unicef madagascar: agent of change
Post on 19-Feb-2016
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Agent of changeThis year in Madagascar 38,000 children under the age of five will die. In almost 70 per cent
of these deaths the cause will be a disease or a combination of diseases and malnutritionthat are preventable and treatable if children get the care they need when they need it. Overhalf of the population of Madagascar lives five km or more from the nearest health centre.For children in the village of Soatsifa Ambony, located in Madagascar’s southern Androy
region, this distance has been a matter of life and death. One man’s work is changing that.
Hard times in Tana 2
The sun rises on another day in the village of Soatsifa
Ambony, population 700. Located in Southern Madagascar’s
Androy Region, life for many here is governed by depriva-
tion: food, income, passable roads, sanitation facilities, and
basic services like health and education are all in short
supply. Of greatest concern, however, is the nearly persis-
tent shortage of something far more important — water.
This morning both the land and the people breathe a sigh
of relief in wake of a brief and unseasonal early morning
downpour. On a nearby road this has given rise to a rush of
human traffic, as buckets in hand, women and children rush
to collect ‘fresh’ water from the road’s potholed surface.
Others take the opportunity to wash in a puddle.
An hour later the water is gone and life returns to hot and
dusty normal. Families lounge on the shaded porches of
ramshackle wooden houses, girls thresh maize, women
leave for the fields and the first ox cart of the day arrives
with water for the village from the Mandrare River, 17
kilometres away.
Meanwhile, the chief of the village, 25-year-old
Remanoseke, starts his day the same way he always does:
by accompanying his family’s cattle to the edge of the
village, where they are then passed to the care two young
herders. He explains what the lack of water means for his
village in simple terms: “Without rain, without water, people
cannot grow their crops. Without crops they cannot eat.”
“It also means they cannot practice proper hygiene and
wash their hands, which affects the preparation of food and
causes them to get sick.”
Add to this the fact that the river water that is delivered
to the village has already been dirtied by animals and by the
hundreds of people who bathe and wash their clothes in it.
For the village’s children, many of whom are already
undernourished, the result is a vicious cycle between
disease and malnutrition that can result in death.
Remanoseke knows this all too well.
Back at home he dons a navy blue lab coat over his shorts
and t-shirt, pulls a matching blue cap onto his head and
walks a few metres down the road where he unlocks the
door of a small wooden house.
As village chief he may not have the power or resources
to solve the community’s biggest problems: he can’t make
it rain, purify the water, fix the roads or ensure that every-
one has enough to eat. But as the village’s community
health worker (CHW) he can have a profound impact on the
future of his village by supporting the health of its children.
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Agent of change 3
4 UNICEF Madagascar Hope for the future
two“Before I was trained as a community health worker there
were a lot of sick children here,” says Remanoseke, “and
they didn’t always get the treatment they needed.”
Like most people in rural Madagascar, the people of
Soatsifa Ambony live far from the nearest health centre.
Parents in the village, most of whom have little or no
education and are busy working to survive, are understand-
ably reluctant to carry all but the sickest children to the
health centre — a 14 kilometre round trip. Until recently
the only other option, and the one most people relied upon,
was a nearby traditional healer. That changed when, in 2009,
Remanoseke decided he would make a difference for the
children in his village and trained to become a CHW.
In Madagascar, as in most of the developing world, just
three diseases — pneumonia, diarrhoea and malaria — are
responsible for the vast majority of illness and death in
children under five. Fortunately they are also the most
preventable and treatable. Through the UNICEF-supported
training Remanoseke learned to recognise and treat these
illnesses within his community — before they became life-
threatening.
In addition to treating children sick with these diseases,
Remanoseke is also working to prevent disease by
educating the community with basic health messages. The
low level of schooling in the community is a limiting factor.
He is still working on the basics: explaining the signs of
pneumonia, diarrhoea and malaria and telling parents that
they should bring their children to see him if they exhibit
any of the symptoms.
He is also working on what he calls his ‘cultural problem’:
“People are used to going to the traditional healer,” he says.
“It can be hard to convince them to come to me instead.
Many of them trust his medicinal plants more than they do
my drugs.”
