the cost associated with antimalarial drugs, people suffering from possible malaria tend to buy only enough drugs to suppress the symptoms.94 The practice of households hoarding antimalarial drugs and sharing them with other family members, neighbours and friends likewise seems to be widespread.95 Such actions might contribute to the development of drugresistant malaria strains in the Region. The opportunity cost of malaria treatment is also greater for the poor, because they often earn income from their labour. Any reduction in labour supply, or decrease in productivity due to periods of illness, directly reduces individual and family income. A study from Gushi and Shangcheng counties in Henan Province, China suggested the cost associated with seeking treatment for malaria.96 The average patient cost per suspected malaria case in 1994-1995 was calculated to be 27.85 yuan, which is equivalent to 10 times the average per capita daily income in this area. Among suspected malaria patients, 96% paid an average of 1.11 yuan each for antimalarial drugs, and 95% bought other drugs and injections amounting to 9.27 yuan. An estimated 63% of suspected malaria patients reported paying consultation fees of 1.18 yuan. Finally, the opportunity cost of lost income was estimated to be an average of 20 yuan and was reported to affect 52% of cases.97 Low education and knowledge A general lack of health information and awareness among poor and marginalized groups can depress
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demand for health care services. In addition, ethnic minorities might hold beliefs and perceptions about health and illness that influence health seeking. In Viet Nam and some other countries throughout the Region, for example, educational attainment is positively associated with socioeconomic status, including level of income and housing conditions.98 Literacy rates tend to be lower among ethnic minorities, compared to the general population (Figure 8). A case study in Khammouane Province, the Lao People's Democratic Republic observed an association between literacy and knowledge of malaria. Only 28.6% of illiterate respondents knew that mosquitos transmit malaria, compared with 48.8% of literate respondents. Only 54.9% of illiterate respondents identified appropriate prevention measures, compared with 75.4% of literate respondents. Three of the four villages surveyed were in a district 100 km from the provincial capital. In these three villages, 12.5%, 23.4% and 26.7% of respondents, respectively, replied that mosquitos transmit malaria.99 A study in the Solomon Islands, however, found that good knowledge was not significantly associated with higher levels of school attainment among the study population.100 These contradictory findings point to the complex pathway between greater knowledge of malaria and improved prevention and treatment. Knowledge of malaria might be lower among poor than non-poor households for several Figure 8: Literacy rates for ethnic minorities compared to total population, selected countries Ethnic Minorities (%) Total Population (%) Female Total Female Total 17 26 55 63 17 33 48 60 73 86 92
reasons. Information, education and communication (IEC) material for malaria might not reach poor people. Illiterate people and those with low levels of education might be unable to understand written health education materials, such as posters and flyers. Poor households might not have access to radios or television, thereby missing health messages broadcast through these mass media. Women and ethnic minorities might have even less access to mass media: women tend to be less educated and literate than men, while ethnic minorities can have limited command of the official language of the area or country. Thus, although health information on the cause, transmission and appropriate treatment for malaria might be available in health centres and within villages, such information might not benefit poor and marginalized groups. Health education delivered through outreach workers likewise might not reach poor households in remote rural villages. In this way, low levels of education can lead to low knowledge of malaria. In turn, such knowledge and perception of malaria is an important factor in determining acceptance and use of malaria prevention and control measures. Different understandings of what causes malaria, and how it is transmitted, have been documented in the Lao People's Democratic Republic, Cambodia and the Philippines. In case studies from the Lao People's Democratic Republic and the Philippines, respondents thought that malaria was caused by bad water and a lack of hygiene.101 The Filipino respondents also identified hard work and suffering from hunger as causes of malaria. Such limited knowledge of malaria becomes a challenge for malaria control programmes, especially when locally held views are not compatible with the recommended strategies for prevention and treatment. Respondents in various studies have divided malaria-related illness into two or more classifications of diseases, or they have explained that malaria might be associated with one set of symptoms but not another. This can be particularly true for convulsions, which might denote spirit possession to some people.102 Adults surveyed in Bataan, the Philippines identified 20 types of malaria.103 People might attribute the
Cambodia Lao PDR Viet Nam
Note: Literacy rates in Cambodia are for age 7 and older. Literacy rates for ethnic minorities are those for the provinces of Mondolkiri and Ratanakiri, which are 67% ethnic minority (source: 1998 census). Literacy rates in Lao People's Democratic Republic are for non-Lao-Phutai speakers (source: 1995 census). Literacy rates in Viet Nam are for the population over age 10 and are from 19971998 Viet Nam Living Standards Survey. Source: Cited in Asian Development Bank 2001. Cambodia: National Institute of Statistics/Ministry of Planning/United Nations Population Fund, 1998. Lao People's Democratic Republic: National Statistics Center, 1995. Viet Nam: General Statistical Office, 1999.
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symptoms of simple malaria to the disease.104 However, more serious symptoms can be attributed to spirits. These varied understandings of the cause of malaria infection influence the type of treatment sought, if at all. However, a study in the Philippines found similar treatment seeking for different classifications of fevers.105 Higher levels of education and greater knowledge of malaria are associated with improved health seeking among households.106 For example, among patients seeking treatment for malaria in a hospital in Honiara, Solomon Islands, bednet use was higher among those with good knowledge of the biomedical cause of malaria than among those with poor knowledge.107 Yet, improved knowledge of the biomedical causes of malaria does not always translate into prompt health seeking for malaria. In areas of high transmission, for example, malaria might be perceived as a mild illness even if knowledge of malaria is widespread. This perception of malaria might influence strongly treatment seeking for malaria illness. During a study in Mon-Khmer villages in Dakcheung and Lamam districts of Sekong Province, the Lao People's Democratic Republic, for example, men said they were not afraid of malaria.108 Importantly, the perception of the severity of malaria has been found to be a key factor in determining treatment action.109 Sociocultural barriers Traditional beliefs and practices also can influence whether communities accept and adopt malaria prevention measures and seek treatment. In the northern parts of Viet Nam, for example, ethnic minorities traditionally use bednets, while those in the Central Highlands traditionally do not. The introduction of bednets into these areas was more difficult.110 In a Mon-Khmer village in Sekong Province of the Lao People's Democratic Republic, people reportedly used bednets because of the “nuisance” biting of mosquitos and other insects, or because they are a status symbol, even though they did not appear to understand the connection between malaria and mosquitos.111 Traditional living and sleeping arrangements vary among ethnic groups in Cambodia and the Lao
People's Democratic Republic. For example, the mean number of people living together among the Jorai ethnic group was 16.71, while among the Taliang it was 6.72. Data from this study shows that the mean number of people sleeping under bednets likewise varies among ethnic groups.112 The colour of bednets has been found to be important in communities throughout the Region. In some areas, as white is associated with mourning, it is considered unacceptable for bednets. In other areas, people prefer colourful bednets. By and large, however, when widespread distribution of impregnated nets in an area reduces morbidity, communities are likely to accept bednet usage and might even demand more nets. Beliefs regarding the effects of certain antimalarial drugs also might affect treatment seeking. In some parts of Africa, chloroquine is believed to cause abortions. This is because of food taboos that prevent pregnant women from eating bitter substances.113 Inequalities in the quality of malaria treatment Public sector: Studies from Viet Nam and the Lao People's Democratic Republic have shown that health staff are reluctant to work in rural and remote health centres.114 Further, health posts in remote areas tend to suffer from shortages in essential medicines and equipment,115 which often result in low-quality care and limited confidence in the health care services. Villages near urban centres or along accessible coastal areas enjoy better quality health care than do villages in the remote interior or on isolated stretches of coast in the Solomon Islands.116 Ethnic minorities in northern Viet Nam are reported to have the least confidence in the health care services among the general population.117 In the Philippines, experience with the public health centre was an important factor in people seeking treatment for malaria at home.118 A case study documented how the rural health unit (RHU) regularly lacked antimalarial drugs. Patients seeking care during these periods would be given a prescription for antimalarial drugs that could be purchased from a local pharmacy. Delays
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in diagnosis of malaria were also recorded in the RHU. The irregular supply of free antimalarial drugs, combined with delayed diagnoses, discouraged community members from seeking prompt care for malaria from the RHU.119 Furthermore, death from malaria in the Philippines has been attributed to delayed consultation, irregular availability of antimalarial drugs for severe cases in peripheral health centres, and improper treatment from hospital-based physicians.120 Private practitioners: Malaria treatment might be offered free in public health centres throughout the Region. However, patients—including some poor patients—seek care from private practitioners for various reasons, including the perceived poor quality of public health care providers. In Cambodia, an estimated 60% of the population seeks care for malaria in the private sector.121 Selftreatment for malaria has been reported in the Philippines and Vanuatu.122 Administering antimalarial drugs at home was observed more commonly in inland villages (those further from health centres) than in coastal villages in Vanuatu. In Viet Nam, almost 60% of respondents with fever consulted a private health clinic instead of receiving free treatment for malaria from the public health care centre in An Trach commune.123 In areas where antimalarial drugs are available commercially, they can be substandard, counterfeit or outdated. However, in North Worsea District of East Sepik, Papua New Guinea, no self-treatment for malaria was observed, because free antimalarial drugs are readily available at the local health centre.124
mean direct cost of seeking care for malaria was estimated at 2%-2.9% of household income.125 Yet, these might mask important economic inequalities. In Malawi, for example, annual spending on malaria treatment accounted for 32.1% of average annual income among poor households and only 4.7% of annual income among better-off households.126 The cost of malaria to poor households can be especially severe when the sick individual is a productive member of the household, particularly the primary income-earner. Other household labour might be diverted from income-generating activities to care for sick family members. Reduced productivity and time away from work reduce household income. According to studies from Africa, the cost of lost labour from malaria illness might account for more than 75% of the total household cost of malaria.127 The cost of a single malaria episode was estimated in five villages in Anuradhapura district of Sri Lanka, where the majority of households were low-income subsistence farmers. The median direct cost for a single episode of malaria was calculated at $3; records show a few families spent 10% of their household income per episode. Moreover, with each episode of malaria, the sick individual lost 7.8 days of work, while the person accompanying the malaria patient to the local health centre lost 2.9 days of work. Most families were able to substitute household labour for the labour lost to illness.128 However, such strategies require shifting labour away from other productive activities or pulling children out of school. When faced with the cost of seeking treatment for malaria, poor households employ a number of coping strategies. These strategies might include offsetting labour lost to illness by substituting labour from other household members, including children who are withdrawn from school. Poor households often lack collateral and social networks to assist in raising money to pay for the cost of health care. Therefore, they must resort to borrowing money from local lenders, or might be forced to sell assets, including productive assets such as land and livestock. For example, a study in Cambodia estimated that 40% of new landlessness was due to ill health.129 Taking children out of
The effect of malaria on poverty Malaria might cause and perpetuate poverty at the household level in a number of direct and indirect ways. As outlined above, the total costs of malaria include the direct, indirect and opportunity costs of falling ill and seeking treatment for malaria. Households suffer significant costs when a household member is sick with malaria. The direct and indirect costs of malaria might be substantial, further impoverishing poor households. Based on findings from studies in Malawi and Sri Lanka, the
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school and selling productive assets can deprive households of future income streams. Some evidence suggests that malaria also leads to lower labour productivity by contributing to the prevalence of anaemia among poor households.130 Further, malaria also might contribute to malnutrition and low birth weight.131 This, in conjunction with reduced learning among children who suffer repeated episodes of malaria,132 might lead to lower levels of human capital among households in malaria-endemic communities. When the costs borne by individuals and households suffering from malaria are aggregated at the national level, the loss to development and economic growth is substantial. Estimates from cross-country regressions suggest that malaria morbidity might reduce annual per capita growth by 0.25 percentage points for the most affected countries. Conversely, lower malaria morbidity was also associated with lower poverty ratios and greater access to health care in rural areas.133 A second study estimated that the rate of economic growth in countries with malaria was 1.3% lower per year than in countries without malaria from 1965 to 1990 (controlling for other factors that might influence economic growth). A fivefold difference in gross domestic product (GDP) has been observed between malarial and non-malarial countries, which had an average GDP per capita in 1995 of $1,526 and $8,268, respectively.134 Such reductions in GDP might reflect lower rates of savings and investments among households that must spend their income on preventing and treating malaria at the cost of reduced productivity. When malaria-related costs borne by individuals and households are aggregated to estimate the burden of disease at the national level, they tend to be smaller than the results of cross-country regression analysis. The reason could be—as a recent paper argues—that malaria has negative externalities, i.e., the total costs of malaria to a society are greater than the sum of costs at the individual and household levels. Among others, these externalities could include modified social and economic behaviour among households and communities in response to the risk of malaria infection, and reduced trade and limited foreign
