UNICEF Madagascar: Agent of change

Agent of change This 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 malnutrition that are preventable and treatable if children get the care they need when they need it. Over half 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

one The sun rises on another day in the village of Soatsifa

herders. He explains what the lack of water means for his

Ambony, population 700. Located in Southern Madagascar’s

village in simple terms: “Without rain, without water, people

Androy Region, life for many here is governed by depriva-

cannot grow their crops. Without crops they cannot eat.”

tion: food, income, passable roads, sanitation facilities, and

“It also means they cannot practice proper hygiene and

basic services like health and education are all in short

wash their hands, which affects the preparation of food and

supply. Of greatest concern, however, is the nearly persis-

causes them to get sick.”

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

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.

downpour. On a nearby road this has given rise to a rush of

For the village’s children, many of whom are already

human traffic, as buckets in hand, women and children rush

undernourished, the result is a vicious cycle between

to collect ‘fresh’ water from the road’s potholed surface.

disease and malnutrition that can result in death.

Others take the opportunity to wash in a puddle.

An hour later the water is gone and life returns to hot and

Remanoseke knows this all too well.

Back at home he dons a navy blue lab coat over his shorts

dusty normal. Families lounge on the shaded porches of

and t-shirt, pulls a matching blue cap onto his head and

ramshackle wooden houses, girls thresh maize, women

walks a few metres down the road where he unlocks the

leave for the fields and the first ox cart of the day arrives

door of a small wooden house.

with water for the village from the Mandrare River, 17 kilometres away.

Meanwhile, the chief of the village, 25-year-old

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-

Remanoseke, starts his day the same way he always does:

one has enough to eat. But as the village’s community

by accompanying his family’s cattle to the edge of the

health worker (CHW) he can have a profound impact on the

village, where they are then passed to the care two young

future of his village by supporting the health of its children.

Agent of change 3

two “Before I was trained as a community health worker there

He is still working on the basics: explaining the signs of

were a lot of sick children here,” says Remanoseke, “and

pneumonia, diarrhoea and malaria and telling parents that

they didn’t always get the treatment they needed.”

they should bring their children to see him if they exhibit

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

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.

education and are busy working to survive, are understand-

“It can be hard to convince them to come to me instead.

ably reluctant to carry all but the sickest children to the

Many of them trust his medicinal plants more than they do

health centre — a 14 kilometre round trip. Until recently

my drugs.”

the only other option, and the one most people relied upon,

He counts those same drugs as his other problem —

was a nearby traditional healer. That changed when, in 2009,

specifically the lack of them. Due to a combination of diffi-

Remanoseke decided he would make a difference for the

cult access and poor planning at the district level, for the

children in his village and trained to become a CHW.

last four months Remanoseke has been without a supply of

In Madagascar, as in most of the developing world, just

the medicines he needs. “Without medicine I couldn’t treat

three diseases — pneumonia, diarrhoea and malaria — are

them,” he explains. “So after a while, parents didn’t see the

responsible for the vast majority of illness and death in

point. They just stopped coming.” This meant that simple

children under five. Fortunately they are also the most

illnesses went untreated, but more important, that parents

preventable and treatable. Through the UNICEF-supported

were no longer involving Remanoseke in identifying serious

training Remanoseke learned to recognise and treat these

cases and referring them to the health centre for treatment.

illnesses within his community — before they became lifethreatening.

In addition to treating children sick with these diseases,

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

Remanoseke is also working to prevent disease by

stock of medicines two days ago, Remanoseke has been

educating the community with basic health messages. The

making the rounds of his community, letting everyone in the

low level of schooling in the community is a limiting factor.

area know that he is now back in business.

4 UNICEF Madagascar Hope for the future

Agent of change 5

ke Remanose CHW name: bony Soatsifa Am Village: dia ame: Masin Child’s n nths Age: 11 mo cough and child has : /6 13 : s m Sympto te iration ra rapid resp A fever s to have m e e s d il h ction 15/6: c tory infe a ir p s e R : or: 13/6 Treated f le malaria 15/6: possib

three Later in the morning when Remanoseke returns to the

Without malaria test kits or the training to use them, there

health post he finds several women and their children

is no way he can be sure of what is causing the fever, but

already waiting for him. The first to see him is Vahonie with

if it is malaria, the drugs could save Masindia’s life.

her 11-month-old daughter Masindia.

Two days ago when Vahonie walked here from an outlying

Community health work may not have the refinement of trained medical personnel working in a fully stocked clinic,

village to bring Masindia to see Remanoseke, she was

but for Vahonie and other parents in the area, it is hard to

taking a chance. “A couple of months ago when my baby

overestimate the value of having a community health

was sick and needed treatment I came here to see

worker and these medicines nearby.

