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.