Memoire Online - Factors affecting women's health in the democratic republic of congo

In partial fulfillment of the requirements for the award of degree of Bachelor of Arts

This research work is dedicated to my beloved family members, Papa Eric Mongo, Mum Yvonne Ontoma, Mum Beatrice Medho, my late Sister Denise Moke and my father Lou Michels, who had great love and interest in my education and has unselfishly, laid the ground for me to reach the top. Mr. Theo Groot, who was my first teacher and has, until now, guided me along my path of studies at Uganda Martyrs University.

I wish to acknowledge the efforts of various individuals, who contributed in one way or the other towards the study, 'Factors Affecting Women's Health in Democratic Republic of Congo: Butembo, Lubero District, North-Kivu Province'.

I appreciate and acknowledge the support of Sr. CECILIA MARY DRARU of the Department of Ethics and Development Studies, Madam OKULLO NELLIE of the Department of Education as well as of my supervisor, VIVIENNE LAING, for their timely guidance, wisdom and invaluable comments at each stage of the study.

I acknowledge the valuable information rendered to me by the various people and NGOs: FEPSI & CFII, families, fellow students without which this study would not have been a success.

I would like to recognize and thank my family for the financial and moral support accorded to me.

This study was to find out factors affecting women's health in the Democratic Republic of Congo (DRC). The objective of the research included: to identify the major health problems of Women in post-conflict Butembo; to identify the coping mechanisms used to combat health problems associated with violence and the major causes preventing use of health care services. The study was descriptive and mainly qualitative methods in design were used to carry out and obtain information from the field. These included the use of interviews and focus group discussions.

The findings show that women suffer from the common ailments found in DRC; that they get very little information concerning their health and have little extra resources to obtain preventative measures for example ITN. The expected result of the study was that people would experience the effects of war, but such effects were not mentioned. Nevertheless, data from a local NGO - FEPSI - show that women suffer some forms of post traumatic shock syndrome, but in a silent way. This has to do with lack of awareness but also with traditional cultural norms. The latter means that «what happens within the home should be kept into the home». General experience however has shown that such behavior makes the situation only worse. It was therefore recommended as a way forward that the Ministry of health should focus more on health promotion and education in order to sensitize the communities on these various issues.

It was also recommended that the health promoters, NGOs and community development officers should discuss issues of domestic violence and post traumatic stress symptoms with the people of Butembo district.

In conclusion, the district health department should liaise with other sectors like education, agriculture and water supply services to streamline health issues concerning Women.

The researcher based his research on factors affecting women's health in Democratic Republic of Congo. It is organised chronologically in five chapters all of which were crucial in the success of this study.

According to the Constitution of the World Health Organization 1948, health is defined as `a state of complete physical, mental, emotional, intellectual, environmental, spiritual health, and social well-being and not merely the absence of disease or infirmity' (WHO, 2004).

In order to justify health it is important not to ignore the fact that health is fundamental to an individual's well being in many ways and it is therefore independently valid. The Joint Initiative on the Fight against Sexual Violence towards Women and Children of the United Nations documented41,225 cases in the provinces of Kivu, Maniema and Kalemi in DRC since 1998 (WHO and HAC, 2005).

Services that address women's needs, especially when they are subject to sexual violence, will reduce the impact of trauma, rates of undesired pregnancy, and the incidence of sexually transmitted diseases (STDs) and HIV infection. The specific purpose of such programmes is to establish the best practices for health services that operate in conflict period so that they promote women's health (with particular attention to the needs of women exposed to acts of violence); to improving sexual and reproductive health, reducing risks of HIV infection, and providing effective health care to those who have acquired HIV and (seeking, where feasible, access to ARV-based AIDS care). Through Women studies, the inequality between men and women in health status and decision making has become clearer. The studies indicate that in most cases women are at a disadvantage (Gender and Health Promotion, 2007) and therefore their health special attention needs to be paid to the issues surrounding in conflict and post conflict.

