The island of Madagascar, off the east coast of Africa, is one of the poorest countries in the world, with a geographical location that regularly causes a wide range of natural disasters with devastating health consequences. A series of socio-political crises also contributed to deteriorating the Malagasy population’s living conditions. As a result, the country faces a large number of healthcare challenges.
Maternal mortality and nutrition indicators have continued to stagnate over the past decade. Maternal mortality is 498/100,000, well above the Millennium Development Goal target of 149/100,000, and half of the children under five years of age in the country are stunted.
PSI/Madagascar was founded in 1998 to help vulnerable and low-income people gain access to essential health products, services and information. Since then, its activities have expanded to include programs in child survival, malaria, reproductive health and HIV.
PSI/Madagascar estimates that, in 2012, its products and services helped avert 1,613,391 DALYs.
In 2001, PSI/Madagascar launched its flagship franchised network of private clinics branded Top Réseau with the support of the Bill & Melinda Gates Foundation. The project aimed to improve reproductive health behaviors among sexually active youth and high-risk groups through quality case management of sexually transmitted infections (STIs) and promotion of consistent condom use. In 2006, Top Réseau started offering voluntary HIV counseling and testing (HCT) services, and received more than 47,000 HCT clients between 2008 and 2012.
In 2011, the Top Réseau brand was repositioned and the network evolved to a largely integrated services franchise, providing the following services in 2012:
- Family planning (short- and long-term methods): 85,053 consultations
- Sexually transmitted infections (STIs) case management: 33,171 cases treated
- Adolescent reproductive health: 3,989 consultations
- Voluntary counseling and testing for HIV: 5,561 patients tested
- Integrated management of childhood illnesses: 27,481 consultations of children under five
Although Madagascar is one of few African countries to show a decline in the under-five mortality rate in recent years, that figure remains high. Out of every 1,000 live births, 72 children will die before their fifth birthday. Malaria, diarrheal diseases and respiratory infections claim the most lives, while chronic malnutrition affects large swathes of Madagascar’s population, leaving 50 percent of children stunted.
By recently expanding the coverage of its interventions to the four main childhood diseases that are considered part of the integrated management of childhood illnesses package, namely pneumonia, diarrhea, malaria and nutrition, PSI/Madagascar is working to improve the health of vulnerable Malagasy children under five. The program aims to increase the availability and use of proven life-saving health and nutrition interventions.
PSI/Madagascar is an important partner in the implementation of malaria control programs in Madagascar. With support from the President’s Malaria Initiative, the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNICEF, PSI/Madagascar largely contributes to reducing malaria-related mortality in the general population. Free distribution of more than 1.6 million nets in 2009 and more than 5.5 million nets in 2010 led to a significant increase in net use and ownership and to a decrease in malaria-related mortality in the country. According to results from the 2011 Malaria Indicator Survey, 94% of the population living in endemic zones owned at least one long-lasting insecticide-treated net (LLIN). The malaria-related mortality decreased from 11.5 percent to 6.8 percent between 2008 and 2011 (MIS 2011).
The recent 2012 LLIN mass campaign allowed coverage and protection for more than 5 million people through the distribution of more than 2.1 million additional treated bed nets in 31 districts of the East Coast.
In order to achieve the National Malaria Control Strategy‘s mission, which is “to accelerate progress towards malaria elimination,” PSI/Madagascar also distributed mosquito nets using social marketing at a highly subsidized price through community health workers and commercial retailers. In addition, with support from the Global Fund and in collaboration with the Ministry of Health and other malaria partners, PSI/Madagascar contributes to improving access to quality artemisin-based combination therapy (ACTs) for children under five. Prepackaged ACTs are distributed at a small fee by the community health workers.
Diarrhea remains the second cause of infant morbidity, and about 41 percent of the Malagasy population does not have access to drinking water. In fact, only 35 percent of mothers of children under five years old even report treating their water. To address this gap, PSI/Madagascar markets a point-of-use water treatment product under the well-known brand name Sûr’Eau, that is easy to use every day. Between 2008 and 2012, more than 9 million bottles of Sûr’Eau were sold – enough to treat approximately 13 billion liters of water.
