August 2009




Gender inequality & healthcare access?

by Matt Young EyeWorld Contributing Editor



Access to healthcare in Africa and other parts of the developing world is often thought of as a financial problem. A new study yielding insights into why young cataract patients often present late for surgery, however, suggests there are serious barriers to proper vision care in the developing world beyond a lack of financial resources or even proper education. Gender inequality, as it turns out, is at the heart of the problem. Based on 117 interviews with parents or guardians who brought their children to undergo cataract surgery at a tertiary hospital in Tanzania, gender was a serious barrier to proper care. “Gender inequity manifests itself in diverse ways at the household level,” according to a scientific article by Robert Geneau, Ph.D., University of Ottawa, Ottawa, Ontario, and colleagues. “In the case of cataract surgery, the main issue relates to the fact that mothers are often the first parent willing to take action but that their level of influence in the decision making process concerning health care is often low.”

The study, published in the November/December 2008 issue of Ophthalmic Epidemiology, also found that respondents had to search long and hard for a diagnosis. But despite their fatalistic attitude toward blindness, “for example by explaining vision loss as God’s will,” according to the study, they often sought immediate treatment once a diagnosis was made.

Eradicating cataracts in the developing world is possible, but doing so begins with a clearer understanding of the situation, presented in part by this research.

Mothers relatively powerless

Despite the fact that mothers are biological and often social female parents of offspring, they may have little influence within their families in the developing world—even concerning decisions about the care of their own children. “Many mothers (particularly young mothers) that we interviewed feel powerless to seek medical services outside of the community, even though, in most cases, the mother was the first person to notice that something was wrong with the child’s vision,” Dr. Geneau reported. The following interview question and answer by an illiterate mother demonstrates this point: “Q: If your husband would reject the idea of sending the child to the hospital, what would you do? “A: There is nothing I could do; she would have to stay with the problem.”

“Among the less educated (generally rural) women a few managed to come to an agreement with their husband to seek help for their children,” Dr. Geneau reported. “However, many reported difficulties, in particular the father not respecting their decision, and their inability to take any action without their husband’s approval. Very few would defy their husband without strong support from an influential member of the family or the community, even if it were in the best interest of the children.”

Additional education, however, gave mothers more familial influence, as the following interview with a mother who advanced into secondary school demonstrates: “His father and I agreed together to bring him for treatment. I would bring him anyway, but it is better to come to an agreement between parents.”

Financial independence from husbands also factored into childcare decisions. “Women who had sufficient income to achieve a level of financial independence felt generally more confident in taking decisions on their own than women without their own source of income, especially for children’s health issues,” Dr. Geneau reported. “Education reinforced that perception; women with some education were more likely to make their own decisions without deferring to husbands or waiting for their approval.”

Having another child already, interestingly, gave women more household respect as well, allowing them to seek health care more quickly.

Working together for proper care

Only five study participants were able to identify their child’s vision problem as cataract initially. Some respondents believed that “blindness is caused by witchcraft or sorcery and is, consequently, incurable and untreatable by surgery and western medicine,” Dr. Geneau noted. Nonetheless, after an accurate diagnosis was obtained, most parents and caregivers considered seeking immediate treatment. “Respondents clearly stated that the problem should be taken care of ‘as soon as it is detected’, ‘as soon’ or ‘as early as possible,’” Dr. Geneau reported. “Only six informants reported otherwise, stating they thought that the child should only be operated on when the eyes are ‘mature’ (defined by them as after 5 years old).”

Clearly, despite the developing world’s lack of resources, illiteracy rates, and cultural beliefs, proper care can and does take place. So does improper care. “Among our study population, 15 respondents (13% of all respondents) reported being sent back home with drops or vitamins or nothing at all, and without getting a diagnosis (or were given an incorrect diagnosis),” Dr. Geneau reported. “This delayed presentation to the surgical facilities by years in a few cases.”

The ophthalmic community looking to eradicate developing world cataracts must therefore understand that plenty of problems exist beyond financial constraints. Reaching outside of the ophthalmic network to institute change will be critical to success. “Since socioeducational status of the mother plays a central role in decision making in the family, empowering women and investing in women and children’s education is important,” Dr. Geneau concluded. “Increasing women’s access to markets and remunerated work can also give women more financial independence and greater ‘negotiation power’ regarding decisions taken within the household.”

An Indian viewpoint

Despite the challenges the developing world poses to eye care, Mohan Rajan, M.D., medical director, Rajan Eye Care Hospital, Chennai, India, still believes progress will come from increasing resources and care networks. “I also have worked in Africa,” Dr. Rajan said. “The problem in central Africa is that there is a lack of manpower and lack of a proper eye care network. There is also a lack of resources, and accessibility and availability of those resources.”

India had a similar problem 10 to 15 years ago, but not anymore, Dr. Rajan said. An excellent partnership between the public and private sector made this positive transition possible, Dr. Rajan said. While the government of India instituted the National Programme for Control of Blindness, which has been very successful, according to Dr. Rajan, various non-governmental organizations have carried its mission forward, helping to eradicate cataracts nationwide. “Now, resources are not a problem, manpower is not a problem, and we have one of the best eye care networks in the world,” he said.

Editors’ note: Dr. Geneau has no financial interests related to this study. Dr. Rajan has no financial interests related to his comments.

Contact information

Rajan: +65 6254 6330,

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