Madagascar

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Picture It: Community
Health Workers and other #HealthWorkersCount 4 #FamilyPlanning

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Improving Health Through the Social Quality Approach in 800 Communes in Madagascar

Anonymous — Thu, 06 Oct 2016 19:02:47 +0000

Improving Health Through the Social Quality Approach in 800 Communes in Madagascar 2013 Anonymous (not verified) October 06, 2016

To help empower the Malagasy people to address their own health needs, the USAID/Santenet2 program introduced the social quality approach in 800 communes in Madagascar. The social quality approach is a community-based approach for encouraging service recipients to get involved in the availability, use, and quality of health services. This report, based on Santenet2 project data, correlation analysis, and qualitative data collection, illustrates the implementation process, successes and essential components to the successful implementation of the social quality approach.

Project: Santénet2

Download (English)

Countries Madagascar

Topics Community Health Quality of Care

Publisher IntraHealth International

By Laura Hurley, Mamy Tiana Rakotoarimanana

In Madagascar, Health Workers Can Help Survivors of Violence Break the Silence

Anonymous — Tue, 27 Sep 2016 13:43:17 +0000

In Madagascar, Health Workers Can Help Survivors of Violence Break the Silence

Anonymous (not verified) September 27, 2016

September 24, 2015

In Madagascar, 30% of women report that they experienced at least one type of violence in the last year, such as physical abuse at the hands of a spouse or intimate partner.

Of these, 8% experienced two types of violence, such as both psychological and sexual abuse. And half of Malagasy women say there are legitimate reasons for a husband to beat his wife.

When almost a third of a population experiences such a health threat, we can consider it an epidemic.

But in Madagascar and around the world, we as a global community do not coordinate swift responses or create urgent plans to eliminate gender-based violence the way we do for other large-scale epidemics. Instead there is silence.

One of the few options available to women is the right of misitaka, which means to distance oneself.

That silence is rooted in a taboo against speaking out about violence, as well as in practical disincentives.

In Madagascar, one of the few options available to women trying to escape abuse is the right of misitaka, which means to distance oneself. In other words, a woman can leave her home. But this is a very destabilizing option, particularly for those with children. And where is a survivor to go? She may return to the home of her parents, who will likely pressure her to return to her husband. If a married woman is willing to talk about the violence she’s suffering at home, she may also go to the head of the fokontany, or group of villages, who can negotiate on her behalf—but often without results. Or she could go to the police or to court, but she’ll face financial barriers such as the 6,000 Ariary (under US$2) fee for the medical certificate she would need to sue her husband. Many women—especially survivors who depend economically on their husbands—simply cannot afford such an option. Under Malagasy law, perpetrators of domestic violence can be sentenced to up to 10 years in jail or be charged a fine of one million Ariary (about $312). These laws are rarely implemented, largely because women rarely press charges.

But Madagascar is making some progress. An emergency shelter is set to open in Antananarivo soon, where it will provide 48-hour stays for survivors of abuse. It’s a very short-term solution, but it’s a sign that more options are slowly becoming available to Malagasy women.

Health sectors must adopt a human rights-based approach to gender-based violence.

And as those options grow, survivors of gender-based violence in Madagascar need information about and access to the social and legal protections and health services available to them—not only to protect themselves, but to end the culture of silence and impunity around abuse. That’s why IntraHealth International, through the PSI-led Madagascar Integrated Social Marketing Project, is working to provide this information and access in Madagascar.

To do this, we’ve partnered with the Ministries of Health, Population, Justice, Communication, and Youth and Leisure, as well as with the Enda OI network—which offers psychosocial, legal, and economic support—and Allo Fanentanana, a free hotline that offers legal education, counseling, and referral and safety planning.

Together, we have:

Developed and adapted gender-based violence case management protocols and corresponding training manual and job aids for Top Réseau providers within the Madagascar context
Trained 14 Top Réseau providers in Antananarivo on gender-based violence case management
Designed a referral system for gender-based violence case management among Top Réseau providers

But we must do more.

