The challenge of gender inequality in Nigeria’s surveillance network

Maiduguri, 10 October, 2019 - Following the detection of a case of acute flaccid paralysis (AFP) in Jere Local Government Area (LGA) Borno State Nigeria, a team of surveillance officers, mostly comprised of men are dispatched by the Local Government to assess the situation.

They make a first stop at the home of Hajiya Liman Bello a mother of 3 and a housewife. As her husband is out of town, she peeps through the window to see who her visitors are.

“Who are all of you and what do you want?”, Hajiya Liman asks, “We are health workers from the Department of Primary Healthcare, Jere Local Government please. We need to collect stool samples from your children as there has been an AFP case in this area”, they told her. As a security compromised state, healthy child stool sampling is conducted in Borno to determine if there is community-wide transmission of poliovirus.

Perplexed by their rather awkward demand for her children’s stool, Hajiya tells them to go away, and if they must return, they must come with a female health worker as she is not comfortable with male health workers.

Such is the scenario male surveillance officers often face in Northern Nigeria, particularly during house to house outreaches, highlighting the need for a gender balance in the recruitment of surveillance officers in Nigeria.

As Nigeria edges closer certification, the important role of women in the fight against the disease cannot be overlooked.
Gender, like other factors such as age, education and socioeconomic status, is an important determinant of health-seeking behavior and health outcomes. This is particularly the case within the polio eradication programme.

“I believe gender strongly influences disease surveillance and access to immunization services,” says Dr Kabir Yusuof, a health worker who has worked within the Nigerian Government polio programme for over ten years. 

“Nigeria is generally a culturally attuned country. There are some communities where men only feel comfortable with female health workers, especially when it comes to house-to-house outreach and matters of maternal health. For this reason, I believe the role of women in both polio surveillance and response cannot be overlooked.”  

The most recent case of wild poliovirus was detected in Nigeria on 21 August 2016. However, since then, there have been multiple cases of acute flaccid paralysis (AFP) – a sudden weakness of the limbs in children and adults – which can also be caused by polio. Quality AFP surveillance is crucial for the region to be certified as “polio free.”   

AFP case detection in Nigeria has consistently improved between 2007 and 2016.  A total of 17, 867 cases were identified in 2016, up from 4,305 cases in 2007. This year, in the 8 months to August 2019, a total of 5 152 cases were detected and reported.

Gender Dimensions of Acute Flaccid Paralysis Surveillance
A 2017 study conducted by WHO called “Gender Dimensions of Acute Flaccid Paralysis Surveillance in Nigeria” looked at gender and AFP. The authors found that the number of cases in boys and girls was similar, as were polio vaccination rates.    

However, the study also found that there were significantly more male health workers engaged in polio surveillance activities than female health workers, highlighting gaps where gender biases exist in relation to surveillance personnel and where intervention is needed. For example, in 2016 there were 29 men employed as state epidemiologists compared with just 8 women doing the same job; there were 23 male state disease surveillance and notification officers (DSNO) compared with 14 women and at LGA level, there were 609 male DSNOs versus 218 female DSNOs. The number of health facility surveillance focal personal was, however, roughly the same (2 814 men and 2 879 women). Generally, the report showed there are more male key surveillance personnel than females in northern zones (3 331 men, 1 081 women), and the reverse is the case in southern zones (687 men, 2 377 women).  

Breaking stereotypes 
WHO believes that involvement of female caregivers in surveillance programmes may help to improve vaccine uptake, in that women generally take care of children and women surveillance officers are more likely to detect more AFP cases given that they have full access to the households. Furthermore, in surveillance activities such as collection of stool or blood samples, women are better positioned to gather historical data and improve stool/blood adequacy, especially in culturally or religiously attuned settings. In the long run, gender balanced surveillance networks will build a more sensitive surveillance that detects cases which will in turn lead to timely intervention. 
“Promoting gender equality is one of the most important catalysts for sustainable development,” according to Dr Fiona Braka, Team Lead, Expanded Programme on Immunization (EPI), WHO Nigeria.  

“The goal of achieving equality between women and men is based on principles of human rights and social justice and is enshrined in the Universal Declaration of Human Rights. Integrating or mainstreaming gender into all facets of socio-economic life is key to tackling gender inequalities. This requires a gender equality policy in which women and men have the same opportunities, rights and responsibilities in all areas of life. WHO advocates for breaking stereotypes, barriers, all discriminatory practices and illusions that women cannot ‘fit in’ when it comes to disease surveillance practice,” she added.  

To reflect the importance of gender equality and the empowerment of women in efforts to eradicate polio, the Global Polio Eradication Initiative (GPEI) Oversight Board officially endorsed   a Gender Equality Strategy in May 2019. The strategy aims to promote the integration of a gender perspective into different aspects of the GPEI’s programming, to support countries in addressing gender-related barriers to polio vaccination to increase coverage and increase women’s participation in the polio programme. 


Technical Contacts:
Dr Abdullahi Walla Hamisu; Email: abdullahih [at] who.int; Tel: +2348050644746
Ms. Kulchumi Hammanyero; Email: hammanyerok [at] who.int 
 

Female Surveillance team in Borno State
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For Additional Information or to Request Interviews, Please contact:
Ms Charity Warigon

Tel: +234 810 221 0093
Email: warigonc [at] who.int