Department of Health Studies, Elon University

Social Determinants of Health (SDOH)

Togo and Tuberculosis

PHS 3020B: Global Health

Professor Tapler

September 29, 2022

 Focusing on the health of populations is crucially important to create a more prosperous

nation, enhance economic growth and improve individuals' overall well-being and quality of life.

The Social Determinants of Health (SDoH) are defined as the economic and social conditions

that influence individual and group differences in health status (Social Determinants of Health -

Healthy People 2030 | Health.Gov, n.d.). Social determinants have a major impact on health

outcomes, specifically for more vulnerable populations. Economic stability, education quality,

healthcare access, the built environment, and community framework will be examined

thoroughly concerning Togo. Factors such as education, healthcare, income level, and

environment must be considered when providing treatment to achieve better overall health

outcomes within the country. With this in mind, Tuberculosis (TB) has been a major health

concern in Togo for several years. Poor economic stability, healthcare access, living conditions,

and education all contribute to the high prevalence of disease rates, specifically TB in Togo.

Economic Stability

To effectively better the health of those living in Togo, it is important to be aware of the

country’s economic stability. Although Togo’s overall economy and gross domestic product

(GDP) have improved in recent years, the rate of poverty is not declining fast enough and is

therefore affecting the overall health of the economy. As the economy grows, so do opportunities

for employment and income growth. Togo’s turbocharged direct injection (TDI) trend

demonstrates a slow incline of progressiveness over the past three decades (Kohnert, 2020). In

1990, the TDI was at 0.40, and in 2018, it progressed to 0.51 (Kohnert, 2020). More recently, in

November 2020, “it has increased to 26.6% which put Togo in the low human development

category; however, when the value is adjusted for inequality, the human development index

(HDI) falls to 0.35- a loss of 31.7%” (Kohnert, 2020). Togo’s country report in 2019 states,
“80% of the population is now at risk of falling below the poverty line, and the rate of extreme

poverty is 49.2%, almost twice the poverty rate in Ghana at 25.2%” (Kohnert, 2020).

Additionally, there is an alarming variation of poverty between the rural and urban parts of Togo

that indicates inequality within the country. Rural residents, specifically farmers, make up 65%

of the Togolese workforce, recognizing the vital role which agriculture plays in Togo’s economy

(Poverty in Togo, n.d.). Over the years, however, Togo's agricultural sector has been greatly

declining due to the lack of effective policies that promise supplies of seeds and fertilizer, in

addition to, underdeveloped markets, and the absence of farming (Poverty in Togo, n.d.).

Without economic steadiness, there is a lack of access to financial resources, quality of housing,

food, and jobs that provide a stable living income. With this in mind, researchers have found that

poverty greatly influences the transmission of TB, primarily through poor living conditions. To

lessen the extreme poverty rate in Togo, it must address the inequities between those living in

rural and urban parts of Togo and its declining agricultural sector to help grow the economy.

Education

While addressing Togo’s SDoH, it is important to examine the country’s education

system and its access and quality. This being said, education provides opportunities for gaining

skills, better employment, raising one’s income, and enhancing one’s social status, all of which

are related to health. From 1991 to 2007, Togo experienced socio-political conflicts due to the

education system’s lack of progress (Project, 2014). From there, Togo’s conflicts only became

increasingly worse when leader Gnassingbe Eyadema died in 2005 after 38 years in power

(Project, 2014). Since then, Togo has been seeking financial help from local and international

organizations to help develop better education systems within the country. Schools in Togo are

state-owned and are either Christian or Islamic (Project, 2014). Starting at the age of six, children
are mandated to go to primary school for a total of six years free of charge (Project, 2014). While

the number of students attending school has increased, about 10% of children are still not

enrolled and the majority of the few school systems available are near Togo’s capital, Lomé;

therefore, leaving children in rural parts of Togo far from reach of schools (Project, 2014).

Despite the increase in students enrolling in primary school, the quality of Togo's education

system remains a key issue. About 50% of children in primary school do not demonstrate the

expected skills and knowledge (Durchbach, n.d.). Additionally, drop-out rates remain high and

the score of Togolese students are well below the average in sub-Saharan countries which is

shown through international assessments such as the PASEC (Durchbach, n.d.). Roughly, “68%

of eligible males and 54% of females in urban areas enroll in secondary education while only

45% of eligible males and 33% of females in rural areas attend secondary school” (Thelwell,

2019a). As a result, more than half of children in Togo do not continue onto secondary school

thus creating a large enrollment gap between primary and secondary schooling (Thelwell,

2019a). Without adequate access to education, the health of individuals is also negatively

affected in Togo; therefore, making TB an even greater concern in Togo. The Education and

Development program of UNICEF Togo aims to improve the access to education for all children,

specifically those who are excluded from the system (Durchbach, n.d.). Those excluded from the

system include girls from certain areas of the country, children with disabilities, or those who

live in rural areas (Durchbach, n.d.). With the help of the Education and Development program

by UNICEF Togo, progress has been demonstrated through teacher training and effective

management from trained professionals within school systems (Durchbach, n.d). It is essential to

understand that education contributes to both disease prevention and management. The result of
higher quality education influences people’s quality of life, therefore, bettering people’s health

outcomes.

