Community Involvement in Maternal and Child Health in Madagascar

"Community and health system collaboration is needed in an engaged and systematic way that ensures integration and the notion of coordinated preventive and curative care for all target populations..."

This document describes Madagascar's experience with community and health system collaboration, which is designed to ensure integration and establish the notion of coordinated preventive and curative care toward the goal of lowering mortality rates for women and children. For immunisation, Madagascar's aims are to achieve an immunisation coverage rate of at least 84% for all antigens, maintain the DPT1 (diphtheria, pertussis (whooping cough), and tetanus) to DPT3 drop-out rate below 10%, and ensure immunisation outreach services to at least 50% of the population who live more than 10 kilometers away from a Basic Health Center (BHC). Since 2002, the Ministry of Health and Family Planning (MOH/FP) and the Expanded Programme on Immunisation (EPI) - with the support of the United States Agency for International Development (USAID), the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and International Coordination Agency (JICA) - is also reinforcing the immunisation system through implementation of the Reaching Every District (RED) approach for strengthening immunisation and integrated services at the district level.

As detailed here, one aspect of this process involved the Government of Madagascar, through the MOH/FP, adopting a policy that links local populations with health services. "The integrated approach for community interventions allows the commune to create its own communal development plan, with activities chosen and co-managed by the commune." Health committees (HCs) and their social mobilisation sub-committees exist at each level of the health pyramid, with an increased number of volunteer community mobilisers (at a minimum 2 per fokontany, which is an administrative subdivision) to reach 90% of intended groups with advocacy and information, education, and communication (IEC) support. The fokontany chiefs, along with the HC coordinators and BHC, are key leaders within the committee. Nutrition workers and other community influences (e.g. religious organisations, traditional leaders, Scouts, Red Cross, non-governmental organisations (NGOs), associations, and teachers) also participate, with a particular role in IEC and advocacy to promote health and development with communities that are not accessing the BHCs. The HC establishes goals to improve key health indicators in its community for improving maternal and child health, the approach's implementation process, and the roles and responsibilities of the different actors at the commune level. These goals are presented in a simplified and illustrative way in a technical implementation guide, which also describes the methodology behind establishing these goals.

More specifically, the integrated approach incorporates a range of IEC support and managerial tools intended for: beneficiaries (e.g., maternal and child health cards, Gazety health magazine, immunisation certificate for complete vaccination), community coordinators (e.g., counseling cards to advocate with communities, invitation cards to encourage visits to services), and health workers (e.g., registers, advertising flags for vaccination session days, job aids, management tools) and trainers (reference guide). The MOH/FP coordinates this support with partners, including a Communication and Health Mobilization Committee, to assist with standardising support and messages. A workshop in 1997, organised with assistance from the USAID/BASICS project, brought together many of the MOH's supervising technical experts and private partners working in the health sector to standaradise messages and support mechanisms on maternal and child health.

Community partners, such as local authorities, community health workers, local NGOs, and nearby radio stations are involved in increasing and sustaining public awareness. Community health workers have been given outreach and marketing kits to support interpersonal communication (IPC) activities. These kits consist of standardised, tested IEC support materials with different presentations, such as television and social marketing products and articles. Distributed at the community level, these products are designed to both increase access to health information and motivate volunteers. Social marketing tools promote the health interventions within the commune. A mass media outreach kit, including various audio materials for radio, supports the mobilisation and outreach activities and reinforces the key messages diffused locally. Mass media (radio and TV), cultural events, door-to-door interactions, evidence of health achievement, and communication through community services (e.g., street salesmen, carnivals, and information in schools, churches, fokontany offices, etc.) are all strategies to inform and reach out to the community, particularly to encourage people to take advantage of available services. Invitation cards are also given out by mobilisers as an outreach tool to invite community members to the BHC for immunisation and reproductive health services.

The report also describes the Kaominina Mendrikaa (or Champion Community - CC) approach launched in 1999 to mobilise and link communities and services and improve health goals, particularly in the context of immunisation and the RED goals. CC activities strategies are outlined in the report. Amongst the strategies that have been found to be successful, according to the report, are:

• improving accessibility of preventive and curative care services;
• reviving and maintaining the population's interest in health and social matters in the commune through municipal and communal meetings and through mobilisation in the public interest, such as leveraging funds for the health centre, constructing latrines in each fokontany, and restoring rural roads;
• developing policies and standards, methodologies, and capacity building and monitoring tools: e.g., the national community health policy; the reference guide on the CC approach; certification instructions to become a CC; road map documents for FP, sexually transmitted infections (STIs), child health, and service management; standards for IEC and human resources; and an integrated supervisory matrix.
• Establishing agreed-upon performance goals for a BHC's minimum activity package on "Champion Community Health Goals" with the involvement of district officials, service providers, and community representatives.
• Training facilitators and providers on the use of job and IEC tools and conducting regular supervision and evaluation (see immunisation example, section VI, which outlines various initiatives that have been implemented, including the CC approach, the RED approach, and supplementary immunization activities - e.g., a polio eradication campaign in 2005, maternal and neonatal tetanus campaigns in 2006 and 2007, and a measles campaign in 2007), as well as developing integrated strategies for the Maternal and Child Health (MCH) Weeks twice a year since 2006).
• Ensuring continuing and increased financing for health, including the community's contribution.

Evaluation data is included in the report. For instance, it is noted that the CC approach "has contributed to the reduction of barriers between service providers and communities and has facilitated implementation of health services. Institutionalizing technical and social mobilization committees at all levels has strengthened the approach's synergy. Most of the BHCs are now familiar with the CC and community approaches and are organizing themselves with their community and mobilization workers. Use of health services is increasing; in the case of immunization, DPT3 coverage has risen from 61% (DHS [Demographic and Health Survey] 2003-2004) to 82% (national immunization coverage survey 2008). In 2004, only seven districts had reported immunizing more than 80% of children less than 1 year with DPT3. In 2006 and 2007, this had increased to 83 districts....In addition to the coverage increases, the drop-out rate between DPT1 and DPT3...has also reportedly declined in districts where interventions, notably the CC approach, have been implemented. These results can, in part, be attributed to the improved linkage of health workers and communities in the intervention zones."

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Click here for the 21-page document in French in PDF format.