Tanzania: Addressing gender barriers to design more inclusive TB interventions

Gender inequality in Tanzania is driven by an internalized patriarchal system that has resulted in lower educational levels for women, less decision-making power within their households, and fewer information, financial and educational resources. Gender-based violence against women remains widespread, and police rarely investigate cases of domestic abuse – especially in rural areas.

Gender barriers and negative norms impair women’s decision-making power when it comes to their health; they are not free to decide when, where and how to access health services. In traditional family hierarchy, the wife needs an approval from a husband to get help for a sick child or for herself. If the wife acts on her own or decided to sell something to afford health services for herself, she can be beaten or face divorce.

Marriage of young girls still exists in Tanzania and is reported by nongovernmental organizations, women’s rights groups, and other advocates as a practice that leads to increased domestic and sexual violence, increased maternal and infant health risks, greater exposure to HIV/AIDS, increased teenage pregnancies, denial of educational opportunities to young girls, psychological trauma, as well as prolongation of the poverty cycle.

Gender norms have a significant impact on sexuality which results in increased stigma toward female sex workers (FSWs) and men who have sex with men (MSM). This is a major determinant of these group’s vulnerabilities as it leads to fear of accessing services, discrimination and abuse at the hands of health providers, law enforcement and other state actors.

The situation is much more difficult with the current administration which is not in favor of MSM programming. At the moment, Tanzanian law does not prohibit discrimination based on sexual orientation or gender identity. Consensual same-sex sexual activity is illegal, and the law punishes “gross indecency” with up to five years in prison or a fine.

Legal intervention usually serves as a pretext for police to collect bribes or coerce sex from vulnerable individuals. LGBTQ persons are often afraid to report violence and other crimes due to fear of arrest or further violence and/or sexual assault.

Conditions of disadvantage and vulnerability put women, MSM, FSWs and LGBTQ populations at higher risk of TB/HIV infection.

Tailored solutions

Gender sensitivity is at the heart of SHDEPHA+Kahama program design and implementation. The organization recognizes that supporting gender equality and the empowerment of women and girls is the best way to build a more inclusive and prosperous community. Social and cultural barriers put certain populations at a disadvantage and by addressing these specific barriers, they look to bring healthcare access to the most vulnerable populations.

SHDEPHA implemented a community outreach intervention that uses trained peer educators (PEs) and community health workers (CHWs) to conduct house-to-house visits to educate and verbally screen the community for TB. CHW’s also transport sputum to diagnostic facilities, facilitate referrals to health facilities for treatment initiation and provide adherence support to patients. This strategy is a scale-up of a successful TB REACH Wave 5 project.

Although the activities are aimed at the general population, a special focus is placed on vulnerable groups such as FSWs, MSM and women.

Trained peer educators, who know the community well, are encouraging participation from households where women are facing barriers to accessing care. Health providers are being oriented to offer friendly services for FSWs and to make TB screening and treatment services available to everyone regardless of sexual orientation.

SASA! Community activist tool/kit (including dramas, community action groups and community conversations through activists and champions) is being implemented to promote women inclusion in health services. Community radio and theatre groups complement peer education and SASA! Strategies to reach larger audiences.

A moonlight approach has been established to reach those who are not easily accessible during day time including FSWs in brothels/bars, mines and community hotspots.

Further steps

In order to continue fighting gender inequalities and to promote positive gender roles for both women and men, SHDEPHA+Kahama envisions further strategies that need to be implemented.

Gender equality champions – young men and women who believe in positive displays of masculinity and femininity, and couples who model equitable relationships – should support and motivate young and adult women to enhance their roles in decision making and control over resources and services.

There needs to be an increase in awareness of gender-based violence as a first step to its prevention. The community must be sensitized through social behavior and communication. There must be more services available to people who experience gender-based violence, such as referral networks to receive comprehensive care that includes legal, psychosocial, and health services.

Adolescents’ access to accurate health information must be improved. Essential health information on TB/HIV has to be made available to dispel myths and misconceptions.

Media channels must be used to explicitly discuss and challenge widely held perceptions and beliefs that contribute to gender-based stigma and discrimination against MSM and FSWs. Messages speaking directly to clients of FSWs, with an emphasis on law enforcement officers who are common perpetrators of sexual violence against vulnerable populations can be developed.

Government commitment to address gender considerations in policy and legislation must be increase and leveraged. It is important to build capacity within government health institutions to better tailor health programs to the needs of women and gender-sensitive populations. Government policy makers should be engaged to change laws that restrict the rights of women and LGBTQ populations. This can be done through training and working with community-based support systems (clan elders, religious and opinion leaders) to deconstruct societal perceptions, norms, and patriarchal values that perpetuate negative behaviors.