direct investment.135 Malaria control reportedly was an essential precondition for the development of rubber and tea plantations during the colonial period in Malaysia, and it remains an important reason for the success of rubber plantations in Southeast Asia today.136 Malaria reductions might improve economic development A study of the dramatic decline in malaria in Viet Nam during the 1990s offers some evidence of the possible effect reduced malaria transmission has on improved livelihoods among households. The decline in malaria transmission during this period has been attributed largely to higher spending on malaria control by the central government. The study argues that this expenditure is uncorrelated with the living standards in each province. Based on this assumption, the study exploits the uneven decline in malaria among provinces in Viet Nam to estimate the possible effect that changes in malaria incidence had on changes in household living standards over 6 years. Controlling for other household characteristics, a 10% decrease in malaria cases at the provincial level was estimated to result in a 0.3% increase in household consumption. Furthermore, the study found that this decrease in malaria cases at the provincial level was associated with a 0.63% reduction in household expenditure on health. Such changes in provincial-level malaria were not associated with similar reductions in health expenditure among poor households. Based on 1998 data, the annual economic benefit of reduced malaria in Viet Nam was calculated to be approximately $10 million.137 The relationship between development and malaria is complex and often context-specific. Well-planned economic development might contribute to poverty reduction, thereby removing the constraints poverty places on malaria prevention, treatment and control. Changes in water and land use during periods of economic growth might or might not reduce malaria transmission. Rapid economic development in Viet Nam, for example, has decreased the risk of malaria in An Trach commune in Bac Lieu Province of the Mekong Delta. However, economic growth has
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increased the risk of malaria in Suoi Kiet commune in Bihn Thuan Province in the central part of the country, where profitable forest work in Suoi Kiet attracts migrants. In An Trach, the growth in shrimp farming has extended brackish water areas and reduced freshwater surfaces. This favours the breeding habits of An. sundaicus over A. subpictus, which has disappeared from the area. This has contributed to the decrease in malaria in the area.138 Correlations between mosquito densities, malaria incidence and patterns of flooding rice lands have been observed in Sichuan Province, China. The introduction of irrigation schemes eliminated breeding sites, which might have eradicated malaria in some areas of the province.139
and credit, and enjoy less access to education, skills, employment opportunities and political representation. An estimated two thirds of the illiterate adult population are women and, although women tend to live longer than men, they are sick and disabled more often.142 Within the household, a skewed distribution of resources and power often disadvantage women further. Women also face immense pressure on their time, often experiencing time poverty (lack of time to complete all their tasks). Local notions of male and female, which shape men's and women's economic and productive capabilities, social roles and perceptions of malaria, also might influence the epidemiology of malaria.143 Gender roles can influence men and women's exposure to mosquitos, access to preventive measures for malaria and their treatment-seeking behaviour. However, because little malaria data are disaggregated by sex, knowledge about how men and women might experience malaria differently is limited.144 Gender-related exposure to malaria
What is the relationship between gender and malaria? Across countries, men and women are responsible for different social and economic activities, and enjoy different access to resources and decisionmaking authority. Local constructs of gender that differ from biologically determined characteristics or those based on sex shape such differences.140 Importantly, as gender roles are socially constructed, they vary between localities. Further, women or men of different socioeconomic status within a given social setting might have different experiences regarding gender roles. Gender roles can also shift with time and social change. According to the United Nations, while women account for half of the world's population, they perform nearly two thirds of the work, receive one tenth of the world's income, and own less than one hundredth of the world's property. Source: United Nations decade for women 1976-1985.
Reports often suggest that the prevalence of malaria is higher among men than women (Figure 9).145 Case studies from the Region support this finding, often attributing the higher prevalence of malaria among men to their greater exposure to Figure 9: Percentage of male and female malaria cases reported, selected countries in the Region, 2003 90 80 70 60 50 40 30 20 10 0 Malaysia Male
Moreover, women's experience of poverty is shaped by locally constructed gender roles, and poverty has been identified as a key determinant of women's health.141 Compared to men, worldwide, women carry a double burden by combining productive and reproductive activities, such as childrearing and other household duties. In addition, women often have less control than men over means of production, such as cash, collateral
Republic of Korea Female
Source: World Health Organization and United Nations Children's Fund 2005.
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mosquitos. That is, men's work tends to take them into the forest at different times, or for a longer duration, than women. In Viet Nam, for example, regular work in the forest was a significant activity for men and not for women. Although women reportedly went into the forest regularly, they did not go as often as men, nor did they stay there as long. This was because women returned home to attend to their domestic tasks. Further, men were described as working stripped to the waist and in shorts, while women remained fully covered.146 A second study in Viet Nam shows that, among the 60% of the study population who sought care at one of four private health clinics, significantly more were men than women.147 Similarly, data from the Philippines show that more men were diagnosed with malaria than women. In East Sepik, Papua New Guinea, men were 9.7% more likely than women to present at rural health clinics.148 However, some evidence from the Region suggests that the prevalence of malaria is not always higher among men than women and, in fact, might be similar. That is, men and women might be similarly exposed to mosquitos, although the timing and location of their exposure might be different. For example, the distribution of malaria cases was the same among men and women in three villages in Attapeu Province, the Lao People's Democratic Republic.149 A survey of communities near forested areas in rural Cambodia found little difference in the slide positivity rate between men and women.150 A few case studies have found that the higher rates of malaria reported for men than women might arise from different treatment-seeking behaviour for malaria. A case study in Sri Lanka, for example, reported slightly higher rates of malaria among men than women. Although sleeping patterns, occupation and clothing differences between men and women could account for the higher rate of malaria among men, the study explained that numerous women in the community refused to be examined because the health staff involved in case detection were predominantly male.151 In Thailand, a study compared the clinical prevalence of malaria and the prevalence of malaria in communities. While the study found parasitaemia rates within communities to be equal, men were six times more
likely than women to seek care at the health care clinic.152 In addition, women's nutritional status, which is on average lower than that of men, might suppress their immune system and lead to a higher risk of severe malaria infection.153 Some evidence from India suggests that women might delay or postpone treatment, and that their recovery period might be longer than that for men because they tend to return to their normal duties while still debilitated.154 Finally, a hospital-based study in India found that mortality rates for men patients (7.6%) were significantly lower than those for women patients (18.4%).155 While these examples are context-specific, they begin to suggest that malaria among women could go undetected because women are less likely than men to seek treatment for malaria. Gender-related inequalities in access to prevention and treatment
Most evidence from the Region on bednet use and treatment seeking for malaria is not disaggregated by sex. The little disaggregated data available suggest that gendered access to prevention and treatment for malaria might be context-specific. Thus, generalizing this information to the national or regional level is difficult. For example, a higher proportion of women slept under bednets (39%) than did men (33.8%) in a study population in Honiara, Solomon Islands.156 In comparison, men's and women's bednet use did not differ significantly among ethnic groups in Cambodia and the Lao People's Democratic Republic.157 The following section considers some barriers women might face, compared to men, when seeking care. These barriers might contribute to the lower levels of malaria among women than men reported in the Region. Geographic barriers The study in East Sepik, Papua New Guinea reports that distance significantly decreased the likelihood of treatment seeking for malaria, a tendency that was most pronounced among women.158 In some societies, women's mobility might be constrained because they must be accompanied when travelling beyond their community. This increases the cost of seeking care
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Figure 10: Who decides how married women spend their own income in Viet Nam (% of women respondents) 60% 50% 40% 30% 20% 10% 0% Decisions made by husbands Decisions made Decisions made jointly by women on their own
Economic barriers Women usually bear more responsibility than men for the well-being of the family. However, gender differentials in access to, and control over, household resources might constrain women's access to prevention and treatment of malaria.161 In the Lao People's Democratic Republic, the decision to purchase and use a bednet is considered a man's decision.162 Within households in Viet Nam, a woman's ability to make decisions on how to spend her own income appears to vary with her level of education (Figure 10). The cost of caring for malaria illness and treatment can fall disproportionately on women. When a household member falls ill with malaria in Viet Nam, 60% of those who stop working to care for them are women.163 A study in a rural community in Colombia explored the time losses and reassignment of labour within households in response to malaria illness. A higher prevalence of disease was reported among men (59%) than among women (41%). However, the economic burden of malaria illness fell largely to women, who assumed 64% of all tasks normally done by the sick individual.164 Sociocultural barriers Among ethnic minorities, social customs can shape women's access to treatment for malaria. Women dwelling in some ethnic minority communities in Viet Nam are expected to place the health of their family ahead of their own. As a result, they might not seek treatment when they fall ill.165 Among the Akha people, who live in the highlands of Thailand, Myanmar, the Lao People's Democratic Republic and China, men and women sleep in different parts of the house. If only one net is distributed for the family, social ranking or perceptions of vulnerability to malaria might determine who has access to it. Low education and knowledge As discussed, knowledge of malaria influences the measures people take—if any—to prevent and seek treatment for the disease. While the poor might face constraints in accessing malaria-related information, women within poor households can
Women with no education Women with secondary education Source: Mohdeen R. 2002.
for malaria in terms of lost household labour. What is considered "near" and "far" may be determined by the sociocultural environment. In some settings, a woman might leave her village on her own, while in others she might not be able to leave her home compound unaccompanied. In still other villages, women face few mobility restrictions. Therefore, local understandings of male and female mobility might further constrain treatment seeking in some communities in the Region. Box 3: Treatment seeking for children with malaria Children are especially vulnerable to malaria. Therefore, they require access to effective prevention and treatment for malaria. It is not clear, however, whether young children receive prompt treatment for malaria. Studies from Myanmar and the Philippines found that children less than 15 years old were more likely to be taken for treatment at a health care facility than those over 15. A study from Thailand, meanwhile, showed that children were underrepresented in malaria clinics.159 In addition, some evidence suggests that boys are more likely to receive prompt treatment for malaria than are girls. In Papua, New Guinea, for example, a study reports that mothers take their male children to the health centre more often and travel further with them than with their girl children.160
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face particular constraints. Women tend to be more poorly informed about disease risks and the possibility of prevention and cure,166 often because they tend to have lower levels of education and literacy than men. Among ethnic minorities in the Lao People's Democratic Republic, boys tend to benefit more from education than do girls, who often marry young.167 Similar patterns are observed among ethnic minorities in Viet Nam.168 The literacy rate for women in rural Cambodia is 55%, compared with 80% for men.169 Women also might enjoy less access to radio and television, because of less capacity in the official language. A case study of ethnic minority peoples in Rattanakiri Province of Cambodia found a generally low level of knowledge among respondents that the bite of infected mosquitos causes malaria. Less than 10% of men and less than 4% of women said that malaria is transmitted by mosquitos. Similarly, as many as 67% of people interviewed explained that malaria is not preventable, while only 20% felt that malaria could be prevented.170 Further, the relatively low status of women among ethnic minorities in Viet Nam prevents them from establishing a broad network of contacts. Instead, they often rely on relatives for information.171 Inequalities in quality of health care Research from various countries shows that health care staff are often unaware of, and inconsiderate Box 4: Gender, development and malaria Social and economic development can change male and female labour patterns and land use. These changes might modify exposure to malaria for better or for worse for women and men. Personal prevention behaviours also determine exposure, however. Therefore, if environmental changes increase mosquito breeding sites, people might invest in more or different mosquito prevention measures, such as more bednets and protective clothing, to offset the increased risk from greater vector presence. In this context, the gender issue is whether social and economic development also results in women having greater access to and control over economic resources, thereby enabling them to improve their malaria prevention behaviours and ability to seek health care.