Women are affected by diseases such as Malaria, sexually transmitted diseases, high-pitched respiratory infections, flu and diarrhoea (Gender and Development, 2005). On the other hand, women's reproductive health activities focus primarily on contraception safety and efficacy, fertility, infertility, and HIV/AIDS and other sexually transmitted diseases. (STDs) http://www.cdc.gov/reproductivehealth/WomensRH/index.htm

Womenfrom socially and economically backward groups have lower odds, both of having awareness of AIDS and knowledge of ways to avoidgetting the disease (Women's Health in Today's Developing World, 2005). The spread of the epidemic to ruralareas presents a need to actively disseminate AIDS related knowledgefor health protection. Approaches tohealth promotion that do not consider differing contextual factorsare unlikely to succeed. Therefore, an innovative strategy to disseminate knowledge among disadvantaged population groups is needed. (Reproductive Health, 2005)

War is one of the factors that have affected Women's health in Butembo from 1998 to 2003. Due to insecurity, people were forced to leave their homes in the town and go to the villages for refuge and safety, escaping the hostilities in Butembo. The women were exposed to sexual violence, rape and other gender based violence by armed groups and also civilians (FEPSI-NGO, 2007). Sexual and gender based violence (SGBV) remains one of the greatest threats to Women's Health.

Moreover, in the villages there were no health facilities of any kind, no food, and no shelter.

After the war they returned home unfortunately few health care units available services were offered so women and their dependants could not access adequate healthcare, including safe contraceptive methods as a greater proportion of money was directed to the war.

People in Butembo are of the Nande ethnic group. Like most rural people throughout the DRC they speak one language, they have the same tradition, culture, customs, which are derived from one ancestral line.

Among the Nande, Women have less rights in the family meaning that men are privileged because of cultural beliefs. In every situation women have to seek permission from their husbands except when it concerns health issue whereby women are allowed to seek treatment according to their will.

Butembo, the second town of the province after Goma is situated in Lubero district, North Kivu province in the Eastern part of Democratic Republic of the Congo. The citizens living in the town majority is of Nande by tribe. Since independence 1960, the population has lived in poor health conditions.

The inhabitants here suffer from various types of diseases such as Malaria, TB, and HIV/AIDS but also reproductive health and non-communicable diseases, such as those linked to Tobacco smoking.

Like most rural people through the country, the population of Butembo depicts a low to average standard of living. As judged by the current definition of poverty, which is the situation where one lacks most of the basic necessities and assets for life or even any means of acquiring them.

As mentioned before, most of the Government health facilities countrywide have not been maintained or rehabilitated during and after war, and many health centers and communities lack appropriate medical equipment and staff (FEPSI-NGO, 2007). The Ministry of Health has recognized the importance of maintenance and is in the process of developing a National Health Infrastructure Development and Maintenance Plan (NHIDMP) as the priority for health.

The study context is characterized by ongoing conflicts where community systems including health systems are weakened, and easily overwhelmed. Societal cohesion and the rule of law are undermined. Proposed responses need to take into account the extreme challenges to their successful study, development and implementation.

During the war in Butembo health facilities were destroyed and rundown resulting into a deterioration of women's health. Even after the war there are still factors affecting women's health. Among these include: Policy reasons such as poor collaboration between health workers and the local council; poor planning, and lack of material.

The overall goal of this study is to offer suggestions that will help improve the impact of health services on the health of women in post-conflict settings. As said before, services that better address women's needs, especially when they are subject to violence, will reduce the impact of trauma, rates of undesired pregnancy, and the incidence of sexually transmitted diseases and also by ascertaining the effects of the war on women's health and studying how women's health is after the cessation of war.

To establish the factors relating to women's health in the post-conflict situation that promotes women's health with particular attention to the needs of women exposed to violent acts, improving sexual and reproductive health, reducing risks of STD infections. While identifying Different types of health care to those who have acquired, for example HIV/AIDS and victims of different types of violence or rape.

2. To identify the coping mechanisms used to combat health problems associated with violence

It is supposed that improving quality of care must begin with the formation of human resources for health; a formation which should include value, care process of men and women. However, what might be important is to provide opportunities to female health workers to come together as women and as professionals to provide care to the community.

Women's health may thus be improved in the way that women engage themselves in public health services, which can play a big role in improving quality of care.