Remanoseke, but ended up having to walk all the way to the health centre because he had run out of medicine,” she

“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

says. Fortunately this time he had just received his new

go to the traditional healer either. I used to buy medicine at

supplies. Masindia had a bad cough. Remanoseke counted

a little pharmacy in the market. I would decide what to buy

her respiration rate and diagnosed the baby with a lung

and how much to give her and treat her that way.”

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

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.

has a fever. Remanoseke reaches out with the back of his

Now, because Remanoseke is here, Vahonie and other

hand to feel the child’s forehead, confirms that she seems

parents like her can get the medicines they need to treat

to have a temperature and then reaches into a box of

their children, they can get them in the right amount, and

medicine. “Now I also have to treat her for malaria,” he

they can get them at the right time — before the child gets

explains. “If there is a fever we always treat for malaria.”

really sick.

Agent of change 7

four Last to arrive outside the clinic this morning is fifty-three

used to own were wiped out in three stages: eighteen died

year old Magnitse with her seven-month-old grandaughter,

of disease, eight were sold during a drought to buy food and

Solondrenee. The baby cries and cries, stops briefly when

the remaining four were killed, as is the custom here, when

she sucks at Magnitse’s dry breast, and then cries again.

there was a death in the family.

Magnitse isn’t sure what is wrong, but she has some ideas.

When Magnitse’s daughter — Solondrenee’s mother —

“Now we don’t have animals to pull our ox cart,” she says. “This means we can’t take water from the river, which

died five months ago, the baby and her four-year-old sister

is very far away.” As a result, the family must rely on others

came to live with their grandparents. With a total of eight

to bring water and then buy it from them for 400 Ariary (US

mouths to feed under their tiny wooden roof, Magnitse and

$0.20) per bucket”. It is a significant amount for a poor family

her husband have taken care of the newcomers as best

to pay, especially when they must buy at least one bucket

they can. “When they first came to live with us we gave the

for the eight family members to share every day.

baby goat’s milk five times a day,” Magnitse says. “But now

“We also need animals to work in the field,” Magnitse

the goats have less milk so she only gets about half a cup

explains. The family has two hectares of land but with only

once a day.” Other than that the baby eats the same as

Magnitse’s husband and one grown son to farm it, they are

everybody else: rice with water three times a day plus

limited in what they can cultivate. “So, without water and

some corn and manioc.”

cattle the parents suffer and their children do too,” she says.

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

“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

nutrition for pregnant women, infants and children under

Circumference (MUAC), and reports to Magnitse that, like

five. “She has taught us about the variety of food that

so many in this food-insecure area, her granddaughter is

children need and how to prepare it,” Magnitse says. “For

likely to be malnourished. Though malnutrition is an

example, mixing in cereals with grains and beans. It’s good

underlying factor in most of the pneumonia, diarrhoea and

to know these things, but I can’t always follow them. If I

malaria cases he sees, Remanoseke is not trained to treat

don’t have the money, how can I buy the food?” Magnitse

it. He fills out a referral form, and tells Magnitse that she

points to the colorful posters tacked up outside health post

needs to take the baby and the papers to the health centre.

illustrating foods for nutrition. “If we’re lucky, we eat meat

Asked if she is happy with the service Remanoseke

twice a year,” she says. “And fruits and vegetables are

provides, Magnitse says she is. “In the past we could only

seldom available at the market here, no matter how much

get plants when we were sick, but now, because he’s here,

money you have.”

Magnitse explains that for her family and for many others

I can get medicine when my granddaughter needs it.” Today, of course, she did not get medicine, she got a referral,

in this area, the reason for their poverty is that they no

which prompts her only complaint: it’s a long walk to the

longer own cattle. The 30 that Magnitse and her husband

health centre and back.

8 UNICEF Madagascar Hope for the future

Agent of change 9

10 UNICEF Madagascar Hope for the future

five Mothers and children crowd the benches, the floor, and the

no one came here. Now many more people come, but last

shade of the few trees outside the clinic. They are waiting to

year I still didn’t reach my targets for antenatal check-ups,

see Frangeline Lilareko, Nurse and Chief of the Maraolipoty

immunisations or external consultations.”