towards, women's unique health needs and the constraints they might face when seeking to access health care. Instead, health staff might blame women for delaying seeking treatment.172 Poor women have been found to be particularly sensitive to the behaviour of health staff, and might not access formal health services when health providers are perceived to be disrespectful and insensitive to their needs.173 Sex differences in the effects of malaria: a focus on pregnancy
The sex of a person influences his or her biological response to malaria. In particular, pregnant women are generally more vulnerable to malarial infection than are non- pregnant women or men, in areas of stable and unstable malaria transmission.174 In Papua New Guinea, for example, the prevalence and incidence of malaria is highest among young children and pregnant women.175 P. falciparum is the most common cause of malaria during pregnancy, while the effect of the other three parasites (P. vivax, P. malariae and P. ovale) on pregnant women is less clear.176 Pregnant women, especially those pregnant for the first time, experience a higher frequency and density of infection. In subsequent pregnancies, however, pregnant women are not at higher risk of malaria than other women in the same setting. Because women of reproductive age in areas of high transmission develop some immunity to malaria, they might not experience fever or other clinical symptoms. Instead, malaria is associated with malaria-related anaemia among mothers and the presence of parasites in the placenta. This impairs fetal nutrition, which can compromise fetal growth and survival.177 Low birth weight (LBW) has serious consequences for child development. Half of the pregnant women treated for malaria along the Thai-Burmese border were anaemic on presentation; of those who were not anaemic, 52% subsequently developed anaemia. In this area, malaria during pregnancy is associated with maternal and fetal mortality, maternal anaemia and LBW.178 Studies comparing the malaria-endemic coastal area in Papua New Guinea with the malaria-free highlands suggest that malaria in pregnancy accounts for up to 11%
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of anaemia and 40% of LBW in malaria-endemic areas.179 Estimates from countries in Africa with stable malaria transmission suggest that P. falciparum infections during pregnancy cause up to 10,000 maternal deaths, 8-14% of LBW babies and 3-8% of infant deaths each year.180 Women dwelling in areas of low or unstable malaria transmission face a risk of severe malaria infection as much as threefold higher than do nonpregnant women or men. These women are at risk of death from severe malaria infection or malariarelated anaemia.181 Various adverse outcomes can occur, including spontaneous abortion, neonatal death and LBW.182 Bednet use decreases pregnant women's exposure to mosquitos, thereby reducing infections. Sleeping under ITNs every night during their first four pregnancies reduced the number of babies born underweight or premature birth by 25% among women in a high transmission area in Kenya.183 In addition, in areas of high malaria transmission, malaria in pregnancy can be prevented through intermittent preventive treatment. This involves providing pregnant women with two preventive treatment doses of an effective anti-malaria drug that is safe for use during pregnancy.184 In areas of low transmission, febrile illness among pregnant women requires prompt treatment. However, as with non-pregnant women in many societies, pregnant women encounter constraints
when trying to access health care facilities, especially if these are far from their community. In many parts of rural Papua New Guinea, since they might lack control over access to family transportation, women must walk for several hours to visit the nearest health post.185 Such restrictions on mobility might be even greater during pregnancy. Figure 11 shows women's access to antenatal care for the poorest and richest income quintiles in Cambodia, the Philippines and Viet Nam. Women from some minority ethnic groups in the Region traditionally give birth in huts in the forest, which might increase their exposure to malaria.186 Figure 11: Women receiving delivery assistance from a doctor or nurse/midwife in Cambodia, the Philippines and Viet Nam (%) 120% 100% 80% 60% 40% 20% 0% Cambodia, 2000 Philippines, 1998 Viet Nam, 2000 Poorest quintile Richest quintile
Source: Gwatkin D. et al. 2003 in Carr D. 2004.
What are the links between poverty, gender and malaria?
3. Why should health professionals address poverty and gender in malaria control?
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3. Why should health professionals address poverty and gender in malaria control? s the preceding analysis aims to show, poor or otherwise marginalized individuals, households and communities, especially women, might benefit less from investments in malaria prevention and control than the non-poor. As such, addressing poverty and gender in malaria control has three main rationales: efficiency, equity and human rights.
A
discussed in the section on how reducing malaria can improve economic development.
Equity Malaria is a preventable and curable disease. However, evidence suggests the burden of malaria in the Region rests disproportionately on poor and marginalized populations. This disproportionate burden on the poor and their relatively worse health outcomes are increasingly viewed as inequitable. Inequities refer to a subset of inequalities that are seen as unfair, unjust and avoidable.188 Although experience shows that some variation in health status is unavoidable—due to biological differences between men and women, for example—inequalities in the health of the poor and non-poor are increasingly understood to mirror social divisions within society, such as those based on income, ethnicity and geographic location. Such social divisions appear to shape the burden of malaria in the Region. Equity in health may be defined as the "absence of systematic disparities in health (or major social determinants) between groups with different levels of underlying social advantage or disadvantage, such as different positions in the social hierarchy." Source: Braveman P., Gruskin S. 2003.
Efficiency Impressive progress has been made towards reducing the burden of malaria in the Region. Notably, the Millennium Development Goal (MDG) for malaria has been met in the Region. Still, many of the remaining malaria-endemic areas are hard to reach and are populated by marginalized communities. Since these groups might suffer disproportionately from malariarelated morbidity, targeting malaria control programmes to poor individuals, households and communities would have a greater impact on reducing the overall burden of malaria than initiatives that miss these populations. Migrants into malaria-endemic areas pose a particular challenge to malaria control programmes. Reaching migrant populations with malaria control will effectively sustain the progress, while reducing the burden of malaria in many areas.187 Further, ensuring that effective prevention and treatment reach poor households and communities might be an effective strategy to tackle the emerging problem of drug resistance in the Region. The efficiency gains from better targeting of poor households by malaria control programmes are even more significant when considering that health improvements among the poor play a central role in poverty reduction strategies. Reducing the burden of malaria on poor households will significantly strengthen efforts to improve the health of the poor. Further, pro-poor health strategies designed to ensure that poor households benefit from malaria prevention and treatment, as well as to help them meet the cost of seeking care for malaria, will protect the poor from many of the impoverishing effects of ill health. At the national level, such interventions can accelerate economic growth and poverty reduction, as
These inequalities in malaria are thus unfair and unjust because of the constraints poverty places on the ability of individuals to influence their health outcomes. Since poor individuals, women, ethnic minorities, migrants and forest dwellers have fewer choices and less access to resources and services, their health outcomes are worse than those of the non-poor. Therefore, efforts are required—within the health sector and beyond it—to address the disproportionate burden of malaria-related morbidity suffered by the poor, their limited access to prevention and treatment for malaria, and the impoverishing effect of health care costs.
Human rights The right to the highest attainable standard of physical and mental health, or the right to health, is
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rooted in the Universal Declaration of Human Rights. Numerous other human rights treaties have endorsed this basic right. Every country in the world is party to at least one human rights treaty that addresses health-related rights.189 Concerning malaria, access to early diagnosis and treatment is encompassed within the right to health. Non-discrimination is a key concept within the right to health. This concept forbids "any discrimination in access to health care and the underlying determinants, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation, civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health.”190 Yet, malaria appears to affect poor rural communities and ethnic minorities more than non-poor populations. These marginalized populations might have less access to services and resources than the non-poor population. The concept of non-discrimination in conjunction with other human rights, such as the rights to information and privacy, should guide the interaction of individuals with the health system. This is reinforced by the inclusiveness of the right to health, which encompasses the right to health services and the right to the underlying determinants of health, such as education and food. However, marginalized populations are often denied multiple human rights. For example,
women and ethnic minorities might lack access to information on how to protect themselves from malaria. Migrants, on the other hand, might face constraints in accessing malaria prevention and control, because they do not speak the local language or are unaware of local health services.191 Member States are responsible for the progressive realization of human rights, including the right to health. Therefore, governments must put in place policies and plans that will make health care available and accessible, and will lead to the realization of other human rights as efficiently as possible. This includes regulating the actions of non-state actors to ensure the right to health is realized. Box 5: Malaria prevention and control and the right to health192 When evaluating the right to health within malaria prevention and control, four criteria may be used: ! Availability: well-functioning malaria prevention and control services are adequately available ! Accessibility: malaria prevention and control services are accessible to all, encompassing four dimensionsnon-discrimination, physical accessibility, economic accessibility (affordability) and information accessibility ! Acceptability: malaria prevention and control services are respectful, culturally appropriate and gender-sensitive, and honour the confidentiality of malaria patients ! Quality: malaria prevention and control services are scientifically and medically appropriate and of good quality
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4. How can health professionals address poverty and gender concerns in malaria control?
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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals
4. How can health professionals address poverty and gender concerns in malaria control? uring the mid-20 century, the world made substantial gains in controlling malaria. By the late 1960s, however, the World Health Organization (WHO) and its partners concluded that eradicating malaria from places with the highest rate of infection would be impossible with existing tools (indoor spraying with DDT and drug chemoprophylaxis).193 The reduction of these intensive malaria control programmes, together with emerging drug and insecticide resistance, allowed malaria to re-emerge in many parts of the globe. Recently, renewed political commitment to tackling malaria has emerged. This global commitment is embodied in initiatives such as the Roll Back Malaria (RBM) partnership and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Launched in 1998 by WHO in partnership with UNDP, the United Nations Children's Fund (UNICEF) and the World Bank, the RBM partnership now comprises more than 90 partners globally. The major goal of the RBM initiative is to halve malaria mortality by 2010. A malaria-related target has also been incorporated into the MDGs. Adopted in 2000, the MDGs represent a global compact to tackle poverty in all its forms by setting measurable and time-bound commitments. Under Goal 6, the malaria target is to “have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases.” RBM endorses the following strategies for malaria control:194 ! early diagnosis and treatment ! insecticide-treated mosquito nets ! localized vector control ! intermittent treatment for pregnant women ! good surveillance ! health promotion through effective communications ! coordinated action through partnerships for locally adapted measures. The strategies employed for malaria prevention and control have been effective in reducing the burden of disease in countries in the Region.195 The challenge for health professionals is to ensure that
D
th
these effective initiatives reach those most in need. Health professionals may follow two main avenues to reduce the disproportionate burden of malaria on poor households and communities. The two broad strategies outlined below are not mutually exclusive. Rather, following these strategies simultaneously can increase the likelihood that malaria prevention and control reach the poor.