He counts those same drugs as his other problem —
specifically the lack of them. Due to a combination of diffi-
cult access and poor planning at the district level, for the
last four months Remanoseke has been without a supply of
the medicines he needs. “Without medicine I couldn’t treat
them,” he explains. “So after a while, parents didn’t see the
point. They just stopped coming.” This meant that simple
illnesses went untreated, but more important, that parents
were no longer involving Remanoseke in identifying serious
cases and referring them to the health centre for treatment.
This morning as he stands outside the health post,
everything looks the same as it has for the last four months:
empty. But that is about to change. Since receiving a new
stock of medicines two days ago, Remanoseke has been
making the rounds of his community, letting everyone in the
area know that he is now back in business.
Agent of change 5
CHW name: Remanoseke
Village: Soatsifa Ambony
Child’s name: Masindia
Age: 11 months
Symptoms: 13/6: child has cough and
rapid respiration rate
15/6: child seems to have
A fever
Treated for: 13/6: Respi
ratory infection
15/6: possible malaria
Later in the morning when Remanoseke returns to the
health post he finds several women and their children
already waiting for him. The first to see him is Vahonie with
her 11-month-old daughter Masindia.
Two days ago when Vahonie walked here from an outlying
village to bring Masindia to see Remanoseke, she was
taking a chance. “A couple of months ago when my baby
was sick and needed treatment I came here to see
Remanoseke, but ended up having to walk all the way to
the health centre because he had run out of medicine,” she
says. Fortunately this time he had just received his new
supplies. Masindia had a bad cough. Remanoseke counted
her respiration rate and diagnosed the baby with a lung
infection. He gave Vahonie the medicine, told her how to
administer it, and asked her to come back in five days.
Now, just two days later, she is back because Masindia
has a fever. Remanoseke reaches out with the back of his
hand to feel the child’s forehead, confirms that she seems
to have a temperature and then reaches into a box of
medicine. “Now I also have to treat her for malaria,” he
explains. “If there is a fever we always treat for malaria.”
Without malaria test kits or the training to use them, there
is no way he can be sure of what is causing the fever, but
if it is malaria, the drugs could save Masindia’s life.
Community health work may not have the refinement of
trained medical personnel working in a fully stocked clinic,
but for Vahonie and other parents in the area, it is hard to
overestimate the value of having a community health
worker and these medicines nearby.
“I have a daughter who is now 13,” Vahonie says. “When
she was little I never took her to the health centre. I didn’t
go to the traditional healer either. I used to buy medicine at
a little pharmacy in the market. I would decide what to buy
and how much to give her and treat her that way.”
When asked if it was effective, Vahonie says it wasn’t,
but the health centre, which is 14 kilometres from her
home, was just too far away.
Now, because Remanoseke is here, Vahonie and other
parents like her can get the medicines they need to treat
their children, they can get them in the right amount, and
they can get them at the right time — before the child gets
really sick.
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Agent of change 7
8 UNICEF Madagascar Hope for the future
Last to arrive outside the clinic this morning is fifty-three
year old Magnitse with her seven-month-old grandaughter,
Solondrenee. The baby cries and cries, stops briefly when
she sucks at Magnitse’s dry breast, and then cries again.
Magnitse isn’t sure what is wrong, but she has some ideas.
When Magnitse’s daughter — Solondrenee’s mother —
died five months ago, the baby and her four-year-old sister
came to live with their grandparents. With a total of eight
mouths to feed under their tiny wooden roof, Magnitse and
her husband have taken care of the newcomers as best
they can. “When they first came to live with us we gave the
baby goat’s milk five times a day,” Magnitse says. “But now
the goats have less milk so she only gets about half a cup
once a day.” Other than that the baby eats the same as
everybody else: rice with water three times a day plus
some corn and manioc.”
Magnitse is well aware that this is not enough food —
nor is it the right kind of food — for a seven-month-old baby.
Remanoseke’s sister is the community nutrition worker.
It is her job to teach the people of Soatsifa Ambony about
nutrition for pregnant women, infants and children under
five. “She has taught us about the variety of food that
children need and how to prepare it,” Magnitse says. “For
example, mixing in cereals with grains and beans. It’s good
to know these things, but I can’t always follow them. If I
don’t have the money, how can I buy the food?” Magnitse
points to the colorful posters tacked up outside health post
illustrating foods for nutrition. “If we’re lucky, we eat meat
twice a year,” she says. “And fruits and vegetables are
seldom available at the market here, no matter how much
money you have.”