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

CHWs like Remanoseke play an important role in promoting the utilisation of the health centre. They encourage parents in surrounding communities to have their children

this clinic, like most in the region, is actually underutilised.

vaccinated, send pregnant mothers for antenatal check-ups,

About half the population has never set foot in a health

and refer difficult cases for treatment.

centre. Their reliance on traditional healers is one reason for this, but it is not the only reason, as District Health Officer

At the same time their presence also serves to lighten Frangeline’s workload. “The principle behind community

Genevieve Ravaosolo, a native of the region, explains:

health work is that we cooperate in taking care of the

“Throughout Madagascar there are different fady — taboos.

people who live more than five kilometres from the health

In this area it is taboo to go into a building — for example,

centre,” Frangeline explains. “It is too far for me to visit all

a health centre or perhaps even a school — that is made of

of the communities that this health centre serves. So the

brick, especially if it is painted white. This is because here

CHWs reach the people and places I can’t reach. And

grave-markers and tombs are made of brick, and many are

because they offer treatment at their level, people from

painted white. So these things are associated with death.”

those outlying communities no longer need to come here

In the South of Madagascar, where 80 per cent of the

seeking treatment for the most common cases. That means

population is animist, these beliefs are powerful. “Believe it

I have more time for my other activities: consultations,

or not, this is one of the biggest obstacles to getting people

outreach, reports....”

to use the health centre,” says Genevieve. “They recognise

CHWs also help Frangeline to get the information she

the value of, say, vaccinations. But they believe that if they

needs on the communities the health centre serves. The

bring their child to the health centre to get those

CHWs’ monthly reports offer valuable information on the

vaccinations the child may die. Medical personnel, on the

number of children under five, the number of cases of

other hand, are telling them that if they don’t bring their

pneumonia, malaria and diarrhoea in a given community

child to the health centre for vaccinations the child may die.

and the number of children who have been vaccinated.

We have learned that we just have to wait for them and eventually they will come. They will ask the ancestors and

One of the main benefits of the CHWs, however, is in acting as ‘translators’ for people in their communities. “One

see what they say and the ancestors will usually tell them

of the main challenges I face is a lack of knowledge in the

that if they first kill a chicken or a goat they can go ahead

members of the community,” says Frangeline. “Most have

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

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

seem nothing could be further from her mind than getting

supports my work by transferring important messages, and

more people to use the health centre. “When I arrived here

because he can read he can also explain posters and

three years ago this health centre was really dirty. Almost

medicine labels — what’s more, they trust him.”

Agent of change 11

six When Frangeline finally sees Magnitse and Solondrenee, an

it is not. A malnourished child normally takes it for a three-

examination confirms Remanoseke’s diagnosis. Like most

month period but bad roads and poor supply management

of the other children sitting with their mothers outside her

at the district level can mean an interruption of supply.

door, Solondrenee is malnourished.

Fortunately there are no fady dealing with the therapeutic

“Then mothers come day after day looking for it,” says Frangeline. “But if those mothers come from far away, like

foods which will allow Magnitse to treat the baby at home.

Soatsifa Ambony, and again and again it is not here, they

As Magnitse loads her bag with a week’s supply of the

simply abandon the treatment.”

silver packets, Frangeline explains that she will need to bring

Child on her hip, therapeutic food in her bag and referral

the baby back once a week for at least the next three

paper in hand Magnitse sets off on the road back to Soatsifa

months so that Solondrenee can be weighed and measured

Ambony. Although UNICEF is working to strengthen drug

and receive another week’s supply of therapeutic food.

supply management in the country, change will take time.

But as Magnitse learns from some of the other mothers

Until then, the road to recovery will not always be an easy

who are waiting outside, this isn’t always how things work.

one — especially for those like Magnitse who live far from

The therapeutic food should be delivered weekly, but often

the nearest health centre.

12 UNICEF Madagascar Hope for the future

Agent of change 13

seven The next morning outside the community health site the

two CHWs. These health workers will receive continued

response to Remanoseke’s efforts to drum up business is

training that will allow them to keep improving the quality

overwhelming. Remanoseke calls the women and their

of the services they offer.

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

Not only will Madagascar’s most vulnerable children receive medical care when and where they need it, their parents will receive important preventive messages

inconsistent supply of medicines, to the need for further

regarding the importance of good nutrition, clean water,

equipment and training, to the tyranny of traditional beliefs

and proper sanitation. “When people hear these messages

and the lack of education in the community — the service

again and again, eventually they will change their behaviour,”

he provides is vitally important to the people in his

says District Health Officer Genevieve Ravaosolo. “But you

community. “They appreciate my work because they can

have to cover everyone with these messages and repeat

see the benefits I bring for their children’s health,” he says.

Under a scale up of the programme planned for 2012 and

them frequently. By putting community health workers in every village people will learn the practices they need to

beyond, every village in the country that is more than five

keep their families healthy. In time this will improve the

kilometres from the nearest health centre will be served by

health of children in all of our remote rural communities.”

Hard times in Tana 14

16 UNICEF Madagascar Hope for the future

Training community health workers like Remanoseke to identify and treat the most common causes of death in children under five will allow children in Madagascar’s most vulnerable communities to get the care they need when they need it most. It will also allow communities to learn the practices that will help to prevent these illnesses in the first place.

UNICEF Madagascar is committed to working with local health authorities to place two CHWs into every hard-to-reach village in the country and to strengthen their role so that they can better work to improve the health and well-being of their communities.