PSI/Madagascar began its diarrhea treatment program in 2009 with the Point-of-Use Water Disinfection and Zinc Treatment Project (POUZN). The objectives of this project were to increase access to pediatric zinc in combination with oral rehydration therapy for caregivers of children under age five and to improve their knowledge on this treatment. Two sets of diarrhea treatment kits (one strawberry-flavored and one orange-flavored) were distributed respectively to the private sector and to community health workers. Now funded by the U.S. Agency for International Development (USAID), these prepackaged diarrhea treatment kits are available at an affordable price and remain one of the most effective ways to treat diarrhea.
Pneumonia is the fourth leading cause of death and the leading cause of morbidity in Malagasy children. In line with the Global Action Plan for the Prevention and Control of Pneumonia and with support from USAID, PSI/Madagascar works on social and behavior change communications for the prevention and protection of pneumonia in children under five and on distribution of a prepackaged pneumonia treatment at the community level.
Undernutrition is the second highest cause of childhood mortality, responsible for 12.7 percent of mortality among children under five in Madagascar. Over half of the children under the age of ﬁve are stunted in Madagascar. As much as 68 percent of children who are 6 to 11 months old are anemic. Only 13 percent of children who are six to 23 months old receive a diverse, nutrient-rich diet. Malnourished children are very vulnerable to diseases such as malaria, diarrhea and pneumonia. Similarly, incorrect treatment of diarrhea increases the risk of developing a state of chronic malnutrition. Micronutrient interventions are ranked as one of the most cost-effective interventions in all health and development activities.
In February 2013, with UNICEF support, the National Nutrition Ofﬁce, the Ministry of Health and PSI launched an 18-month pilot project for social marketing of micronutrient powder (MNP) for home fortiﬁcation of complementary foods for children aged 6-23 months to tackle high levels of anemia and micronutrient deﬁciencies. The project includes the promotion of optimal infant feeding practices with a focus on food diversiﬁcation using an innovative communication strategy and the distribution of a locally branded micronutrient powder called Zazatomady, which has previously been proven to reduce anemia rates and other micronutrient deficiencies in infants and young children. The product is distributed through trained community health workers for a nominal cost of US$0.1 and through social franchising channels in private clinics for the cost of US$0.5. The model is being closely monitored for sustainability, so that the results can feed into the national scale up plan. The integration of a nutrition intervention will also enable PSI/Madagascar to address the four major childhood killers in the country.
To help reduce unwanted pregnancies, abortion, maternal mortality and infant mortality in Madagascar, PSI/Madagascar has implemented a program offering a wider range of high-quality modern contraceptive methods and services.
Products include Pilplan-branded oral contraceptives; Confiance-branded three-month injectables; and generic implants and intra-uterine devices (IUDs). Pilplan and Confiance are accessible through community health workers and pharmacies as well as through drug shops. The insertion of long-term methods is a service available through private providers. Since 2006, PSI/Madagascar has worked closely with the Ministry of Health and NGO partners such as Marie Stopes International and local NGO SALFA to promote IUD and implant use. Selected Top Réseau providers received training in insertion of one or both of these methods. In 2008, PSI/Madagascar also received a multi-million dollar grant from a private foundation for the promotion of these methods. From 2008 to 2012, PSI/Madagascar distributed more than 80,000 IUDs and 10,000 implants.
Given the low prevalence of HIV in the general population, PSI/Madagascar targets HIV risk awareness efforts towards high-risk groups, including female sex workers and their clients, men who have sex with men and sexually active youth aged 15 to 24.
PSI/Madagascar aims to improve reproductive health behaviors among sexually active youth and most-at-risk groups through quality sexually transmitted infections, case management and voluntary, counseling and testing of HIV services. PSI/Madagascar’s outreach program supported the Top Réseau network services by creating demand through peer education activities, ensuring the promotion of consistent condom use and promoting safe behavior among target groups.
PSI/Madagascar offers a variety of interventions in the HIV prevention program, including:
- Peer education through high-risk group peer educators and youth peer educators.
- Mobile video units (MVU) sessions to deliver health messages to rural and other vulnerable communities in an entertaining and interactive format. Each MVU team consists of three well-trained young men and women, audio-visual equipment and an all-terrain vehicle.
- Prepackaged treatment kits to manage sexually transmitted infections such as chlamydia, gonorrhea and genital ulcers.