Healthcare

Togo’s current healthcare crisis greatly influences the health status of the Togolese

people. Currently, health workers and centers are mainly concentrated in Togo’s capital, thus

leaving rural areas at a disadvantage. Like much of sub-Saharan Africa, “government spending

on healthcare in Togo is low, about 1.4% of GDP, with out-of-pocket spending representing

about two-thirds of all expenses” (Thelwell, 2019b). Recently, Togo has taken its first steps in

establishing a new universal healthcare system, aiming to cover residents by 2025 (Togo, n.d.-a).

Togo’s universal healthcare system is composed of two tiers, a public sector, and a private

sector. Employees would be covered by the mandatory régime d'assurance maladie obligatoire de

base (RAMO), and a separate system would apply to the poor and other individuals on public aid

(Togo, n.d.-a). The academic journal, "Integrating childhood TB: applying the care delivery

value chain to improve pediatric HIV/TB services in Togo, West Africa,” discusses and analyzes

pediatric TB being historically neglected due to poor quality health care and education on

diseases in Togo. With this in mind, TB has been overlooked in children due to the nature of the

disease. Health officials believe that there is “less” bacteria in the mucus to spread to others

when a child has TB; however, children carry a significant burden of diseases and are more

prone to life-threatening cases of TB (Dubois et al., 2020). Children living with HIV have an

increased risk of TB morbidity and mortality because they are immunocompromised and have a

greater chance of complications during TB treatment (Dubois et al., 2020). In Togo, health care

facilities are limited and there is a shortage of health workers and a lack of professional training.

Given these disadvantages, a more systematic approach is needed for pediatric TB care in Togo,
specifically for those living with HIV (Dubois et al., 2020). At an HIV center in northern Togo,

patients with HIV receive complex health services through a partnership with a community-

based organization, an international partner, and Togo's Ministry of Health. The Care Delivery

Value Chain (CDVC) is an effective tool to provide a systematic structure to assess the overall

care for medical conditions in patients (Dubois et al., 2020). Given the WHO recommendations

to integrate HIV and TB care as one, the objective of the research highlighted in the article is to

create a CDVC framework for HIV/TB services for children ages 0–19 years old at an HIV clinic

in Kara, Togo (Dubois et al., 2020). After the trial was conducted, the limitations found in the

study included poor technology to report electronic medical records and documentation from

medical providers, lack of financial support to perform highly efficient TB screenings and

diagnosis, in addition to the lack of tools to effectively conduct contact tracing in more

vulnerable populations (Dubois et al., 2020). Adequate access to health care that results in

appropriate and effective TB treatment as well as all diseases, is crucial to improving a

population’s quality of life.

Neighborhood and Built Environment

Depending on where an individual may live, their health can be affected by

environmental factors such as poor water quality, insufficient housing, lack of access to

nutritious foods, and safe places to exercise and play. In Togo, rural housing is typically made

from sun-dried mud bricks and mud plaster, with straw roofs. Whereas, urban housing is made of

cement blocks or bricks with brick or iron sheeted roofs, typically (Housing - Togo - Problem,

n.d.). Here is an example of inequality between two different housing situations in different parts

of Togo based on one’s economic status. Over the last couple of years, Togo has been trying to

solve the problem of urban overcrowding by promoting housing systems and implementing
sanitation facilities however little progress has been made (Togo, n.d.-b). According to UNICEF,

“33% of people living in Togo do not have access to clean water, and a quarter of the population

do not have access to drinking water within 30 minutes walking distance of their home” (Togo,

n.d.-b). Due to the social unrest that has lived in Togo for as long as residents have remembered,

places to safely exercise and play almost do not exist. Many residents are also food insecure due

to the lack of reliable information on agriculture markets and climate change (Housing - Togo -

Problem, n.d.). More recently, hunger in Togo has significantly worsened post-COVID-19

pandemic which in turn has affected more vulnerable populations like pregnant women and

children. Widespread poverty, low agricultural productivity, land and environmental deprivation,

and population growth in Togo greatly affect residents' access to food and resources (Housing -