Magnitse explains that for her family and for many others
in this area, the reason for their poverty is that they no
longer own cattle. The 30 that Magnitse and her husband
used to own were wiped out in three stages: eighteen died
of disease, eight were sold during a drought to buy food and
the remaining four were killed, as is the custom here, when
there was a death in the family.
“Now we don’t have animals to pull our ox cart,” she
says. “This means we can’t take water from the river, which
is very far away.” As a result, the family must rely on others
to bring water and then buy it from them for 400 Ariary (US
$0.20) per bucket”. It is a significant amount for a poor family
to pay, especially when they must buy at least one bucket
for the eight family members to share every day.
“We also need animals to work in the field,” Magnitse
explains. The family has two hectares of land but with only
Magnitse’s husband and one grown son to farm it, they are
limited in what they can cultivate. “So, without water and
cattle the parents suffer and their children do too,” she says.
“The parents have nothing — no water for the field — and
that means no crops, which affects the children.”
When Remanoseke finally sees Magnitse and
Solondrenee, he measures the baby’s Mid Upper Arm
Circumference (MUAC), and reports to Magnitse that, like
so many in this food-insecure area, her granddaughter is
likely to be malnourished. Though malnutrition is an
underlying factor in most of the pneumonia, diarrhoea and
malaria cases he sees, Remanoseke is not trained to treat
it. He fills out a referral form, and tells Magnitse that she
needs to take the baby and the papers to the health centre.
Asked if she is happy with the service Remanoseke
provides, Magnitse says she is. “In the past we could only
get plants when we were sick, but now, because he’s here,
I can get medicine when my granddaughter needs it.” Today,
of course, she did not get medicine, she got a referral,
which prompts her only complaint: it’s a long walk to the
health centre and back.
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Agent of change 9
10 UNICEF Madagascar Hope for the future
Mothers and children crowd the benches, the floor, and the
shade of the few trees outside the clinic. They are waiting to
see Frangeline Lilareko, Nurse and Chief of the Maraolipoty
Commune Health Centre, who is responsible for the health
of some 13,000 people.
You’d never know it to look at all of these people — but
this clinic, like most in the region, is actually underutilised.
About half the population has never set foot in a health
centre. Their reliance on traditional healers is one reason for
this, but it is not the only reason, as District Health Officer
Genevieve Ravaosolo, a native of the region, explains:
“Throughout Madagascar there are different fady — taboos.
In this area it is taboo to go into a building — for example,
a health centre or perhaps even a school — that is made of
brick, especially if it is painted white. This is because here
grave-markers and tombs are made of brick, and many are
painted white. So these things are associated with death.”
In the South of Madagascar, where 80 per cent of the
population is animist, these beliefs are powerful. “Believe it
or not, this is one of the biggest obstacles to getting people
to use the health centre,” says Genevieve. “They recognise
the value of, say, vaccinations. But they believe that if they
bring their child to the health centre to get those
vaccinations the child may die. Medical personnel, on the
other hand, are telling them that if they don’t bring their
child to the health centre for vaccinations the child may die.
We have learned that we just have to wait for them and
eventually they will come. They will ask the ancestors and
see what they say and the ancestors will usually tell them
that if they first kill a chicken or a goat they can go ahead
with the vaccinations and everything will be okay.”
Looking out at the women and children who continue to
arrive and are waiting to be seen, Frangeline sighs. It would
seem nothing could be further from her mind than getting
more people to use the health centre. “When I arrived here
three years ago this health centre was really dirty. Almost
no one came here. Now many more people come, but last
year I still didn’t reach my targets for antenatal check-ups,
immunisations or external consultations.”
CHWs like Remanoseke play an important role in promo-
ting the utilisation of the health centre. They encourage
parents in surrounding communities to have their children
vaccinated, send pregnant mothers for antenatal check-ups,
and refer difficult cases for treatment.
