A legion of over 35,000 community volunteers has been created to fill the health void left in Madagascar's remote rural villages in the wake of the country’s 2009 coup d'état.
Since Andry Rajoelina, with the backing of the army, removed President Marc Ravalomanana from power, the international community has withheld all but emergency donor funding. The sanctions have resulted in budget shortfalls that have forced the government to slash social service spending.
In 2010, the health budget was cut by 43 percent from the 2009 pre-crisis level, and it was cut by a further 14 percent in 2011. Only 66 percent of the reduced budget was spent, according to a 2012 African Development Bank country note.
In the past four years hundreds of health centres have closed or run out of supplies, making an already fragile health system even less accessible than before.
Santénet2, a US Agency for International Development (USAID) project to train and assist community volunteers, has bypassed the sanctions by routing its US$6 million in annual funding through civil society. The trained volunteers are now providing health care to about 800 remote communes, the majority in the eastern and southern coastal areas, in 12 of the country’s 22 regions.
The UN Children’s Fund (UNICEF) also has a programme to train health volunteers; it is also working to improve health centres. "The volunteers have to send severe cases on to the health centres, so these need to be functioning also," explained Paul Ngwakum, UNICEF Madagascar’s head of child survival. The UN agency has its volunteers in 84 out of 112 health districts in the country and plans to have them in all districts by 2017, as part of a national health volunteer policy created by the Ministry of Health.
The UNICEF volunteers work in villages located more than 5km away from the nearest public health centre, providing essential services to those who would otherwise have difficulty accessing care. According to a report by Population Services International (PSI), less than 65 percent of the country's population lives within 5km of a health center.
The report also highlights that Madagascar’s health professionals are unevenly distributed, with more than 70 percent of doctors practicing in urban areas. Rural areas are also more prone to stock-outs of drugs and medical supplies. "Many health centres have closed, and even those that are still open have often only one staff member. So when that person has to go somewhere, the centre ceases to work," Ngwakum told IRIN.
The community-based volunteers are trained in primary health care, which includes: the detection and treatment of malaria, pneumonia and diarrhoea; nutrition screenings and promotion; breastfeeding promotion; pregnancy screening; early detection of obstetric and neonatal complications; and the provision of family planning.
Sabine Raharimalala, 37, lives near Imerintsiatosika, about 30km west of Madagascar’s capital, Antananarivo. She was selected by the village’s mayor to provide family planning advice to her community as part of the Santénet2 project.
“I am proud to be selected and to contribute to the lives of women in the village,” she told IRIN.
During her one-week training course, Raharimalala learned about different forms of family planning, including the provision of contraceptives and condoms. “They can obtain these products for free at the public health centre or hospital, but these places are far away, and it takes a lot of time to go there,” she told IRIN.
Raharimalala provides the family planning products at a nominal fee: 400 ariary ($0.18) for an injection and 300 ariary ($0.13) for a month of contraceptive pills. The medicine is provided by the local Centre de Santé de Base (CSB) or through PSI. “I also organize education sessions in the more remote places to inform women about the benefits of family planning and the different method options,” she said.
One of Raharimalala’s clients, Berthine Raharisoa, started using contraceptives from the local health centre after the birth of her third child. “They gave me an implant [IUD], but I didn’t feel well, so I had them take it out. Then I had my fourth child, and I started coming to see the community health volunteer. It’s much better. The health centre is far away [6km] and it costs 600 ariary ($0.27) to take the bus. People from all the villages in the area go there, so you have to spend a long time queuing up. One trip to the health centre can take a whole day,” she told IRIN.
Raharimalala has also been trained to treat child ailments, such as diarrhoea, and she has learned how to identify malnutrition. “When cases are really bad, I tell them to go to the hospital or health centre, but for small ailments, I am right here, so the women don’t need to spend time and money to go so far to the health clinic.”
Jenannot Randriamihaja, 37, a farmer from Ambodiranokely, a small village near Imerintsiatosika that is barely accessible by road, told IRIN, “Before, people used to take their babies to the Red Cross centre in the nearby town, but that closed down last year, so now people don’t weigh their children any longer.”
Randriamihaja, a Santénet2 volunteer, is working to fill the gap. “I try to talk to the people, to inform them that they can come to me. Some don’t trust me, because I’m a farmer, not a doctor. But once they have been here, they come back.”
Herivololona Rabemanantsoa, a doctor with Santénet2, explained that the project started in 2008 by training health volunteers to just give information about nutrition, breastfeeding and hygiene in 300 communities in the country. “But once the crisis started, USAID decided that health volunteers in remote places could be trained to do more,” she said.
The Santénet2 health volunteers can restock their medicines from either public health centres or private supply points. “It works really well in remote areas, where people are far away from the nearest clinic,” said Rabemanantsoa.
“We’ve set up an impressive network in the remote places with small stocks of medicine," added Rudolph Thomas, USAID's Madagascar mission director. “The formal health network in Madagascar is inadequate. The clinics are often too far away, and if you are in a remote place, you are out of luck. The volunteer network is more sustainable, as volunteers are not paid, but rather are accountable to their communities. We are changing people’s behaviour, and that is an empowerment that is permanent.”
UNICEF’s programme went through a similar transition. "We used to train volunteers in prevention of simple diseases and promotion of healthy practices, like breast feeding. Now they are able to give first treatment for the three diseases that kill the most children under five - diarrhoea, pneumonia and malaria," Ngwakum told IRIN.
He added that keeping volunteers supplied with medicine was often a challenge. "Malaria medicine is funded through the Global Fund [to Fight AIDS, Tuberculosis and Malaria] and so there is enough, but we do not have enough funds to provide all health workers with diarrhoea and pneumonia medicines. This is not a good situation as there is a risk of overtreatment for malaria and missed opportunities for treatment of the other illnesses."
Once Madagascar’s protracted political crisis comes to an end, said Thomas of USAID, the Santénet2 volunteer network will be integrated into the public health system. “It might be an imperfect system for now, but it is better than having no services at all.”