Togo - Problem, n.d.). In the article “Housing and child health in sub-Saharan Africa: A cross-

sectional analysis,” housing is thoroughly discussed since it is essential to people’s well-being

yet greatly ignored in global health (Tusting et al., 2020). Through the cross-sectional analysis of

housing conditions in sub-Saharan Africa, researchers found that improved housing is associated

with better health in children (Tusting et al., 2020). In the article, “824,694 children were

surveyed in 54 Demographic and Health Surveys, 21 Malaria Indicator Surveys, and two AIDS

Indicator Surveys which were conducted in 33 countries between 2001 and 2017 that measured

malaria, diarrhea, acute respiratory infections and underweight or anemic children aged 0-5

years” (Tusting et al., 2020). From there, researchers assessed whether improved housing is

associated with a lower risk of five major causes of death in children in sub-Saharan Africa:

malaria, diarrhea, acute respiratory infection, growth failure, and anemia (Tusting et al., 2020).

As a result, “children living in housing with improved drinking water and sanitation and stable

housing, had a reduced likelihood of four major causes of death: malaria (12%–18% reduction),
diarrhea (8% reduction), growth failure (stunting: 17% reduction, wasting: 10% reduction,

underweight: 15% reduction), and anemia (11%–13% reduction) while accounting for

differences in levels of urbanization, poverty, vaccinations, and other public health

interventions” (Tusting et al., 2020). The research highlighted shows proof that infectious

disease rates increase when one’s living situation, access to resources, and income is insufficient.

Therefore, adequate living conditions for those living in Togo are imperative to minimize the

prevalence of diseases, one being TB, within a population.

Social and Community Context

Social and community support has a major impact on an individual’s health and well-

being. Many Togolese children will not live to see their fifth birthday, very few education and

health care systems are prevalent, and very poor living conditions and discrimination and societal

mistreatments greatly burden the communities of Togo. Because of these reasons, community

development projects have been established with the help of international and local organizations

to help aid and rebuild Togo’s communities. The Community Development and Social Safety

Nets Project (PDCplus) has assisted in alleviating social struggles within communities in Togo

(Alexander, 2021). In total, “the project has created more than 346 micro projects to improve

social infrastructures, 208 micro-projects to develop more income-generating activities, 305

schools with school canteen programs, and 196 school buildings” (Alexander, 2021). The

program has been extremely successful in reducing poverty rates within Togo. As a result,

community development programs increase citizen participation through microprojects that

provide training for community members (Alexander, 2021). One nonprofit, Education

Leadership Community Development, known as EDULCOD Togo, works to improve the quality

and accessibility of education for impoverished populations (Alexander, 2021). The mission of
this non-profit organization reflects outcomes from PDCplus (Alexander, 2021). To continue

community participation, new projects created by the government have to be pushed for. The

creation of community development programs will help influence individual and group

differences in health status within Togo. With the reduction of poverty rates in Togo due to

community-based projects, the prevalence of disease rates will also begin to lessen because

people's overall living conditions will improve. Overall, community development programs are

reducing poverty rates in Togo which in turn affect many other social determinants of health and

help to lessen disease spreads within the country.

Overall, the country of Togo struggles with many hardships including a declining

agriculture sector, inequity between those living in rural and urban parts, poor sanitation and

living conditions, an underdeveloped healthcare system, a struggling education system, and

many other difficulties. All these issues contribute to health inequities and have been shown to

increase disease prevalence in lower-middle income countries. It is important to understand

Togo's SDoH to improve the overall health status and people's way of living. Fewer children in

school, inequitable access to nutritious foods, overcrowding, and so forth, influence the spread of

TB and therefore demonstrate a vicious cycle. As a result, it is important to continue addressing

major concerns in Togo to improve people's overall well-being and the country as a whole.
 References

Alexander, L. (2021, July 7). Community Development Programs in Togo. The Borgen Project.

https://borgenproject.org/community-development-programs-in-togo/

Dubois, M., Faro, E. Z., Lee, D. S., Katin, V., Kenkou, K., & Fiori, K. P. (2020). Integrating

childhood TB: applying the care delivery value chain to improve pediatric HIV/TB

services in Togo, West Africa. AIDS care, 32(11), 1445–1450.

https://doi.org/10.1080/09540121.2020.1770672

Durchbach, E. S. (n.d.). Sectoral and OR+ SC189904 Report. 25.

Housing—Togo—Problem. (n.d.). Retrieved September 14, 2022, from

https://www.nationsencyclopedia.com/Africa/Togo-HOUSING.html

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https://borgenproject.org/tag/poverty-in-togo/

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https://borgenproject.org/education-togo/

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28, 2022, from https://health.gov/healthypeople/priority-areas/social-determinants-health

Thelwell, K. (2019a, July 16). 8 Facts About Education in Togo. The Borgen Project.

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