Madagascar: A Crisis Propels Community Health Forward

In late August, The Lancet published an article entitled “Madagascar’s Health Challenges,” which outlined the disappointingly deep and negative impact of the 2009 political crisis on the health of the island’s population and future prospects.

The  article made me think in a broader sense about what had happened to the health care system and overall population health in Madagascar since the beginning of the crisis. I’m always interested to read research about Madagascar, a country in which JSI has worked for 25 years. However, the article disappointed in that it lacks metrics–available statistics would back up many of the stated opinions. Furthermore, the authors fail to note some of the inventive and committed ways in which the public health community continued to work and function, in spite of the political upheaval.

Photo: Robin Hammond
Photo: Robin Hammond

The Malagasy political crisis began in January 2009 and reached its climax in March 2009 when Antananarivo mayor Andry Rajoelina was declared president of the High Transitional Authority of Madagascar, five days after President Marc Ravalomanana transferred his power to a military council and fled to South Africa. The resulting government was deemed illegal by the international community, and many of Madagascar’s strongest bilateral and multilateral supporters cancelled or restricted funding. However, USAID chose not to halt funding, but rather to find new partners and methods to support community health.

JSI began work in 2011 on MAHEFA, a USAID-funded program focusing on community health in isolated areas, so we had a front row seat and a major responsibility to improve community health without spending any funds on the public sector. JSI committed to implementing the National Community Health Policy, training community-selected and supported Community Health Volunteers (CHVs).   Here are a few lessons we learned along the way:

Assume Professional Commitment.   JSI wanted and needed MOH clinicians to assist with the practical training of CHVs; the MOH were their supervisors, and this linkage was critical to sustainability and support for the new CHVs. At the same time, JSI was prohibited from funding the attendance of the MOH supervisors at the CHV training or providing material support. The practicums which were designed to take place in the supervising health post and to reinforce linkages to the public health system. Over the course of the years during which situation persisted, very few MOH staff blocked CHV training or refused to assist; most of them donated time and resources for the CHV training in spite of the obstacles. This is especially stunning given the lack of resources in the MOH, the lack of salary payment to many MOH staff, and the extremely difficult working conditions in many of the project zones. The commitment of these physicians and nurses continued in spite of the circumstances.

Since 2011, JSI's MAHEFA project has worked to improve health outcomes in Madagascar at the community level by training and equipping community health workers to deliver health services and education. Photo: Robin Hammond
Since 2011, JSI’s MAHEFA project has worked to improve health outcomes in Madagascar at the community level by training and equipping community health workers to deliver health services and education. Photo: Robin Hammond

Redefine Access.   Our donor stipulated that most commodities for CHVs would be provided through the social marketing network. When the project started, none of the CHVs working in MAHEFA-supported rural communities were served by a social marketing depot. At the same time, the social marketing partner reached all communities that they defined as accessible. Many of MAHEFA’s communities were thus deemed inaccessible due to lack of roads, flooding, or other reasons. Working together, we redefined access to create a system of community depots at existing shops to manage social marketing commodities for a modest profit. Accessibility is no longer defined by paved roads or population size, but rather by the need for each community to have at least one depot.

Access and transportation are challenges to delivering health care in many of Madagascar's remote and rural communities. Photo: Robin Hammond
Access and transportation are challenges to delivering health care in many of Madagascar’s remote and rural communities. Photo: Robin Hammond

Reference Policy.   Even when a donor prohibits working with Ministries, following policy and protocols builds more sustainable programs and lays the groundwork for a strong future relationship with the public sector. JSI showed respect by continuously referencing Ministry policy and protocols, and sharing credit for successes. When we were able to work with the three Ministries , we  built good will and solid relationships.

The US government restrictions were lifted about a year ago, and JSI’s MAHEFA program is now working closely with the Ministries of Health, Water and Youth. MAHEFA is focusing on sustainability of community health approaches and improved quality of care and staff are enjoying collaboration with the Ministries.

MAHEFA's respectful collaboration with the Ministry of Health throughout the project has fostered sustainability of interventions that are improving the health and well-being of Malagasy families. Photo: Robin Hammond
MAHEFA’s respectful collaboration with the Ministry of Health throughout the project has fostered sustainability of interventions that are improving the health and well-being of Malagasy families. Photo: Robin Hammond

Biographical note: Elaine joined JSI in 1991 for a job in Madagascar, and has supported a variety of projects there since then including two long-term assignments.   Currently, she is the Senior Advisor for the MAHEFA program as well as supporting new business development.