unicef madagascar: the doctor is out
DESCRIPTION
It is said that maternal mortality, more than any other health indicator, reflects the overall performance of a country’s health system. In Madagascar eight women die every day in childbirth or of pregnancy-related causes. It is a number that points to a health system stretched to the breaking point. Nowhere is this more apparent than in the rural health centres that serve 70 per cent of Madagascar’s population: they lack not only essential personnel, but also critical medicines, supplies, emergency equipment and funding. With so few resources, it falls to paramedics like Midwife Christine Razafindrasoa, the only health professional at the health centre in Ambodihazinina, a small village in the eastern district of Fenerive Est, to hold it all together.TRANSCRIPT
The doctor is inout
It is said that maternal mortality, more than any other health indicator, reflects theoverall performance of a country’s health system. In Madagascar eight women die
every day in childbirth or of pregnancy-related causes. It is a number that points to ahealth system stretched to the breaking point. Nowhere is this more apparent than in
the rural health centres that serve 70 per cent of Madagascar’s population: they lack notonly essential personnel, but also critical medicines, supplies, emergency equipment
and funding. With so few resources, it falls to paramedics like Midwife ChristineRazafindrasoa, the only health professional at the health centre in Ambodihazinina, a
small village in the eastern district of Fenerive Est, to hold it all together.
3 UNICEF Madagascar Hope for the future
To do
water
Family planning
daily reports
Midwife Christine Razafindrasoa is tired. It’s not just the up and down on the
water pump. It’s everything. As the only health professional at Ambodihazinina
health centre she is responsible for the health of 8,612 people in seven villages.
“I work night and day,” she says. “During the day I see patients who come to the
clinic, and attend to traumas and emergencies… and then I have my regular schedule
to follow: Monday it is family planning, Tuesday and Friday immunisations, and
Thursday antenatal consultations. I also take care of the CRENAS (Outpatient
Centre for the nutritional rehabilitation of severely malnourished children with-
out complications) and supervise community health and nutrition workers in various
villages. Every afternoon I have to fill out reports and every month I have to
organize and conduct outreach for immunisations and other health activities in
villages far from here. Then I have to complete and send my monthly report to the
district. During the night I have to take care of emergencies: it is not unusual to
see three or four cases a night that involve accidents or fights, in addition there
are women who started giving birth at home, and were brought to me in the middle of
their labour when they developed complications. It seems I am always multi-tasking
— going, going, going from one thing to the next.”
While Christine may be alone at the health centre, she is certainly not alone
in facing this situation. “It’s the same everywhere,” she says, “so it’s no use
complaining. There aren’t enough trained professionals, so we just have to continue
working like this. There have been times when I thought I couldn’t go on. I
remember one particular day when I was so tired I fell asleep in the office. It
was during an outbreak of dengue fever and many people were sick. I was also
feeling sick. In the evening a family came with a woman who was about to deliver.
They knocked on the door. At that moment I thought it was beyond my ability to wake
up and deliver that baby, but I had to do it. I had no choice. This job can be
overwhelming, but it is important. People need me.”
Date 16 / 05
The doctor is out 4
5 UNICEF Madagascar Hope for the future
The doctor is out 6
To do
Antenatal care sessions
daily reports
organize vaccines for measles campaign
Date 19 / 05
This morning Maureen is the first to arrive for an antenatal care checkup. Now
five months pregnant, she has walked seven kilometres to attend the second of four
recommended antenatal checkups. However, she has no plan to come to the clinic for
the delivery. “My village is too far away,” she says. “I’m afraid I would give
birth on the way.”
Like Maureen, over half of Madagascar’s population lives five kilometres or more
from the nearest health facility — in remote areas inaccessible by a car or even
a motorcycle. This means when it is time to give birth most women follow tradition.
“Women are used to delivering at home with a traditional birth attendant (TBA),”
Christine explains. But delivery with TBAs can be risky for both mother and child.
Statistically, 15 per cent of all deliveries will run into life threatening
complications requiring emergency obstetric care. If something goes wrong all the
TBA can do is load the woman onto a makeshift stretcher and have people carry her
to the health centre. “I have no idea how many women die on the way,” she says,
“but I can tell you that, without a doubt, the number one cause of maternal
mortality is arriving late at the health facility with complications.”
