UNICEF Madagascar: Agent of change

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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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.

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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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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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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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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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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.”


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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UNICEF Madagascar: Agent of change