Integrate malaria prevention and control into the poverty reduction agenda Improving health outcomes among the poor is increasingly understood to be an effective strategy for poverty reduction. This is reflected in the MDGs, Poverty Reduction Strategy Papers (PRSPs) and various global health initiatives, such as RBM. Likewise, the Commission on Macroeconomics and Health (CMH) report outlines the critical links between poverty and health. The report finds that malaria exerts a heavy toll on the health of the poor, and reducing the prevalence of malaria-related morbidity and mortality will help improve the overall health of poor individuals and households. Ministries of health and health professionals should build on this momentum and promote malaria prevention and control as a central component of community and national development. Based on this understanding of the links between malaria and poverty, health professionals must advocate effectively for increased resources for national malaria control programmes (NMCPs) to fill the funding gaps. Various international efforts to augment funding for malaria prevention and control are underway. Increased funding for the health sector is anticipated from debt relief granted under the PRSP process; GFATM has increased funding for malaria programmes and projects; and RBM aims to increase funding and build technical capacity for malaria prevention and control. The PRSPs for Cambodia, the Lao People's Democratic Republic and Viet Nam include malaria prevention and control. GFATM has provided funding for malaria control projects to eight countries in the Region. At the country level, a more efficient and equitable allocation of financial and human resources within the health sector—more
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specifically in malaria prevention and control programmes—will enhance the pro-poor impact of increased resources for malaria. More resources can allow health professionals to better tackle the burden malaria places on the poor. However, the multiple determinants of malaria that lie beyond the health sector also need to be addressed. A broad cross-sectoral strategy that is encouraged and coordinated by malaria prevention and control programmes to reduce inequalities in income, education attainment and nutritional status, among others, can enhance propoor malaria prevention and control initiatives. At the global level, the recently launched Commission for Social Determinants of Health aims to draw attention to the impact such social determinants have on producing and sustaining inequalities in health. The Commission's mandate includes recommending strategies to improve the health of the poor by addressing the social determinants of health.196 Nationally, PRSPs theoretically provide an example of a crosssectoral approach to tackling social determinants of health; PRSPs or any multisectoral planning instrument offer an opportunity to increase policy coherence and undertake joint planning to address the determinants of malaria within and beyond the health sector.197
Incorporating the goal of reducing gender inequalities into such policies and goals can help ensure that men and women benefit equally from malaria prevention and control programmes. These clearly defined objectives then might be used to guide all stages of policy and project design, implementation and monitoring. Improving the accessibility of malaria prevention and treatment for poor men and women is an important means of addressing inequalities in the burden of malaria. In other words, for poor and marginalized households and communities to benefit disproportionately from increased resources for malaria prevention and control and pro-poor goals and policies, interventions that more effectively reach poor and marginalized households and communities must be prioritized. The following section presents information on innovative strategies health professionals are employing to improve the accessibility and equity of malaria prevention and control for the poor. These interventions are still in their early stages, and have not yet been evaluated rigorously or standardized. However, they suggest some ways forward. Each strategy must be refined, based on further analysis and country-specific situations. Moreover, this list of strategies is not exhaustive, as the evidence base for pro-poor malaria prevention and control needs to be augmented through more systematic operational research. As discussed in Section 2, context-specific gender roles influence men and women's exposure to mosquitos, as well as their access to prevention and treatment for malaria. As a result, a gender perspective needs to be incorporated into the strategies outlined below—from the planning stage through implementation, monitoring and evaluation. This includes, among other things, addressing how gender norms might shape men's and women's access to prevention and treatment of malaria. For example, women's access to resources and decision-making power within the household determines, in part, their ability to purchase bednets. In particular, the strategies below need to be tailored to the local context in such a way to ensure that they do not reinforce existing gender norms. This includes reinforcing women's prescribed role as caregiver for sick
Integrate poverty and gender into malaria prevention and control Malaria-related goals and policies typically aim to reduce the burden of malaria among the population as a whole; malaria indicators are often expressed as national or population averages. Thus, these can be achieved without improving malaria morbidity and mortality among poor and marginalized households and communities. Goals and policies for malaria control programmes that are reformulated to clearly articulate a concern for marginalized groups, and are gender-sensitive, can more effectively guide efforts to reduce the burden of malaria among the poor. These can be expressed in terms of reducing inequalities in the burden of malaria, malaria-related morbidity and access to health services, as well as limiting the impoverishing effects of malaria-related illness and treatment seeking among the poor.
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family members, and assuming that women do not work and have ample free time to participate in community-based management of malaria or other volunteer outreach work.198 In some areas, the most effective approach might be to tackle gender inequities directly through initiatives that improve women's access to income, for example.199 Reduce geographic barriers
Box 6: BHWs improve access to malaria diagnosis and treatment in Agusan del Sur, the Philippines200 In Agusan del Sur, the Philippines, malaria diagnosis is available for free at RHUs. Yet, as RHUs are often difficult and expensive to access, self-treatment for malaria is common in this area. A survey of four villages found that parasite prevalence was significantly higher in the two villages without resident barangay health workers (BHWs) than in the two villages that had resident BHWs. Bednets were also more common in the villages with resident BHWs than in those without resident BHWs. The survey found that 49% of respondents in the villages with resident BHWs failed to access antimalarial drugs at least once, compared with 70% in the villages without BHWs. Lack of medicine was the explanation for not accessing antimalarial drugs in all four villages. In the two villages without resident BHWs, distance was also an important factor for not seeking treatment. Overall, the absence of a resident BHW was associated significantly with failing to seek treatment for malaria through the public health services and with using alternative herbal remedies. Notably, the mean education level of adults under 20 years old and income level in the two villages with no resident BHW was lower than those of villages with resident BHWs. Geographic and social distance (or kinship) were found to be the main determinants of BHW utilization. Difficulty in accessing BHWs, in turn, was associated positively with self-treatment.
Targeting malaria prevention and control strategies to poor, remote or underdeveloped areas and communities will improve the geographic accessibility of malaria control programmes for poor men and women. This might be particularly effective where distance to health facilities prevents people from seeking treatment for malaria-related illness. These might include ethnic minority communities dwelling in mountainous areas and remote island communities in the Pacific. This sort of targeting requires prioritizing investments for malaria in these geographic areas to improve the availability and quality of malaria prevention and control services. Another strategy to improve the physical accessibility of malaria prevention and control entails regular outreach services, which effectively bring ITNs, diagnosis and treatment for malaria closer to poor communities. Outreach services might be used to increase the coverage of ITNs and access to treatment for malaria in hard-to-reach communities. Outreach services might include regular health staff visits, mobile clinics and recruiting community health workers (Box 6). Outreach services might be tailored to meet the needs of specific sub-populations, such as ethnic minorities and migrants. Designing outreach services in coordination with community members will help ensure that these strategies are acceptable to communities, address gender-related barriers to access, and reach those most in need. Another means of expanding malaria prevention and control into underserved areas is by providing financial incentives to nongovernmental organizations (NGOs) and private providers. Providing subsidies to NGOs can expand malaria prevention and control effectively in underserved areas, as NGOs might be more accessible to the poor and
are often found in rural and remote areas.201 Forging partnerships with community groups can also ensure better sustainability. Similarly, in areas where the poor consult private practitioners, information dissemination and financial incentives might be employed to encourage private practitioners to provide the poor with higher quality affordable services, including quality antimalarial drugs. Prompt access to effective antimalarial drugs is a key component of malaria control programmes. Yet, as poor households are often beyond the reach of the public health care system, they might seek care instead from unregulated private practitioners or choose to self-medicate. Networks of community health workers have
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expanded the reach of public health care services, thereby increasing access to malaria diagnosis and treatment in numerous countries.202 Volunteer health workers with little or no education effectively treated malaria in Guatemala.203 Evidence also suggests that diagnosis and treatment are often more cost-effective when they occur in the community.204 In response, RBM developed a set of guidelines to make effective treatment available as near as possible to the home.205 In these guidelines, community-based management of malaria (called Home Management of Malaria) aims to "ensure early recognition of and a prompt and effective response to malaria illness in the home and community, especially for children under five years of age, in order to reduce morbidity and mortality arising from severe malaria." To achieve this goal, Home Management of Malaria seeks to: ! enable and increase the capacity of caregivers to recognize malaria illness promptly and take early appropriate action; ! empower service providers by imparting adequate knowledge, skills and capacity that enable them to respond to malaria illness appropriately; ! create an enabling environment for implementation.
Reduce economic barriers
Tailoring malaria control programmes to overcome economic barriers might facilitate access by the poor to prevention, diagnosis and treatment of malaria. Malaria control programmes can target poor households and communities based on a means test, broad characteristics (e.g., location) or membership in a vulnerable group (e.g., ethnic minorities, landless farm labourers or displaced persons). Once identified, such groups or areas need to be prioritized in the allocation of resources for malaria control. In particular, women are often targeted in such initiatives because they are viewed as making decisions concerning the welfare of their families. However, if payments for malaria prevention or treatment are required, an assessment of whether women have access to, or control over, the allocation of household income is needed. As a result, men and women might need to be targeted in malaria prevention and control. ITNs have proven effective in reducing malaria morbidity.208 In the Region, ITNs tend to be purchased privately. Since the cost of ITNs might be beyond the economic means of poor households, various strategies are being employed to improve the coverage of ITNs among poor households. Subsidized ITNs have been distributed effectively through:
Box 7: Extending accurate and prompt malaria diagnosis into hard-to-reach communities206 Microscopy-based diagnosis commonly is recommended for identifying malaria. Yet, health facilities in rural and remote areas might lack microscopes, electricity or the supplies necessary to perform accurate diagnosis consistently. In addition, health personnel might not be adequately trained to handle microscopes and slides. Such constraints lead to delays in diagnosis. In such situations, people might be deterred from seeking care and might choose to self-medicate instead.207 Rapid diagnostic tests (RDTs) are a recent innovation that, when used correctly, make quick, accurate diagnosis available to at-risk populations in hard-to-reach areas. As with microscopy-based diagnosis, the accuracy of RDT depends on the quality with which it is performed and interpreted. Thus, monitoring is required to ensure that health workers are properly trained in the preparation and interpretation of RDTs. Although RDTs might be more expensive than microscopic diagnosis, the opportunity to extend diagnostic capacity into remote communities might justify the additional cost, as it could reduce the costs of seeking treatment for poor patients. In Agusan del Sur, microscopy-based diagnosis for malaria was commonly delayed by several weeks. Despite minimal training, the BHWs produced accurate and timely results with RDTs. This allowed the BHWs to provide treatment promptly. Moreover the community preferred a blood-based diagnosis as soon as the illness was detected to a delayed diagnosis by microscopy or treatment based on symptoms alone.