At the same time their presence also serves to lighten
Frangeline’s workload. “The principle behind community
health work is that we cooperate in taking care of the
people who live more than five kilometres from the health
centre,” Frangeline explains. “It is too far for me to visit all
of the communities that this health centre serves. So the
CHWs reach the people and places I can’t reach. And
because they offer treatment at their level, people from
those outlying communities no longer need to come here
seeking treatment for the most common cases. That means
I have more time for my other activities: consultations,
outreach, reports....”
CHWs also help Frangeline to get the information she
needs on the communities the health centre serves. The
CHWs’ monthly reports offer valuable information on the
number of children under five, the number of cases of
pneumonia, malaria and diarrhoea in a given community
and the number of children who have been vaccinated.
One of the main benefits of the CHWs, however, is in
acting as ‘translators’ for people in their communities. “One
of the main challenges I face is a lack of knowledge in the
members of the community,” says Frangeline. “Most have
little or no education so I find it hard to sensitise them. This
is why having CHWs like Remanoseke is so important. He
can act as an interface between his community and me. He
supports my work by transferring important messages, and
because he can read he can also explain posters and
medicine labels — what’s more, they trust him.”
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Agent of change 11
12 UNICEF Madagascar Hope for the future
When Frangeline finally sees Magnitse and Solondrenee, an
examination confirms Remanoseke’s diagnosis. Like most
of the other children sitting with their mothers outside her
door, Solondrenee is malnourished.
Fortunately there are no fady dealing with the therapeutic
foods which will allow Magnitse to treat the baby at home.
As Magnitse loads her bag with a week’s supply of the
silver packets, Frangeline explains that she will need to bring
the baby back once a week for at least the next three
months so that Solondrenee can be weighed and measured
and receive another week’s supply of therapeutic food.
But as Magnitse learns from some of the other mothers
who are waiting outside, this isn’t always how things work.
The therapeutic food should be delivered weekly, but often
it is not. A malnourished child normally takes it for a three-
month period but bad roads and poor supply management
at the district level can mean an interruption of supply.
“Then mothers come day after day looking for it,” says
Frangeline. “But if those mothers come from far away, like
Soatsifa Ambony, and again and again it is not here, they
simply abandon the treatment.”
Child on her hip, therapeutic food in her bag and referral
paper in hand Magnitse sets off on the road back to Soatsifa
Ambony. Although UNICEF is working to strengthen drug
supply management in the country, change will take time.
Until then, the road to recovery will not always be an easy
one — especially for those like Magnitse who live far from
the nearest health centre.
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Agent of change 13
Hard times in Tana 14
The next morning outside the community health site the
response to Remanoseke’s efforts to drum up business is
overwhelming. Remanoseke calls the women and their
children in one at a time, providing medicine for some, and
advice or referrals for others.
It is clear that despite the problems he faces — from the
inconsistent supply of medicines, to the need for further
equipment and training, to the tyranny of traditional beliefs
and the lack of education in the community — the service
he provides is vitally important to the people in his
community. “They appreciate my work because they can
see the benefits I bring for their children’s health,” he says.
Under a scale up of the programme planned for 2012 and
beyond, every village in the country that is more than five
kilometres from the nearest health centre will be served by
seventwo CHWs. These health workers will receive continued
training that will allow them to keep improving the quality
of the services they offer.
Not only will Madagascar’s most vulnerable children
receive medical care when and where they need it, their
parents will receive important preventive messages
regarding the importance of good nutrition, clean water,
and proper sanitation. “When people hear these messages
again and again, eventually they will change their behaviour,”
says District Health Officer Genevieve Ravaosolo. “But you
have to cover everyone with these messages and repeat
them frequently. By putting community health workers in
every village people will learn the practices they need to
keep their families healthy. In time this will improve the
health of children in all of our remote rural communities.”
16 UNICEF Madagascar Hope for the future
Training community health workers like Remanoseke to identify andtreat the most common causes of death in children under five will allowchildren in Madagascar’s most vulnerable communities to get the carethey need when they need it most. It will also allow communities to learnthe practices that will help to prevent these illnesses in the first place.
UNICEF Madagascar is committed to working with local healthauthorities to place two CHWs into every hard-to-reach village in thecountry and to strengthen their role so that they can better work toimprove the health and well-being of their communities.
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