Health sectors must adopt a human rights-based approach to gender-based violence that not only promotes and protects the survivor’s rights to live without violence, but challenges violence and discrimination against women in the community. Health care organizations must engage their health workers in new ways of thinking and acting, individually and in coalitions.

And community health workers—who know the families and communities—need to be part of the solution.

Health workers must know how to provide care without treating the violence as merely a clinical problem.

A health worker may be the first or only point of contact outside the home for a woman who is experiencing violence. Even where legal systems are weak and referral services are not available, by asking about violence and assuring a confidential response, health workers can reassure women that they are not to blame, mitigate isolation, raise women’s awareness about the health risks of violence for themselves and their children, and help women and girls plan for their safety and get help before violence escalates.

And health workers must know how to provide care without treating the violence as merely a clinical problem. They have the power to assuage victims’ fears of being stigmatized—or to reinforce those fears, continuing a destructive convention of silence.

Health workers can send women the message that the health care system knows that violence is a problem, that violence is not part of a healthy life, and that talking about it is acceptable and normal.

Primary prevention—stopping violence before it begins—is as important as treatment and support. Health organizations should seek opportunities beyond the clinic walls to work with community groups and coalitions to raise awareness about violence against women and children, help shelter survivors of violence, challenge the social and gender norms driving the violence, and strengthen community activism to prevent it. Health workers should engage women and girls in meaningful ways in processes of empowerment.

By equipping health workers to effectively screen for and respond to the social roots of gender-based violence, we not only help women who are suffering today—we set the stage for meaningful health system engagement that can prevent violence in generations to come.

By Constance Newman

Former global technical lead for gender equality and health, IntraHealth International

Gender Equality Madagascar

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Echoes of Change from Community Health Work in Madagascar

Anonymous — Wed, 14 Sep 2016 13:13:34 +0000

Echoes of Change from Community Health Work in Madagascar Anonymous (not verified) September 14, 2016

January 19, 2012

In Madagascar, a hilly island nation of 20 million, many people live in small, widely scattered hamlets often made up of just a few houses. Hamlets may be many kilometers apart, and many people may have to walk hours or even days to the health center to seek care.

The Santénet2 project, which is known locally as KM Salama, engages nearly 11,000 community health workers in Madagascar to offer basic health care and education in communities that are more than 5 kilometers from a health center and when necessary, make referrals to the health center. These community health workers are appointed by the village council and are typically literate, well-respected people in the community. These workers are trained to focus either on women and offer basic reproductive health care including prenatal care and family planning information and contraceptives; or focus on children and offer integrated management of childhood illness and nutrition services.

All of the community health workers participate in a five-day, intensive training program, which teaches them specific skills such as how to offer contraceptives including Depo Provera injections and how to diagnose malaria in children using a rapid diagnostic test. The training also covers non-clinical skills that are critical to the work such as the importance of respectfully welcoming clients, maintaining confidentiality and recordkeeping

Evaluating What’s Working in Training and Supervision

A recent qualitative evaluation of the program suggests that these trainings do offer community health workers important technical skills and improve their mastery of the use of simple medical equipment such as the timers to monitor infant breathing. The evaluation also showed that these workers could successfully document consultations and referrals and identify when to treat patients and when to refer them to the local health center.

In interviews, two health workers shared their thoughts on the most valuable parts of the training:

For me the strong point [of the training] was that we were shown how to give Depo Provera injections because normally women have to wait in line at the hospital, and they are all employed and in a hurry to get to work. It is very good that we know how to give this injection. It is a strong point.
—Female community health worker, 51 years old, Anjeva Gare

For me, after having received the training, the community then trusted me, and I would say that, for them, my house has become a little hospital. Parents don’t go to the real hospital unless I refer them, and that only happens if I can’t help them here. The community has confidence in me, and they come if the child is sick, even at night.
—Male community health worker, 49 years old, Talata Ampano

The project evaluation found that most community health workers have good working relationships with the health center managers, a finding that supports proposed changes in the supervisory system. Previously, health workers met every three to six months with Santénet2 project supervisors, the project is now moving towards more frequent and local supervision by the health center and local non-governmental partners, in keeping with the project’s commitment to local ownership and sustainability.