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! routine antenatal care visits; ! contacts with the health care system, such
as on immunization days; ! sales at a subsidized price by the health care
communities.212 However, the cost of subsidized nets still might be beyond the reach of poor households.213 Therefore, distributing nets for free to the poorest households might be necessary. Evidence from Ghana and Zambia suggests that integrating the delivery of ITNs into measles vaccination campaigns might increase ITN ownership significantly. Moreover, the generally wide coverage of measles campaigns increased equity of coverage among poor and non-poor households in these countries. The coverage of ITNs increased by nearly 90 and 68 percentage points in the poorest quintile in Ghana and Zambia, respectively. The comparable increase among households in the wealthiest quintile was nearly 83 percentage points in Ghana and 58 percentage points in Zambia.214 Integrating ITNs into measles vaccine campaigns also reduces costs to households, as repeated trips to the health centre are not required.
system or community-based organizations to targeted consumers; ! coupons and vouchers, distributed to targeted households by the health care system, which are used to purchase ITNs commercially at a discount.209 Social marketing approaches have been employed in some countries to increase the coverage of ITNs (Box 8). Social marketing applies commercial marketing principles to promote products that have a social benefit.210 Data from a project in Tanzania shows that, although the cost of social marketing was higher than an approach relying solely on the commercial sector, it was more effective than the commercial sector in reaching poor households and those located in rural
Box 8: Reaching the poor with ITNs in Tanzania211 Population Services International and Ifakara Health Research and Development Centre used social marketing techniques to improve the coverage of ITNs in two rural districts of Tanzania. This social marketing project aimed to significantly increase the use of ITNs among pregnant women and children under 5 years old, and do so in a sustainable manner. Community participation was a central element of the project, influencing implementation strategies; the colour, size and quality of bednets; and promotional (IEC) materials. ITNs were distributed through a network of village retail agents, who were identified in partnership with the communities and wholesalers in each division. Retail agents included private shopkeepers, community leaders, health workers and priests. A dip-it-yourself kit for re-impregnation of nets was subsequently sold through the same network. The ITNs were sold for $5 (in 1997), which was near the cost of recovery. This price was set based on willingness-to-pay information solicited from the communities and experience gleaned through previous bednet projects. The sachets of insecticide for re-impregnation were sold for $0.42. Retailers and wholesalers received incentives once sales targets were met. This social marketing project combined the distribution of ITNs commercially with a voucher system to encourage coverage among pregnant women and young children. Discount vouchers were issued through maternal and child health clinics to women seeking antenatal care and care for children under 5 years old. The voucher, which was worth $0.50, could be used to purchase ITNs from commercial retailers at a reduced price. The retailers were reimbursed for each voucher with an added handling charge during subsequent orders. In the project areas, 73% of households had at least one net in 2000, compared with 37% in 1997. For the poorest income quintile, however, the coverage of ITNs rose from 20% in 1997 to 54% in 2000. In addition to the overall increase in ITN use in these rural districts, the proportional increase in coverage was highest among the poorest households.
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To remain effective, ITNs require reimpregnation every 6 months. In general, although re-impregnation is free in the Region, costs and logistics might prevent health care staff from reaching remote communities. In these communities, long-lasting impregnated nets might be a more cost-effective means of improving and sustaining protection against malaria. Even though the initial investment costs are high ($510), with an average lifespan of roughly 5 years, long-lasting impregnated nets might be more efficient and effective than ITNs in such communities. The direct, indirect and opportunity costs of seeking treatment for malaria might be more than poor households can bear. Thus, strategies designed to reduce the economic burden of diagnosis and treatment at the time of illness might improve access for the poor. In areas where public health facilities do not offer free malaria diagnosis and treatment, a system of exemptions or graduated fees can be introduced to improve access for the poor. Exemptions authorize non-payment of fees for specific patients, based on personal characteristics or membership of a marginalized group. The most direct way to identify poor households is through a means test, a direct assessment of an individual's capacity to pay. Lower fees (graduated frees) might be charged for diagnosis and treatment of malaria offered in locations or by service providers frequented almost exclusively by the poor. However, even the lowest fees might discourage the poor from accessing services. Prepayment schemes spread the cost of seeking care according to ability to pay. One type of prepayment scheme that has succeeded in developing countries is community health insurance, which spreads the financial burden of ill health among households over predictable periods. However, evidence suggests that even community-based schemes tend to miss the poorest of the poor who subsist day to day.215 Enablers (in cash or kind) for patients from particularly marginalized groups to offset the indirect and opportunity cost of seeking treatment also might be considered. The distribution
of free ITNs might improve equity in coverage, if the poor are targeted explicitly. The protection offered to the poor by prepayment schemes might be enhanced through a concerted effort to reduce unofficial fees charged by health professionals, which can be particularly harmful to the poor. Box 9: Experience with revolving funds in Lao People's Democratic Republic216 In 1998, the Asian Development Bank (ADB) funded the Lao Primary Health Care Project, which introduced revolving funds for bednets and insecticide into villages in the provinces of Oudomxay and Xiengkhoang. The project financed the supply of bednets and insecticide during the first year, and insecticide only during the second year. In the third year of the project, villages were expected to be able to supply insecticide from the revenues accumulated through the revolving fund. The design of the revolving fund was based on 100% cost recovery. Of the amount in the fund, 40% was allocated to provide insecticide for the poor. In 1998, large bednets sold under the project cost $6.83, while small nets cost $6.64. These prices, which included dipping, remained below the market price. The price of dipping was $1.26 for large nets and $1.06 for small nets. Although the revolving funds generated a considerable amount of money, they brought in only a fraction of the expected revenue. Outstanding debts, limited management and accounting skills, and a general lack of clear guidelines hampered the success of the revolving funds. Improve information and communication to stimulate demand
IEC strategies might increase the poor's knowledge and awareness of malaria effectively. Enhanced awareness and understanding of how malaria is caused and transmitted, as well as where and when to seek preventive and curative services, might lead to behavioural changes that reduce exposure to mosquitos and increase demand for prompt malaria treatment. Concerted efforts are likewise required to ensure that people understand the importance of re-impregnating ITNs.
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IEC strategies and messages need to be tailored carefully to ensure that they reach poor and marginalized groups. This might include the creation and dissemination of illustrated messages for individuals with low literacy levels. Culturally appropriate IEC messages delivered in the local language are also required to ensure that the messages are acceptable for marginalized communities, including ethnic minorities. Health staff or community-based health workers likewise might undertake outreach strategies to increase knowledge and awareness among hard-to-reach groups. Gender issues relating to exposure to mosquitos and accessing malaria diagnosis and treatment also can be tackled through IEC campaigns. The message and medium should be accessible to women who might face particular constraints in accessing information. For example, interpersonal IEC strategies might be more appropriate when targeting women, as they might have less access to print media than men. Involving the community, poor individuals and women, in particular, in the design and implemen-
tation of information campaigns can increase the likelihood that local knowledge, priorities and needs are understood and subsequently addressed. When seeking to mobilize community participation in IEC campaigns, poor and marginalized voices, including those of women, must be heard. Poor members of the community and women otherwise might be excluded from community decision-making processes. The opinions of these groups might be solicited in separate forums to ensure that they are willing and able to speak. Scheduling community meetings at a convenient time for women will facilitate this process. Improve health system responsiveness
Public sector: In many areas, the actual or perceived low quality of health services might deter the poor from seeking care for malaria in public health clinics. Improved system responsiveness and quality service delivery will help meet the increased demand for health services stimulated by IEC strategies and targeted malaria control programmes, maximizing the impact of such
Box 10: Reaching ethnic minorities with appropriate and effective IEC Using a participatory approach to IEC development, the countries in the Greater Mekong subregion have created IEC materials tailored to meet the needs of hard-to-reach ethnic minorities living in border communities. Although ethnic minority communities in the subregion are not uniformly poor, they tend to be marginalized and vulnerable. Further, conventional IEC strategies tend to miss them. The Mekong Roll Back Malaria Information, Education and Communication Project, which is implemented in partnership with ADB and WHO, uses community-based participatory approaches to produce IEC strategies and materials that are appropriate for specific ethnic communities and local situations. The country projects involved actors from different sectors to ensure that the IEC materials developed were as meaningful and comprehensive as possible. Although participatory processes for IEC development tend to be longer and more involved than conventional top-down approaches, the outcomes of participatory approaches have been found to be more appropriate and locally owned. In China, for example, marginalized ethnic communities in Yunnan Province were identified as the target population for the project, namely the Wa, Lahu and Dai peoples. These ethnic groups reside in remote areas, where locally appropriate IEC materials generally are lacking. IEC materials were designed to communicate two primary messages—prompt and effective treatment-seeking behaviour, and proper use of bednets and ITNs—in combination with a number of secondary messages, such as signs and symptoms of malaria, prevention, etc. IEC materials included a video, story booklets, posters, teachers' manuals and educational flipcharts. Participatory approaches were used to guide the production of these materials. For example, Wa leaders participated in creating the storyline of the video. These IEC materials will be disseminated in eight townships and 366 villages in Ximeng Wa autonomous county, covering approximately 80% of the Wa population.217
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strategies. This might include changing staff attitudes, communication skills, and the general quality of services provided; decreasing waiting times; and increasing confidentiality. In particular, efforts should be made to increase awareness, sensitivity and skills of health care providers in dealing with poor and marginalized communities. This would help ensure that all clients, especially the poor and women, are treated with dignity and respect. Disseminating information on quality improvements and ensuring transparency of health fees would enhance this initiative. Private sector: In many countries, private practitioners are active in malaria diagnosis and treatment. Ensuring that private practitioners comply with malaria control guidelines will help improve the quality of malaria diagnosis and treatment. Private practitioners frequented by poor individuals, such as low-cost and traditional providers and drug sellers, should be included in such initiatives. Box 11 shows such an initiative in Cambodia. Box 11: Bringing private practitioners into the National Malaria Control Programme in Cambodia218 Poor Cambodians frequently seek care for malaria from the unregulated private sector, which poses a challenge to malaria control in the country. Poor individuals tend to bypass the public health care facilities in favour of private practitioners, traditional healers and self-treatment. Founded in 2003, the Society for Malaria Control in Cambodia (SMCC) is an NGO that aims to incorporate private health care providers—many of whom do not have formal training—into the National Malaria Control Programme. In partnership with the national and provincial governments, SMCC collects, monitors and evaluates malaria-related information from nearly 200 private practitioners in Kampot, Pursat, Pailin and Stung Treng provinces. SMCC has introduced the Malaria Information Register, which records the name, age, sex, occupation, symptoms, severity, diagnosis, treatment dosage and results for each patient. SMCC staff regularly visit private practitioners to check the register and to ensure that the national treatment guidelines for malaria are being followed.
In monitoring and evaluation, disaggregate the collection and analysis of information
Despite the growing recognition of ongoing and often increasing health inequities in developing and developed countries alike, health information systems (HIS) have been weak in yielding information needed to assess and address these inequities. The challenges are to ! determine the information needs for addressing health inequities ! shape health information systems to meet those needs ! promote sensitization to equity issues ! develop the skills required to use information for effective planning and policymaking.219 The Health Metrics Network (HMN) has begun work on constructing equity indicators and creating mechanisms to link records between data sources.220 Complementary measures to the global HMN for malaria prevention and control can be undertaken at the country level. An important constraint in tackling inequalities in malaria is the lack of disaggregated data at the national and subnational levels. Disaggregated data are required to assess and analyse the extent of inequalities in malaria, as well as to monitor changes over time. Likewise, disaggregated data are required to identify priority areas and interventions that will benefit the poor. Thus, data collected routinely within national malaria control programmes should be disaggregated and analysed to the extent possible by social exclusion indicators, such as socioeconomic status, gender, urban-rural location, ethnicity, region or province, educational level, occupation, or other indicators of disadvantage identified through a poverty analysis. Monitoring and evaluation also should consider these variables. This might be supplemented with appropriate research, including quantitative data collection, to assess the unmet need, perceived quality of servers, and various financial and non-financial barriers the poor might face when seeking to access prevention and treatment for malaria.
How can health professionals address poverty and gender concerns in malaria control?
5. Facilitator's notes
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5. Facilitator's notes hese notes are provided to support facilitators as they work with learners on integrating poverty and gender issues into specific health topics. Facilitators are recommended to refer to Section 5 of the foundational modules of this Sourcebook, dealing respectively with poverty and gender, which contain additional notes on the target audience, role of the facilitator and suggested methodologies for learning sessions and for evaluation. The learning sessions and exercises that follow are practical and oriented toward active learning. They are designed to promote group discussion and presentation in analysing malaria in terms of gender, poverty and other factors that determine exposure to, and prevention and treatment of, malaria in local areas. The time required for all learning sessions is approximately 16 hours.
