UNICEF Madagascar: The Doctor is Out

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

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.”


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


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


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.

UNICEF Madagascar: The Doctor is Out

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