The scope of this study focused on the factors affecting women's health, in Butembo, Lubero District as the case study. Data was obtained from the NGO-FEPSI headquarter 63 Martyrs Road, Butembo town.

Diseases have had profound social and health consequences on women in Butembo. Sometimes they remain mute and suffer silently from the diseases and trauma. The outcome of this study will identify how healthcare delivery can support women after identifying the factors which affect women and their health. It will also identify healthcare gaps in service delivery, which once identified can aid health planners and policy makers in provision of services.

The chapter focused on the researcher's area of study, the introduction, and the objectives that helped the researcher carry out his study including the Significance and hypothesis of the study.

INTRODUCTION

Women's health is among the most important problems that developing countries face. The magnitude of the women's health problem is so important that it has affected their development.

The current concept of women's health should be expanded to embrace the full spectrumof health experienced by women, and preventive and remedialapproaches to the major conditions that afflict women. Allocationof health service resources should be aligned with the epidemiologicalrealities of these threats to women's health,(Women's Health in Today's Developing World, 2005).

Income and loss of employment leads to poverty that can become rampant and widespread in such a way that one cannot easily sustain him/herself and provide the basic needs like food, shelter and maintenance of a good quality of health, especially in post-conflict communities. The challenge is to define the essential elements of women's reproductive health services, upgrade the services as appropriate and reduce women's risks of disease and suffering, (WHO, 2004).

War is one of the major factors that affect Women's health. Discrimination and gender difference are the most brutal consequences of war on women's health. In war areas women are the most affected, especially those wars in which the world's media take only token interest. For example, the incidence of rape in Darfur, DRC, Northern Uganda and Sierra Leone may never be known, let alone carry any hope of accountability. ( http://uk.oneworld.net/guides/uganda/development)

According to UHB (2000) the overall goal of organizations in war, such as local and international NGO's is to improve the impact of health services on the health of women caught up in violent conflict, or post-conflict settings. Services that better address women's needs especially when they are subject to situations like sexual violence will reduce the impact of trauma, rates of undesired pregnancy, and the incidence of sexually transmitted disease and HIV infection, (Uganda Health Bulletin, 2000).

In the majority of poor countries only a small proportion of women will be engaged in paid employment which itself is likely to be of low quality, (Senators and Representative, 2006).

According to the Global Policy (2006) in Asia a relative important proportion of women are able to find employment. This is quite different from Congo and for instance few women in Butembo think of having work. Otherwise, they are mostly focused on agricultural work and business, while Asian Women focus more on the business model of global corporations, which typically engages them at the bottom of the production chain, for example in factories.

According to the Executive director of UNFPA - [Ms.Thoraya Obaid], (2007) - HIV/AIDS constitute another big area of health factors affecting Women. Part of it is that developing countries are facing critical shortfalls of contraceptives and condoms. The solution to the HIV problem is the combination of sex education, abstinence, couples remaining faithful to their partners and greater use of condoms.

According to UNFPA (2005) gender inequalities need to be addressed including violence, limited access to education and violation of human rights. When women are educated, healthy and employed, and able to make decisions about childbearing and reproductive life, everyone benefits.

According to WHO (2005; 2007) being poor or being a woman was often a reason for being discriminated. Worldwide, millions of women are unable to protect themselves from HIV infection due to lack of prevention methods that can be controlled by women, causing unnecessary suffering and death. One of the most urgent actions is to increase funding for vaccine development, proper nutrition and invest in education that will ensure they are accepted within communities.

The Convention on Elimination of all forms of Discrimination Against Women [adopted and opened for signature, ratification and accession by General Assembly resolution 34/180 of 18 December 1979 entry into force 3 September 1981, in accordance with articles 27(1)] stipulates that «the discrimination against women violates the principles of equality of rights and respect for human dignity, is an obstacle to the participation of women, on equal terms with men, in the political, social, economic field and in the family and makes more difficult to realise the full development of the potentialities of women in the service of their countries and of humanity», (The conventions on the elimination of all forms of discrimination against women, 1981).

According to Farr, (2002) health is not a gender issue, but a poverty issue. It effects men as well as women and depends on the area they live. For this to be seen as a woman issue is typical of real discrimination.