Challenges for Community Health Workers

The qualitative evaluation also identified four of the program’s specific challenges. First, some of the community health workers do not have scales to weigh children. Having a baby weighed is popular among mothers and allows the health worker to regularly interact with them. Secondly, the evaluation showed that health workers occasionally run out of stock of essential medicines, which can mean that clients go without treatment or have to be referred to a health center, often affecting the community’s opinion of the preparedness of the health worker. A third problem identified in many villages was that community health workers were seeing clients in their homes because they have nowhere else to receive them.

Some village social development committees have responded to this need by encouraging villagers to build a separate health hut where consultations can take place discreetly. Finally, community health workers themselves expressed the need for additional, and more holistic, training to offer their clients the best care. For example, they suggested that community health workers focused on maternal care should also be trained in basic pediatric care and vice versa so the health workers can care for their female clients and the clients’ children at the same time. One community health worker who focuses on pediatric care said:

Learning how to manage childbirth is our wish, and we would like to be trained in this. Once, in my village, my sister-in-law was about to give birth, and they called me, but when I arrived she had already delivered. I was afraid and asked myself, ‘What am I supposed to do?’ I was ashamed because I am a health worker, and I didn’t even know how to deal with the umbilical cord.
—Female community health worker, 42 years old, Anjeva Gare

Echoes of Early Change

The evaluation identified specific ways to strengthen the reach and effectiveness of the community health worker training program. Anecdotal evidence also suggests the program is already prompting important changes such as clients reporting they are seeking health care earlier.

With regard to illnesses, we no longer wait until the illness gets serious, but as soon as the illness starts, for example a fever or headache, we immediately go and consult the community health worker.
—Female client, 32 years old, Fianarantsoa

As the project progresses, epidemiological evidence is needed to evaluate the community health workers' effects on the population's health, but initial data suggests that more people are seeking malaria treatment and family planning services and that the number of cases of diarrhea are down.

At the time of the harvest in April-May, fevers are very widespread among children. Before, the child would die after two days. Now the fever may last up to four days, but then the child gets better. You see, even if we don’t have the statistics, we can see ‘echoes’ of the project…Now if someone is ill, when mothers and fathers go and see the community health worker, they get help. They either get advice as to how to treat the child or the recommendation to go to the health center.
—Male client, 48 years old, Talata Ampano

Santénet2 is a USAID-funded project, which is led by RTI International and supported by IntraHealth International.

Madagascar Community Health Primary Health Care Community Health Workers

Malagasy Communities Empowered to Address Their Own Health Needs

Anonymous — Wed, 14 Sep 2016 13:13:29 +0000

Malagasy Communities Empowered to Address Their Own Health Needs Anonymous (not verified) September 14, 2016

August 14, 2013

Men and women in 800 communes (or municipalities) throughout rural Madagascar are now more knowledgeable, effective advocates for their own health care, thanks to IntraHealth International and the Santénet2 project.

Through the project, IntraHealth worked with local authorities in the Communal Health Development Commissions (CHDCs) to empower the Malagasy to be more involved in their own health care and to help the CHDCs better respond to their communities’ health needs. The project also provided training for over 11,000 community health workers in rural Madagascar.

Madagascar is one of the poorest countries in the world. In 2010, 76.5% of its people were living below the poverty line of $1 per day. Maternal mortality is high and half of children under the age of five are stunted—an indication of chronic malnourishment. Political crises and a coup d’etat in 2009 have only made matters worse by destabilizing the health system and limiting citizens’ access to high-quality health care.

But even during such uncertain times, communities can have the power to make sure their health needs are heard and addressed.