Even if they manage to make it to the health centre in time and find Christine
there (she is often away doing outreach or taking care of other medical business)
she cannot always help. “For example, if they need a cesarean section, I can’t do
it,” she says. “I have to refer them to the district hospital in Fenerive Est,
which is 25 kilometres away — at least five kilometres on foot followed by a 20
kilometre ride in a bush taxi on a dirt road.” Assuming the woman makes it there
alive it is possible that even the hospital may temporarily lack the personnel or
the supplies to perform the operation.
Christine explains that all of these factors point to the great importance of
antenatal care. “Not only can we ensure mothers are eating properly and getting
the medicines and vaccinations they need to prevent illnesses and other problems,
we can also identify the difficult cases early. This allows those mothers to get
the help they need before they run into serious trouble.”
7 UNICEF Madagascar Hope for the future
Next, Christine calls in Violette. She is three months pregnant and this is her
first checkup. Violette was referred to the clinic by Brigitte, a Community Health
Worker in Ambodihazinina. “Brigitte heard that I was pregnant so she came to my
house to talk to me about going to the health centre for antenatal checkups,”
Violette explains.
Violette did not need convincing. In 2008 when her sister Tina was pregnant
Brigitte came to check on her sister every few days. She made sure Tina attended
all of her antenatal checkups, taught her about proper nutrition during pregnancy
and encouraged her to deliver at the health centre.
But all of this couldn’t prepare the family for the ‘complications’ that arose the
night Tina went into labour: Cyclone Ivan, a powerful category four storm, hit the
island, making landfall in nearby Fenerive Est. “During the cyclone my sister went
into labour,” Violette says. “We carried her to the health centre. It had been
destroyed. But with the midwife’s help, she gave birth on the ground at 4 am. The
midwife kept them there for a few hours to be sure they were both okay and then
helped them back to what was left of our house. She helped Tina and the baby get
settled before she returned to the clinic. Over the next couple of days she
continued to visit and check up on my sister and the baby as often as she could.”
While it is unlikely that Violette will experience the same ‘complications’ as her
sister, she knows that things can and do go wrong during pregnancy and delivery,
and today’s visit to the clinic has left her feeling reassured. “Today the midwife
checked my abdomen and measured it, she checked my eyes and my ankles and she gave
me some medicine. It feels good to know that everything is okay.” When the time
comes Violette plans to deliver in the health centre. Her only fear is that with
everything Christine has to do, she may not be there when Violette needs her most.
Date 19 / 05 continued
The doctor is out 8
The doctor is out 10
To do
immunisations
monthly reports
order medicines
“After Cyclone Ivan I was busier than ever,” Christine says. “The most difficult
thing was doing deliveries. There was no space. I had to do them on the ground. And
after four hours, if there were no problems, I would send mother and baby home. In
the month after the cyclone I did ten deliveries this way. Fortunately all of them
were normal and everyone was fine.”
UNICEF provides additional training to paramedics and places them in overstretched
health centres across the country. With so much need after the cyclone, Christine
was relieved when they sent a nurse to help. “She and I worked together for two
months. During that time we were seeing 200 patients a day. There was no way I could
have helped them all without her. You have to understand, when it comes to cyclones
the main cause of death is not the cyclone itself, it’s the illnesses that come
afterwards: malaria, diarrhoea and pneumonia. Many houses were destroyed so people
had no way to protect themselves from malaria. Without safe water and proper
hygiene, people who already lacked sufficient nutrients got diarrhoea. For many,
living outside in the cold and rain resulted in pneumonia.
“A few weeks after the cyclone, the community built me another clinic. Like the
old one, it was a small house made of bamboo with a thatched roof. Over time UNICEF
had provided the clinic with delivery kits, a stretcher, a delivery table, medicines
and a refrigerator. With all of it crammed into that tiny room there was no space
for me to move. And in another cyclone, I knew that clinic too would be lost.
“I was so grateful when UNICEF built this new clinic. It has had a huge impact on
the quality of care that I am able to provide. There is much more space, which makes
everything easier. I have a room for consultations and deliveries, an office, a
storeroom for medicine and supplies and a room with two beds — so I can keep an eye
on mothers who had complications during delivery and their babies. There is also a
pump, a tank on the roof, and a water filter, so I now have access to clean water.
“Working in this new clinic I feel a lot more motivated. And it’s really good to
know that this one will remain standing in the next cyclone — so I will be able to
provide the help my community needs when they need it most.”
