Background
The Greater Mekong Subregion (GMS) has made significant progress towards malaria elimination in recent years as a result of significant investments in improving surveillance systems, that contribute to better deployment of available technologies to prevent, and test and treat malaria. National Malaria Programs recognise that the last cases are likely going to be the hardest to find, particularly as they are often in the hardest-to-reach areas, and often among the most vulnerable people. Vulnerability in malaria elimination can be considered in terms of the factors that may make an individual (a) more likely to get malaria, (b) less likely to be able to seek or access quality health services, (c) less likely to receive quality health care, and (d) less likely to complete malaria treatment. These factors tend to be considered by location (proximity to mosquitos) or occupation (exposure to mosquito bites), however, other factors, such as gender, have not been systematically reviewed.
The Civil Society Organisation Platform was created in 2014 to support the Regional Artemisinin Resistance Initiative (RAI) funded by the Global Fund for AIDS, Tuberculosis and Malaria to engage communities and civil society more directly in malaria efforts. Through its work with communities, particularly in the field, the Platform has identified gender as a factor that has been neglected in the region, and may hold some keys for accelerating progress towards elimination. It was with this backdrop that the CSO Platform and the Asia Pacific Community, Rights, and Gender Regional Platform (APCRG) – an initiative of the Global Fund’s Community Engagement Strategic Initiative (CE SI), that modest resources were found to explore this issue. Using APCRG’s Strategic Funding, the CSO Platform was able to mobilise a consultant and data collectors better understand gender dimensions of malaria in order to seek new opportunities to accelerate malaria elimination in the GMS.
Conclusions
- Both men and women face different vulnerability to malaria: While all people in forested areas are at risk of malaria, men can be at higher risk due to spending more time in forests. However, women also stay overnight in fields with their husbands, and sometimes their entire family, increasing their exposure to mosquito bites. They may also be at higher risk than men because they are less likely than men to wear clothing that covers all their skin – in accordance with gender expectations in the community.
- Women face higher barriers to accessing health care information and services: While men and women receive equal treatment in health facilities, women face higher barriers in accessing information and health care due to cultural norms. Women are less likely to be educated in the Lao language, which reduces her direct access to information. Women are less likely to be able to take herself to a health centre as she is less likely to know how to ride a motorbike or have direct access to transportation. And women are less likely to have decision-making agency in her household, in addition to being expected to stay home and take care of others. These norms also constrain female VHV’s ability to provide the same services as their male counterparts.
- VHVs are helping women overcome barriers: The work of VHVs has proven to be critical to ensuring that women receive access to malaria information in their language, and have improved access to malaria testing and treatment through the transportation services provided by VHVs.
- Cultural norms can negatively impact men’s health seeking behaviour: Cultural norms, such as men’s need to be strong in the face of illness, result in delayed treatment seeking, potentially until the malaria case is more serious, and potentially contributing to further onward transmission.
Gender-responsive Recommendations
To the CSO Platform
- Seek or secure additional funding to conduct Malaria Matchbox-type assessments in more settings across the GMS where malaria elimination progress has slowed in order to identify gender or socio-cultural barriers.
- Propose a gender-focused RSC meeting to the RSC secretariat, and work with them to develop a participatory meeting to help raise RSC member awareness of gender dimensions of malaria elimination and prevention of re-establishment.
To CHW program implementers
- Ensure that malaria information materials are available in all necessary local languages and presented in formats that are more accessible to all community members. These materials can be designed in consultation with the community – particularly the women, using a human-centred design approach.
- Review forest pack, LLIN,LLIHN, IEC/BCC materials distribution criteria to ensure that sufficient numbers are provided to cover all necessary individuals and households, including as children grow up.
To the RAI Regional Steering Committee (RSC)
- Dedicate a meeting to Gender and Malaria, reviewing gender-disaggregated data, sharing the learnings of this paper, and providing an introduction to gender responsive vs. gender transformative approaches, to identify potential changes to be made in future National Strategic Plans or through Global Fund reprogramming.
- Request the Independent Monitoring Panel to mobilize appropriate technical assistance – either from within the IMP or externally – to work with the CSO Platform to design, conduct and/or analyse results of Matchbox assessments, and co-develop recommendations for follow-up through the RSC.
To NMCPs
- Following Matchbox assessments in other GMS countries, organise a Gender and Malaria meeting with the Ministry of Health, and the Ministry/Commission on Gender/Women in each country to examine gender disaggregated data, review best practices, and begin exploring linkages and opportunities for joint efforts towards shared goals of malaria elimination and gender equality.
Gender-transformative Recommendations
To CHW program implementers
- Provide support to female VHVs to learn how to ride motorbikes safely – and potentially to negotiating access to one – to be able to transport people to health facilities, and to challenge gender norms.
- Consult women in the community on how they can better protect themselves from mosquito bites in their communities, and when they stay in the field. This may include discussing how they can more fully cover their skin to protect themselves.
- Organise community meetings to review this study’s findings and facilitate discussions among community leaders, men and women regarding how gender and cultural norms can create barriers to accessing health care.