Using the IntraHealth-developed social quality approach, Santénet2 project staff worked to bolster and strengthen the CHDCs through better planning and training. This allowed the CHDCs to organize meetings where locals could gather with CHDC officials—usually at a village chief’s house or outside a health hut—to talk about the problems they encounter when they seek out health care.

One common holdup, they said, was stockouts, or shortages of medicines and family planning supplies. Another was staff absences—particularly irksome to clients who had just walked great distances or missed work to make the trip. Women said they wanted to be able to consult midwives at primary care centers, rather than just male physicians. Young people said they needed greater access to adolescent reproductive health services. And other clients wanted to see health workers perform demonstrations when they were giving advice about nutrition—how to cook certain foods for young children, for instance.

Overall, almost 1 million people took part in the community meetings. More than half were women. Madagascar’s rural population—80% of its people—is generally less informed about health services, and the meetings have helped to remedy that.

The Santénet2 project and the CHDCs also worked with local health workers—called community health volunteers—to make sure they had the right training and to develop ways to respond to the community feedback. CHDC members conducted self-assessments, identified key areas for improvement, developed timeframes for the changes, and put specific members in charge of each component. They also constructed or refurbished some 3,552 rural health huts to give community health volunteers a confidential setting in which to see and care for clients.

Over the course of the project, assessments showed that community satisfaction in the services provided by community health volunteers rose 24% for patient management, 39% for availability of medicines, and 76% for the environment in which community health volunteers care for clients.

A Good Cultural Fit

Community responsibility is a key part of Malagasy culture. That’s one reason the social quality approach is successful there—community members want to have the power to ask for the services they need, and health workers and local authorities take their responsibilities to the community very seriously. Project results showed that the more involved the communities were, the more competent the community health workers became.

And not only has the approach resulted in higher quality and greater use of services in Madagascar—it has encouraged greater gender equality as well.

The community meetings have given Malagasy women a place to talk specifically about their own health needs and pulled them into conversations and decision-making processes they haven’t traditionally been a part of. And through both the community meetings and the work of the CHDCs, men have become more engaged in family health issues, as well.

While the social quality approach was designed to be sustainable in Madagascar, upcoming elections and political instability could make it difficult to sustain as well as to expand the approach to the 766 other communes across the country. Still, project staff say, scaling up to a countrywide approach would instill a new understanding in Madagascar that poor health is not inevitable.

The social quality approach is based on IntraHealth’s Partenariat pour l'amélioration de la qualité (or PAQ) approach, which was first developed in Rwanda and has been adapted to the Malagasy context. The Santénet2 project used IntraHealth’s Learning for Performance Approach and supportive supervision to train Malagasy community health volunteers. The project, which ended in June 2013, was funded by the US Agency for International Development and led by RTI International.

Madagascar Health workforce development Leadership and Governance Policy & Advocacy

Perle Combary

ihadmin2 — Tue, 13 Sep 2016 19:23:41 +0000

Perle Combary Former senior director of program delivery ihadmin2 September 13, 2016

Perle Combary is a sociologist with over 35 years of experience with strategic programming, program management, evaluation and research in the areas of population, reproductive health, family planning, health financing, community-based services, and quality and performance improvement.

Before becoming senior director of program delivery, she served 12 years within a USAID country office in West Africa as program manager and 23 years with evolving leadership responsibilities at IntraHealth’s offices in various countries in Africa and at headquarters, providing technical and management support to numerous health development projects. In this capacity, she fulfilled short term and long term assignments in many countries including Benin, Botswana, Burkina Faso, Ghana, Guinea, Lesotho, Madagascar, Malawi, Mali, Morocco, Nigeria, Rwanda, Senegal, South Africa, Swaziland and Togo. More recently, as Benin Country Director, Combary provided overall leadership, technical and management guidance to the USAID-funded ACQUIRE’s project. She led the regional Southern Africa Human Capacity Development (SAHCD) project based in South Africa, and she also served as program director for West Africa and Middle East. Combary has a PhD in Sociology from Paris VIII University in France and a master's in information sciences. She is fluent in English and French.