Date 20 / 05
11 UNICEF Madagascar Hope for the future
To do
order medicines
family planning
monthly reports
organize outreach
As happy as she is in the new clinic, Christine’s work is still hampered by a lack
of essentials “...like electricity,” Christine laughs. “You might be surprised to
learn that it isn’t easy delivering babies by candlelight.” But it is actually the
clinic’s refrigerator that poses a bigger problem: vaccines must be kept cold or
they will cease to be effective. However, severe cuts to the health budget mean
Christine can no longer afford the 30 litres of petrol she needs each month to keep
the refrigerator working. This is having a direct impact on the services she can
offer — and on the health of the communities for which she is responsible.
“Every time I organise immunisation activities I have to collect vaccines from the
nearest health facility with refrigeration, which is 25 kilometres away in Fenerive
Est,” she explains. “I then have just 48 hours to vaccinate people with that stock
before it becomes useless. This makes it impossible to provide immunisations as
often as I am supposed to.”
Add to this the fact that aid money that used to finance outreach activities in
remote communities — including immunisations — has been suspended since the
beginning of the crisis, and it is clear why nationwide vaccination coverage for
preventable diseases like measles, has steadily declined since 2009.
The clinic’s medicine cabinet is as empty as the refrigerator. Christine orders
new stock every two months and sends a community member to Fenerive Est to collect
it. “Sometimes he arrives at the government pharmacy to find that the director
isn’t there, or that the medicines are not available,” she says. “Like Iron folate.
It is essential for pregnant women, but for the past six months it has been out of
stock at the government pharmacy, so I have been buying it from a private pharmacy
and providing it to mothers at a cost.”
But even that is too costly for some. “Around here people’s main sources of income
are coffee and cloves,” Christine explains. “During the crisis the prices for these
have been low, so people are earning less. Now people cannot always afford to buy
all of the medicines they need.”
Date 23 / 05
13 UNICEF Madagascar Hope for the future
To do
Meeting with health inspector
organize outreach
When she hears the motorbike pull up outside the health centre Christine goes to
the front porch to greet Honoré Andriatsiva, the Chief of Public Health for the
district. As he does on these twice-yearly visits, Andriatsiva looks over
Christine’s reports and asks how things are going. When Christine tells him about
some of the difficulties she’s facing he is sympathetic, but there is not a lot he
can do. He has problems of his own. The government’s health budget for the district
— one of the wealthier districts in the country — has been cut in half. It now
stands at just 84 million Ariary (US $ 42,520) or 227 Ariary (US $0.11) per person.
Prior to the political crisis, not only was the government’s contribution to the
health budget greater, the addition of foreign aid put the average district health
budget at US $8 per person per year. That figure is now just US $2 per person per
year. This has real consequences for the health of the population.
“Bednets are just one small example,” says Andriatsiva. “We have lots of bednets
at district level, but no funds to dispatch them. It’s not the kind of work I can
do on my motorbike: one load of bednets weighs 40 kg, and a health centre this size
would need seven loads. The same is true for cool boxes and emergency drugs.”
Another example is the closing of health centres. “Two were recently closed in this
district,” Andriatsiva says. “One because the paramedic left and the other because
the paramedic died.” Without replacements, the 29,000 people served by those health
centres must now travel 40 kilometres to reach the nearest health facility.”
“Fortunately UNICEF is helping us to address personnel problems by recruiting
paramedics for health centres,” Andriatsiva says. UNICEF is also helping to
support the health system by putting systems in place to ensure the availability
of essential medicines, helping to fund vaccinations and outreach and providing the
equipment, supplies and training to ensure mothers and their unborn children have
access not only to antenatal care but also to life-saving emergency obstetric and
newborn care.
“The health of the population is our priority,” says Andriatsiva. “Managing
everything with this reduced budget is difficult, but we are in a crisis here
and we just have to do the best we can.”
Date 25 / 05
To provide quality services to the communities in their care, and toprevent stubbornly low health indicators — notably maternal mortality— from rising still further, health centres in Madagascar needconsistent access to essential medicines, supplies, emergencyequipment, and trained personnel.
While the international community remains unable to work directlywith the government, UNICEF is working alongside local authorities tofill the gaps in Madagascar’s overstretched health system and to ensure that funds are invested and targeted to directly benefitmothers and children.