Women are the bearers of new life. In order to protect future lives we must protect women. Promoting women's health physically and mentally should be a top priority internationally. A progressive society can be measured by the way that its women are treated. If women are healthy then their children and families will have a greater chance of also being healthy and productive, (Gender Perspectives on Small Arms and Light Weapons, 2002).

There is no excuse for this grave human inequality. Women should no longer be valued as second class citizens. If all the money that has been poured into aid for third-world countries was used for a common benefit, there would be no hunger and health problem in the world today.

According to Östlinet al, (2007) women and men are different as regards their biology, the rolesand responsibilities that society assigns to them and theirposition in the family and community. These factors have a greatinfluence on causes, consequences and management of diseasesand ill-health and on the efficacy of health promotion policiesand programmes.

Health promoting interventions aimed at ensuringsafe and supportive environments, healthy living conditionsand lifestyles, community involvement and participation, accessto essential facilities and to social and health services needto address these differences between women and men, boys andgirls in an equitable manner in order to be effective, (Gender and Health Promotion, 2007).

The different health measures showedconsiderable variation in strengths of association with health relatedfactors, most noticeably so with gender and socio-economic status.The choice of health measures in population studies should complywith the intention to analyze its associations with any of thoserelated factors, or, in reverse, with the wish to prevent theirconfounding properties, (Health Measures, 2007).

Extending the definition of women's health to includea concern for chronic diseases is critical if the needs of womenin less developed nations are to be met. In less developed countries,chronic diseases are the most important cause of female deatheven during childbearing years and for women with young families.Development agencies and private philanthropy must begin tofund the studies that will further refine our understandingof the role of chronic diseases in women's health in the developingworld, (Women's health in today's developing world, 2005).

Introduction

This chapter presents the research design, area and population, as well as the sampling techniques research instruments and data analysis and presentation.

It is descriptive in nature. A qualitative approach was used to suggest ways of empowering Women to fight against diseases affecting their health, looking at reasons for the situation the Women of Butembo face. The research also looked at how to identify the root causes of diseases affecting Women's Health in Butembo.

As far as the content of the study is concerned, the focus was on factors affecting Women's Health in Butembo in collaboration with the local NGO called FEPSI based in Butembo city in the North Kivu province (D R Congo).

The respondents all come from different parts of the District and from Butembo in particular.

A total of fifty (50) women were targeted, which included adolescents from 16 to 20 years, young married women from 20 to 30 years, and women of 30 to 49 (Menopause) years.

This included using the library sources; that is reading and reviewing journals and magazines about Women's Health, Gender and Development and Primary Health Care that could give an insight.

The researcher also used internet sources with actual information needed in the study.

With the help of a questionnaire the researcher conducted interviews with the 50 women of the research sample.

However, during the interviews the researcher realized that some respondents had expectations other than helping him for his research, that's why there was a need to throw more light on certain points in order to avoid any misunderstanding of the questions. This also allowed the researcher to interact more with the respondents to get to see the real situation because the interviews were conducted in the field.

The data collected from the field using interviews and observation techniques were mainly qualitative and they were analyzed. This makes this study explanatory.

The respondents of the interviews were targeted through the local NGO FEPSI. As a consequence of that, the data collected does not allow the researcher to know whether this sample group is representative for the whole population of women in the region of Butembo.

Another problem was in the fact that the participants initially believed that extra help would come from this study, thus raising their expectations. This was solved by carefully explaining that this was a research study for degree purposes. Nevertheless it may be that some of the respondents while answering were still expecting a reward.

The researcher maintained maximum confidentiality of the findings from the research. The researcher followed all the legal procedures to reach the respondents such as getting a letter of introduction from the university (UMU) and presenting it to the local government Office of Butembo district and NGO-FEPSI. The researcher conducted out the research in person not getting another individual to conduct the interviews or analyses. The research being explanatory and exploratory on a social issue, namely factors affecting Women's health, it called for ethical standards. For example, the researcher was bound not to disclose the respondents' names in order to protect their privacy and allow them to live normal lives. Each respondent's permission was sought prior to answering questions.

