Gender issues in the community-directed treatment with ivermectin (CDTI) of the African Programme for Onchocerciasis Control (APOC)

Abstract

This paper reviews the issues relating to compliance and participation among the men and women of three countries within the remit of the African Programme for the Control of Onchocerciasis (APOC): Cameroon, Nigeria and Tanzania. Project-monitoring data from 109 focus-group discussions, 6069 household-survey respondents and 89 interviews with ivermectin distributors were analysed to gain an insight into the attitudes and behaviours of men and women in relation to ivermectin treatment and their participation in the programme. Although there are no statistically significant gender differences in coverages for ivermectin treatment, culturally prescribed gender relationships influence the ways in which men and women express and experience treatment-related behaviours. Gender roles also affect participation in the programme. Decision-making in communities on the selection of distributors tends to follow socio-cultural hierarchies based upon patriarchy and gerontocracy. Relatively few ivermectin distributors (21%) are women. Although they receive less support than their male counterparts, the female distributors are just as willing to continue ivermectin distribution in the community, and they perform as well or better than men in this regard. The terms 'community-directed', 'community participation' and even 'compliance' obfuscate important gender differences that are inherent in the implementation of onchocerciasis control. Development of strategies that recognize these gender differences will have important implications for long-term adherence to treatment and for the overall quality and sustainability of the programme.

Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review

“…Examples of local financial resource mobilization included charging small fees to support service delivery [21, 23, 24], equity fund collection boxes alongside those used for daily operations or voluntary community donations [18]. Articles also documented the converse: setbacks due to lack of resources and support [25–28].…”

“…However, several articles were exceptions to this overall pattern as they related to specific health conditions but also disseminated information supporting broader community participation. These included articles focusing on mental health [33], onchocerciasis control [24, 34, 35], participatory learning and action cycles through women’s groups in India and Nepal to improve maternal and newborn health [19, 20, 36], and efforts by community-based organizations in India to support to HIV-positive individuals to access government entitlement programs [37]. …”

“…The premise of community directed treatment programs supported by African Program for Onchocerciasis Control (APOC) was that the target communities assume full ownership and responsibility for planning, implementing, overseeing control of Onchocerciasis and emerge as a lead stakeholder [24, 34, 35]. This strategy, launched in the mid-1990s, was sustained over a 20 year period to reach 100.79 million people by 2013 and is estimated to have decreased the number of people infected from 37.9 million in 1995 to 15.1 million in 2011 [49].…”

“…Successful participation by women either hinged upon the support of the male members of their households [72, 73] or was observed in roles that were coherent with their culturally prescribed responsibilities such as input on maternal and child health [22, 24, 27]. In a study of decision making processes related to health services in Tanzania, Shayo, Norheim, et al [65] found that women’s voices were particularly valued during decision-making around maternal health, but were not given the same consideration when discussing other health priorities.…”

“…Certain articles highlighted the minimization or exclusion of women from decision-making forums such as community meetings [24, 27, 59]. In another example, Harpham and Few [64] note that despite efforts to prioritize the involvement of women on ‘health boards’ in Dar es Salaam, Tanzania, women’s representation did not meet the minimum requirement.…”