T
epidemiology, transmission, prevention and management of malaria within the context of gender and poverty and related socioeconomic, cultural and behavioural factors. Suggested exercises: Before the session, ensure that malaria references and relevant statistical data, studies and publications are available in the library or nearby health offices. Also ask vector-borne disease personnel, researchers and laboratory personnel to be available for visits by groups of participants. Ask participants to work in small groups to consider the extent of the local malaria situation and methods of gathering data to answer key questions about the extent of the problem. Each of the groups is asked to focus on one of the four sets of questions found in Box 12 from a poverty and gender perspective. The groups are to identify all possible information sources to assess the extent of the malaria situation locally, and to gather, analyse and summarize relevant data, using all available resources. After the groups have had sufficient time to gather and analyse data, ask each one to present its findings to the whole group for discussion, using flipcharts or transparencies to illustrate key findings. Beforehand, place the following issues and questions on the board or flipcharts, and facilitate a discussion of them by participants during the plenary discussion. ! What are the possible gender differences in exposure to mosquitos? 6 Why do these differences exist? ! What are the possible gender differences in access to malaria prevention and control? 6 How do these influence malaria prevention and control programmes? ! How do poverty and vulnerability influence exposure to vectors and access to prevention and treatment for malaria? ! What sociocultural and behavioural factors influence vector exposure and access to prevention and treatment for malaria?
Expected learning outcomes Upon completion of the module, participants will be able to: 1. Demonstrate an understanding of malaria, including symptoms, transmission and disease burden, as well as general principles of prevention, control and treatment. 2. Demonstrate an understanding of WHAT the links are between poverty, gender and malaria. 3. Explain WHY it is important for health professionals to address poverty and gender concerns in relation to malaria 4. Indicate HOW health professionals and the health system as a whole can address poverty and gender in malaria prevention, control and treatment. 5. Demonstrate familiarity with some tools, resources and references available to support health professionals in dealing with poverty and gender in malaria prevention and control.
Suggestions for workshop sessions on poverty, gender and malaria Session 1: Gathering and analysing information about malaria in your area
Objective: Participants will have increased awareness and understanding of the local
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Box 12: Group work questions to describe the local malaria situation 1. Extent of the problem ! How common is malaria in the area and how serious is it? ! How big is the population (to determine the total number of people at risk)? ! Who is affected by malaria? ! How many are sick from malaria (percentage of all outpatient attendance due to malaria), how seriously, and how many deaths are caused? ! What are the causes of malaria illness and death (by age and sex)? ! What are the characteristics of people who are at the greatest risk for malaria? ! Who is most affected? ! Are some groups or areas affected more than others? ! Epidemiological characteristics—endemic, stable, perennial, seasonal? ! Is the situation getting better or worse compared to previous years? 2. Why it happens (medical causes and non-medical factors, such as poverty, gender, and living patterns and conditions) ! What environmental/ecological areas and factors influence malaria in the local area? ! What economic, occupational and work habits influence malaria locally? ! How do these differ among men and women and poor and better-off households? ! Do the economic, occupational and work habits that influence malaria locally vary seasonally? ! What are the social factors and living conditions—including types of dwellings, sleeping habits and other factors—influencing malaria locally? ! Does migration influence malaria in the area? ! Why is the malaria situation getting better or worse? 3. Why it happens (local biological features of malaria vectors) ! What Anopheles species and malaria vectors are in the area? ! What are the breeding sites of mosquitos, resting locations; feedingtimes/location and host preferences? ! How susceptible are the mosquitos to insecticides? ! Why is the malaria situation getting better or worse? 4. Community health services (use and quality) ! What is the situation with bednets coverage, the quality of bednets, and reimpregnation of bednets? ! Are bednets provided free, subsidized or available commercially? ! Among families who have bednets, who sleeps under a bednet regularly? ! Are bednets taken and used when family members work and sleep away from their house? ! Are bednets re-impregnated regularly? How is re-impregnation financed? ! Are diagnostic services and anti-malarial drugs available? ! Are people in the community accessing diagnosis and treatment services? ! Are they reliable and of good quality? ! Are treatment guidelines followed? ! How are diagnosis and treatment financed? ! How far and for how long must people travel to access diagnosis and treatment for malaria? Does this vary at different times of the year, i.e., dry and rainy seasons? ! What are the costs associated with malaria prevention, diagnosis and treatment? ! What types of health promotion interventions are carried out for malaria prevention and control?
Conclude the plenary discussion by summarizing the data presented by each of the groups, asking participants how poverty and gender influence malaria risks, as well as malaria prevention and treatment.
Session 2: Involving the community in information gathering
Objective: Participants will have gained a greater understanding and appreciation for community
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perspectives, understanding and values about malaria. Also, they will be able to address information gaps between health service data and community perspectives. Suggested exercises: Before the learning activity, work with a local community that is endemic for malaria and plan the learning experience with community representatives or leaders, asking them to identify subgroups within the community to meet and talk with participants about the local malaria situation. Community members should be grouped according to gender, age, socioeconomic status or ethnicity, for example. Make arrangements in advance for community members to meet with participants in a quiet and relaxed setting. Link Session 2 with the information gathered in Session 1 by providing a written flipchart summary of the local malarial situation, with verbal highlights of the identified links to poverty and gender factors. Provide participants with local, practical survey tools or group discussion questions, such as the tool listed in Box 13, to gather information from different groups in the community about malaria. Emphasize how such data gathering or operational research provides the community with an opportunity to understand its own health problems better and to play an active role in addressing these problems. The data to be gathered fall into five basic categories: ! Knowledge and perceptions: what people know about the causes of malaria, high fever and fits. ! Attitudes: what people think of mosquito nets; where they prefer to go for treatment. ! Practices: what people do to prevent or manage malaria; activities that increase or decrease the risk of malaria. ! Obstacles: constraints or things preventing people from taking actions, such as why they might be unable to give or take medicines; why women might not sleep under mosquito nets, etc. ! Sources of information: who do people listen to for advice about malaria; do they believe health workers, traditional healers, chemists, or others?
Divide participants into small groups. A representative of each group draws a piece of paper from a box that lists the community group they will meet with. Following the discussion with community groups, participants analyse the data by identifying the range of answers to each question and the related percentages of responses. For example, participants might learn that 50% of men and women do not know clearly the biomedical causes of malaria. The groups of participants plan and deliver a presentation to the whole group, to which community representatives are invited. During the plenary presentation, ask participants, including community representatives, a variety of questions to deepen their mutual understanding of the analysed data. Such questions might include, but are not limited to, the following: ! Compare and contrast the differing perceptions of malaria among the different groups of community members, e.g., adult community members, health workers, children and elderly community members; ! Why do these groups have different understandings of malaria, i.e. children and adults, men and women? ! Why are persons who might have a poor understanding of the causes of malaria using bednets? ! How do the answers of household heads (often a male) differ from those of caregivers, mothers or women, the rest of the family? ! Do the groups rely on different sources for information on malaria? Why might this be so? ! How might community elders and school children play an important role as agents of change in making decisions and plans to address the malaria problem? ! What can be done to improve communication and understanding between health providers and the community? During the conclusion of the summary presentation, ask participants to use and apply the information carefully as the community members and groups interviewed might be insufficient in
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Box 13: People's knowledge, beliefs, attitudes and practices about malaria221 Question Does malaria have a local name? What is the cause of (insert local term for malaria)? How do people get (insert local term for malaria)? What are the symptoms of (insert local term for malaria)? Can you prevent (insert local term for malaria)? If so, what do you do for prevention? Who makes decisions about adopting preventive measures for (insert local term for malaria)? What makes prevention difficult? How much do you pay for prevention? Do you have any bednets? If so, how many and do they meet the needs of your family? How much do bednets cost? Is your bednet impregnated? How much does reimpregnation cost? If so, do you use the bednet regularly? Why or why not? If you do have a bednet, what is the condition? If you do not have any bednets, would you buy one? How much would you be willing to pay for a bednet and where would you buy one? Where do you go first for treatment of (insert local term for malaria)? Why? If you are not cured after this treatment, where do you go next? Why? Who makes decisions about when and where to seek treatment? How far do you travel for treatment? What type of transportation do you use? How much does transport cost? How much does diagnosis and treatment cost? Are there any other costs? What do you think of the quality of treatment from different sources? Do you have ideas how to improve (insert local term for malaria) prevention and control? If yes, what are they? Where do you get information on malaria? Does your community have any health committees? Do they meet regularly? What is discussed during these meetings? Community/group response
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number and breadth to draw firm conclusions on the full extent of the malaria situation. Session 3: Who else can health professionals work with to address the poverty and gender aspects of malaria recognition, prevention and control?
Objective: Participants will identify who else they can work with to address poverty, gender and malaria, including community members. Suggested exercises: Provide a summary of the local malaria situation, including the community data provided by representatives of the community. Invite ministerial or provincial health leaders, educators, traditional healers (if relevant) and community representatives to join the session. Divide the participants into smaller groups, ensuring that each smaller group has at least one external participant. Ask the groups to brainstorm to develop a list of all persons, agencies, NGOs and key community representatives, including persons living in economic difficulty and women and men, whom they might partner with to address poverty, gender and malaria. Partners might be from within and beyond the health sector. Ask each of the small groups to present their list of “partners” to the whole group. Ask each small group to consider how to address some of the key poverty, gender and malaria issues and needs identified in the situational assessment. Provide a handout to guide the group work, which highlights key poverty- and/or gender-related issues identified within each of the following categories
of interventions: ! IEC needs, including differing knowledge, beliefs and practices among men, women, children, and ethnic groups, about the causes and management of malaria; the community literacy rate; knowledge of official language; ! Protection, including insecticides, insecticide-treated bednets, beliefs about bednets, access to and costs of bednets, conditions of the bednets, local production of treated bednets, repair capabilities; ! Early diagnosis and treatment, including family decision-making regarding care seeking; access to and cost of care; social and economic constraints; access to highquality anti-malaria drugs; health workers competencies, training and supervision; diagnostic tests, etc. After all groups have had sufficient time to discuss the interventions, each group presents its findings to the larger group. Summarize the session by highlighting the socioeconomic factors (gender, poverty, ethnicity, remoteness), community partnerships and locally tailored approaches to be taken into account when designing effective malaria prevention and intervention programmes. Session 4: Wrapping up
The facilitator reviews exposure, prevention, diagnosis and treatment, highlighting again the importance of locally tailored approaches for effective malaria control programmes that are sensitive to gender, poverty and ethnicity.
Facilitator's notes
6. Tools, resources and references
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6. Tools, resources and references Malaria resources The Global Fund to Fight AIDS, Tuberculosis, and Malaria: http://www.theglobalfund.org/en/ PREMA-EU, Malaria and Anaemia in Pregnancy: http://www.prema-eu.org/ Roll Back Malaria Partnership:http://www.rbm.who.int/cgi-bin/rbm/ rbmportal/custom/rbm/ home.do Special Programme for Research and Training in Tropical Disease (TDR): http://www.who.int/tdr/ World Bank: www.worldbank.org World Health Organization: http://www.who.int/topics/malaria/en/
Malaria, poverty and gender resources Liverpool School of Tropical Medicine and Hygiene, The Malaria Knowledge Programme: http://www.liv.ac.uk/lstm/majorprogs/malaria/outputs.htm ID21 www.id21.org has a useful section on infectious diseases under the section on health. Searching for "malaria" yields a number of resources. World Health Organization, Gender, Women and Health: http://www.who.int/gender/en/ World Health Organization, Gender, Women and Health tools for gender mainstreaming: ! 'En-gendering' the MillenniumDevelopment Goals (MDGs) on Health: http://www.who.int/gender/ mainstreaming/MDG.pdf ! Gender Analysis in Health: A Review of Selected Tools: http://www.who.int/ gender/documents/en/Gender.analysis.pdf
Planning checklists The following checklists aim to assist health professionals in addressing poverty and gender in malaria prevention and control programmes. The checklists are not exhaustive; they are intended to suggest some poverty and gender-related issues that need to be considered when planning and implementing malaria prevention and control programmes. A few more issue-specific examples, such as those concerning prevention of malaria, are provided in boxes. In particular, discussing many of the points raised below with the affected communities is often useful. For an overview of possible survey methods, including participatory approaches, please see the Foundational Module on Poverty in this series. General considerations
Poverty ! What are the general socioeconomic conditions in the community, including distance to markets? ! What are the literacy rates in the affected communities? ! Can individuals in the community communicate in the national language? ! Are household incomes seasonal? ! Do households have regular access to cash income?
