Mention of Madagascar, the fourth largest island in the world, evokes visions of idyllic beaches and baobab trees dotting a tropical landscape inhabited by lemurs and other exotic fauna.
However, Madagascar’s human population is among the world’s poorest, with nine out of 10 people living on less than $2 per day. With almost half of all children under the age of five suffering from chronic malnutrition, Madagascar has the fourth highest stunting rate in the world. Maternal mortality rates are alarmingly high. Every day 10 women, among them three adolescents, die from complications related to pregnancy or childbirth.
Most of the island’s 22 million people live in rural areas, 65 percent of them more than 3 miles (5km), or a one-hour walk, from the nearest health facility. Infrastructure is poor, and roads are particularly difficult to traverse in the rainy season.
In one remote part of the island, a marine conservation group met villagers’ health needs.
Blue Ventures began work to rebuild tropical fisheries at an isolated coastal community in the southwest of the country. But as soon as the staff arrived, local residents asked them if they could provide health services.
Their instinctive response was that as a marine conservation organization this was not their area of expertise, said Caroline Savitzky, Madagascar population, health and environment coordinator for Blue Ventures. “But it became quite obvious that human health, community health and ecological health were really linked.”
After receiving the blessing of Madagascar’s ministry of health, Blue Ventures found partners that were quite far from their own site to provide reproductive health services to women and families, who had asked for family-planning help as a priority. From 2007 to 2009 – even at the height of a political crisis that eventually sparked an aid embargo – Blue Ventures trained health volunteers to provide these services. The effort has steadily expanded to offer increased maternal and child health services, as well as water and sanitation assistance.
“Conservation organizations are working in remote, isolated areas with lots of biodiversity. This provides an opportunity for useful partnerships,” Savitzky said. “We are really well placed in terms of logistics and practical support and have the trust of the people to provide what is usually a high priority for the communities.” Blue Ventures now serves a total of 20,000 people in 50 villages in Madagascar.
Madagascar is leading the world in the development of integrated health delivery through partnerships of ecological and conservation groups with health service providers, Savitzky said. “There are large integrated health projects in East Africa as well, but we’re working in a more sustainable, less project-oriented way,” she said. “Local partnerships can go on really long-term without additional infrastructure, responding to priority needs of the community.”
Health services in Madagascar have taken a serious hit over the past few years. Donor aid dried up in 2009 after a coup toppled the elected government; international sanctions were not lifted until 2014, following presidential elections. Without aid, health spending declined – and it was mothers’ and children’s health that suffered most.
“Many of the indicators have been stagnating. In terms of mother and child health, the number of skilled birth attendants decreased during this [politically uncertain] period,” Jean-Claude Mubalama, a health specialist at UNICEF, told the Lancet.
Poorly funded health services made it even more difficult for Madagascar’s people to get healthcare. Providing it via volunteers is a method that other organizations, as well as Blue Ventures, find effective.
“Access to care [is the biggest challenge for women and girls in Madagascar], be it [for] geographic, financial or social [reasons],” said Chuanpit Chua-oon, who served as chief of party at the JSI Research & Training Institute/Madagascar’s Community-Based Integrated Health Program (CBIHP – also called MAHEFA), which ran from 2011 to April 2016.
To get healthcare into more of the island’s remote villages, CBIHP trained more than 6,000 community health volunteers to be the “extended arms” of the country’s formal health facilities which are frequently difficult to reach. They worked to bring basic, quality healthcare to isolated populations in six regions.
The volunteers, supervised by health facility staff, provided essential services and counseling to people in their own communities. They doubled the number of pregnant women receiving antenatal care and significantly increased the number of assisted deliveries during childbirth, Chua-oon said.
Nevertheless, Madagascar needs more international investment to turn around the state of its health. Childhood malnutrition alone is costing the country $1.5 billion a year – almost 15 percent of its GDP. Women’s empowerment is a key pillar in such health challenges, said U.N. secretary-general Ban Ki-moon during his visit to Madagascar last month. “The human toll is immeasurable,” he added.