The island of Madagascar is one of the poorest countries in the world. Off the east coast of Africa, it has a geographical location that regularly causes a wide range of natural disasters with devastating health consequences. A series of socio-political crises also contributes 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 are stunted.
PSI/Madagascar was founded in 1998 to help priority populations 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.
People We Serve
PSI/Madagascar estimates that in 2015, its products and services helped avert 1,426,767 DALYs, including, by health area:
- 866,223 Malaria DALYs
- 58,208 HIV DALYs
- 353,949 FP DALYs
- 139,481 MNCH DALYs
- 8,906 WASH DALYs
PSI/Madagascar’s family planning programs also provided 1,121,279 couple-years of protection.
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 113,024 HCT clients between 2008 and 2016.
In 2011, the Top Réseau brand was repositioned and the network evolved to a largely integrated services franchise, providing the following services (from 2008 to 2016):
- Family planning (short- and long-term methods): 585,903 consultations
- STI case management: 150,165 cases treated
- Adolescent reproductive health: 438,970 consultations
- Voluntary counseling and testing for HIV: 113,024 patients tested
- Integrated management of childhood illnesses: 206,286 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% of children stunted.
PSI/Madagascar is working to improve the health of Malagasy children under five. The child health program aims to increase the availability and use of proven life-saving health and nutrition interventions. It has expanding the coverage of its interventions to the four main childhood diseases that are considered part of the integrated management of childhood illnesses package: pneumonia, diarrhea, malaria, and nutrition.
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 10 million nets in 2015 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 2013 Malaria Indicator Survey (preliminary results), 96% of the population living in endemic zones owned at least one long-lasting insecticide-treated net (LLIN).
The recent 2015 LLIN mass campaign allowed coverage and protection for more than 18 million people through the distribution of more than 10 million treated bed nets in 91 districts of Madagascar.
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 improve access to quality Artemisin-based combination therapy (ACTs) for children under five.
Diarrhea remains the second cause of infant morbidity, and about 41% of the Malagasy population does not have access to safe drinking water. In fact, only 35% 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 2016, more than 19 million bottles of Sûr’Eau were sold – enough to treat approximately 27 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 the age of 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% 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 six 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 18month pilot project for social marketing of micronutrient powder (MNP). The aim was for home fortiﬁcation of complementary foods for children aged six to 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. This nutritional supplement had 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 2016, PSI/Madagascar distributed more than 184,212 IUDs and 36,747 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 priority communities in an entertaining and interactive format. Each MVU team consists of two or 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 109 million branded and generic condoms between 2008 and 2016.
- U.S. Agency for International Development
- The Global Fund to Fight AIDS, Tuberculosis and Malaria
- Private foundations and companies
- Ministry of Public Health
- Ministry of Education
- Ministry of Water, Hygiene and Sanitation
- Ministry of Youth and Sports
- United Nations Children’s Fund (UNICEF)
- Roll Back Malaria
- Office national pour la Nutrition (National Office of Nutrition)
- Comité national de lutte contre le SIDA (National AIDS Control Committee)
- SAF FJKM
- Country Coordinating Mechanism
- Do anti‑malarials in Africa meet quality standards? The market penetration of non quality‑assured artemisinin combination therapy in eight African countries
This paper uses national and sub-national medicine outlet surveys conducted in eight study countries (Benin, Kinshasa and Kantanga [Democratic Republic of the Congo, DRC], Kenya, Madagascar, Nigeria, Tanzania, Uganda and Zambia) between 2009 and 2015 to describe the non-QAACT market and to document trends in availability and distribution of non-QAACT in the public and private sector.
- Quality Issues with Malaria Rapid Diagnostic Test Accessories and Buffer Packaging: Findings from a 5‑Country Private Sector Project in Africa
This paper describes quality problems with buffer and accessories encountered in a project promoting private sector malaria rapid diagnostic test use in five African countries and suggests steps to avoid or more rapidly identify and resolve such problems.
- Webinar: Stimulating the Market for Malaria RDTs in the Private Sector
PSI, UNITAID, Malaria Consortium, FIND, and JHSPH held a webinar to discuss leveraging the power of the private sector to transform the mRDT market in support of universal access to malaria diagnostics.
- Shaping the Family Planning Market by Strengthening the Public Sector
PSI considers total market approaches to be critical for achieving universal health coverage, especially when it comes to contraception. This program brief presents cases, supported by several different donors, which take into consideration the total family planning market.
- Transforming the Private Sector to Support Universal Malaria Diagnostic Coverage
To assure the available and use of malaria rapid diagnostic tests in the private sector, PSI and partners conducted a three-year project between 2013 and 2016 to increase the uptake of quality-assured mRDTs in private-sector markets in Kenya, Madagascar, Nigeria, Tanzania, and Uganda by taking a market development approach to identify market failures.
- ￼Trends in Public and Private Sector Readiness to Manage Malaria in Madagascar, 2010-2015
Stronger private sector strategies are needed to improve malaria case management in Madagascar. In the vast majority of cases, people seeking malaria treatment
in both public and private sectors of Madagascar are treated with non-artemisinin therapies including SP and chloroquine. The majority of antimalarials in Madagascar are distributed in the private sector. 2015 findings also highlight widening gaps in public sector readiness and performance for appropriate malaria treatment.
- 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).
- Measuring the Impact of Interpersonal Communication on HIV Testing in Madagascar
PSI Madagascar uses its network of socially franchised health clinics (Top Reseau) to offer HIV services to high risk populations such as sex workers. Peer educators in collaboration with Top Réseau clinics use interpersonal communication (IPC) to promote the availability of this service. This paper examines whether the IPC intervention activities led by peer educators for female sex workers is resulting in higher rates of HIV testing in Top Réseau facilities.
- 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.