The island of Madagascar is one of the poorest countries in the world. Located off the east coast of Africa, its climate regularly causes a wide range of natural disasters with devastating health consequences. A series of socio-political crises has also contributed to the Malagasy population’s deteriorating 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 all children under five years of age are stunted.
PSI Madagascar was founded in 1998 to help priority populations and those with low income gain access to essential health products, services, and information. Since then, its activities have expanded to include programs focused on child survival, malaria, reproductive health and HIV.
PSI/Madagascar estimates that in 2016, its products and services helped avert 830,297 DALYs, including, by health area:
- 310,458 Malaria DALYs
- 42,522 HIV DALYs
- 299,061 FP DALYs
- 167,373 MNCH DALYs
- 10,790 WASH DALYs
PSI/Madagascar’s family planning programs also provided 945,116 couple-years of protection.
Although Madagascar is one of the few African countries to show a decline in the under-five mortality rate in recent years, that figure still remains high. Out of every 1,000 live births, 62 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 47.3% of children stunted.
PSI Madagascar is working to improve the health of Malagasy children under five. The children’s health program aims to increase the availability and use of proven life-saving health and nutrition interventions. The coverage of these interventions has expanded to include 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 a central partner in the operation of the fight against malaria in Madagascar. With the financial backing of “The President’s Malaria Initiative”, “Global Fund to Fight AIDS”, “Tuberculosis and Malaria and Unicef”, PSI contributes significantly to the reduction of malaria-related deaths among the general population and vulnerable groups (pregnant women and children under 5) by distributing, at no cost, long-lasting mosquito nets through mass campaigns, prenatal consultations, and services at public health centers. By assisting in the national effort to eliminate Malaria, PSI uses social marketing to advertise certain mosquito nets (Supermoustiquaire®) distributed by commercial retailers.
The program also contributes to the treatment of Malaria by improving community level access to quality ART (Artemisinin-Based Combination Therapies) for children under five and increasing the availability of Rapid Diagostics Tests at affordable prices for the vast majority of the population. These tests, solely administered by trained personnel, are reliable and fast.
Diarrhea remains the second-leading cause of infant mortality, and only about 38.9% of the Malagasy population have access to safe drinking water. To address this gap, PSI Madagascar markets a well known and convenient point-of-use water treatment product named Sûr’Eau. Between 2013 and 2017, more than 11 million bottles of Sûr’Eau and 200 million tablets of Sûr’Eau were sold – enough to treat approximately 20 billion liters of water. During 2016 to 2017, in the Atsinanana region, PSI gave 193 local health care centers and 101 primary schools WASH kits (2 containers of water, soap, and sȗr’eau tablets). Additionally, 383 teachers were trained on the implementation of school WASH programs. The Revolving Fund was established to address the supply of tablets in the region and develop the National Guide on “CSB Friends of WASH.”
PSI Madagascar began its diarrhea treatment program in 2009 with the Point-of-Use Water Disinfection and Zinc Treatment Project (POUZN). The project’s objectives were to increase access to pediatric zinc, in combination with oral rehydration therapy, for caregivers of children under five and to improve caregivers’ knowledge about the 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 number one disease prevalent in Malagasy children. In line with the Global Action Plan for the Prevention and Control of Pneumonia and with support from USAID, PSI Madagascar employs social and behavior change communications for the prevention and protection of pneumonia in children under five and distributes a prepackaged pneumonia treatment at the community level.
In Madagascar, 47.3% of children under ﬁve are stunted. As much as 50% percent of children who are six to 59 months old are anemic. Only 13% 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-long pilot project using social marketing to increase the consumption of micronutrient powder (MNP) among target populations. The project focused on household fortiﬁcation of complementary foods for children aged six to 23 months to tackle high levels of anemia and micronutrient deﬁciencies. Included were the promotion of optimal infant feeding practices with emphasis on food diversiﬁcation using innovative communication strategies 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 was distributed through trained community health workers for a nominal cost of US$0.1 and social franchising channels in private clinics for the cost of US$0.5. The model was 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 causes of death in the country.
In 2016, with USAID funding and in collaboration with the National Office of Nutrition and the Ministry of Public Health, PSI expanded Zazatomady’s household food fortification program to the Vakinankaratra region. From January to December 2017, more than 15,000 children used Zazatomady and 11,246 mothers received nutritional advice through home visits led by Community Agents.
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 Malagasy population, PSI Madagascar direct 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 treatment of sexually transmitted infections, case management, voluntary counseling, and testing of HIV services. 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 oftwo or three well-trained young men and women, audio-visual equipment and an all-terrain vehicle.
- Prepackaged treatment kits to manage sexually transmitted infections
- 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, Energy and Hydrocarbons Ministry of Youth and Sports
- Ministry of Social Protection of the Population and the Promotion of Women
- United Nations Children’s Fund (UNICEF)
- Roll Back Malaria
- National Office of Nutrition
- National AIDS Control Committee
- The University of Antananarivo
- SAF FJKM
- Country Coordinating Mechanism
- Peace Corps
- Diorano Wash
- Serasera Fanantenana
- Association of Doctors
- Association of Pharmacians
- Plate forma HINA
- 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.