- Condom distribution of more than 64 million branded and generic condoms between 2008 and 2012.
- U.S. Agency for International Development
- The Global Fund To Fight AIDS, Tuberculosis and Malaria
- Private foundations and companies
- The World Bank via local organizations
- Roll Back Malaria
- Office National pour la Nutrition (National Office of Nutrition)
- Ministry of Public Health
- Comité National de Lutte Contre le SIDA (National AIDS Control Committee)
- The World Bank
- SAF FJKM
- Country Coordinating Mechanism
- Fever Case Management Provider Job Aid
The aim of these provider job-aids developed for Tanzania, Madagascar and Kenya is to visually support providers during their day-to-day activities and guide them through the steps they must undertake to perform, read and dispose of malaria Rapid Diagnostic Tests (RDTs).
- Market Trends for Malaria Blood Testing in Sub-Saharan Africa, 2009-2014
In 2012, the World Health Organization (WHO) launched the Test, Treat, Track initiative recommending confirmatory testing prior to antimalarial treatment. National malaria control programs (NMCP) across subSaharan Africa (SSA) subsequently aligned national guidelines with this recommendation. Strategies to scale up testing using malaria rapid diagnostic tests (mRDT) were introduced by NMCPs. We examine malaria testing availability, price and market share using national market survey data collected by the ACTwatch project.
- Measuring the Impact of Behavior Change Communication on Contraceptive Use in Madagascar
Despite recent success stories in Madagascar, modern contraceptive use remains low with significant unmet need. CPR for Madagascar stands at 33.3%, (a) having tripled over a period of 10 years. Unmet need is 18%(a) . PSI Madagascar is working to improve access to family planning (FP) for all women, by implementing behavior change communication (BCC) to promote voluntary use of modern FP methods. This presentation examines the relationship between contraceptive use and BCC exposure in order to measure the effect of mass-media activities.
- Private Sector Providers: Key Partners in Improving Quality of Fever Case Management – Insights From Madagascar
Ensuring universal diagnosis of all cases of suspected malarial illness is a public health priority (and WHO recommendation) to ensure correct diagnosis and treatment and to counter resistance to artemisinin-based combination therapies (ACTs). This issue is particularly pertinent for the private sector which is often unregulated, where presumptive treatment is common, and where a significant portion of the population seeks care.
- SP Availability and (Mis)Use in Sub-Saharan Africa: Antimalarial Market Data From 8 Countries
As evidence of reduced chloroquine efficacy against plasmodium falciparum mounted in the 1990’s, sulfadoxine-pyrimethamine (SP) became first-line malaria treatment in many endemic countries in sub-Saharan Africa (SSA). Between 2002-2005, countries in SSA adopted artemesinin combination therapies (ACT) as first-line treatment. SP is still recommended by the WHO and used across SSA for intermittent preventive treatment of malaria during pregnancy (IPTp). We examine availability and distribution of SP using national antimalarial market survey trend data collected by the ACTwatch project.
- Improving Provider Behavior Change Communication and IPC: Best Practices from the Women’s Health Project
This brief describes the challenges faced, strategies developed, and lessons learned by the Women's Health Project. It also proposes a set of best practices for improving productivity of interpersonal communications (IPC) agents and increasing providers' skills and motivation.
- Approaches to Measuring Equity: Methods & Pilots from 12 Franchise Programs
PSI's presentation at the iHEA conference highlighted equity results from social franchising programs and introduced standard methods for the collection and analysis of equity data.
- UNITAID Private Sector RDT Project
This one pager outlines how the UNITAID Private Sector RDT Project aims to stimulate the creation of a private sector market for malaria, the project's expected impact and outcomes, and the partners involved.
- Partners Launch Pilot Program to Combat Undernutrition in Madagascar
Intensive interpersonal communication by trained community health workers, radio messages and mobile video units will support a new pilot program that aims to tackle one persistent form of malnutrition in Madagascar. In late February 2013, PSI/Madagascar started distributing the new Micronutrient Powder branded Zazatomady targeting caregivers of children 6-23 months old.
- 8 iCCM Programs Highlight Diverse Approaches to Reduce Top Child Killers
This brief shows how PSI is exploring models to scale-up integrated community case management (iCCM) of pneumonia, diarrhea and malaria for remote populations.