After decades of improvement, the health of women and children across sub-Saharan Africa is declining. In Madagascar, however, it is on the upswing: the new 2003-2004 Demographic and Health Survey (DHS) reveals great improvements in fertility as well as maternal and child health. These results reflect the efforts of several successful health interventions by donors and the government. At a meeting co-sponsored by the Environmental Change and Security Project, Africa Program, and ORC Macro, the authors of the latest survey joined Dr. Roland Rajaonson, the chief of cabinet of Madagascar's Ministry of Health and Family Planning, and development practitioners from USAID and UNICEF to discuss the preliminary results and examine how these successes might help other countries improve their programs.
Like earlier surveys in 1992 and 1997, the 2003-2004 Madagascar DHS provides estimates of key indicators of fertility and family planning, maternal and child health, sexually transmitted infections, and AIDS awareness. Mohamed Ayad, regional coordinator for ORC Macro/Demographic and Health Surveys, explained that in 2003-2004 researchers surveyed 8,400 households, adding four new biomarkers (on syphilis, tetanus, anemia, and measles) and interviewing men for the first time. Preliminary results indicate major improvements:
- Madagascar's overall fertility rate dropped from 6.0 in 1997 to 5.2 children per woman, which is one of the lowest rates among surveyed countries in Africa;
- Use of modern family planning methods increased from 5 percent in 1992 to 18 percent; rates for urban women are even higher;
- The number of children breastfed exclusively for the first six months almost doubled from 35 percent in 1992 to 67 percent;
- Overall vaccination rates improved, and the prevalence of diarrhea dropped by half since 1997; and
- Vitamin A supplementation has skyrocketed from 4 percent in 1997 to 76 percent.
From 1997 to 2004, USAID directed focused interventions in the provinces of Antananarivo and Fianarantsoa, home to more than 50 percent of Madagascar's entire population, on maternal and child health, vaccination, family planning, breastfeeding, and nutrition. These interventions appear to have had a material effect; relative to the country as a whole, the target areas reported:
- A greater decline in fertility rates;
- Higher rates of medical assistance at delivery; and
- Significantly greater rates of full vaccination coverage.
The Three Pillars
Wendy Benazerga of USAID-Madagascar's Health, Population, Nutrition and Food Security office described the efforts of USAID's "Smaller, Healthier Families" program, which is based on the three pillars of partnership, national support, and community support. The program's success rests on its "strong partnerships with the government of Madagascar, the private sector, with technical health partners and other donors, and with other sectors, especially environment and agriculture," according to Benazerga. As part of the effort to improve health norms, standards, and systems, they worked closely with the government to integrate essential nutrition information into the curricula of medical and nursing schools and implement cost-effective training in family planning methods. The program particularly focused on logistics, like cold-chain spare parts: as Benazerga pointed out, health clinics must have "the parts to make the refrigerators work, which is not always easy out in the remote areas."
"The community level is really the foundation," said Benazerga, turning to the third pillar. Through innovative social marketing techniques, such as specially-marked products and mobile video units, the program links communities with health services, providers, and products. Benazerga emphasized the importance of "working through existing community structures and utilizing volunteers at that level. And most importantly, to introduce small, doable actions that mothers, fathers, and children can utilize to improve their own behavior." For example, the curricula and training developed for the medical schools are translated into "small, doable actions that a mother can take to improve her own health and the health of her children." In USAID's "champion communities," the residents are empowered to take on their own health care and set their own targets. By measuring the changes, "the community is mobilized to achieve results that they themselves set," said Benazerga.
"Mobilizing and empowering communities, using innovative approaches like social marketing and linking communities with services, as well as using an integrated approach—health, population, and environment," are all essential components of the program's success over the past five years, which is reflected in the DHS results. According to Benazerga, USAID plans to ramp up the program from the current 40 communities to 300, which will test "how we can really take this to a broader scale."
On the Right Road
"Madagascar is aware that only healthy children can guarantee economic and social development," said Dr. Roland Rajaonson, the chief of cabinet of Madagascar's Ministry of Health & Family Planning. He described the traditional emphasis on a high birth rate—"a marriage is blessed with many children"—and the dark days of Madagascar's economic collapse in 1980s-90s, which witnessed the explosion of several epidemic diseases and social problems. With the support of several partners, including USAID, UNICEF, World Health Organization, and the Centers for Disease Control, the government launched vaccination and malaria prevention campaigns, baby-friendly hospital initiatives, safe motherhood programs, and basic health care and drug policies, including a cost-recovery program.