This chapter gives information on the case study, how data was collected, and shows how data was to be analysed. Limitations and delimitations of the research are also presented in this chapter.

Introduction

This chapter deals with research findings, analysis and discussion on women's health merits and demerits as well as negative impacts of non-health provision in Butembo District. The results of the study carried out in Butembo District from 25^th May to 6^th July 2007 are presented in consecutive diagrams.

The 10% shown on pie chat figure below, women stated, they were unsure of their health status. This number of 10% if extrapolated over all areas inflicted by war would be substantial and Health services may not recognize or identify the causes of this uncertainty. This uncertainty may be due to the situations these women found themselves during the conflict.

Fifty per cent stated that their health has improved. It is of major concern that 30% claim no improvement in their health status. The most serious and worrying issue is that 10% are unaware. This has major implications for the future health of families and especially children, (FEPSI-NGO, 2007).

As seen in figure 4.2 above, women stated illnesses which are regular and not specific to war conditions, and there are no direct signs of post traumatic stress disorder. The only notable illness that requires more attention is headache, seen by the fact that 40% of the women said they suffered regularly from this and is a symptom of stress. The worrying aspect of this finding is that it is clear that health services are not addressing the common disorders and moreover that mosquito nets that prevent malaria are not used. All the diseases mentioned by the women are preventable.

Why women are experiencing these problems seems to be due to the fact that there are no health promotion activities and although FEPSI is treating the women, there is a gap in health services that would promote women's health and educate the communities on ways to prevent illness.

70% of the Women interviewed go for modern treatment (as for example in the FEPSI hospital). The other 30% (15/50) were influenced to use traditional medicine for a number of reasons such as lack of money for transport [even though treatment for instance in FEPSI hospital was free] or because they believed the traditional medicine were found in the areas where they live. Moreover, they have been using them for decades.

However, this figure clearly illustrate that the women were ready to use the medical facilities especially if they were free, but also because the services that are provided were influenced by the doctors competency, fast services, skills and experiences.

Even though the FEPSI facility treatment was free, the women still felt that the availability of money for health was a major set back [Figure 4.4 above]. Caught with the long distance to this facility, shows that access to services is still problematic even after over 4 years of peace in the area. Health services are still few and women have long journeys to make to seek services that they can afford.

To solve the above problems, solutions mentioned by the women could be to construct more clinics (60 %) and to improve drug supplies (40 %). However, construction requires a strong and resourceful health sector. This can only be achieved with a country at peace and a steady and growing economy. Also, the presence of health workers would be a help to the women.

Sixty percent (60%) of the women fled the town during the conflict to the villages; thus health care remained poor. This resulted into Women moving between the villages and towns, thus increasing their risk to the consequences of war, since it was only in town that health services were available.

Fifty percent (50%) of Women stated they were getting free treatment that helped them to maintain their health at normal levels but to improve one's health conditions is the affordability of one's financial positions. That is why. This situation was reported by 50% of women who do not have access to afford a high health treatment.

It is clear that the women want good health for themselves, and their families, but the constraints shown before in figure 4.4 clearly indicate that they come to FEPSI because the treatment is free and they have access to qualified doctors. As FEPSI not only treats, but offers health education it is not surprising that the women know what they want and need to have good health. These needs are there and some women try to go for it. Nevertheless they need to attend more regularly to be realized. They need a systematic response from all the sectors of government.

introduction

This section presents the discussion, conclusion and recommendations of the research; the study investigated the factors affecting women's health in Democratic Republic of Congo. The studies major respondents were the patients from the NGO-FEPSI in Butembo District, North Kivu province.

In the study «Factors Affecting Women's Health in Butembo» it was expected that Women would discuss the issue of domestic violence as one of their challenges in health, but they did not talk about it. However, In Butembo District, we know from research (FEPSI NGO, 2007) that domestic violence against women is worsening. There are many different reasons why women in Butembo could not discuss this issue. First, culturally it is a taboo for «private» issues to be discussed in public. Also, if sexual harassment is happening in homes there is the denial that there is a problem accompanied by the trauma which has tortured the women both physically and psychologically. Although both men and women are equal under the law, within communities and tribes they are not equal in strength and power. That is why they keep silent on these issues.