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! ! ! !
What are the types of dwellings in the communities? Are families living in the area temporarily or permanently? Do families or family members migrate seasonally? How accessible are forms of mass media? For example, do households possess radios or televisions?
Gender ! Do women face constraints on their mobility outside of their households or communities? ! Do men and women have different access to household income? ! Do men and women play different roles related to illness, e.g., detection of illness, response to perceived illness? ! What are men's and women's understanding of malaria and beliefs concerning severity, ability to prevent, ability to treat (differences between women and men); differences among ethnic groups? Box 14: Checklist of people's understanding about malaria Sociocultural factors influence whether people adopt preventive measures and seek prompt treatment for malaria. Find out: ! What people know and think about malaria ! What local terms are used to describe malaria symptoms ! Whether people consider malaria an important health problem ! Whether other health issues are a greater priority ! What people do to prevent malaria or to protect against mosquitos The answers to these and other possible questions can help shape local IEC messages and the best way to promote prevention and treatment for malaria. For example, finding out if communities traditionally use bednets is useful.222 Exposure to mosquitos
! What are women's and men's (and girls' and boys') seasonal activities, and how do they influence their exposure to mosquitos? Prevention of malaria
Poverty ! Are bednets available commercially? If so, which households can afford to purchase them? ! Do households need extra bednets (or hammock nets) to take with them for overnight stays at their fields or in the forest? ! Would they have the cash available to get all their nets regularly impregnated? ! Are impregnated nets acceptable to them (i.e., any objections to smell, chemicals, etc.)? ! Even if they don't want to use treated nets, would they be willing to use untreated nets? ! Where could they get their nets re-impregnated if the service is not available locally? ! How well are nets maintained? ! How long do nets of a certain quality last in the villages? ! If people need new or additional nets, are they available nearby and at "reasonable" cost? ! Would spraying with residual insecticides be an extra cost for poorer households? Can they afford such additional costs? Gender ! When is the best time for most villagers to get their nets impregnated?
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Box 15: Checklist of factors affecting community payment for bednets The Insecticide Treated Net Projects: A Handbook for Managers223 explains that when the introduction of bednets seems to be a feasible and effective malaria prevention strategy based on local epidemiological and sociocultural factors, economic issues can affect the sustainability of such initiatives. In addition to possible sources of external funding for bednets, factors affecting community payment for bednets need to be considered. These include: ! Ability and willingness to pay, which is determined by how much money people have available and whether they want to spend their money on bednets. Assessing how much households currently spend on malaria prevention and treatment might provide an indication of ability and willingness to pay. ! Seasonality of income. In rural communities, households might have cash income only after the harvest season, and this can affect their ability to pay for bednets at other points during the year. Seasonality of income also might affect whether households have enough cash to pay for bednets in a single payment or require a system that allows instalments. ! Existing community financing schemes might be used to finance bednet purchases; other funding mechanisms might include local cooperatives or private sector schemes.
! If nets have been provided for free, does this have an impact on women's/men's use and/or maintenance of the nets? ! Will women ensure that their infants and small children are resting and sleeping under nets when mosquitos are biting? ! Will women sleep under a net? What might prevent them from doing so? ! Do women understand the crucial importance of preventing infection when they are pregnant? ! Can women be provided nets when (if) they attend antenatal services? ! Do women know how to properly use (tuck under mattress, avoid contact with sharp edges) and maintain a net (mending holes, putting net up during daytime)? ! What to do when people do not have mattresses and sleep, for example, on a bamboo floor with holes where mosquito can bite from below? ! Do women know that they should wash an impregnated net as little as possible to avoid the washing out of the insecticide? ! If they wash an ITN, do they know they should not dry it in the sun as this might negatively affect the insecticide? ! Do the clothing men and women wear offer them differing levels of protection against mosquitos? Do men or women use smoky fires in the home often, thereby protecting themselves from mosquitos? ! If small pools of water close to human settlements should be drained, whose work is this? ! Would it be among women's tasks? ! Do they have time for this work? ! Do they understand the importance of the tasks (i.e., do they understand the connection between mosquitos and malaria)? ! Are they able to enlist their husbands' help? ! Are such decisions required from the community leaders? ! Who can decide to let a team come into the house to spray with residual insecticide? Treatment for malaria
Poverty ! What is the cost of seeking care for malaria and how does this compare to local levels of income?
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! Are health care services available? How far must poor families travel to access health care and what is the cost of this travel? ! Are they of good quality? ! Are health care providers sensitive to the needs of poor families? ! How do local attitudes and beliefs influence health seeking behaviours for malaria? Gender ! What are women's and men's perceptions of past treatment events involving suspected/ confirmed malaria (with different health service providers or self-treatment), including the diagnosis and treatment of malaria? ! Are more men than women (or vice versa) seeking care for malaria at health facilities? Why is this? Prophylaxis among women: ! How can pregnant women be reached if they do not attend antenatal clinics? ! Are there any food taboos, or taboos about leaving the community, which would prevent them from accepting such treatment? ! Is it possible to provide mobile services to pregnant women in endemic areas? What kind of information system would be needed to know where to provide these services? ! Is it possible to combine services for outreach? Box 16: Checklist for integrating gender analysis into malaria programmes The following broad questions outlined in the Canadian International Development Agency Policy on Gender Equality offer some guidance on how to integrate a gender analysis into malaria prevention and control programmes:224 What to ask includes: ! Who is the target, who will benefit and who will lose? ! Have women been consulted and involved in development of the solution? ! Does the intervention challenge the existing gender division of labour, tasks, responsibilities and opportunities? ! What is the best way to build on the government's commitment to the advancement of women? ! What is the relationship between the intervention and other action and organizations? ! Where do opportunities exist for change? ! What specific ways can be proposed for encouraging and enabling women to participate despite their traditionally more domestic location and subordinate position? ! What is the long-term impact regarding women's increased ability to take charge of their lives and to take collective action to solve problems? What to do includes: ! Gain an understanding of gender relations, the division of labour and who has access to, and control over, resources. ! Include domestic (reproductive) and community work in the work profile. ! Use participatory processes and include a wide range of female and male stakeholders at the governmental and civil society level, including women's organizations and gender equality experts. ! Identify barriers to women's participation and productivity; gain an understanding of women's practical needs and strategic interests; and identify opportunities to support both. ! Consider the differential impact of the initiative on women and men, and identify consequences to be addressed. ! Establish baseline data, ensure sex-disaggregated data, set measurable targets and identify expected results and indicators. ! Outline the expected risks (including backlash), and develop strategies to minimize these risks.
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ENDNOTES World World Bank 2004. United Nations Development Programme 1995. 3 Malaria Fact Sheet. Roll Back Malaria. 4 Ibid. 5 World Health Organization Regional Office for the Western Pacific 2001. 6 World Health Organization Regional Office for the Western Pacific 2003. Globally, P. falciparum is the most common species in tropical and subtropical areas, while P. vivax is responsible for over half of the malaria transmitted outside of Africa (Mendis K. et al. 2001). 7 Malaria Fact Sheet. Op cit. Ref 3. 8 Warrell D., Gilles H. 2002. 9 Ibid. 10 World Health Organization and United Nations Children's Fund 2005. 11 The DALY is a health gap measure, which combines information on the impact of premature death and of disability and other non-fatal health outcomes. One DALY can be thought of as one lost year of healthy life. 12 Guerin PJ. et al. 2002. 13 Lightfoot C., Ryan T. 2001. The vulnerability of many Pacific Island developing nations to external shocks (including natural disasters and market failures) and their small resource base have led to their inclusion among Least Developed Countries. Please see the United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States for more information on Least Developed Countries: http://www.un.org/specialrep/ohrlls/ldc/default.htm. 14 United Nations Development Programme Op cit. Ref 2. 15 Lampietti J., Stalker L. 2000. 16 Gwatkin D., Guillot M. 2000. 17 Barat L. et al. 2004. 18 The World Bank Country Classifications divides economies according to 2004 GNI per capita, calculated using the World Bank Atlas method. The groups are: low income, $825 or less; lower middle income, $826-$3,255; upper middle income, $3,256$10,065; and high income, $10,066 or more. Available at http://www.worldbank.org/data/countryclass/ countryclass.html (accessed 27 July 2005). 19 United Nations Development Programme 2004. The human development index of these countries is as follows: Cambodia, 0.568; Lao People's Democratic Republic, 0.543; Solomon Islands, 0.624; and Vanuatu, 0.570. 1 2
UNDP human development index. Available at http://hdr.undp.org/statistics/data/indic/indic_8_ 1_1.html (accessed 11 August 2005). 21 Asian Development Bank 2005. 22 World Health Organization Regional Office for the Western Pacific Op cit. Ref 5. 23 Malaria epidemiology. World Health Organization Regional Office for the Western Pacific; United Nations Country Team in China 2004. 24 United Nations Country Team in Malaysia 2005. 25 Committee for Population, Family and Children [Vietnam], and ORC Macro 2003. 26 Mohdeen R. 2002. 27 Worrall E., Basu S., Hanson K. 2003. 28 Filmer D. 2001. 29 Sychareu et al. 2000 in Worrall E., Basu S., Hanson K. Op cit. Ref 27. 30 Butraporn P., Sornmani S., Hungsapruek T. 1986. 31 Espino F. et al. 1997. 32 The HDI is a composite indicator that captures the most basic human capabilitiesgood health, knowledge and access to resourcesby measuring three variables: life expectancy, educational attainment and income. 33 United Nations Development Programme 2003. 34 United Nations Country Team in Viet Nam 2003. 35 United Nations Country Team in Viet Nam 2002. 36 United Nations Development Programme 2001. 37 Asian Development Bank 2002b. 38 Van Nam N. et al. 2005. 39 Asian Development Bank 2001. 40 United Nations Country Team in Malaysia Op cit. Ref 24. 41 United Nations Development Programme Op cit. Ref 33. 42 Walford V. 2000, Asian Development Bank Op cit. Ref 37; Asian Development Bank 2002d. 43 United Nations 2002a. 44 Lao People's Democratic Republic 2003. 45 World Health Organization Regional Office of the Western Pacific Op cit. Ref 6. 46 Phetsouvanh R. et al. 2004. 47 Migration and resettlement of ethnic minorities is a complex issue in some countries in the Region. See for example, Alton C., Rattanavong H. 2004. 48 After migration to the lowlands areas, the incidence of the three major disease types increased dramatically: hemorrhagic fevers, especially malaria and dengue; upper respiratory diseases; and gastrointestinal disease such as diarrhoea (Alton C., Rattanavong H. 2004). 49 Lindsay S. et al. 2003, Gunawardena D.M. et al. 1998, 20
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50 51 52 53
54
55 56 57 58
59
60 61 62 63 64 65
66 67
68
69 70 71 72 73
74 75 76 77 78 79
Konradsen F. et al. 2003, Butraporn P., Sornmani S., Hungsapruek T. Op cit. Ref 30., Phetsouvanh R. et al. Op cit. Ref 46. Gamage-Mendis A. et al. 1991. Van Nam N et al. Op cit. Ref 38. Ghebreyesus T.A. et al. 2000. Alton C., Rattanavong H. Op cit. Ref: 47; Espino F. et al. Op cit. Ref. 31. Erhart A. et al. 2004b; Espino F. et al. Op cit. Ref. 31, Butraporn P, Sornmani S, Hungsapruek T. Op cit. Ref 30. Ibid. Espino F. et al. Op cit. Ref 31. Malaria epidemiology. Op cit. Ref 23. ACT Malaria. Available at http://www.actmalaria.org/index.php3?page=malar ia (accessed 11 August 2005). World Health Organization 2002b. Iron deficiency is one of the most prevalent nutrient deficiencies affecting an estimated 2 billion people. This is because of the high iron demands of infant growth and pregnancy. Caulfield L. et al. 2004. Williams T.N. et al. 1997. Shankar A. et al. 1999. Shankar A. et al. 2000. Gebert R. (unpublished). World Health Organization and United Nations Children's Fund Op cit. Ref 10. Urban/rural data: net and ITN usage from seven surveys, net possession from one survey; poorest/least poor households data: net and ITN usage from five surveys, no surveys available on net or ITN possession. Countries surveyed: Azerbaijan, Indonesia, Iraq, Lao People's Democratic Republic, Tajikistan, Timor-Leste and Viet Nam. McCombie S. 2002. United Nations Development Programme 2001 Op cit. Ref 36. McCombie S. 1996 in Worrall E., Basu S., Hanson K. Op cit. Ref 27. Oum S., Chandramohan D., Cairncross S. 2005. Malaria Epidemiology. Op cit. Ref 23. Worrall E., Basu S., Hanson K. Op cit. Ref. 27. Hsiao W., Liu Y., In: Evans T. et al. (eds.) 2001. United Nation 1996 in Asian Development Bank Op cit. Ref 39. Asian Development Bank Op cit. Ref 39. Asian Development Bank 2004. United Nations Op cit. Ref 43. Asian Development Bank Op cit. Ref 39. Van Nam N et al. Op cit. Ref 38. Muller I. et al. 1998.
