I am back in the Tana office following a week in the Fort Dauphin region in the south east of Madagascar. I was on a mission with my colleagues from UNICEF to support a community led maternal and neonatal health project in 2 districts in the region. The project goals are to increase the demand and access for community health services which in turn will lead to a reduction in the alarmingly high maternal and neonatal mortality rates. One aspect of the project involved incentivising community health workers (CHWs) to encourage the community to avail of their local health centres by providing performance based bonuses.
Before going on this mission I didn’t fully appreciate the importance of the role of the Community Healthcare Worker. As in many developing countries, there is a critical shortage of educated medical professionals in Madagascar and there are simply not enough doctors or nurses, nor are there the means to pay for them. CHW volunteers are elected by their community, and, as such, are respected and trusted individuals with cultural insight. They are given a limited amount of training, supplies, and support to provide essential primary health-care services to the population. In our project, CHWs carry out health promotion by visiting pregnant women, teaching them about birth planning and danger signs, and assisting them in obtaining both prenatal and obstetric services at the health centres in the target districts. To motivate CHWs, they are given a bonus for every referral they provide or for every woman they accompany to the health centre.
We visited the Sampona village and commune in the Ambosary district, which has a population of approximately 11,000. The majority 92% of the population of the commune are farmers. The region is prone to drought and the people here suffer frequently from famine as very few vegetables grow, apart from the root vegetable cassava. We drove past field after field of sisal plants whose fibres are used to make rope and twine.
We met Veronique who works as a midwife in Sampona’s heath centre, and her team of 38 CHWs. The only building large enough to accommodate our meeting was the village school so we all squeezed into one of its classrooms. Veronique is 26, from Tana, and moved to this remote and isolated part of Madagascar upon completion of her studies 2 years ago. Before she arrived there were only 6 deliveries a month taking place at the health centre. Today, she delivers about 30 babies a month. She gave a very motivational speech reinforcing the importance of the work that the CHWs carry out. I was very impressed with this young midwife who has made many sacrifices to work so far from home in such harsh conditions. The meeting itself was like none I’d ever been to. The CHWs were men and women of all ages. Nearly all the women brought their children with them and at one point four of the mothers were breastfeeding at the same time!
From the most recent health indicators collected for the commune, it was clear that this CHW performance incentive is delivering the desired results in terms of improved health outcomes for women and new-borns in Sampona. More women are delivering at Sampona heath centre and are receiving pre and post-natal care along with family planning services whilst more new-borns are provided with the required care.
There are some major challenges however. Many of the CHWs we met are illiterate and as a result are not in a position to correctly document their work which has a significant impact on accurately reporting results. One volunteer I spoke to said many women are too ashamed to deliver at the health centre as they have no clothes or nappies for their new babies. Additionally, the small sum of money that is offered to these volunteers is shocking and hardly motivating. For example a CHW will receive 1000Ar for accompanying a woman to the health centre for an antenatal visit. This is approximately €0.33! I met one CHW from a village that’s 25km away from Sampona and he usually makes this journey on foot which takes 6 hours as the bush taxi only passes by once a week. It made me wonder how difficult must it be for a pregnant woman to undertake this journey.
At the end of the week we met with the Director of Health for the Fort Dauphin region and gave our feedback on areas for improvement and encouraged best practices to be shared within the districts.
I made the most of my visit to the very sunny south east, and spent the weekend exploring spectacular coastline around Fort Dauphin. I took a guided tour to the most beautiful, remote beaches and learned about the local flora and fauna, got up close and personal to a particularly curious chameleon, and close, but not too close, to the famous carnivorous pitcher plant.
Only a month to go and plenty to do yet.
Until next time,