As shown by the United Nations (UN) General Assembly resolution, it is stated that violence against women violates the principles of equality of rights and respect for human dignity. However, there is a reason why we could not focus more on domestic violence since it was not the main problem raised by the women. However, we know that women suffer from all aspects of domestic violence and that these are one of the major factors, which affect women's health in Butembo district. This can be seen by the types of problems raised such as the preponderance of headaches and stomach pains.

Since domestic violence is a silent trauma in Butembo, women merely talked openly of other situations or diseases which were affecting them. As expected, malaria was top on the list because of the fact that they did not have freedom of asking their husbands for money. This disparity on accessing funds is also affecting women's ability to access health care and the high numbers attending the free facilities offered by the NGO.

From NGO-FEPSI workers it was found that a big number of women received free treatment in their clinic. However, this had somehow an impact on women's health whereby most of them did not care much about determining their health in the sense that few could finish taking their dose of medicine. That is why it was discovered that the same people after a certain period were coming back in the clinic with the same health problem, but this was not stated in the study and is one of the reasons women were having treatment more often than men. This continual need to come for medical care may reflect the women's way of coping with the trauma of what they had experienced and the seeking for physical problems may be masking the mental stress that the women are experiencing. Post traumatic stress can cause physical symptoms, but there is lack of sufficiently skilled health personnel to deal with this, by recognising the mental stress rather than continue with treating the physical needs to be addressed.

In this research «Factors affecting women's health», women talked of distance and transport issues which came up in their view as one of the factors which is affecting their health just because a hospital is far from their homes and they cannot easily go for treatment by walking a long distance when they are feeling weak. As a suggestion, women would like the organisations, institutions and the government to construct more hospitals to reduce the distance and cost and to increase supplies of drugs in health sectors, to train more health workers in order to avoid all kind of problems of women's health in future.

Conclusion

Since this research is based on Women's Health, it has been stated in the introduction that women are most affected by diseases such as malaria, sexually transmitted diseases, flu and diarrhoea.

Since war is a main factor which gives a gap to a number of factors affecting women's health, armed conflict often leads to a reduction in formal medical or psychological support for home-based care, most of whom are women. Sexual transmitted diseases against women are rampant during the war and have reached epidemic proportions. The risks do not end when the war is officially over; the number of diseases in the community increases with the return of the women back home.

The Ministry of Health needs to focus more on health promotion and health education to sensitise the communities on various issues in health sector that affect their livelihood. In other hand, the ministry should also carry out researches in order to know what are the problems or factors affecting the communities. Through this, the communities will be in position to be treated and aware of what is affecting them.

The Ministry of Health needs to mainstream gender in all sectors by equal participation of both men and women in health promotion. This will help the citizens to work hard in order to improve their health without the ministry intervention.

Butembo Health promoters, NGOs and community development officers have to discuss issues of domestic violence and post traumatic stress symptoms with the people of Butembo district.

District Health Department needs to liaise with other sectors (education, agriculture, water, etc) to work together to promote development issues and to mainstream the three main cross-cutting issues.

The Ministry of health has to implement primary health care services in the zone affected by conflict and in the rural areas.

Conclusion

This chapter gives information on the discussion, conclusion and recommendation whereby various issues such as violence against women, distance and transport to the clinic were raised. Apart from these, factors like war, diseases and number of recommendations are also presented in this chapter.

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2. Did you have any major health problems over the last few years related to the war?

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8. Did you stay in Butembo or did you flee? If yes ask for :(b)----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

(a)---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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10. What in your opinion can improve the health services offered to you in Butembo?

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TIME	ACTIVITY	RESULTS AT THE END
1^st Week of Research (May 2007)	Seeking permission from authority team leaders and getting familiar to the place.	Permission got
2^nd Week of Research (Jun 2007)	Collecting data from selected sample.	Data collected ready for analysis
3^rd Week of Research (October 2007)	Computing and analyzing of data	Data ready for drafting
4^th Week of Research (November 2007)	Drafting the research book	Final draft ready

THE MAP OF D.R. CONGO SHOWING THE LOCATION OF BUTEMBO TOWN WITH ARROW (Uganda side)

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