United Nations Development Programme Op cit. Ref 36. 81 Van Nam N. et al. Op cit. Ref 38. 82 Espino F. et al. Op cit. Ref 31. 83 Bell D. et al 1997. 84 Chima R.I., Goodman C., Mills A. 2003. 85 Ettling M.B., Shepard D.S. 1994; Hanson K., Jones C. 2000. 86 National Institute of Public Health, Cambodia and Malaria Consortium, 2005. 87 Bell D et al. Op cit. Ref 83. 88 Asian Development Bank 2000. 89 Espino F. 1992 in McCombie S. 1996. 90 Ibid. 91 Filmer D. Op cit. Ref 28. 92 See McCombie S. 2000 for a review of the literature on self-treatment for malaria. 93 Espino F., Manderson L. 2000. 94 Espino F. et al. Op cit. Ref 31. 95 Espino F et al. Op cit. Ref 31; Dulhunty et al. 2000. 96 The costs for malaria patients were calculated based on the direct costs of consultation fees and payments for drugs, the indirect costs of transportation and food, and the opportunity costs associated with lost productivity or lost income. 97 Jackson S., Sleigh A., Liu X. 2002. 98 Committee for Population, Family and Children [Vietnam], and ORC Macro. Op cit. Ref 25. 99 Uza M. et al. 2002. 100 Bell D. et al. Op cit. Ref 83. 101 Gebert R. Op cit. Ref 64; Espino F. et al.Op cit. Ref 31. 102 Gebert R. Op cit. Ref 64. 103 Espino F. et al.Op cit. Ref 31. 104 McCombie S. Op cit. Ref 66. 105 Espino F., Manderson L. Op cit. Ref 93. 106 McCombie S. Op cit. Ref 66. 107 Bell D. et al Op cit. Ref 83. 108 Gebert R. Op cit. Ref 64. 109 McCombie S. Op cit. Ref 66. 110 Asian Development Bank. Op cit. Ref 37. 111 Gebert R. Op cit. Ref 64. 112 Haifa R. 2005. 113 Heggenhougen H.K., Hackethal V., Vivek P. 2003. 114 Asian Development Bank. Op cit. Ref 39. 115 Asian Development Bank. Op cit. Ref 37. 116 McMurry C. 2004. 117 Asian Development Bank. Op cit. Ref 37. 118 Espino F., Manderson L. Op cit. Ref 93. 119 Ibid. 120 Multisectoral Committee on International Human Development Commitments and the UN Country Team in the Philippines 2005. 80
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National Institute of Public Health, Cambodia, and Malaria Consortum Op cit. Ref 86; Chaterjee P. 2005. 122 Espino F., Manderson L. Op cit. Ref 93; Dulhunty J. et al. Op cit. Ref 95. 123 Erhart A. et al. Op cit. Ref 54. 124 Shankar A. et al. Op cit. Ref 62. 125 Evans P.J. 1994 in Russell R. 2004. 126 Ettling M.B. et al. 1994. 127 Attanayake N. et al. 2000 ; Shepard D.S. et al. 1991. 128 Konradesen F. et al. 1997a. 129 Oxfam GB. 2000. 130 Malaney P., Spielman A., Sachs J. 2004. 131 Sharp P.T., Harvey P. 1980. 132 Bates I. et al. 2004. 133 McCarthy F.D., Wolf H., Wu Y. 2000. 134 Gallup J., Sachs J. 2001. 135 Malaney P, Spielman A, Sachs J. Op cit. Ref 130. 136 Watson 1921 in United Nations Millennium Project 2005. 137 Laxminarayan R. 2004. 138 Erhart A. et al. 2004a. 139 Qunhau L. et al. 2004. 140 See Krieger N. 2003 for a discussion of how gender and biology might overlap and influence health outcomes. 141 Heggenhougen H.K., Hackethal V., Vivek P. Op cit. Ref 113. 142 Asian Development Bank 1999 143 Heggenhougen H.K., Hackethal V., Vivek P. Op cit. Ref 113. 144 Vlassof C., Bonilla E. 1994; Tanner M., Vlassof C. 1998. 145 See World Health Organization Regional Office for South-East Asia 2001, which reports higher male than female prevalence of malaria throughout the Asian region, specifically citing statistics from several countries (including Bhutan, India, Myanmar and Sri Lanka). 146 Erhart A. et al. Op cit. Ref 54. Studies from the Caribbean and Ghana report a higher risk of malarial infection for women than for men. The studies have attributed this to the gendered division of labour; women contact water more frequently than men, thus resulting in a higher risk of malaria infection for women (Vlassof C., Bonilla E. 1994). 147 Erhart A. et al. Op cit. Ref 54. 148 Espino F., Manderson L. Op cit. Ref 93; Muller I. et al. Op cit. Ref 79. 149 Phetsouvanh R. et al. Op cit. Ref 46. 150 National Institute of Public Health, Cambodia, and Malaria Consortium. Op cit. Ref 86. 151 Silva 1986 in Rahman S.H. et al. 1995. 121
Ettling M.B. et al. 1989. Heggenhougen H.K., Hackethal V., Vivek P. Op cit. Ref 113. 154 Ibid. 155 Kochar D. et al. 1999 in Allotey P., Ravindran T.K. 2005. 156 Bell D. et al. Op cit. Ref 83. 157 Haifa R. Op cit. Ref 112. 158 Muller I. et al. Op cit. Ref 79. 159 Ejov et al. 1999 in McCombie S. Op cit. Ref 66; Espino F., Manderson L. Op cit. Ref 93; Ettling M.B. et al. Op cit. Ref 152. 160 Muller I. et al. Op cit. Ref 79. 161 Rashed S. et al. 1999. 162 LWU 2000 in Mohdeen R. Op cit. Ref 26. 163 NCAW 2000 in Mohdeen R. Op cit. Ref 26. 164 Bonilla E., Rodrigquez A. 1993. 165 Ministry of Health, Socialist Republic of Viet Nam 2004. 166 Vlassoff et al. 1995 in Tanner M., Vlassof C. 1998. 167 Asian Development Bank Op cit. Ref 88. 168 VTN 1999 in Mohdeen R. Op cit. Ref 26. 169 Mohdeen R. Op cit. Ref 26. 170 Brown E. et al. 2002. 171 United Nations Children's Fund 2003. 172 Tanner M., Vlassoff C. Op cit. Ref 166. 173 Organization for Economic Cooperation and Development and World Health Organization 2003. 174 Sims J. 1994. 175 Mueller T., Rogerson S., Reeder J. 2005. 176 Malaria in pregnancy, Geneva, Roll Back Malaria. 177 Sims J. 1994. Op cit. Ref 174. 178 McGready R., Nosten F. 1999. 179 Brabin B., Piper C., 1997 in Mueller T., Rogerson S., Reeder J. Op cit. Ref 175. 180 Malaria in pregnancy. Op cit. Ref 176. 181 Ibid. 182 Ibid. 183 Ibid. 184 See World Health Organization 2000 for more information on the use of antimalarial drugs during pregnancy. 185 Mueller T., Rogerson S., Reeder J. Op cit. Ref 175. 186 Mohdeen R. Op cit. Ref 26. 187 Verle et al. 1998 in Trung H. et al. 2004. 188 Evans T. et al. Op cit. Ref 72. 189 World Health Organization 2002a. 190 Ibid. General comment on the right to the highest attainable standard of health, article 12 ICESCR. 191 See World Health Organization 2003 for more information on migration, health and human rights. Additional information on human rights and 152 153
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indigenous peoples may be found at the UN Permanent Forum on Indigenous Peoples. Available at http://www.un.org/esa/socdev/unpfii/ index.html. 192 World Health Organization. Op cit. Ref 189. 193 Klausner R 2004. 194 World Health Organization and United Nations Children's Fund. Op cit. Ref 10. 195 United Nations Millennium Project. Op cit. Ref 136. 196 For more information on the Commission on Social Determinants of Health, see: http://www.who.int/social_determinants/en/. 197 World Health Organization 2004b. A review of PRSPs undertaken by the World Health Organization found that, although the value of a cross-sectoral approach to health is often recognized in the health section of PRSPs, little evidence is available to show that this concern is translated into strategy. 198 Sen G., George A., Ostlin P. 2002. 199 Gender perspectives in malaria management 200 Bell D. et al. (in press). 201 Wheeler M., Florisse S. 2003 (unpublished). 202 United Nations Millennium Project. Op cit. Ref 136. 203 Ruebush T.K. 1990. 204 Pang and Piovesan-Alves 2001 in Espino F., Koops V., Manderson L. 2004. 205 WHO 2005b.
Bell D. et al. 2001; World Health Organization 2004a. 207 For example, see Espino F et al. 1997. 208 Evans D., Azene G., Kirigia J. 1997. 209 Maximize Access and Quality. 2005. 210 Andreason 1995 in Nathan R. et al. 2005. 211 Nathan R. et al. 2005. 212 Kikumbih N. (unpublished data) in Hanson K. 2004. 213 Guyatt H., Ochola S., Snow R. 2002. 214 Grabowsky M. et al. 2005. 215 Desmet et al. 1999 in Wheeler M., Florisse S. 2003 (unpublished). 216 World Health Organization Regional Office for the Western Pacific (unpublished). 217 World Health Organization Regional Office for the Western Pacific. 2005. 218 Chatterjee P. Op cit. Ref 121. 219 World Health Organization. 2005a. 220 Ibid. 221 World Health Organization, Division of Tropical Diseases and the Malaria Consortium. 1995. 222 Chavasse D., Reed C., Attawell K. 1999. 223 Ibid. 224 CIDA 1999. In: Department of Gender and Women's Health, World Health Organization, gender analysis in health: a review of selected tools. Geneva, World Health Organization, 2002. 206
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World Health Organization Western Pacific Region
www.wpro.who.int