The ministry's priorities include increasing the number of qualified staff; continuing the vitamin A campaign; fighting communicable diseases like malaria, filaria, leprosy, and tuberculosis; improving blood safety; and increasing the number of family planning and reproductive health sites. "Madagascar is on the right road towards improving the health and wellbeing of the Malagasy population. There is still much to be done. However, through continued partnership, we shall achieve our dream, where the majority of people die of old age," concluded Rajaonson.
The Way Forward
After a disheartening decrease in 1997, explained UNICEF/Madagascar's Eric Ribaira, vaccination, breastfeeding, and diarrhea treatment rates returned to 1992 levels by 2003, and in the case of diarrhea treatment, greatly improved. Ribaira praised the government and its partners for taking these steps to reverse the 1997 decline:
- Revitalizing the cost sharing system;
- Redeploying staff at all levels;
- Increasing participation of women in key decision posts;
- Reopening nurse training schools; and
- Increasing budget allotment in favor of essential social services.
"The success of the efforts in partnership must be supported and extended to other programs," urged Ribaira, warning that programs that seek to improve acute respiratory infection treatment, antenatal care, and clean delivery are lagging behind. He identified key challenges that UNICEF will focus on:
- Implementing child survival initiatives;
- Reinforcing partnerships;
- Improving health system performance; and
- Implementing Medium-Term Expenditure Framework (MTEF) exercises
The Open Door: Population-Health-Environment
Several attendees praised USAID's Madagascar program for its unique integration of population and environment, including Africa Bureau representative Subhi Mehdi, who called its efforts "so innovative and so much to learn from." Dr. Rajaonson echoed this point, noting that the government is educating the public "to protect the principal forests and rivers, the sea, and the highlands, because it helps the population to have something to eat and have jobs to do."
Sanitation is another example of a health-environment linkage. For the first time, the DHS survey asked participants if they had tools for washing. The results were discouraging: about half of the respondents lacked tap water, soap, or ashes to clean their hands. Dr. Noe Rakotondrajaona of USAID/Madagascar described the government's WASH initiative, a partnership between the Ministry of Energy and Mines, USAID, UNICEF, and World Bank: "For example, with USAID's support, we are launching this water purification system through the WASH initiative. Other partners, like UNICEF, are involved in latrine construction at the school level and at health centers." Diane Coury of UNICEF said they hoped that by starting at the community level, they would be able to propagate the idea to householders, who may then be motivated to build their own latrines with the support of NGOs.
Forward to Tomorrow and Beyond
A participant asked if the expansion plans for the programs would be financially sustainable, given Madagascar's limited financial resources. Ribaira noted that the "needs are still huge; we need more partnerships between donors and private sector." While agreeing that continued inputs are needed, Benazerga noted that, at the community level, USAID's efforts are designed to encourage sustainability: "Community health workers are also community sales agents, selling socially marketed products like safe water solutions or mosquito nets," so that while "they are offering products to mothers and caretakers of children in the community, they make a little bit of money."
Why is Madagascar so successful? Benazerga cited not only the partnership among USAID, UNFPA, and UNICEF, who are "working with the government hand-in-hand to improve the use of modern contraceptives so that women are able to space their children for better health," but most importantly, "the highest level commitment from the government to position family planning as really critical to improve health and economic and social development." Dr. Rakotondrajaona praised the strong commitment shown by Madagascar's president, who has called every agency and institution in the country to work on the family planning program. The Ministry of Health even changed its name to include family planning, Mehdi remarked: "Donors cannot make a difference without political will of the government, so we commend the government of Madagascar for prioritizing health as an issue."
Mehdi called USAID/Madagascar "one of the best in the Africa region—a stellar success program."
Note: key findings from the DHS Survey are available in English and French. The English version of the final DHS survey for Madagascar will be posted at when it is available.
Drafted by Meaghan Parker.
- Regional Coordinator, ORC Macro/Demographic and Health Surveys
- Team Leader, Office of Population and Reproductive Health, USAID/Madagascar
- Planning Officer, UNICEF/Madagascar
- Africa Bureau, USAID
- Assistant Project Officer for Health, UNICEF/Madagascar
- Public Health Specialist, USAID/Madagascar
- Chief of Cabinet, Ministry of Health & Family Planning Madagascar
- Deputy for Communication, ORC Macro/Demographic and Health Surveys
- Office of Population and Reproductive Health, USAID